Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BACKGROUND

Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.

METHODS

Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.

RESULTS

Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.

CONCLUSIONS

Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes

Purpose

To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes.

Methods

A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes.

Results

The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class.

Conclusions

There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress.

Level of Evidence

Level III, retrospective cohort study.

Influence of running on femoroacetabular joint bone-to-bone distances

There is limited data quantifying the influence of running on hip cartilage mechanics. The goal of this investigation was to quantify changes in hip joint bone-to-bone distance in response to a 3-mile treadmill run. We acquired magnetic resonance (MR) images of the dominant hip of eight young, asymptomatic runners (five males, three females) before and immediately after they ran 3 miles at a self-selected pace on a level treadmill. The femoral heads and acetabula were semiautomatically segmented from the pre- and post-exercise MR images to generate three-dimensional models of each participant's hip that were used to compute changes in the bone-to-bone distances incurred by the running exercise. We observed a significant 3% decrease in bone-to-bone distance from 3.47 ± 0.20 to 3.36 ± 0.22 mm between the femoral head and acetabulum after a 3-mile treadmill run (mean ± 95% confidence interval; p = 0.03). These findings provide new baseline data describing how running impacts the hip joint in young, asymptomatic runners.

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review

PURPOSE

To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury.

RESULTS

Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively.

CONCLUSIONS

The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries.

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV evidence.

Superficial femoral artery stent extrusion

The superficial femoral artery is a common location for endovascular treatment of occlusive arterial disease. Stent extrusion is an uncommon complication of stent placement. In the present case report, we sought to raise awareness of this rare complication and have described the management of a single unique case. Although rare, the complication of stent extrusion should be considered in patients with abnormal symptoms after endovascular treatment of superficial femoral artery disease.

Axillary pullout syndrome: A novel approach to managing a devastating complication

OBJECTIVES

Axillary pullout syndrome is a complex, potentially fatal complication following axillary-femoral bypass graft creation. The re-operative nature, in addition to ongoing hemorrhage, makes for a complicated and potentially morbid repair.

METHODS

We present the case of a 57-year-old man with history of a previous left axillary-femoral-femoral bypass who presented with acute limb-threatening ischemia as a result of bypass thrombosis managed with a right axillary-femoral bypass for limb salvage. His postoperative course was complicated by an axillary anastomotic dehiscence while recovering in inpatient rehabilitation resulting in acute, life-threatening hemorrhage. He was managed utilizing a novel hybrid approach in which a retrograde stent graft was initially placed across the anastomotic dehiscence for control of hemorrhage. He then underwent exploration, decompression, and interposition graft repair utilizing the newly placed stent graft to reinforce the redo axillary anastomosis.

RESULTS AND CONCLUSION

Compared with a traditional operative approach, the hybrid endovascular and open approach limited ongoing hemorrhage while providing a more stable platform for repair and graft revascularization. A hybrid approach to the management of axillary pullout syndrome provides a safe, effective means to the management of axillary anastomotic dehiscence while minimizing the morbidity of ongoing hemorrhage.

Opioid legislation and narcotic filling in total hip arthroplasty: descriptive study of time and state-level trends in the United States

Background

The opioid misuse epidemic focused national attention on reducing opioid overprescribing. The purpose of this study is to describe the relationship of time and state-level interventions and opioid filling surrounding total hip arthroplasty (THA) in the United States.

Methods

A national database with diverse insurance constituents was queried for first-prescription and cumulative perioperative opioid filling volumes and rates in oxycodone 5-mg equivalents (OE’s) in 487,942 patients undergoing primary THA from 30-days pre-operative to 90-days post-operative. Descriptive statistics evaluated pre-legislative and post-legislative opioid filling by state, legislative type, and surgery year.

Results

At the national level, initial opioid filling volumes have remained largely unchanged (56.2 OE’s in 2010 to 51.7 OE’s in 2018). Meanwhile, cumulative opioid filling volumes (151.9 OE’s in 2010 to 111.7 OE’s in 2018) have decreased considerably. Rates of initial opioid prescriptions exceeding 90 OE’s were similar in 2010 (6.4%) and 2018 (5.6%). States with legislation targeting duration and volume of opioid prescriptions saw the largest decreases in opioid prescription filling. That is, 75% of states with opioid legislation had large (> 10 oxycodone 5-mg equivalents) decreases in cumulative 90-day opioid filling compared to only 20% of states without opioid legislation having large decreases in cumulative 90-day opioid filling.

Conclusions

This descriptive study demonstrates decreases in perioperative opioid filling for THA. Although this study was descriptive in nature, states enacting opioid-limiting legislation had larger decreases. Although causal relationships could not be inferred from this analysis, the results suggest that states without legislation could improve prescriber compliance with national goals of decreased opioid overprescribing by enacting opioid-limiting legislation.

Level of evidence

Level III, retrospective prognostic cohort study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00410-w.

Hybrid repair for acute aortic occlusion using aortobifemoral bypass and AngioVac thrombectomy

Aortic thrombus with multilevel acute ischemia is rare. We report the use of vacuum-assisted thrombectomy of an aortic mural thrombus with superior mesenteric artery involvement causing bilateral lower extremity ischemia and acute mesenteric ischemia, in conjunction with embolectomy and fasciotomy. We describe the novel use of the AngioVac device (AngioDynamics, Latham, NY) for reperfusion in the systemic arterial circulation. This case report demonstrates a feasible and less invasive alternative to the management of aortic thrombi with acute ischemia in patients unfit for open aortic thrombectomy of the visceral segment aorta.

