Guidelines for improvement of the procedural aspects of devices and surgical instruments in the operating theatre

Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments.

Optimisation of perioperative procedural factors to reduce the risk of surgical site infection in patients undergoing surgery: a systematic review

Surgical site infections (SSI) are the leading cause of hospital readmission after surgical procedures with significant impact on post-operative morbidity and mortality. Modifiable risk factors for SSI include procedural aspects, which include the possibility of instrument contamination, the duration of the operation, the number of people present and the traffic in the room and the ventilation system of the operating theatre.The aim of this systematic review was to provide literature evidence on the relationship between features of surgical procedure sets and the frequency of SSI in patients undergoing surgical treatment, and to analyse how time frames of perioperative processes and operating theatre traffic vary in relation to the features of the procedure sets use, in order tooptimise infection control in OT. The results of the systematic review brought to light observational studies that can be divided into two categories: evidence of purely clinical significance and evidence of mainly organisational, managerial and financial significance. These two systems are largely interconnected, and reciprocally influence each other. The decision to use disposable devices and instruments has been accompanied by a lower incidence in surgical site infections and surgical revisions for remediation. A concomitant reduction in post-operative functional recovery time has also been observed. Also, the rationalisation of traditional surgical sets has also been observed in conjunction with outcomes of clinical significance.

Influence of sex and gender on the management of late-stage knee osteoarthritis

PURPOSE

The exact nature of sex and gender differences in knee osteoarthritis (OA) among patient candidates for total knee arthroplasty (TKA) remains unclear and requires better elucidation to guide clinical practice. The purpose of this investigation was to survey physician practices and perceptions about the influence of sex and gender on knee OA presentation, care, and outcomes after TKA.

METHODS

The survey questions were elaborated by a multidisciplinary scientific board composed of 1 pain specialist, 4 orthopedic specialists, 2 physiatrists, and 1 expert in gender medicine. The survey included 5 demographic questions and 20 topic questions. Eligible physician respondents were those who treat patients during all phases of care (pain specialists, orthopedic specialists, and physiatrists). All survey responses were anonymized and handled via remote dispersed geographic participation.

RESULTS

Fifty-six physicians (71% male) accepted the invitation to complete the survey. In general, healthcare professionals expressed that women presented worse symptomology, higher pain intensity, and lower pain tolerance and necessitated a different pharmacological approach compared to men. Pain and orthopedic specialists were more likely to indicate sex and gender differences in knee OA than physiatrists. Physicians expressed that the absence of sex and gender-specific instruments and indications is an important limitation on available studies.

CONCLUSIONS

Healthcare professionals perceive multiple sex and gender-related differences in patients with knee OA, especially in the pre- and perioperative phases of TKA. Sex and gender bias sensitivity training for physicians can potentially improve the objectivity of care for knee OA among TKA candidates.

Baropodometry on patients after total knee arthroplasty

PURPOSE

It is well known that total knee replacement surgery decreases pain and improves function, but the effect on postural assessment needs to be studied better with the use of new technological devices. Total knee arthroplasty (TKA) improves motor coordination and stability of the knee. On the other hand, changing joint functionality can modify the balance. The aim of this trial is to record and analyze the static and dynamic baropodometric data of patients in the first few months following joint replacement. For the physiatrist, this tool can be useful to check if the rehabilitation treatment protocols and times are correct.

METHODS

We designed a prospective observation longitudinal study to assess postural stability following TKA. Between December 2014 and May 2015, sixty consecutive patients were recruited through local orthopedic physician offices and hospitals. The patients scheduled to undergo TKA were recruited and were monitored before surgery (T0) and at 1 (T1), 3 (T2) and 6 months (T3) after knee surgery. The correction of varus/valgus deviation at X-ray and the Knee Society Score were performed to verify the functional recovery. We used static and dynamic baropodometric analysis to evaluate postural assessment.

