Association of Laminar Airflow During Primary Total Joint Arthroplasty With Periprosthetic Joint Infection

Effect of unidirectional airflow ventilation on surgical site infection in cardiac surgery: environmental impact as a factor in the choice for turbulent mixed air flow

BACKGROUND

Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF).

AIM

To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF.

METHODS

This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used.

FINDINGS

Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4-1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA.

CONCLUSION

Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to high electricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgery can diminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

Current Practice Trends in Knee Arthroplasty in India Among ISHKS Members: ISHKS Annual Meeting 2019

Aim

To assess the current practice trends in knee arthroplasty in India among ISHKS members.

Methods

Literature review on 12 areas of key interest in total knee arthroplasty was conducted. Twenty-eight questions pertaining to these key areas in total knee arthroplasty surgery were presented to the delegates for a physical voting with audience response system (ARS) at ISHKS meeting, Bangalore, 2019. The members who could not attend the meeting voted by an online monkey survey. All questions were given three responses: a. Agree, b. Disagree, and c. Abstain.

Results

310 delegates participated and 295 voted in the physical meeting and 110 voted online. Consensus was reached for 28 statements representing five domains on the best practices. Overall, 92% of statements reached unanimous or strong consensus. The statements that achieved strong majority (> 90%) were the factors on pre-operative skin preparations, administration of antibiotics 30 min prior skin incision, and current practices of bilateral TKR. Furthermore, there was strong consensus approval on the role of aspirin for prophylaxis of DVT, lack of benefit on use of drain, considerations for pre-emptive analgesia, and neuraxial anesthesia. Finally, there were disparate views and weak consensus on use of laminar airflow theaters and use of surgical space suits, length of antibiotic administration postoperatively, and linking of DVT with PE and death.

Conclusion

This study gives the surgeon practice preferences in knee arthroplasty in India and assists in clinical decision-making for all healthcare professionals.

Laminar airflow ventilation systems in orthopaedic operating room do not prevent surgical site infections: a systematic review and meta-analysis

BACKGROUND

Laminar airflow (LAF) technologies minimize infectious microorganisms to enhance air quality and surgical site infections (SSIs). LAF lowers SSIs in some clinical studies but not others. This study analyzes laminar airflow ventilation's capacity to reduce orthopaedic surgery-related SSIs.

METHODS

The PRISMA-compliant keywords were utilized to conduct a search for pertinent articles in various databases including PubMed, MEDLINE, CENTRAL, Web of Sciences, and the Cochrane databases. Observational studies, including retrospective, prospective, and cohort designs, satisfy the PICOS criteria for research methodology. The assessment of quality was conducted utilizing the Robvis software, while the meta-analysis was performed using the RevMan application. The study's results were assessed based on effect sizes of odds ratio (OR) and risk ratio (RR).

RESULTS

From 2000 to 2022, 10 randomized controlled clinical trials with 10,06,587 orthopaedic surgery patients met the inclusion criteria. The primary outcomes were: (1) Risk of SSI, (2) Bacterial count in sampled air and (3) Reduction in SSIs. The overall pooled OR of all included studies was 1.70 (95% CI 1.10-2.64), and the overall pooled RR was 1.27 (95% CI 1.02-1.59) with p < 0.05. LAF is ineffective at preventing SSIs in orthopaedic procedures due to its high-risk ratio and odds ratio.

CONCLUSIONS

The present meta-analysis has determined that the implementation of LAF systems does not result in a significant reduction in the incidence of surgical site infections (SSIs), bacterial count in the air, or SSIs occurrence in orthopaedic operating rooms. Consequently, the installation of said equipment in operating rooms has been found to be both expensive and inefficient.

Sterile Setup Table in the Operating Room Is Not So Sterile

BACKGROUND

One of the important factors for surgical site infection prevention is the implementation of an ultraclean operating room. This study was designed to evaluate back-table sterility during total joint arthroplasty.