Hip Dysplasia

Acetabular dysplasia represents a structural pathomorphology associated with hip pain, instability, and osteoarthritis. The wide spectrum of dysplasia anatomically refers to a 3-dimensional volumetric- and surface area-based insufficiency in coverage and is classified based on the magnitude and location of undercoverage. Borderline dysplasia has been variably defined and leads to management challenges. In symptomatic dysplasia, treatment addresses coverage with periacetabular osteotomy. Concomitant simultaneous or staged hip arthroscopy has significant advantages to address intra-articular pathology. In nonarthritic individuals, there is evidence PAO alters the natural history of dysplasia and decreases the risk of hip arthritis and total hip arthroplasty.

The Association of Prescriber Awareness of Opioid Consumption Trends with Postoperative Opioid Prescription Volume in Hip Arthroscopy: Prescriber Awareness of Opioid Consumption

Purpose

To evaluate the impact of prescriber knowledge of 6-week postoperative opioid usage trends on postoperative opioid prescribing in hip arthroscopy for femoroacetabular impingement syndrome.

Methods

Two groups of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with the same 2 surgeons were defined. One group preceded study design and implementation and 1 group was after study completion termed the preawareness group (n = 129) and awareness group (n = 130). Baseline clinical and operative characteristics and cumulative 6-week postoperative opioid prescription amount in oral morphine equivalents (OMEs), initial discharge OMEs, and cumulative 6-week postoperative opioid refills were recorded. Multivariable models were constructed to evaluate the impact of provider awareness of opioid usage along with the other baseline characteristics previously mentioned on the outcomes of postoperative opioid prescribing.

Results

Preawareness group (365.8 additional OMEs; 95% confidence interval [CI], 132.6-599; P = .002), preoperative opioid usage (506.2 additional OMEs; 95% CI, 268.0-744.3; P < .001), postoperative nonsteroidal anti-inflammatory drugs (-664.6 additional OMEs; -1002.6 to -326.6; P < .001), and Caucasian race (-597.5 additional OMEs; 95% CI, -914.8 to -280.2; P < .001) were significantly associated with 6-week postoperative opioid prescribing. Caucasian race (odds ratio, 0.4; 95% CI, 0.18-0.86; P = .02) was associated with lower odds of additional postoperative opioid prescriptions whereas preoperative opioid usage (odds ratio, 2.47; 95% CI, 1.4-4.36; P = .002) was associated with increased odds of additional postoperative opioid prescriptions.

Conclusions

Patients in the awareness group received significantly lower opioid volume without an increase in overall prescription numbers.

Level of Evidence

III, prognostic, retrospective comparative study.

Resident perception of fundamental endoscopic skills exam: a single institution's experience

BACKGROUND

Graduating general surgery residents are required to pass the FES exam for ABS certification. Trainees and surgery educators are interested in defining the most effective methods of exam preparation. Our aim is to define trainee perceptions, performance, and the most effective preparation methods regarding the FES exam.

METHODS

General surgery residents from a single institution who completed the FES exam were identified. All participated in a flexible endoscopy rotation, and all had access to an endoscopy simulator. Residents were surveyed regarding preparation methods and exam difficulty. Descriptive statistics and a Kruskal-Wallis test were used.

RESULTS

A total of 26 trainees took the FES exam with a first-time pass rate of 96.2%. Of 26 surveys administered, 21 were completed. Twenty trainees (76.9%) participated in a dedicated endoscopy curriculum. Scores were not different among those who received dedicated curricular instruction compared to those who did not (547 [IQR 539-562.5] vs. 516 [484.5-547], p = 0.1484; 535.5 [468.5-571] vs. 519 [464.75-575], p = 0.9514). Written exam difficulty was rated as 5.5 on a 10-point Likert scale, and 85.7% felt it was a fair assessment of endoscopy knowledge; skills exam difficulty was rated as 7, and 71% felt it was a fair assessment of endoscopy skills. Online FES modules, the endoscopy clinical rotation, and an exam preparation session with a faculty member were most effective for written exam preparation. The most effective skills exam preparation methods were independent simulator practice, the endoscopy clinical rotation, and a preparation session with a faculty member. The most difficult skills were loop reduction and retroflexion. Skill decay did not appear to be significant.

CONCLUSIONS

A clinical endoscopy rotation, a method for independent skills practice, and faculty-mediated exam instruction appear to be effective exam preparation methods. When these are present, trainees report minimal need for dedicated exam preparation time prior to taking the FES exam.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database

BACKGROUND

Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions.

METHODS

The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days.

RESULTS

We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5).

CONCLUSIONS

The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

Achieving Post-Free Distraction in Hip Arthroscopy With a Pink Pad Patient Positioning Device Using Standard Hip Distraction Tables

Iatrogenic pudendal nerve and groin complications have been reported to occur at rates up to 4.3%. While many of these complications are transient, the hip preservation community is in search of a safe postless distraction technique. Currently available postless distraction tables are expensive, require the surgeon to adopt a different technique, and have a high disposable fee. We present our technique for postless distraction using a standard table and a pink pad positioning device. Using our technique, we have demonstrated safe and cost-effective post-free distraction.

