A standardized and safe method of sterile field maintenance during intra-operative horizontal plane fluoroscopy

The safety of a novel single-drape cover for sterile back tables in the operating room compared to the standard two-drape method: an experimental study

BACKGROUND

Covering the prepared sterile back tables (PSBTs) during periods of nonuse and during active surgeries may decrease contamination of sterile surgical instruments that have direct contact to surgical wound. The Association of periOperative Registered Nurses (AORN) declared that an easy method for covering and removing the drape will ultimately be most effective (e.g. standard two-drape method). Hence, this study was designed to test the hypothesis that using a novel single-drape cover had more efficiency and safety in decreasing airborne bacteria-carrying particles (ABCPs) settling on the PSBTs during static and dynamic periods than the standard two-drape method.

METHODS

This experimental study was conducted with using 918 agar plates to detect contamination of the PSBTs with ABCPs on two conditions (static and dynamic) at an academic medical center in Kashan, Iran, from September 25, 2021, to January 20, 2022. The contamination of PSBTs was evaluated by 6 agar settle plates (n = 918 in total) on each PSBT in static and dynamic operating room (OR) conditions. At each time-point, this set-up was repeated on two occasions else during data collection, establishing 81 PSBTs in total. Tested groups included the PSBTs covered with the standard two-drape method, the novel single-drape cover, or no cover. The plates were collected after 15, 30, 45, 60, 120, 180, 240 min and 24 h. The primary outcome measured was comparison of mean bioburden of ABCPs settling on covered PSBTs on two conditions by using agar settle plates. The secondary outcomes measured were to determine the role of covering in decreasing contamination of PSBTs and the estimation of time-dependent surgical instrument contamination in the uncovered PSBTs on two conditions by using agar settle plates.

RESULTS

Covering the PSBTs during static and dynamic OR conditions lead to a significantly decreased bioburden of ABCPs on them (P < 0.05). No differences were seen between the standard two-drape method and the novel single-drape cover (P > 0.05).

CONCLUSIONS

We found that there is no preference for using the novel single-drape cover than the standard two-drape method. Our results showed a significant decrease in bioburden of ABCPs on the PSBTs when those were covered during static and dynamic OR conditions, indicating the efficiency for covering the PSBTs during periods of nonuse and during active surgery.

C-arm contamination of the surgical field: Can contamination be reduced with an intervening drape?

INTRODUCTION

Contamination of the surgical field by the C-arm in orthopaedic procedures is a significant potential source for surgical site infections. The purpose of this study was to explore the utility of a split sheet to aid in prevention of secondary contamination from the C-arm on the C-arm side of the operative field.

METHODS

A C-arm and a surgical table were draped by standard techniques. The surgical table was split in thirds: the surgeon's side, the C-arm side of the operative field, and the middle for contamination analysis. Fluorescent powder was used to simulate a contaminant and placed on the C-arm, floor and lower portions of drapes. The C-arm was cycled between PA and Lateral positions. Powder transfer to the field was visualized with a camera under uniform UV light. Photographs were taken to measure fluorescent pixels prior to cycling the C-arm and at 5, 10 and 15 cycles. This protocol was repeated using a split sheet (U-drape) to isolate the C-arm below the operative field. Image J was utilized to calculate differences in the number of pixels brighter than the control image.

RESULTS

Using standard draping techniques, there was contamination of the surgical field with the C-arm side of the operative field having the highest level of fluorescent pixels. The number of fluorescent pixels was linearly correlated with the number of PA to Lateral cycles. At the end of 15 cycles, the average number of fluorescent pixels for the intervening draping technique was 2.9 pixels compared to the standard draping technique of 3939 pixels (p = 0.0078).

DISCUSSION

The addition of a U-drape between the C-arm and the table results in a statistically significant reduction in surgical field contamination as a result of secondary transfer from the C-arm.

LEVEL OF EVIDENCE

II.

Contamination of the Mini C-Arm During Foot and Ankle Surgery

BACKGROUND

Many orthopedic surgeries utilize intraoperative fluoroscopy. The mini C-arm is an advantageous device as it can be easily used without the need for a dedicated radiology technician. However, there are concerns that the mini C-arm may represent a potential source of contamination and subsequent postoperative infection. Previous investigations of standard C-arm drapes have shown high rates of contamination. Similar contamination rates would be even more concerning for the mini C-arm as it requires physically maneuvering the machine. This study aimed to determine the rate of mini C-arm drape contamination and identify high-risk areas.

METHODS

Fifty foot and ankle surgeries requiring the use of mini C-arm fluoroscopy were included. Eight locations on the mini C-arm drape were sampled at the conclusion of each procedure. Culture Q-swabs were used for sampling defined locations. Swab samples were then assessed for bacterial growth on a 5% blood agar plate using a semiquantitative technique.