METHODS

This prospective study includes 52 patients undergoing primary total joint arthroplasty between November 2021 and January 2022. A total of 4 swabs (2 air swabs and 2 table swabs) were obtained for each case, at the conclusion of surgery and prior to the takedown of drapes. One swab from each set was sent for culture, and the other was sent for next-generation sequencing (NGS) analysis.

RESULTS

Among 104 back-table swabs, a total of 13 (12.5%) organisms were isolated. Of these, 7 organisms were isolated by culture and 6 by NGS. No microorganisms were isolated by both culture and NGS from back-table swabs. Among 104 air swabs, a total of 11 (10.6%) organisms were isolated. Of these, 6 microorganisms were isolated by culture and 5 by NGS. In 4 of the 104 swabs, both culture- and NGS-isolated organisms were from air swabs. Of the 104 (12.5%) back-table and air swabs, 13 were culture positive. While more than 1 pathogen was identified in 2 air swabs, all back-table swabs were monomicrobial by culture. Pathogens were identified from 11 of 104 (10.6%) swabs by NGS, while more than 1 pathogen was identified in 4 swabs (2 air and 2 back table).

CONCLUSION

The findings of this study raise an important issue that the surgical field including the sterile table setup for instruments is not "sterile" and can harbor pathogens.

Technical Considerations and Avoiding Complications in Total Hip Arthroplasty

Total hip arthroplasty (THA) is considered to be the surgical procedure of the 20th century. Current projections show that by 2030, primary THA is expected to grow by 171%, with revision THA expected to increase by 142% in the same time frame. Although complications are not common, when they occur, they can cause notable morbidity to the patient. Understanding the unique anatomy and needs of each patient will prepare the surgeon to avoid soft-tissue or bony injury, optimize prosthesis placement, and decrease the risk of infection. This article aims to highlight common causes of early revision THA and provide specific technical strategies to avoid these complications. Following a systematic approach to the primary THA and using these techniques will assist the surgeon in avoiding complications to revision hip arthroplasty.

Current Status and Factors Associated with Clean Operating Rooms: A Survey of Hospitals in China

Background

Indoor air quality is controlled in the clean operating room (OR) to reduce the risk of surgical-site infections (SSIs). The aim of this study is to assess the usage and management of clean ORs in China and to identify factors associated with the risk of SSIs.

Methods

An online survey was distributed to hospitals in China from August 5 to September 5, 2018 via the WeChat account of the Shanghai International Forum for Infection Control and Prevention. The questionnaire consisted of two parts: basic information (hospital type, level, and number of beds) and usage and management (number of ORs, usage time, maintenance mode, test frequency, compliance with current standards, and comfort of healthcare workers). The significance of factors associated with the cleanliness and maintenance of clean ORs was assessed by univariate and multivariate logistic regression analyses.

Results

Among 1,308 responding hospitals, 25.7% failed to comply with current standards. “Maintenance mode” had a significant effect on compliance with current standards for clean ORs (p < 0.0001) and “professional” maintenance was superior to “outsource or no” maintenance (odds ratio = 0.511, 95% confidence interval = 0.367–0.711). There was a significant difference in the comfort of healthcare workers in clean ORs that complied with current standards vs. those that did not (39.92% [388/972] vs. 64.28% [216/336], respectively, p < 0.0001). Humidity was the chief complaint among healthcare workers.

Conclusion

Maintenance of clean ORs was significantly associated with the compliance of current standards. Noncompliance with current standards was associated with greater risks of SSIs. Maintenance of ORs for prevention of SSIs should consider the costs and benefits.

Surgical Helmets Used During Total Joint Arthroplasty Harbor Common Pathogens: A Cautionary Note

BACKGROUND

The use of personal-protection surgical helmet/hood systems is now a part of the standard surgical attire during arthroplasty in North America. There are no protocols for the disinfection of these helmets.

METHODS

This is a prospective, single-center, observational study. Helmets worn by 44 members of the surgical team and foreheads of 44 corresponding surgical personnel were swabbed at three distinct time points. In addition, 16 helmets were treated with hypochlorite spray to determine if pathogens could be eliminated. Swabs obtained were processed for culture and next-generation sequencing (NGS).