Sex-dependent outcomes following elective endovascular aortic repair

BACKGROUND

Evidence has shown that women derive less benefit from endovascular aortic repair (EVAR) in large part due to more challenging aortoiliac anatomy. This study sought to examine whether sex-dependent outcomes exist following elective EVAR cases.

METHODS

An institutional retrospective review was performed on patients who underwent elective EVAR procedures between 2008 and 2014. Outcome data collected included procedural and hospital morbidity, mortality, and overall EVAR durability based on the incidence of unplanned graft-related secondary interventions (SIs) (e.g., open conversion, proximal or distal extensions, and coil embolizations).

RESULTS

One hundred eighty-one patients (150 men, 31 women) met the study inclusion criteria. Median follow-up was 40.3 mo. Women had more challenging anatomy compared to men including smaller overall iliac diameters (6.8 mm versus 8.0 mm, P < 0.001) and more severe iliac angulation (77% moderate to severe versus 44%, P < 0.001). Women had increased risk of postoperative complications compared to men (41.9% versus 11.3%, P = 0.003). There was no perioperative mortality in our series of elective EVAR cases. Median 5-y survival following EVAR was 64.4% for men and 76.3% for women (P = 0.599). Late SI rates following EVAR was 10.5% with 16 (10.7%) men and 3 (9.7%) women needing interventions (P = 0.870). Overall durability of EVAR extrapolated as time to SIs was 91% at 2 y and 85% at 5 y. Factors predisposing SIs were iliac tortuosity (P = 0.046), aortic neck angle (P = 0.022), and endoleak at the follow-up (P = 0.030).

CONCLUSIONS

In this study, immediate outcomes following EVAR were different between men and women, with women having increased rates of postoperative complications. Mortality and overall long-term durability of EVAR, however, were the same between sexes despite anatomical differences. EVAR durability was significantly dependent on the severity of iliac tortuosity, aortic neck angulation, and presence of endoleak at the follow-up.

Aortic Graft Infection Secondary to Iatrogenic Transcolonic Graft Malposition

Aortic graft infections are a rare but devastating complication of aortic revascularization. Often infections occur due to contamination at the time of surgery. Iatrogenic misplacement of the limbs of an aortobifemoral graft is exceedingly rare, and principles of evaluation and treatment are not well defined. We report 2 cases of aortobifemoral bypass graft malposition through the colon.

CASE REPORT

Case 1 is a 54-year-old male who underwent aortobifemoral bypass grafting for acute limb ischemia. He had previously undergone a partial sigmoid colectomy for diverticulitis. Approximately 6 months after vascular surgery, he presented with an occult graft infection. Preoperative imaging and intraoperative findings were consistent with graft placement through the sigmoid colon. Case 2 is a 60-year-old male who underwent aortobifemoral bypass grafting due to a nonhealing wound after toe amputation. His postoperative course was complicated by pneumonia, bacteremia thought to be secondary to the pneumonia, general malaise, and persistent fevers. Approximately 10 weeks after the vascular surgery, he presented with imaging and intraoperative findings of graft malposition through the cecum.

CONCLUSIONS

Aortic graft infection is usually caused by surgical contamination and presents as an indolent infection. Case 1 presented as such; Case 2 presented more acutely. Both grafts were iatrogenically misplaced through the colon at the index operation. The patients underwent extra-anatomic bypass and graft explantation and subsequently recovered.

Early recovery after hip arthroscopy for femoroacetabular impingement syndrome: a prospective, observational study

The early post-operative course after hip arthroscopy for femoroacetabular impingement syndrome has not been thoroughly characterized or correlated to factors that may influence recovery. The aim of this study was to report on early pain, function and attitudes towards rehabilitation and to determine predictors of early recovery after hip arthroscopy. Sixty-two patients reported pre-operative pain, iHOT-12 (hip functional score), psychological status and other baseline characteristics. Pain, iHOT-12, hip flexion and several other outcomes were measured through 6 weeks post-operative. Baseline characteristics were correlated with outcomes using univariate and multivariable models. Pain relief started on post-operative day 1 and consistently improved throughout the 6 weeks of follow-up. The average patient’s pain was reduced from a pre-operative level of 5/10 to 2/10 by 6 weeks post-operative. Similarly, iHOT-12 improved from 33/100 to 57/100 whereas hip flexion increased by 9° by 6 weeks post-operative. At 2 weeks post-operative, pre-operative anti-inflammatory usage was associated with greater improvement in pain and swelling; pre-operative opioid usage with poorer patient-reported helpfulness of and adherence to rehabilitation; and higher ASA (American Society of Anesthesiologists) score and lower procedure time with improvement of the pre-operative pain complaint. At 6 weeks, greater depression was associated with lower post-operative pain reduction but greater pre-operative pain complaint improvement. Continuous passive motion usage was associated with increased hip flexion. Pain improved from pre-operative by Day 1 after hip arthroscopy, and early functional improvements were seen by 6 weeks post-operative. Pre-operative anti-inflammatory and opioid usage, depression, race, ASA score, procedure time and continuous passive motion usage were significantly associated with study outcomes.

