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Tsay EL, Sabharwal S. Reuse of Orthopaedic Equipment: Barriers and Opportunities. JBJS Rev 2024; 12:01874474-202403000-00005. [PMID: 38466800 DOI: 10.2106/jbjs.rvw.23.00117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
» Reuse of orthopaedic equipment is one of many potential ways to minimize the negative impact of used equipment on the environment, rising healthcare costs and disparities in access to surgical care.» Barriers to widespread adoption of reuse include concerns for patient safety, exposure to unknown liability risks, negative public perceptions, and logistical barriers such as limited availability of infrastructure and quality control metrics.» Some low- and middle-income countries have existing models of equipment reuse that can be adapted through reverse innovation to high-income countries such as the United States.» Further research should be conducted to examine the safety and efficacy of reusing various orthopaedic equipment, so that standardized guidelines for reuse can be established.
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Affiliation(s)
- Ellen L Tsay
- University of California, San Francisco, San Francisco, California
| | - Sanjeev Sabharwal
- University of California, San Francisco, San Francisco, California
- UCSF Benioff Children's Hospital Oakland, Oakland, California
- Institute of Global Orthopaedics and Traumatology, San Francisco, California
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Biofilme em parafusos ortopédicos prontos para uso adquiridos por meio de sistema de consiganação/comodato. ACTA PAUL ENFERM 2023. [DOI: 10.37689/acta-ape/2023ao00811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Josephs-Spaulding J, Singh OV. Medical Device Sterilization and Reprocessing in the Era of Multidrug-Resistant (MDR) Bacteria: Issues and Regulatory Concepts. FRONTIERS IN MEDICAL TECHNOLOGY 2021; 2:587352. [PMID: 35047882 PMCID: PMC8757868 DOI: 10.3389/fmedt.2020.587352] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022] Open
Abstract
The emergence of multidrug-resistant (MDR) bacteria threatens humans in various health sectors, including medical devices. Since formal classifications for medical device sterilization and disinfection were established in the 1970's, microbial adaptation under adverse environmental conditions has evolved rapidly. MDR microbial biofilms that adhere to medical devices and recurrently infect patients pose a significant threat in hospitals. Therefore, it is essential to mitigate the risk associated with MDR outbreaks by establishing novel recommendations for medical device sterilization, in a world of MDR. MDR pathogens typically thrive on devices with flexible accessories, which are easily contaminated with biofilms due to previous patient use and faulty sterilization or reprocessing procedures. To prevent danger to immunocompromised individuals, there is a need to regulate the classification of reprocessed medical device sterilization. This article aims to assess the risks of improper sterilization of medical devices in the era of MDR when sterilization procedures for critical medical devices are not followed to standard. Further, we discuss key regulatory recommendations for consistent sterilization of critical medical devices in contrast to the risks of disinfection reusable medical devices.
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Affiliation(s)
- Jonathan Josephs-Spaulding
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Om V. Singh
- Advance Academic Program, The Johns Hopkins University, Washington, DC, United States
- Technology Science Group (TSG) Consulting Inc., A Science Group Company, Washington, DC, United States
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Agarwal A, Schultz C, Agarwal AK, Wang JC, Garfin SR, Anand N. Harboring Contaminants in Repeatedly Reprocessed Pedicle Screws. Global Spine J 2019; 9:173-178. [PMID: 30984497 PMCID: PMC6448207 DOI: 10.1177/2192568218784298] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN It consisted of evaluation of the pedicle screws for presence of residual nonmicrobial contaminants and tabulation of the minimum steps and time required for reprocessing implants as per guidelines and its comparison with actual practice. OBJECTIVE An evaluation of the nonmicrobial contaminants prevalent on the pedicle screws used for spine surgery and the underlying practice cause behind the source. METHODS The first component consisted of a random selection of 6 pedicle screws and its assessment using optical microscopy, scanning electron microscopy with energy dispersive spectroscopy, and Fourier transform infrared spectroscopy. The second component consisted of review of implant reprocessing guidelines and its applicability. RESULTS Three types of contaminants were identified: corrosion, saccharide of unknown origin, and soap residue mixed with and were mostly present at the interfaces with low permeability. In addition, manufacturer's guideline recommends 19 hours of reprocessing, whereas the real-time observation revealed a turnaround time of 1 hour 17 minutes. CONCLUSION Repeatedly reprocessed pedicle screws host corrosion, carbohydrate, fat, and soap, which could be a cause of surgical site infection and inflammatory responses postsurgery. The cause behind it is the impracticality of repeated cleaning and inspection of such devices.