RESULTS

Of the 132 helmet samples, 97 (73%) yielded bacteria on culture and 94 (71%) had evidence of bacterial-deoxyribonucleic acid (DNA) on NGS. Of the swabs sent for bacterial identification at the three time points, at least one from each helmet was positive for a pathogen(s). Of the 132 forehead samples, 124 (93%) yielded bacteria on culture and 103 (78%) had evidence of bacterial-DNA on NGS. The most commonly identified organism from helmets was Cutibacterium acnes (86/132) on NGS and Staphylococcus epidermidis (47/132) on culture. The most commonly identified organism from the foreheads of surgical personnel was Cutibacterium acnes (100/132) on NGS and Staphylococcus epidermidis (70/132) on culture. Sanitization of helmets was totally effective; no swabs taken the following morning for culture and NGS identified any bacteria.

CONCLUSION

This study demonstrates that surgical helmets worn during orthopedic procedures are contaminated with common pathogens that can potentially cause surgical site infections. The findings of this study should at the minimum compel us to develop protocols for the disinfection of these helmets.

Surgeon specialty effect on early outcomes of elective posterior spinal fusion for adolescent idiopathic scoliosis: a propensity-matched analysis of 965 patients

BACKGROUND AND OBJECTIVE

Comparative effectiveness research plays a vital role in health care delivery. Specialty training is one of these variables; surgeons who are trained in different specialties may have different outcomes performing the same procedure. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

This is a retrospective, 1:4 propensity score-matched cohort study. 5520 AIS patients were reviewed from ACS-NSQIP pediatric database. Propensity score matching was utilized.

RESULTS

Patients operated on by orthopedic surgeons were more likely to have shorter operation time (263 min vs 285 min), shorter total hospital stay (95 h vs 118 h), lower rate of return to operating room within the same admission (1.2% vs 3.8%), lower discharge rates after postoperative day 4 (23.8% vs 30.9%), and lower unplanned readmission rate (1.6% vs 4.1%), (p < 0.05). On the other hand, patients operated on by neurosurgeons had lower perioperative blood transfusion rate (62.1% vs 69.8%), (p < 0.05). Other outcome measures and mortality rates were not significantly different between the two cohorts.

CONCLUSIONS

This retrospective study found significant differences in early perioperative outcomes of patients undergoing PSF for AIS by neurosurgeons and orthopedic surgeons. Further studies are recommended to corroborate this finding which may trigger changes in the educational curriculum for neurosurgery residents.

Risk factors for reoperation due to periprosthetic joint infection after elective total hip arthroplasty: a study of 35,056 patients using linked data of the Swedish Hip Arthroplasty Registry (SHAR) and Swedish Perioperative Registry (SPOR)

Background

In Sweden, the incidence of a prosthetic joint infection (PJI) after a planned Total Hip Arthroplasty (THA) is 1.3%, but the worldwide incidence of PJI after THA is unknown. This study explores associations between reoperation due to PJI and potential risk factors.

Methods

Primary elective THA surgery registered in both the Swedish Hip Arthroplasty Registry (SHAR) and the Swedish Perioperative Registry (SPOR) between 1 January 2015 and 31 December 2019 were included in this registry study, resulting in a total study population of 35,056 cases. The outcome variable was reoperation as the result of PJI within a year after surgery. Data were analysed using a multivariable Cox regression model.

Results

Reoperation due to PJI occurred in 460 cases (i.e., 1.3% of the study population). Each year of age increased the risk with 2% (HR 1.02 Cl 1.01, 1.03 P = < 0.001). Compared to men, women had significantly less risk for reoperation (HR 2.17 Cl 1.79, 2.53 P = < 0.001). For patients with obesity (BMI > 30), the risk increased considerably compared to underweight, normal weight, or overweight patients (HR 1.89 Cl 1.43, 2.51 P = < 0.001). The risk also increased by 6% for every 10 min of operative time (HR 1.06 Cl 1.02, 1.09 P = < 0.001). Patients having general anaesthesia had greater risk compared to those with spinal anaesthesia (HR 1.34 Cl 1.04, 1.73 P = 0.024). Finally, a lateral approach showed higher risk of reoperation than a posterior approach (HR 1.43 Cl 1.18, 1.73 P = < 0.001).