Post-operative opioid pain management patterns for patients who receive hip surgery

Background

Identifying optimal, post-operative opioid management strategies is a priority of health providers and government agencies. At present, there are no studies we are aware of that have formally investigated opioid prescribing patterns for post-operative non-arthroplasty orthopedic conditions such as femoroacetabular impingement, nor has any study investigated the influence of opioid prescription patterns on health care costs and utilization. We aimed to investigate a subgrouping scheme associated with post-operative opioid prescription strategies and measure the subgroups’ direct and indirect health care utilization and costs in individuals undergoing non-arthroplasty orthopedic hip surgery.

Methods

The study was an observational cohort of routine military clinical practices. We used cluster analysis to characterize pre-operative (12 months) and post-operative (24 months) opioid prescription patterns. Linear mixed effects modeling (with statistical controls for baseline status) identified opioid prescription pattern subgroups and identified subgroup differences in health care utilization and costs.

Results

Two distinct clusters were identified representing 1) short-duration, high total days’ supply (SD-HD), and 2) long-duration, lesser total days’ supply (LD-LD) post-operative prescription patterns. Significantly higher costs and health care utilization for both hip-related and non-hip-related variables were consistently identified in the SD-HD group.

Conclusions

Long-term opioid prescription use has been identified as a concern, but our findings demonstrate that LD-LD post-operative opioid management for hip surgery recipients was associated with lower costs and utilization. Whether these management patterns were a reflection of pre-operative health status, impacted pain-related outcomes, or can be replicated in other orthopedic procedures remains a consideration for future studies.

Trial registration

NA.

Arthroscopic hip preservation surgery practice patterns: an international survey

To design and conduct a survey analyzing pre-, intra- and post- hip arthroscopy practice patterns among hip arthroscopists worldwide. A 21-question, IRB-exempt, HIPAA-compliant, cross-sectional survey was conducted via email using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. Seventy-five respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing AP pelvis, false profile and Dunn 45 were the most common radiographs utilized. CT scans were utilized by 54% of surgeons at least some of the time. Only 56% of participants recommended an arthrogram with MRI. Nearly all surgeons either never (40%) or infrequently (58%) performed arthroscopy in Tönnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51% never; 44% infrequently). Only 25% of participants perform a routine 'T' capsulotomy and 41% close the capsule if the patient is at risk for post-operative instability. Post-operatively, 52% never use a brace, 39% never use a continuous passive motion, 11% never recommended heterotopic ossification prophylaxis and 30% never recommended formal thromboembolic disease prophylaxis. Among a large number of high-volume experienced hip arthroscopists worldwide, pre-, intra- and post- hip arthroscopy practice patterns have been established and reported. Within this cohort of respondents, several areas of patient evaluation and management remain discordant and controversial without universal agreement. Future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Computed Tomography Angiography to Evaluate Thoracic Outlet Neurovascular Compression

The objective was to evaluate the efficacy of computed tomography angiography with upper extremity hyperabduction to diagnose thoracic outlet syndrome. Over 5 years, 21 patients were treated surgically for neurogenic symptoms of thoracic outlet syndrome. For patients whose diagnosis was unclear after history and physical examination, adjunctive tests (duplex, magnetic resonance angiography, or computed tomography angiography) were performed to help establish the diagnosis. Five of the 6 computed tomography angiograms were positive. The sixth computed tomography was deemed to be an incomplete study. With mean follow-up of 9.4 months, 95% (n = 19) of patients with a positive hyperabduction test on physical examination were free of symptoms postoperatively. All patients with a positive computed tomography angiogram, with their neurovascular compression localized to the thoracic outlet, had successful operative decompression. Computed tomography angiogram with abduction of the arm can be used as an adjunct to confirm the diagnosis of neurovascular compression and then predict successful operative decompression.

Hip Dislocation or Subluxation After Hip Arthroscopy: A Systematic Review

PURPOSE

To determine patient- and surgery-specific characteristics of patients sustaining postarthroscopic hip dislocation or subluxation.

METHODS

A systematic review of multiple medical databases was registered with PROSPERO and performed using Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines. Level I to IV clinical outcome studies reporting the presence of hip dislocation or subluxation after hip arthroscopy were eligible. Length of follow-up was not an exclusion criterion. All patient- and surgery-specific variables were extracted from each, specifically evaluating osseous morphology and resection details; labral, iliopsoas, ligamentum teres, and capsular management; generalized ligamentous laxity; instability direction and mechanism; management; and outcome. Study authors were individually contacted to assess most recent outcome.

RESULTS

Ten articles with 11 patients were analyzed (mean patient age: 36.6 ± 12.3 years). There were 9 hip dislocations and 2 subluxations. Mean time between surgery and dislocation was 3.2 ± 4.0 months (range: recovery room to 14 months). Anterior was the most frequent dislocation direction (8 cases). Acetabular undercoverage (preoperative dysplasia or iatrogenic rim over-resection) was observed in 5 cases. Labral debridement was performed in 5 cases, iliopsoas tenotomy in 3 cases, and ligamentum teres debridement in 1 case. A "T" capsulotomy was created in 1 case (isolated interportal in other 10 cases). Capsular closure was performed in 2 cases (both interportal). Generalized ligamentous laxity was diagnosed in 1 case. A combination of external rotation and extension was observed in 5 of the 6 cases reporting the mechanism of anterior dislocation. Four cases were successfully treated with closed reduction; 4 required total hip arthroplasty; and 3 required revision capsulorrhaphy.