RESULTS

In 70% of surgical cases, contamination was observed in at least 1 location. Six of the 8 evaluated locations were found to have significantly higher contamination in comparison with their corresponding negative controls (Mann-Whitney U test, P < .05). The "outer portion of the upper arm" (location 1) exhibited bacteria growth in 26% (P < .0001) of cases. The "superior portion of the x-ray source" (location 2) exhibited growth in 30% (P < .0001) of cases. These were the highest-risk areas for contamination and were both significantly more likely to be involved than the "inferior portion of the x-ray source" and "superior portion of the beam receiver," locations 4 and 5, respectively. Fourteen percent (7/50) C-arm cases and 1.72% (1/58) Achilles tendon surgery control cases developed surgical site infection (P = .0234; OR, 9.27).

CONCLUSION

Bacterial contamination of the mini C-arm drape was found to be common after foot and ankle procedures. Contamination was more prevalent on the outer ring areas of the C-arm, both at the emitter and receiver.

LEVEL OF EVIDENCE

Level III, prospective cohort study.

Evaluation of a novel C-Arm draping technique to minimize surgical field contamination and surgery time

BACKGROUND

The purpose of this study is to compare the sterility of three C-Arm draping techniques: the clip-drape, sterile pouch, and a novel drape tower method. We hypothesize that our novel technique will minimize floor contamination from reaching the surgical field while allowing the C-Arm machine to rotate between lateral and anterior-posterior positions more quickly.

METHODS

Five trials consisting of rotating the C-Arm and simulating surgeon movement were run using each technique. Ultraviolet light illuminating melamine powder was used to represent floor contamination. Measurements of melamine powder encroachment on the drapes were taken using the top of the C-Arm in lateral position as the reference point. The time needed to assemble, deploy, and retract the C-Arm was measured for each technique. The gown, gloves, and mayo stand were also examined after each trial for contamination.

RESULTS

Compared to the clip drape, the drape tower prevented contamination from reaching the C-Arm by an additional 30.5 cm (95% confidence interval (CI): 17.0-43.9, P < 0.001). The drape tower had faster deployment and retraction times than both the clip drape (P < 0.001 and P < 0.001, respectively) and sterile pouch (P = 0.011 and P < 0.001, respectively). The clip drape and sterile pouch exhibited glove contamination in two (40%) simulations, while the drape tower showed no instances of contamination (P = 0.255).

CONCLUSIONS

The novel drape tower technique limits the encroachment of floor contamination onto sterile drapes. It should be considered as an alternative draping method for lower extremity surgery.

Comparison of 3 C-Arm Draping Techniques to Prevent Far Side Contamination

OBJECTIVE

To assess the effectiveness of reducing contamination using 2 methods of C-Arm draping compared with traditional methods.

MATERIALS AND METHODS

The authors simulated an operating room using an extremity drape, commercially available C-Arm drapes, and C-Arm. A black light was placed above the field. A fluorescent powder was placed on the nonsterile portions of the field. Baseline light intensity was recorded by photo. The C-Arm was brought into the surgical field for orthogonal imaging for 15 cycles. A repeat photograph was taken to measure the increase in intensity of the fluorescent powder to assess degree of contamination. This was repeated 5 times for each configuration: standard C-Arm drape, a proprietary close-fitting drape, and a split drape secured to the far side with the split wrapped around the C-Arm receiver. Light intensity difference was measured and average change in intensity was compared.

RESULTS

Compared with standard draping, the proprietary close-fitting drape resulted in a 71.3% decrease in contamination (4.84% vs. 16.90%, P = 0.101) that trended toward significance and the split drape resulted in a 99.5% decrease (0.09% vs. 16.90%, P = 0.017) that was statistically significant.

CONCLUSION

Far side contamination can be reduced by using a split drape connecting the operative table to the C-Arm receiver, effectively "sealing off" contaminants. The proprietary close-fitting drape may also decrease contamination, but this was not statistically significant in this study. Use of the split drape technique will help prevent contamination and may ultimately lead to decreased infection risk.

The Drape Tower: A "Hands-Free" Draping Technique for Intraoperative Lateral Fluoroscopy Views

Maintaining surgical field sterility during fracture surgery is critical for reducing the likelihood of postoperative infection. Lateral fluoroscopic views are frequently obtained by rotating the emitter under the bed and up immediately adjacent to the sterile field on the side of the injured limb. Contamination can be prevented by sterilely covering the emitter with each rotation from the upright to the lateral positions. Here, we describe a novel draping setup, which maintains fluoroscopic coverage in a "hands-free" manner. The technique uses widely available materials and allows the surgeon to proceed with surgery without the need for additional hands to manage the drape.

