Prevention of surgical site infections in orthopaedic surgery: a synthesis of current recommendations

Despite adopted precautions, surgical site infection (SSI) rate in orthopaedic surgery and its consequences still remain a major problem. Worldwide, infection prevention and control in perioperative settings are considered of primary importance for every healthcare system. The management of perioperative infections carries a heavy psychological and financial burden, since patients who experience SSI have increased hospital length of stay, morbidity and mortality rates, and higher hospital costs. As the treatment of such infections is particularly difficult in the presence of an implanted biomaterial, the prevention of SSI in orthopaedic surgery represents a challenging key issue, requiring the integration of a range of measures before, during and after surgery. In fact, over the years several aspects of SSI prevention have been studied in order to identify the best SSI prevention strategies and set out appropriate clinical practices. This article will review and summarize the recent international guidelines released on this subject together with other published relevant evidence.

Static and dynamic baropodometry to evaluate patients treated by total knee replacement with a mobile meniscus

It was the purpose of this study to use static and dynamic baropodometry pre- and postsurgery in patients submitted to knee replacement with a mobile bearing. Baropodometric analysis was accompanied by clinical and subjective evaluation. Data obtained from the baropodometer revealed considerable oscillations occurring between pre- and postsurgery. Static examination showed a significant increase in the percentage of loading on the side treated that was not observed in the dynamic evaluation. An analysis of the Knee Society score showed a considerable increase in values between pre- and postsurgery similar to how the interpretation of correlations presurgery revealed statistically significant values between function and length of step, between pre- and postsurgery data for scores for function and length of step and Knee Score. The short-term results obtained are encouraging but only a long-term follow-up will be able to confirm the use of evaluating total knee replacement.

Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery † †Declaration of interest. This work was supported by AstraZeneca, Basiglio, Milano, Italy. Presented in part at the Third European Congress of Orthopaedic Anaesthesia, 31 May–2 June 2001, London, UK

BACKGROUND

As continuous wound instillation with local anaesthetic has not been evaluated after hip/knee arthroplasties, our study was designed to determine whether this technique could enhance analgesia and improve patient outcome after joint replacement surgery.

METHODS

Thirty-seven patients undergoing elective hip/knee arthroplasties under spinal block were randomly assigned to two analgesia groups. Group M received continuous i.v. infusion of morphine plus ketorolac for 24 h. Then, a multi-hole 16 G catheter was placed subcutaneously and infusion of saline was maintained for 55 h. Group R received i.v. saline. Thereafter the wound was infiltrated with a solution of ropivacaine 0.5% 40 ml, then a multi-hole 16 G catheter was placed subcutaneously and an infusion of ropivacaine 0.2% 5 ml h(-1) was maintained for 55 h. Visual analogue scale scores were assessed at rest and on passive mobilization by nurses blinded to analgesic treatment. Total plasma ropivacaine concentration was measured.

RESULTS

Group R showed a significant reduction in postoperative pain at rest and on mobilization, while rescue medication requirements were greater in Group M. Total ropivacaine plasma concentration remained below toxic concentrations and no adverse effects occurred. Length of hospital stay was shorter in Group R.

CONCLUSION

Infiltration and wound instillation with ropivacaine 0.2% is more effective in controlling postoperative pain than systemic analgesia after major joint replacement surgery.

The Italian version of the Oxford 12-item Knee Questionnaire-cross-cultural adaptation and validation

Questionnaires must be translated and adapted to suit the cultural characteristics of different countries with different languages; they then need to be validated using a standard process. This was done for the Italian version of the Oxford Knee Questionnaire (OKQ), and its reliability and validity were assessed in a cross-sectional study of 50 consecutive patients referred for gonarthrosis and whose knees were replaced. A "subsample" of 20 patients was assessed prospectively to confirm the reliability of the Italian version, and these results were then compared with other clinical studies. The Italian OKQ scale correlated well with other clinical studies and also showed good results with regard to reproducibility, consistency, and validity when compared to the other published versions of the OKQ.