CONCLUSIONS

Postarthroscopic hip instability was observed in patients with acetabular undercoverage (including iatrogenic resection), labral debridement, capsular insufficiency, or iliopsoas tenotomy. Most dislocations were anterior, occurring with hip extension and external rotation.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Influence of clerkship sites on National Board of Medical Examiners surgery subject examination performance

BACKGROUND

As one measure of comparability of student experiences on a 2-month surgery clerkship, scores on the National Board of Medical Examiners Surgery Subject Examination (NSSE) were evaluated against a number of variables.

METHODS

NSSE scores for 701 students completing the surgery clerkship over 3.5 years were analyzed. Students rotated at academic, VA, and community hospitals with 1 month of general surgery paired with 1 month of a surgical subspecialty. The effect of 15 rotation site pairings on NSSE performance was analyzed by analysis of variance. The relationship of site-specific student evaluation variables and NSSE scores was examined by stepwise multivariate linear regression.

RESULTS

No statistical differences were demonstrated between NSSE scores and site-specific parameters of duty hours, resident participation, or type of hospital, nor between NSSE scores and paired sites constituting the overall clerkship experience.

CONCLUSION

Performance on the NSSE was not impacted by any assigned paired sites, supporting comparability of overall clerkship experiences.

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay

Terminal cleaning in the operating room is a critical step in preventing the transmission of health care-associated pathogens. The persistent disinfectant activity of a novel isopropyl alcohol/organofunctional silane solution (ISO) was evaluated in 4 operating rooms after terminal cleaning. Adenosine triphosphate bioluminescence documented a significant difference (P < .048) in surface bioburden on IOS-treated surfaces versus controls. RODAC plate cultures revealed a significant (P < .001) reduction in microbial contamination on IOS-treated surfaces compared with controls. Further studies are warranted to validate the persistent disinfectant activity of ISO within selective health care settings.

Antimicrobial activity of ceftaroline and other anti-infective agents against microbial pathogens recovered from the surgical intensive care patient population: a prevalence analysis

BACKGROUND

Ceftaroline is a new parenteral cephalosporin agent with excellent activity against methicillin-sensitive (MSSA) and resistant strains of Staphylococcus aureus (MRSA). Critically ill surgical patients are susceptible to infection, often by multi-drug-resistant pathogens. The activity of ceftaroline against such pathogens has not been described.

METHODS

Three hundred thirty-five consecutive microbial isolates were collected from surgical wounds or abscesses, respiratory, urine, and blood cultures from patients in the surgical intensive care unit (SICU) of a major tertiary medical center. Using Clinical and Laboratory Standards Institute (CLSI) standard methodology and published breakpoints, all aerobic, facultative anaerobic isolates were tested against ceftaroline and selected comparative antimicrobial agents.

RESULTS

All staphylococcal isolates were susceptible to ceftaroline at a breakpoint of ≤1.0 mcg/mL. In addition, ceftaroline exhibited excellent activity against all streptococcal clinical isolates and non-ESBL-producing strains of Enterobacteriaceae (93.5%) recovered from SICU patients. Ceftaroline was inactive against ESBL-producing Enterobacteriaceae, Pseudomonas aeruginosa, vancomycin-resistant enterococci, and selective gram-negative anaerobic bacteria.

CONCLUSIONS

At present, ceftaroline is the only cephalosporin agent that is active against community and healthcare-associated MRSA. Further studies are needed to validate the benefit of this novel broad-spectrum anti-infective agent for the treatment of susceptible serious infections in the SICU patient population.

Carotid endarterectomy national trends over a decade: does sex matter?

BACKGROUND

The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease.

METHODS

This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition.

RESULTS

Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97).

CONCLUSIONS

In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Management of carotid stenosis in women

The management of carotid stenosis in women remains a topic of controversy. In this review article, we aimed to define carotid disease burden in women, review outcomes of carotid endarterectomy and carotid artery stenting in women, discuss differences in practice patterns based on sex, and provide guidelines for management of women with carotid stenosis. Symptomatic women with high-grade stenosis derive benefit from carotid endarterectomy, although they have different risk profiles than men and are often not taking appropriate medical therapy. Women with asymptomatic carotid artery stenosis have less stroke risk reduction with CEA than their male counterparts; therefore, they should be screened for other treatable risk factors for stroke, with the institution of lifestyle changes and the appropriate medical therapy. After medical optimization, the decision to proceed with CEA in asymptomatic women must be made by carefully assessing that the benefits of stroke risk reduction outweigh perioperative risks.

Ruptured mycotic infrapopliteal aneurysm

Mycotic aneurysms involving infrapopliteal arteries are rare. Ruptured infrapopliteal aneurysms are particularly uncommon and represent a surgical or endovascular emergency. We describe a case of 51-year-old male who presented with a 12-cm ruptured aneurysm of the tibioperoneal trunk 5 years after an episode of bacterial endocarditis. Our surgical approach included using extremity exsanguination and tourniquet to control hemorrhage during aneurysm ligation, followed by successful arterial reconstruction. Review of the English literature suggests that this is the largest ruptured infrapopliteal aneurysm reported.