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Affiliation(s)
- Aakash Agarwal
- University of Toledo, Toledo, OH, USA,Aakash Agarwal, Engineering Center for Orthopaedic
Research Excellence, University of Toledo, 5051 Nitschke Hall MS 303, 2801 W. Bancroft
Street, Toledo, OH 43606, USA.
| | | | | | | | | | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles CA, USA
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Agarwal A, Lin B, Wang JC, Schultz C, Garfin SR, Goel VK, Anand N, Agarwal AK. Efficacy of Intraoperative Implant Prophylaxis in Reducing Intraoperative Microbial Contamination. Global Spine J 2019; 9:62-66. [PMID: 30775210 PMCID: PMC6362554 DOI: 10.1177/2192568218780676] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN A prospective single-center study. OBJECTIVES Assess to what degree contamination of pedicle screws occur in standard intraoperative practice and if use of an impermeable guard could mitigate or reduce such an occurrence. METHODS Two groups of sterile prepackaged pedicle screws, one with an intraoperative guard (group 1) and the other without such a guard (group 2), each consisting of 5 samples distributed over 3 time points, were loaded onto the insertion device by the scrub tech and left on the sterile table. Approximately 20 minutes later, the lead surgeon who had just finished preparing the surgical site touches the pedicle screw. Then instead of implantation it was transferred to a sterile container using fresh clean gloves for bacterial and gene analysis. Guarded screw implies that even after unwrapping from the package, the screw carries an impermeable barrier along its entire length, which is only removed seconds prior to implantation. RESULTS The standard unguarded pedicle screws presented bioburden in the range of 105 to 107 (colony forming units/implant) with bacterial genus mostly consisting of Staphylococcus and Micrococcus, the 2 most common genera found in surgical site infection reports. The common species among them were Staphylococcus epidermis, Staphylococcus aureus, Micrococcus luteus, and Staphylococcus pettenkoferi, whereas the guarded pedicle screws showed no bioburden. CONCLUSIONS Shielding the pedicle screws intraoperatively using a guard provides a superior level of asepsis than currently practiced. All unshielded pedicles screws were carrying bioburden of virulent bacterial species, which provides an opportunity for the development of postoperative infections.
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Affiliation(s)
- Aakash Agarwal
- University of Toledo, Toledo, OH, USA,Aakash Agarwal, Engineering Center for Orthopaedic Research Excellence, University of Toledo, 5051 Nitschke Hall MS 303, 2801 W, Bancroft St, Toledo, OH 43606, USA.
| | - Boren Lin
- University of Toledo, Toledo, OH, USA
| | | | | | | | | | - Neel Anand
- Cedars Sinai Medical Center, Los Angeles, CA, USA
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Agarwal A, Schultz C, Goel VK, Agarwal A, Anand N, Garfin SR, Wang JC. Implant Prophylaxis: The Next Best Practice Toward Asepsis in Spine Surgery. Global Spine J 2018; 8:761-765. [PMID: 30443488 PMCID: PMC6232723 DOI: 10.1177/2192568218762380] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN A literature review. OBJECTIVES An evaluation of the contaminants prevalent on implants used for surgery and the aseptic methods being employed against them. METHODS PubMed was searched for articles published between 2000 and 2017 for studies evaluating the contaminants present on spine implants, and associated pre- and intraoperative implant processing and handling methodology suggested to avoid them. Systematic reviews, observational studies, bench-top studies, and expert opinions were included. RESULTS Eleven studies were identified whose major focus was the asepsis of implants to reduce the incidence of surgical site infection incidences during surgery. These studies measured the colony forming units of bacteria on sterilized implants and/or gloves from the surgeon, scrub nurse, and assistants, as well as reductions of surgical site infection rates in spine surgery due to changes in implant handling techniques. Additionally, the search included assessments of endotoxins and carbohydrates present on reprocessed implants. The suggested changes to surgical practice based on these studies included handling implants with only fresh gloves, keeping implants covered until the immediate time of use, reducing operating room traffic, avoiding reprocessing of implants (ie, providing terminally sterilized implants), and avoiding touching the implants altogether. CONCLUSIONS Both reprocessing (preoperative) and handling (intraoperative) of implants seem to lead to contamination of sterilized implants. Using a terminally sterilized device may mitigate reprocessing (preoperative implant prophylaxis), whereas the use of fresh gloves for handling each implant and/or a permanent shielding technique (intraoperative implant prophylaxis) could potentially avoid recontamination at the theatre.