Italian version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Cross-cultural adaptation and validation

An Italian version of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire has been devised and its reliability and validity have been assessed in a cross-sectional study of 108 consecutive patients with upper extremity pathologies. A sub-sample of 30 patients was used to assess re-test reliability. The principal DASH scale showed a high correlation with other patient-oriented measures and demonstrated good reproducibility, consistency and validity, which were similar to those for other languages' versions of DASH. These findings suggest that the evaluation capacities of the Italian DASH are equivalent to those of other language versions of the DASH.

Italian version of the Roland Disability Questionnaire, specific for low back pain: cross-cultural adaptation and validation

Over the last 10 years, patient-oriented evaluations using questionnaires have become an important aspect of clinical spinal outcome studies. Any questionnaire must be translated and culturally adapted in order to be used with different language groups, and the translated version must then be evaluated for reliability and validity, which are fundamental attributes of any measurement tool. The Roland Disability Questionnaire, a low back pain disease-specific tool, was submitted to translation into Italian and to cross-cultural adaptation following the Guillemin criteria. It was then validated on 70 patients (37 male and 33 female; mean age 58, range: 28-67) suffering from low back pain as assessed by clinical examination, imaging and also electromyography in cases of suspected neurological impairment. The test-retest reliability, assessed with intraclass correlation, was 0.92 and the internal consistency reached a Cronbach's alpha of 0.82. The Italian version of the Roland Disability Questionnaire satisfied the validation criteria, showing characteristics of reliability and validity similar to previously published versions translated and adapted for other countries.

Visual analog scales for interpretation of back and leg pain intensity in patients operated for degenerative lumbar spine disorders

STUDY DESIGN

A prospective observational study of visual analog scale (VAS) scores for pain in patients operated at one institution within the framework of a national registry.

OBJECTIVE

To describe the use of recording VAS for pain intensity in patients operated on for lumbar spine problems.

SUMMARY OF BACKGROUND DATA

There is no consensus regarding pain outcomes assessment in spine patients. Pain intensity, recorded on a VAS, is one of the most used measures. Still, many aspects of its interpretation are still debated or unclear.

METHODS

A total of 755 consecutive patients, mean age 50 years (range, 15-86 years), operated from 1993 to 1998 were included in the study; there were 420 males and 335 females. Diagnoses included herniated nucleus pulposus (45%), central stenosis (19%), lateral stenosis (14%), isthmic spondylolisthesis (9%), and degenerative disc disease (9%). Local pain, radiating pain, analgesic intake, and walking ability were recorded before surgery and at 4 and 12 months after surgery. The patients' opinions regarding the change in pain and satisfaction with the result were assessed separately. Correlation among variables reflecting perceived pain was sought.

RESULTS

Preoperative VAS mean values for local and radiating pain were significantly different in the five diagnostic groups. Significant but moderate correlation between different types of pain outcomes and with patient satisfaction was present in all cases.

CONCLUSIONS

Measuring pain intensity with VAS is a useful tool in describing spine patients. In the search for a standard in the evaluation of pain as an outcome, the differences between the various methods should be taken into account.

Cross-cultural adaptation of the lumbar North American Spine Society questionnaire for Italian-speaking patients with lumbar spinal disease

STUDY DESIGN

A cross-cultural adaptation and cross-sectional study of a sample of lumbar spine patients, with a subsample followed prospectively for retest reliability.

OBJECTIVES

To assess the Italian version instrument reliability and validity.

SUMMARY OF BACKGROUND DATA

The orthopaedic outcome measurements have been usually focused on objective parameters as radiograph measures or other technical aspects. However, these parameters are weakly related with outcomes that are more relevant to patients as functional status and symptoms. In the last ten years, the patient-oriented measures have become an important aspect of spinal clinical outcome evaluation. The most common instruments to assess patient perspective are self-administered questionnaires that must be validated by a widely accepted process to evaluate reliability and validity, which are fundamental for every instrumental measure.