RESULTS

After surgery, there was a significant improvement in physiological alignment of knee axes (p < 0.0001) and of Knee and Function Scores (excellent, mean values 80.5 and 80.7, respectively, p < 0.0001). The static analysis showed that the center of gravity and the pressure on the foot of the operated limb were corrected toward the physiological center (p < 0.0001) and the body weight displaced to the forefeet and to the hindfeet reduced bilaterally (p < 0.0001). The type of footprint did not change. The dynamic analysis confirmed the significant normalization of the pressure on the foot of the operated limb at all follow-ups (p < 0.0001). The percentage of load was reduced on the operated limb (p = 0.0096) and speed of step, cadence and semi-step length increased (p < 0.0001).

CONCLUSION

These data show the progressive recovery of stability after TKA from the immediate postoperative to the subsequent months. The clinical and functional improvement correlated with a load redistribution between the two limbs. The baropodometry could be an excellent noninvasive method for monitoring effects of rehabilitation treatment.

Restoring the femoral offset prevent early migration of the stem in total hip arthroplasty: an EBRA-FCA study

The use of modular stems is still debated and controversial. Some authors have highlighted a number of disadvantages of modular prostheses including high costs, the tendency to fracture, the fretting and corrosion and the increased production of debris. Other authors have emphasized several advantages to adapt the prosthesis to the morphometric differences of patients, to allow better accuracy in restoring the anatomy and biomechanics of hip joint. The advantages of the modular devices appear to be more evident in patients with developmental dysplasia of the hip (DDH). In our study we compared 96 patients, operated for arthritis of the hip with 55 modular neck prostheses (PROFEMUR®, Wright® Arlington, Tennesse, USA) and 41 standard femoral stems (SYMAX®, Striker® Kalamazoo, Michigan, USA). The precision of restoring the natural offset during surgery was correlated with the clinical outcome and the radiological early migration of each stem measured using the computer-assisted EBRA-FCA method. The average preoperative HHS (Harris Hip Score) was 44 (23-66); the postoperative 86.56 in the 55 patients operated with modular prostheses and 81.70 in the 41 patients with monoblock stem. The worst HH Scores were seen in patients in whom the offset was not restored properly. On the contrary, the best scores have been reached in patients in which that value is closer to the “target” value (offset value of the contralateral hip). Restoring the proper offset seems to determine an appropriate tension of the abductor muscles of the hip and implies a better functioning of the joint and a better primary stability of the implant, with less early migration. This has to be a primary objective of THA surgery.

PAIN MANAGEMENT AFTER TOTAL KNEE ARTHROPLASTY: THE GOOD, THE BAD AND THE UGLY

Improvement in pain management after knee replacement surgery has made progress in the last years, improving the results of this type of operation. Among these techniques, multimodal have shown the best results. In this study we try to compare the results of a combination of intravenous analgesia (IA), oral controlled analgesia (OCA) and periarticular injection (PAI) with our traditional protocol consisting in intravenous analgesia and femoral nerve block (IA/FNB). ne-hundred patients, undergoing primary unilateral total knee arthroplasty between June 2014 and June 2015 were randomized into 2 groups. Mean patient age was 69.4. The first group received the intravenous analgesia combined with continuous femoral nerve block, while the second group received the new combined protocol. We used the same technique with standard medial parapatellar approach for all patients and they all received pre-emptive analgesia and postoperative pain protocols. All patients were interviewed daily postoperatively at 3 days, at discharge and at 3 months. The 2 groups had a similar discharge period (traditional group 7.3 days, combined group 6.9 days). In both groups, the results indicated no statistical difference in regards to rest and continuous passive movement. Pain on ambulation was the only category that was statistically lower in the PAI/IA/OCA group compared to traditional group.

ASSESSING BONE MINERAL DENSITY IN ITALIAN ADULT CYSTIC FIBROSIS PATIENTS: A CROSS SECTIONAL STUDY

The purpose of this study was to assess bone mineral density in a cystic fibrosis (CF) outpatient clinic population and to investigate the relationship between BMD and forced expiratory volume in one second (FEV1), DEXA T-scores and 25-hidroxivitamin D (25-OHD) serum levels. We examined a consecutive series of 44 CF patients. Bone mass density was measured by dual-photon X-ray absorptiometry of lumbar spine and femur (total and neck) and lung function was performed in all patients. Medication data were obtained from medical records. A correlation analysis was performed to determine the relationship between BMD and forced expiratory volume in one second (FEV1), DEXA T-scores and 25-hidroxivitamin D (25-OHD) serum levels. In the results, age showed a significant inverse correlation indicating that as the age increases, bone density decreases and we concluded that most CF patients have low BMD and that there is a positive correlation with lung function and an inverse correlation with age.

