Introduction.
As a result of laser imaging studies in an ultraclean theatre we concluded that obstructions to horizontal airflow at the periphery might produce areas of high particulate residence times. High residence times may allow a higher proportion of infected particles to land. We decided to investigate this effect by placing settle plates in defined positions on instrument trays during surgery. In an initial study contamination was 0.25 colonies/plate/hour. When the surgeon, assistant and scrub person all used a body exhaust system the contamination rate was 0.04 colonies/plate/hour. We then organised the instrument tables with two large tables orientated so that the scrub person did not have to stand between the airflow and the table. We placed plates on both trays with the locations recorded. With the instrument trolleys in optimised positions the contamination rate remained consistently at 0.04 colonies/plate/hour. An animation was produced showing how the bacterial colonies appeared over 18 hours of surgery. The majority of the contamination occurred on the surgeons’ side trolley at the opposite end of the trolley to the surgeon. Ultraclean enclosures in the UK are specified by HTM03-01, which sets a standard of <10 cfu/cubic meter measured by active air sampling. The measurement does not however take place during surgery, as it is very difficult to perform air sampling during surgery. There is a reasonable correlation between air contamination and settle plates so they are a viable method for during surgery monitoring. In a modern operating enclosure, using body exhausts, our contamination rate compares favourably to the fourth phase of Charnley's classic study in which he used 300 air changes/hour in the prototype closure. The rate compares favourably to the multi-centre Italian GISIO-ISChIA study. The contamination rate achieved could form a basis for comparative audits based on realistic during surgery monitoring.
Surgeons working in orthopaedic operating theatres are exposed to significant noise pollution due to the use of powered instruments. This may carry a risk of noise-induced hearing loss (NIHL). This study was designed to quantify the noise exposure experienced by orthopaedic surgeons and establish whether this breaches occupational health guidelines for workplace noise exposure. A sound dosimeter was worn by the operating surgeon during 3 total hip replacements and 2 total knee replacements. A timed record of the procedures was kept concurrently. Noise levels experienced during each part of the procedure were measured and total noise exposures calculated. Quantified noise exposures were compared with occupational health guidelines. Noise exposure in total hip replacement averaged 4.5% (1.52–6.45%) of the allowed daily dose (average duration 77.28 min). Total knee replacement exposure was 5.74% (4.09–7.39%) of allowed exposure (average duration 69.76min). Maximum sound levels approached, but did not exceed recommended limits of 110 dBA (108.3dBA in total hip replacement and 107.6dBA in total knee replacement). Transient peak sound levels exceeded occupational health maximum limits of 140dB on multiple occasions during surgery. Overall total noise dose during orthopaedic surgery was acceptable, however orthopaedic surgeons experience brief periods of noise exposure in excess of legislated guidelines. This constitutes a noise hazard and carries a significant, but unquantified risk for NIHL.
Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure.
The image intensifier is an essential part of orthopaedic trauma surgery. The Image Intensifier can move in a number of planes and has to be positioned accurately. Frustration arises in the surgeon, the radiographer and the rest of the theatre staff when the image intensifier is moved in the wrong direction and there are also increased radiation hazards to all involved if unnecessary x-rays are taken due to incorrect positioning. Communication between the surgeon and the radiographer lies at the heart of safe practice. A questionnaire was designed and circulated to all the radiographers using the image intensifier and to orthopaedic surgeons including consultants, SpRs in London southwest deanery and SHOs of St George’s Hospital, London. They were then asked to write descriptors on a diagram illustrating the major movements of the image intensifier (Vertically up/down, to the patients left/right and head/feet). The questionnaires were completed by 32 radiographers and 48 surgeons (8 consultants, 33 registrars and 7 SHOs). There was very little consensus either within or between the groups as to what command should be used for which direction. A set of directions was agreed upon and put on image intensifier machine. When used these produced a significant reduction in misunderstood commands Confusion abounds when directing the Image Intensifier. When a set of directions can be agreed upon stress reduces and satisfaction improves although it is difficult to measure the reduction in radiation exposure.
Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in a temporary operating theatre. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates. A total of 1233 primary hip and knee arthroplasties were performed between August 2012 and June 2013. 44% were performed in temporary theatres. The two groups were matched for age, sex, BMI and ASA grade. The deep infection rate for standard operating theatres was 0/684 (0%); for temporary theatres it was 8/539 (1.5%); p=0.001. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty.
For patients who had sustained a subcapital fracture (n=117), 21% (P<
0.05) of those who had been treated with cannulated screws required further surgery compared with 2–14% who had the other types of surgery.
347 operations (78%) were of a non-emergency nature and 96 carried out as emergencies (22%). Of the 111 military patients operated on, 63 were from the UK, 25 were Dutch, 16 Canadian and the rest from other countries. The vast majority of orthopaedic procedures performed were of a minor nature, such as incision and drainage, wound debridement and tendon repair. The general surgical procedures consisted largely of elective surgery in the local civilian population. During my deployment of three months, from November 2002 - January 2003, I carried out 11 operative procedures on 9 patients, 6 of these patients were civilian and 3 military. During the same period, 23 general surgical procedures were performed.