METHODS

The North American Spine Society (NASS) questionnaire was culturally adapted for Italian-speaking people following the Guillemin criteria. The Italian version was tested on 74 consecutive patients who were referred to the authors' department and suffered from low back pain with leg irradiation. The results were compared with other validated patient-oriented measures. Forty-eight-hour retests were performed on a subsample of 45 patients.

RESULTS

The questionnaire was favorably accepted by patients. The lumbar spine pain and disability and neurogenic symptoms subscales showed a high correlation with other patient-oriented measures, as hypothesized, and it also showed good values on test-retest.

CONCLUSIONS

The questionnaire should be considered for patient health status monitoring and for clinical trials.

Patient outcomes after Harrington instrumentation for idiopathic scoliosis: a 15- to 28-year evaluation

STUDY DESIGN

A retrospective study was performed, using the Short Form-36 Health Survey and the Roland and Morris Disability Questionnaire, to investigate patient outcomes after fusion for adolescent idiopathic scoliosis using Harrington rod instrumentation.

OBJECTIVE

To evaluate health-related quality of life and low back pain in a long-term follow-up study of surgery for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The commonly accepted surgical treatment for idiopathic evolutive scoliosis is vertebral fusion. It has been suggested that this procedure may cause low back pain and a poor quality of life over the long term. Outcome measures after surgery for adolescent idiopathic scoliosis have focused mainly on objective parameters such as radiographic measures. However, this information has proved to be correlated only weakly with outcomes that are more relevant to patients, such as functional status and symptoms. Until recently, only a few long-term outcome studies have used standardized and validated patient-oriented tools to evaluate surgically treated patients with scoliosis.

METHODS

In this study, 70 patients treated with a standard Harrington technique were recontacted and evaluated by means of self-administered questionnaires (Short Form-36 Health Survey and Roland and Morris Disability, clinical examination, and radiographic analysis. Preoperative and follow-up radiographic findings were registered. Relations between radiographic and patient-oriented data were evaluated.

RESULTS

A comparison between the current sample and the Italian age-matched normative data for the Short Form-36 Health Survey showed them to have a similar pattern. Findings showed the patient-oriented outcome to be correlated inversely with the extension of vertebral fusion and the preoperative Cobb angle.

CONCLUSION

Long-term follow-up evaluation of Harrington rod fusion for adolescent idiopathic scoliosis showed no important impairment of health-related quality of life, as measured by patient-oriented evaluation.

Coxa pedis dysplasia in congenital convex pes valgus

A dissection was carried out on bilateral congenital convex pes valgus in a newborn who died of congenital visceral malformations. The main finding was a modification in the neck-body relations of the talus. Nearly all muscles showed morphologic alterations. No insertional or histologic anomalies were shown. The plantar calcaneonavicular ligament was stretched and attenuated. The alterations observed in our case affected all the anatomic structures forming and stabilizing the coxa pedis. Our case suggests that the dysplastic evolution of the talar body-neck angle halts, and the neck assumes an adducted, medially inclined and plantar-tilted angle with respect to the talar body. We propose the term "congenital dysplasia of the coxa pedis" to describe this condition, because it emphasizes the primary alteration in the morphogenesis of the talocalcaneonavicular joint.

Zanoli's procedure for overlapping fifth toe: retrospective study of 18 cases followed for 4-17 years

Digitus quintus superductus pedis (overlapping fifth toe) is a congenital deformity, often bilateral, in which the fifth toe is medially directed, rotated and hyperextended. There is no consensus regarding the best treatment. We describe our experience using Zanoli's procedure, which is a tenodesis procedure using the extensor tendon of the fifth toe. Between 1979 and 1993, we operated on 16 patients (7 bilateral, total 23 feet). 13 (10 women) patients (18 feet), with a mean age of 26 (19-40) years, were seen on follow-up. The mean follow-up time was 8 (4-17) years. Pain relief was achieved in all patients. From the surgeon's point of view, 3 toes overcorrected due to technical errors were considered unsatisfactory. All patients, however, were satisfied with the result and would advise other patients to undergo the same operation.