A unique hybrid approach to the treatment of an aberrant right subclavian artery aneurysm

Aberrant right subclavian artery (ARSA) is an uncommon congenital anomaly that often becomes aneurysmal. The ARSAs are often asymptomatic but aneurysms arising in this location are potentially lethal. Due to the high morbidity and mortality rates associated with the traditional open repair methods, less invasive endovascular methods are becoming more popular. This is a case describing a unique hybrid repair of an aneurysmal ARSA in an asymptomatic male.

Evaluation of an antimicrobial surgical glove to inactivate live human immunodeficiency virus following simulated glove puncture

BACKGROUND

Percutaneous injuries associated with cutting instruments, needles, and other sharps (eg, metallic meshes, bone fragments, etc) occur commonly during surgical procedures, exposing members of surgical teams to the risk for contamination by blood-borne pathogens. This study evaluated the efficacy of an innovative integrated antimicrobial glove to reduce transmission of the human immunodeficiency virus (HIV) following a simulated surgical-glove puncture injury.

METHODS

A pneumatically activated puncturing apparatus was used in a surgical-glove perforation model to evaluate the passage of live HIV-1 virus transferred via a contaminated blood-laden needle, using a reference (standard double-layer glove) and an antimicrobial benzalkonium chloride (BKC) surgical glove. The study used 2 experimental designs. In method A, 10 replicates were used in 2 cycles to compare the mean viral load following passage through standard and antimicrobial gloves. In method B, 10 replicates were pooled into 3 aliquots and were used to assess viral passage though standard and antimicrobial test gloves. In both methods, viral viability was assessed by observing the cytopathic effects in human lymphocytic C8166 T-cell tissue culture. Concurrent viral and cell culture viability controls were run in parallel with the experiment's studies.

RESULTS

All controls involving tissue culture and viral viability were performed according to study design. Mean HIV viral loads (log(10)TCID(50)) were significantly reduced (P < .01) following passage through the BKC surgical glove compared to passage through the nonantimicrobial glove. The reduction (log reduction and percent viral reduction) of the HIV virus ranged from 1.96 to 2.4 and from 98.9% to 99.6%, respectively, following simulated surgical-glove perforation.

CONCLUSION

Sharps injuries in the operating room pose a significant occupational risk for surgical practitioners. The findings of this study suggest that an innovative antimicrobial glove was effective at significantly (P < .01) reducing the risk for blood-borne virus transfer in a model of simulated glove perforation.

Does the surgical clerkship meet the needs of practicing primary care physicians?

INTRODUCTION

A substantial amount of medical students enter primary care (PC) specialty careers. With the interest in reforming the curriculum to align the needs of our students to practice in their chosen specialties, an evaluation of our current surgical clerkship was done with the needs of PC practitioners in mind. We explored the needs of selected PC physicians in Wisconsin in relationship to the surgical clerkship curriculum.

METHODS

A survey was mailed to 186 PC physicians practicing in Wisconsin. Included in this group were internal medicine, family medicine, and pediatric physicians. One follow-up mailing and an e-mail were sent to all non-respondents. Respondents rated the importance of 10 curricular areas, including the specialties of general, orthopaedic, plastic, transplant, vascular, cardiothoracic, and pediatric surgery, as well as otolaryngology, neurosurgery, and urology. Respondents also rated the importance of exposure to 24 surgical diagnoses and identified office procedures important to PC physicians.

RESULTS

A total of 84 PC physicians responded to the survey. The highest-ranked curricular areas were general surgery, orthopaedic surgery, and otolaryngology. The 5 diagnoses that received the highest ranking from the PC physicians surveyed were abdominal pain, gastrointestinal bleeding, gastroesophageal reflux disease (GERD), biliary tract/gallbladder disorders, and breast disease, all of which are included in the general surgery curriculum. The 5 most common office procedures important to PC physicians were suturing, local anesthetic administration, dressing/wound management, wound debridement, and insertion of intravenous cannula.

CONCLUSIONS

Our survey confirmed the importance of core knowledge of general surgery and common general surgical disease processes to PC physicians. The need for additional exposure to otolaryngology and orthopaedic surgery was identified, as was as the importance of basic procedures. This information may be valuable to students interested in PC and inform the surgical clerkship curriculum in order to optimally prepare students for their chosen careers.

Molecular evidence for transplacental transmission of Theileria equi from carrier mares to their apparently healthy foals

The intra-erythrocytic parasite Theileria equi is one of two tick-transmitted causative agents of equine piroplasmosis. Piroplasms of T. equi can be transmitted across the equine placenta and once a horse is infected, it appears to remain a lifelong carrier, since anti-theilerial drugs suppress but do not eliminate the parasite. Carrier mares may transmit the organism to their offspring and this may result in abortion or neonatal piroplasmosis, but observations by some researchers suggest that foals may be born as carriers yet remain apparently healthy. Using a T. equi-specific oligonucleotide probe, we have determined that transplacental transmission occurs early in equine foetal development and that carrier mares may give birth to healthy carrier foals. Investigation of parasite levels and the effect of maternal colostrum on the newborn suggests that colostral T. equi antibody may act to suppress parasitaemia in the newborn, reducing the incidence of clinical neonatal piroplasmosis.

Pediatric vascular injuries: patterns of injury, morbidity, and mortality

PURPOSE

The purpose of this study was to identify the patterns of injury and associated morbidity/mortality related to pediatric vascular trauma.