To investigate the effect of lab-based simulator training, on the ability of surgical trainees to perform diagnostic knee arthroscopy. 20 orthopaedic SHOs with minimal arthroscopic experience were randomised to 2 groups. 10 received a fixed protocol of simulator based arthroscopic skills training using a bench-top knee model. Learning curves were clearly demonstrated using motion analysis equipment to monitor performance. All 20 then spent an operating list with a blinded consultant trainer. They received instruction and demonstration of diagnostic knee arthroscopy before performing the procedure independently. Their performance was assessed using the intra-operative section of the Orthopaedic Competence Assessment Project (OCAP) procedure based assessment (PBA) protocol for diagnostic arthroscopy. Performance was further quantified with a ten point global rating assessment scale.Objective
Method
To assess outcomes of manipulating upper extremity fractures with conscious sedation compared with formal reduction and casting in theatre under general anaesthesia and image intensifier control. Prospective six month period all patients presenting to the Emergency Department with a both bone forearm or distal radial fracture that was deemed suitable for closed reduction and casting where included in the study. All fractures deemed to require instrumentation were excluded.Purpose
Method
In patients with hand sepsis does bedside debridement compared to operating theatre debridement have similar clinical outcomes, hospital cost and time to discharge in a District Hospital setting in South Africa? A case series of 130 adult patients presenting to a district level orthopaedic unit over 1 year with hand sepsis requiring debridement. All included patients were debrided at the bedside (i.e. the emergency room, ward, OPD) under wrist or digital block. Patients excluded from the study included patients with necrotising soft tissue infections that required debridement in theatre. A cost analysis was done based on operating theatre (OT) costs saved as defined by Samuel1 et al. If an average theatre time of 45 min is taken then the cost saved per patient is approximately R1500 and approximately R300000 for the patients included in the case series. This excludes ward and other hospital costs related to a longer hospital admission. The mean time to discharge for the included patients was 24 hours. This study suggests that bedside debridement can be a viable and cost effective option for selected cases of hand sepsis that can avoid the high cost and time associated with operating theatre debridement with similar outcomes. This has implications for the future treatment of hand sepsis in resource constrained settings were operating theatre time is not only very expensive but also very scarce.
The critical relationship between airborne microbiological contamination in an operating theatre and surgical site infection (SSI) is well known. The aim of this annotation is to explain the scientific basis of using settle plates to audit the quality of air, and to provide information about the practicalities of using them for the purposes of clinical audit. The microbiological quality of the air in most guidance is defined by volumetric sampling, but this method is difficult for surgical departments to use on a routine basis. Settle plate sampling, which mimics the mechanism of deposition of airborne microbes onto open wounds and sterile instruments, is a good alternative method of assessing the quality of the air. Current practice is not to sample the air in an operating theatre during surgery, but to rely on testing the engineering systems which deliver the clean air. This is, however, not good practice and microbiological testing should be carried out routinely during operations as part of clinical audit. Cite this article:
Aims. The aims of this study were to estimate the cost of surgical
treatment of fractures of the proximal humerus using a micro-costing
methodology, contrast this cost with the national reimbursement
tariff and establish the major determinants of cost. Methods. A detailed inpatient treatment pathway was constructed using
semi-structured interviews with 32 members of hospital staff. Its
content validity was established through a Delphi panel evaluation.
Costs were calculated using time-driven activity-based costing (TDABC)
and sensitivity analysis was performed to evaluate the determinants
of cost. Results. The mean cost of the different surgical treatments was estimated
to be £3282. Although this represented a profit of £1138 against
the national tariff, hemiarthroplasty as a treatment choice resulted
in a net loss of £952. Choice of implant and theatre staffing were
the largest cost drivers.
We conducted a randomized controlled trial (RCT) to investigate if iodine impregnated incision drapes (IIID) increases bacterial recolonization rates compared to no drape use under conditions of simulated total knee arthroplasty (TKA) surgery. Background: To prevent surgical site infection (SSI), one of the important issues is managing the patient´s own skin flora. Many prophylactic initiatives have been suggested, including the use of IIID. IIID has been debated for many years and was deemed ineffective in preventing SSI in a recent systematic review [1], while some evidence suggests a potential increase in postoperative infection risk, as a result of IIID use [2]. IIID is sparsely investigated in orthopaedic surgery. An increase in the number of viable bacteria in the surgical field of an arthroplasty operation has a potential to increase the risk of SSI in an otherwise elective and clean procedure [3]. 20 patients scheduled for TKA were recruited. Each patient had one knee randomized for draping with IIID [4] while the contralateral knee was left bare, thus the patients acted as their own controls.
International and national predictions from the late 1990s warned of alarming increases in hip fracture incidence due to an ageing population globally. Our study aimed to describe contemporary, population-based longitudinal trends in outcomes and epidemiology of hip fracture patients in a tertiary referral trauma centre. A retrospective review was performed of all patients aged 65 years and over with a diagnosis of fractured neck of femur (AO classification 31 group A and B) admitted to the John Hunter Hospital, Newcastle, New South Wales between 1st January 2002 and 30th December 2009. Datawas collated and cross referenced from several databases (Prospective Long Bone Fracture Database,
Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours. The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium. The second case report is of a soldier who sustained multiple injuries including open fractures of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in the jungle. After immediate debridement locally he was transferred to the UK. On arrival he was found to be septic and with ARDS, requiring ITU treatment. One week later he underwent debridement and stabilisation of his thumb injury with an external fixator. This got infected and he went on to develop a non-union. He needed multiple visits to the
Extensor Pollicis Longus (EPL) rupture occurs in 0.2 – 3% of fractures of the distal radius. The underlying mechanism is unknown. This study prospectively evaluates EPL and surrounding structures using high-resolution ultrasound (US) in patients with distal radius fracture 6 weeks after injury and correlates the findings with initial radiographic measurements. US can assess tendon size, echogenicity and peak velocity, haematoma depth and thickness of the extensor retinaculum and tendon sheath. The normal wrist was examined as a control. Results: 58 patients with mean age 54 yrs (39 female, 19 male), 28/58 underwent manipulation in the Emergency Department and 11/58 went to the
Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation. Cite this article:
As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre.Aims
Methods