Conclusion

Recognition of the several risk factors identified in this study will be important for the perioperative management of patients undergoing THA.

Effect of patient's sex on early perioperative outcomes following anterior cervical discectomy and fusion

OBJECTIVE

Differences in morbidity and mortality measures between males and females have been demonstrated for a variety of spinal surgeries, however, studies of anterior cervical discectomy and fusion (ACDF) are limited. To investigate the impact ofsexon 30-day perioperative outcomes of ACDF.

METHODS

Retrospective 1:1 propensity score-matched cohort study. Patients who underwent ACDF between 2016 and 2018 were reviewed from the ACS-NSQIP database.Propensity score matchingand subgroup analysis were used.

RESULTS

21,180 patients met inclusion criteria. 11,194 patients underwent single-level ACDF and 9986 patients underwent multi-level ACDF. In the single-level group, there were 6168 (55.1%) males and 5026 (44.9%) females. In the multi-level group, there were 5033 (50.4%) males and 4953 (49.6%) females. In both single/multi-level groups, females were more likely to be of older age, be functionally dependent, and have higher BMI and lower preoperative hematocrit level. Males were more likely to be Caucasian, smokers, have myelopathy, diabetes mellitus, hypertension and bleeding disorders. In both single/multi-level groups, except for the higher incidence of urinary tract infection (UTI) in females and myocardial infarction (MI) in males, there were no significant differences in morbidity and mortality between males and females.

CONCLUSIONS

Several differences in demographics and baseline health status exist between males and females undergoing ACDF. When attempting to control for comorbid conditions, we found that sex by itself is not an independent risk factor for higher perioperative morbidity or mortality in patients undergoing ACDF, except for the higher incidence of UTI in females and MI in males. These results are important findings for clinicians and spine surgeons while counseling patients undergoing this type of procedure.

Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes?

BACKGROUND

Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases.

METHODS

In a retrospective, 1:1 propensity score-matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used.

RESULTS

In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty.

CONCLUSIONS

Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

Influence of Sex on Early Outcomes of Elective Lumbar Fusions: An Updated Propensity-Matched and Subgroup Analysis

OBJECTIVE

Existing data have demonstrated significant differences in morbidity and mortality measures between men and women undergoing various spinal surgeries. However, studies of lumbar fusion surgery have been limited. Thus, we investigated the effects of patient sex on 30-day perioperative outcomes after elective lumbar fusion spine surgery.

METHODS

Patients who had undergone lumbar fusion from 2015 to 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching was used to determine whether the patient's sex had influenced the 30-day perioperative complications.

RESULTS

A total of 44,526 cases had met the inclusion criteria and were reviewed. Of the 44,526 patients, 13,715 had undergone posterior lumbar fusion, 21,993 had undergone posterior/transforaminal lumbar interbody fusion, and 8818 had undergone anterior/lateral lumbar interbody fusion. The women were more likely to be older, functionally dependent, and taking steroids for chronic conditions and to have a higher body mass index and lower preoperative hematocrit level. The men were more likely to be white, to smoke, and to have diabetes mellitus, hypertension, and bleeding disorders. In all cohorts, except for a higher incidence of urinary tract infection in the female patients and myocardial infarction in the male patients, no significant differences were found in morbidity and mortality between the sexes.

CONCLUSIONS

Several differences in demographics and baseline health status were found between men and women undergoing lumbar fusion. When attempting to control for comorbid conditions using propensity score matching, we found that sex was an independent predictor of urinary tract infection in women and myocardial infarction in men across major morbidity and mortality categories in patients undergoing lumbar fusion surgery.