METHODS

A retrospective review of children and adolescents treated between 1993 and 2005 was performed. Patients were identified by International Classification of Diseases, Ninth Revision codes within an institutional pediatric trauma registry.

RESULTS

One hundred seventy-six patients with vascular injury were identified. Those with injuries isolated to the digits and unspecified vessels were excluded (n = 73). The remaining 103 patients were evaluable and are the basis for subsequent comparisons. Seventy-four percent of injuries occurred in male patients. The average age of the male patients was 11.3 years and that of the female patients was 9.1 years (range, 1-18 years; overall, 10.7 years). Penetrating wounds caused 68% of the injuries, followed by blunt trauma (31%) and burns (0.97%). Anatomical locations of injury included the head/neck (19.4%), torso (13.5%), and extremities (67%). Amputation was required in 11 (10.7%) patients. The average hospital length of stay of the patients was 12.1 days (range, 1-155 days). The overall mortality was 9.7%. Nonoperative management was given to 9.7% of the patients; one death caused by carotid injury occurred. Overall, 24 patients underwent arteriography, with 1 patient receiving definitive treatment in interventional radiology. Of the 103 patients, 29.1% were managed by pediatric surgeons, 38.8% were managed by extremity specialists, 17% were managed by vascular surgeons, 5.8% were managed by neurosurgeons, and 9.3% were managed by others.

CONCLUSIONS

Despite the available multidisciplinary diagnostic and treatment modalities at tertiary care pediatric trauma centers, traumatic vascular injuries in children and adolescents are associated with significant morbidity and mortality in contemporary surgical practice.

Impact of selective antimicrobial agents on staphylococcal adherence to biomedical devices

BACKGROUND

Infection of intravascular or implanted biomedical devices often involves biofilm-forming staphylococci that are recalcitrant to antimicrobial therapy. The present study investigated the activity of 6 antimicrobial agents against biofilm-forming and non-biofilm-forming strains of staphylococci adherent to the surface of selected biomedical devices.

METHODS

Five clinical staphylococcal strains were selected for study in (1) antibiotic-lock model (ALM) and (b) vascular graft model (Dacron and expanded polytetrafluoroethylene [ePFTE]) devices. Test strains were inoculated for 30 minutes to stabilize microbial adherence and then exposed to antibiotic; the impact on bacterial adherence was assessed at 1, 2, 4, 7, and 10 days.

RESULTS

Regarding ALM, daptomycin and rifampin were effective at eradicating staphylococcal adherence by day 4 (P<.01); linezolid and gentamicin by day 7 (P<.01); vancomycin by day 7; and ceftriaxone failed to eradicate staphylococcal adherence in 4 of 5 strains by day 10. Regarding ePTFE, daptomycin and linezolid eradicated staphylococcal adherence by day 2 (P<.01); rifampin by day 4 (P<.01); vancomycin and gentamicin by day 7 (P<.01); and ceftriaxone failed to eliminate staphylococcal adherence in 3 of 5 strains by day 10. Regarding Dacron, daptomycin and rifampin eradicated adherent strains by day 4 (P<.01); linezolid by day 7 (P<.01), and vancomycin, gentamicin, and ceftriaxone decreased staphylococcal adherence by 90%, 95%, and 78%, respectively, by day 10.

COMMENTS

Daptomycin, rifampin, and linezolid demonstrated greater efficacy and speed in eradicating microbial adherence of staphylococcal isolates from selected devices compared with vancomycin, gentamicin, or ceftriaxone (P<.01). Further studies are warranted, however, to validate the clinical efficacy of daptomycin and linezolid in the treatment of biomedical device-associated infections.

Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination?

BACKGROUND

Surgical site infections are associated with severe morbidity and mortality. The role of surgical sutures in the etiology of surgical site infection has been the objective of discussion for decades. This study used a standardized in vitro microbiologic model to assess bacterial adherence and the antibacterial activity of a triclosan-coated polyglactin 910 (braided) suture against selected Gram-positive and Gram-negative clinical isolates that may infect surgical wounds.

STUDY DESIGN

Standardized cultures (2.0 log(10) colony forming units/mL and 5.0 log(10) colony forming units/mL of three clinical strains, Staphyllococcus aureus (methicillin-resistant S aureus [MRSA]), S epidermidis (biofilm-positive) and Escherichia coli (extended-spectrum beta-lactamase [ESBL]-producer) were inoculated to triclosan-coated and noncoated polyglactin 910 sutures to evaluate comparative adherence of bacterial isolates to the antibacterial coated and noncoated surgical sutures; to assess the impact of serum proteins (bovine serum albumin) on antibacterial activity of triclosan-coated suture; and to document the duration of antibacterial activity of the triclosan-coated material. Selected suture samples were prepared for scanning electron microscopy to demonstrate bacterial adherence.

RESULTS

Substantial (p < 0.01) reductions in both Gram-positive and Gram-negative bacterial adherence were observed on triclosan-coated sutures compared with noncoated material. Pretreatment of surgical sutures with 20% BSA did not diminish antibacterial activity of the triclosan-coated braided device compared with noncoated suture (p < 0.01), and antibacterial activity was documented to persist for at least 96 hours compared with controls (p < 0.01).