Interprosthetic femoral fractures-A challenge of treatment. A systematic review of the literature

The success of prosthetic surgery has led to an increase in the percentage of the population having more than one prosthetic implant. This, combined with an increase in the average life expectancy and functional requirements for the elderly, has led to a higher incidence of periprosthetic and interprosthetic fractures. More precisely, the femoral shaft is compressed between two ipsilateral implants with most of these fractures being located on the supracondylar femoral shaft. Their treatment is not only technically demanding and challenging, but can also be associated with serious complications. Treatment must be determined and assessed according to the type of fracture, the stability of the prosthesis, the bone quality and the general condition of the patient. There is little information in the literature about this type of injury: there are several published case reports detailing unconventional solutions and the case studies presented are limited and not significant. This review aims to provide an updated and comprehensive list of diagnostic and therapeutic protocols accepted today, while recognising that these protocols are being continuously updated according to experience gained.

Relevance of orthostatic posturography for clinical evaluation of hip and knee joint arthroplasty patients

In order to verify whether orthostatic posturography (OP) can support clinical assessment of total hip (THA) and knee arthroplasty (TKA), 81 subjects with THA and 100 with TKA were recruited and compared with 59 healthy volunteers. All patients were tested one or two days prior to surgery; 42 subjects (20 THA and 22 TKA) were tested again after six months, and 34 (14 THA and 20 TKA) yet again after 12 months. OP was performed using a Kistler 9286A piezoelectric force plate and the following postural parameters (PPs) were adopted on account of their functional meaning: mean velocity and the root mean square of the distance of the centre of pressure (CoP), sway area, and 95% of the CoP power frequency. Eye condition and fatigue related to the test duration were also examined. The three most meaningful PPs were identified and a logarithmic transformation was then applied to these, as well as standardization. Almost all the PP values were higher preoperatively in the patients as compared with the healthy subjects and it was possible to detect many statistically significant differences between patients and healthy subjects. However, when examining the 181 subjects at the preoperative stage, the PPs did not show congruence with the clinical scores as well as they did during follow-up. Therefore, the use of the OP is not recommended to monitor patients undergoing THA or TKA.

Heterotopic ossification after total hip arthroplasty: our experience

Heterotopic ossification is a condition characterized by the presence of mature lamellar bone and often bone marrow in soft tissues surrounding a major joint. It represents a common complication after total hip arthroplasty (THA). The etiology and predisposing factors are not completely known, but some authors reported that the implant of a non-cemented prosthesis seems to be associated with a greater incidence of HO. Two hundred and two non-cemented total hip arthroplasties were performed between October 1997 and February 2002. The mean age was 70.2 years. The average follow-up for 181 hips included in the study was 96 months (range, 72-120 months). A standard lateral approach (Hardinge) was performed for the implant of a non-cemented femoral component and a non-cemented acetabular component. Radiographs were done before and after surgery, at 1, 4 and 12 months postop, then every year. The incidence of HO was assessed in the antero-posterior view at each interval and graded according to Brooker classification. Out of 181 implants, HO was observed in 52 hips (28,7%). Heterotopic bone was graded as class I in 32 (17.7%) hips, class II in 14 (7.73%) hips, class III in 6 (3,3%) hips and class IV in none (0%). The mean preoperative Harris hip score was 48; at the last follow-up, the mean postoperative score was preoperatively to a mean of 89 points (range, 76-97 points) in HO Hip and of 91 points (range, 78-100 points) in the other Hip. In our experience, non-cemented THA led to a higher incidence of class I and II HO according to Brooker Classification, the incidence of HO is comparable to the rates reported in recent studies about the HO finding after a non-cemented THA, the importance of clinical symptoms in the presence of HO is very low.