The Far Side Opposite the Surgeon is Most Prone to Contamination From the C-Arm

OBJECTIVE

Fluoroscopy is used in many orthopaedic procedures. The C-Arm drape is known to be easily contaminated during orthogonal imaging. However, it is unknown if one area of the operative field is more prone to contamination than another. The purpose of this study was to determine if secondary transfer of contaminate from the undraped portion of the C-Arm occurs.

METHODS

A C-Arm was utilized with standardized draping in a simulated operating room. We used a simulated contaminant: a fluorescent powder that phosphoresces under ultraviolet light. The powder was placed over nonsterile portions. A darkened room with a black light, and a camera was used. C-Arm movements were simulated by cycling through lateral to Anteroposterior imaging. Images were taken before (control) and after cycles of orthogonal imaging. The change in light intensity was quantified at each time point over each area as a percentage of change.

RESULTS

Contamination of the surgical field was observed in all areas after 15 cycles, with the area adjacent to the C-Arm being most pronounced. A linear increase in intensity with increased cycles was observed (R = 0.297; P = 0.036), with the mean increase in intensity of 5% after 15 cycles (95% confidence interval, 1.97-7.86). The remaining areas (closest to surgeon and middle) showed an increase as well but were not significant (P > 0.05).

CONCLUSIONS

Secondary contamination of the surgical field from the C-Arm occurs. The area most prone to contamination is the area immediately adjacent to the fluoroscopy unit, usually opposite the surgeon.

The Mini C-Arm Sock: A Novel and Simple Technique for Draping to Prevent Contamination and Penetration

The mini C-arm is frequently used in foot and ankle surgery. However, its continuous manipulation introduces potential means of contaminating the sterile surgical field. A simple and effective draping technique of the mini C-arm is described to minimize risk of contamination and sharps penetration that can damage the C-arm. Levels of Evidence: Level V.

Does the type of surgical drape (disposable versus non-disposable) affect the risk of subsequent surgical site infection?

Aims

Determine whether disposable or reusable drapes are better at reducing surgical site infection (SSI) rates.

Methods

A systematic review of the English literature from inception to 2018 with search terms relating to infection and drapes in orthopaedic and spine surgery.

Results

No orthopaedic or spinal surgery studies assessed the risk of SSI between reusable or disposable drapes. However, two articles, with conflicting results, compared current reusable and disposable drapes in other surgical disciplines.

Conclusion

There is no evidence to support a difference between reusable or disposable drapes to reduce the risk of SSI in orthopaedic and spinal surgery.

A Comparison of Three C-Arm Draping Techniques to Minimize Contamination of the Surgical Field

The use of intraoperative fluoroscopy has become a routine and useful adjunct within orthopaedic surgery. However, the fluoroscopy machine may become an additional source of contamination in the operating room, particularly when maneuvering from the anterior-posterior position to the lateral position. Consequently, draping techniques were developed to maintain sterility of the operative field and surgeon. Despite a variety of methods, no studies exist to compare the sterility of these techniques specifically when the fluoroscopy machine is in the lateral imaging position. We evaluated the sterility of 3 c-arm draping techniques in a simulated operative environment. The 3 techniques consisted of a traditional 3-quarter sterile sheet attached to the side of the operative table, a modified clip-drape method, and a commercially available sterile pouch. Our study demonstrated that the traditional method poses a high risk for sterile field contamination, whereas the modified clip-drape method and commercially available sterile pouch kept floor contamination furthest from the surgical field. With the current data, we urge surgeons to use modified techniques rather than the traditional draping method.

Interlocking screws placed with freehand technique and uni-planar image intensification: the "dip-stick" technique

OBJECTIVE

To report our experience with a novel alternative method of freehand interlocking of intramedullary nails. This method requires the use of only anterior-posterior image intensification and an intramedullary guide wire to verify screw placement. Our results are compared with historical results in the literature.

METHODS

A total of 815 patients were treated using this technique from January 2008 to December 2012; 603 patients had fractures of the tibia and 212 had fractures of the femur.

RESULTS

The mean duration of surgery for tibial shaft fractures was 55.6 minutes (range 42-60 minutes) and that for fractures of the femur was 78 minutes (range 50-90 minutes). The mean time for each distal locking was 3.8 minutes (2.5-5.1 minutes), with 7.65 seconds of exposure to radiation during each block.

CONCLUSIONS

The surgical technique is simple, easy and reproducible. Mean time of surgery and radiation exposure was less than that in the literature. A comparative study should be performed.