CONCLUSIONS

The in vitro model demonstrated a considerable reduction (p < 0.01) in Gram-positive and Gram-negative bacterial adherence to a triclosan-coated braided suture, which was associated with decreased microbial viability (p < 0.001). Because bacterial contamination of suture material within a surgical wound may increase the virulence of a surgical site infection, treating the suture with triclosan provides an effective strategy for reducing perioperative surgical morbidity.

Treatment of neuroendocrine cancer metastatic to the liver: the role of ablative techniques

Carcinoid tumors and islet cell neoplasms are neuroendocrine neoplasms with indolent patterns of growth and association with bizarre hormone syndromes. These tumors behave in a relatively protracted and predictable manner, which allows for multiple therapeutic options. Even in the presence of hepatic metastases, the standard of treatment for neuroendocrine malignancy is surgery, either with curative intent or for tumor cytoreduction, i.e., resection of 90% or more of the tumor volume. Image-guided ablation, as either an adjunct to surgery or a primary treatment modality, can be used to treat neuroendocrine cancer metastatic to the liver. Image-guided ablative techniques, including radiofrequency ablation, alcohol injection, and cryoablation, can be used in selected patients to debulk hepatic tumors and improve patient symptoms. Although long-term follow-up data are not available, the surgical literature indicates that significant ablative debulking may improve patient survival. In this review, we discuss metastatic neuroendocrine disease and its treatment options, especially image-guided ablative techniques.

Molecular epidemiology of microbial contamination in the operating room environment: Is there a risk for infection?

BACKGROUND

Modern operating rooms are considered to be aseptic environments. The use of surgical mask, frequent air exchanges, and architectural barriers are used to reduce airborne microbial populations. Breaks in surgical technique, host contamination, or hematogenous seeding are suggested as causal factors in these infections. This study implicates contamination of the operating room air as an additional etiology of infection.

METHODS

To investigate the potential sources of perioperative contamination, an innovative in situ air-sampling analysis was conducted during an 18-month period involving 70 separate vascular surgical procedures. Air-sample cultures were obtained from multiple points within the operating room, ranging from 0.5 to 4 m from the surgical wound. Selected microbial clonality was determined by pulse-field gel electrophoresis. In a separate series of studies microbial nasopharyngeal shedding was evaluated under controlled environmental conditions in the presence and absence of a surgical mask.

RESULTS

Coagulase-negative staphylococci were recovered from 86% of air samples, 51% from within 0.5 m of the surgical wound, whereas Staphylococcus aureus was recovered from 64% of air samples, 39% within 0.5 m from the wound. Anterior nares swabs were obtained from 11 members of the vascular team, clonality was observed between 8 strains of S epidermidis, and 2 strains of S aureus were recovered from selected team members and air-samples collected throughout the operating room environment. Miscellaneous Gram-negative isolates were recovered less frequently (<33%); however, 7 isolates expressed multiple patterns of antimicrobial resistance. The traditional surgical mask demonstrated limited effectiveness at curtailing microbial shedding, especially during symptomatic periods of rhinorrhea.

CONCLUSIONS

Gram-positive staphylococcal isolates were frequently isolated from air samples obtained throughout the operating room, including areas adjacent to the operative field. Nasopharyngeal shedding from person participating in the operation was identified as the source of many of these airborne contaminants. Failure of the traditional surgical mask to prevent microbial shedding is likely associated with an increased risk of perioperative contamination of biomedical implants, especially in procedures lasting longer than 90 minutes.

Comparative in vitro antimicrobial activity of a novel quinolone, garenoxacin, against aerobic and anaerobic microbial isolates recovered from general, vascular, cardiothoracic and otolaryngologic surgical patients

OBJECTIVES

The aim of the study was to analyse the susceptibility of unique and non-duplicate aerobic and anaerobic isolates from surgical patients to a novel des-F(6)-quinolone (garenoxacin) and other selected antimicrobial agents.

METHODS

Eleven hundred and eighty-five aerobic and anaerobic isolates from general, vascular, cardiothoracic and otolaryngologic surgical patients were tested for susceptibility to garenoxacin and seven other antibiotics (ciprofloxacin, moxifloxacin, levofloxacin, piperacillin/tazobactam, imipenem, clindamycin and metronidazole) using the referenced microbroth and agar-dilution method.

RESULTS

Garenoxacin exhibited greater antimicrobial activity than comparator quinolones such as ciprofloxacin, levofloxacin and other antimicrobials when tested against selected gram-positive organisms. The in vitro aerobic and anaerobic activity of garenoxacin was similar to that of moxifloxacin. All fluoroquinolones tested were effective against most gram-negative facultative anaerobes including Escherichia coli. Garenoxacin and moxifloxacin demonstrated similar in vitro antimicrobial activity against selected anaerobic gram-positive and gram-negative anaerobic bacteria such as members of the Bacteroides fragilis group. Overall, the in vitro activity of the advanced spectrum quinolones against anaerobic surgical isolates compared favourably with selected comparator agents, metronidazole, imipenem and piperacillin/tazobactam.

CONCLUSIONS

These findings suggest that 82.4% of aerobic surgical isolates were susceptible to a concentration of garenoxacin < or = 1.0 mg/L, whereas 84.5% of the anaerobic isolates were susceptible to a garenoxacin concentration < or = 1.0 mg/L. Garenoxacin may be a valuable surgical anti-infective for treatment of serious head and neck, soft tissue, intra-abdominal and diabetic foot infections.