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Affiliation(s)
- Aakash Agarwal
- University of Toledo, Toledo, OH,
USA,Aakash Agarwal, Engineering Center for
Orthopaedic Research Excellence, University of Toledo, 5051 Nitschke Hall MS
303, 2801 W Bancroft Street, Toledo, OH 43606, USA.
| | | | | | | | - Neel Anand
- Cedars Sinai Medical Center, Los
Angeles, CA, USA
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Abstract
Given the complexity of the sterilization process, and the risk involved in absence of strict adherence to the protocol described by the medical device manufacturers, terminally sterilized devices are emerging and being promoted in the field of medical practices. The characteristics associated with conventional reprocessing are demanding logistics, costs of delay, operations and adverse events, and unacceptable liability. Demanding logistics were a result of decoupled staff between the operating room and sterilize processing department, understaffed and high-volume processing with an additional burden due to inventory management and inefficient training. Other costs arose from upkeep, delay in operating room, and surgical-site infections. Liability arose from the repeatedly use of an unquantifiable process thus adding uncertainties, limited shelf life of the reprocessed implants, contingency of flash sterilization and introduction of newer technology with higher demand on cleaning performances. In contrast, terminally sterilized single-use devices do not carry any of the aforementioned-characteristics, deeming it to be the simplest solution to the current conundrum. This review serves to provide an evaluation of logistics, costs, and potential adverse effects, both directly and indirectly, associated with current practices in the sterile processing department, and also describes as to how the use of terminally sterilized devices can help circumvent those.
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França R, Alfa M, Olson N, Yahia L, Sacher E. Characterization of endotoxins on orthopaedic fixation screws, using physicochemical surface analyses. J Orthop Res 2017; 35:240-247. [PMID: 27107265 DOI: 10.1002/jor.23271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/04/2016] [Indexed: 02/04/2023]
Abstract
The objective of this study was to determine if surface analysis techniques could be used to detect endotoxin on stainless steel malleolus screws. New malleolus screws were compared to ones that had been coated in purified lipopolysaccharide (LPS) or Artificial Test Soil (ATS) containing lipopolysaccharide. X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM), and time-of flight secondary ion mass spectrometry (TOF-SIMS) were used to assess the fixation screws surface. Organic material was visualized on the LPS and ATS-LPS inoculated screws but not on the new unsoiled screws. This was further supported by the peaks observed at masses between 40 and 100 D in TOF-SIMS spectra of the LPS and ATS-LPS inoculated screws. After deconvolution of N1s high resolution XPS spectra, the LPS inoculated screws showed amide groups whereas the ATS-LPS inoculated screws showed predominantly nitroso groups (C-NO). Our data demonstrate that surface analysis can be used to detect organic residuals present on fixation screws. The XPS data confirmed that LPS reacted predominantly with positively charged surface metallic ions (Fe and Cr), whereas proteins reacted with the surface oxide layer of fixation screws, forming C-NO groups. The application of these surface analysis techniques will be helpful in determining if the reprocessing of such items results in an accumulation of organic material that might lead to aseptic loosening, when implanted. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:240-247, 2017.
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Affiliation(s)
- Rodrigo França
- Dental Biomaterials Research Laboratory, Faculty of Health Sciences, Department of Restorative Dentistry, University of Manitoba, 780 Bannatyne Avenue, Winnipeg, Manitoba R3E 0W2, Canada.,Laboratoire d'Innovation et d'Analyse de Bioperformance, École Polytechnique de Montréal, C.P. 5079, Succursale Centre-ville, Montréal, Québec H3C 3A7, Canada
| | - Michelle Alfa
- St-Boniface Hospital Research Center, 351 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada.,Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba R3E 0l9, Canada
| | - Nancy Olson
- St-Boniface Hospital Research Center, 351 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
| | - L'Hocine Yahia
- Laboratoire d'Innovation et d'Analyse de Bioperformance, École Polytechnique de Montréal, C.P. 5079, Succursale Centre-ville, Montréal, Québec H3C 3A7, Canada
| | - Edward Sacher
- Regroupement Québecois de Matériaux de Pointe and Département de Génie Physique, École Polytechnique de Montréal, C.P. 6079, Succursale Centre-ville, Montréal, Québec H3C 3A7, Canada
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