Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates. In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates. Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres. Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection. There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice. Cite this article: Bone Joint J 2018;100-B:1264–9

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used.

Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect.

A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures.

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: Bone Joint J 2024;106-B(9):887–891

Introduction. One method of surgical site infection prevention is lowering intraoperative environmental contamination. We sought to evaluate our hospitals operating room (OR) contamination rates and compare it to the remainder of the hospital. We tested environmental contamination in preoperative, intraoperative and postoperative settings of a total joint arthroplasty patient. Materials & Methods. 190 air settle plates composed of trypsin soy agar (TSA) were placed in 19 settings within our hospital. Locations included the OR with light and heavy traffic, with and without masks, jackets, and shoe covers, sub-sterile rooms, OR hallways, sterile equipment processing center, preoperative areas, post-anesthesia care units, orthopaedic floors, emergency department, OR locker rooms and restrooms, a standard house in the local community, and controls. The plates were incubated in 36 degrees celsius for 48 hours and colony counts were recorded. Numbers were averaged over each individual area. Results. The highest CFU was the OR locker room at 28 CFU/plate/hr. Preoperative & post anesthesia care unit holding areas were 7.4 CFU & 9.6 CFU, respectively. The main orthopaedic surgical ward had 10.0 CFU/plate/hr, while the VIP hospital ward had 17.0 CFU/plate/hr. The OR environment all had low CFUs. A live OR had slightly higher CFUs than ones without OR personnel. The OR sub-sterile room had 5.2 CFU/plate/hr, and the OR hallway had 11.2 CFU/plate/hr. The local community household measured 5.6CFU/plate/hr. Discussion. In comparison to the local community household, the OR locker room, restrooms, hospital orthopaedic wards, ED, pre-operative holding, PACU and OR hallway all had higher airborne contamination than the local household in our surrounding community. We were surprised to find some areas with high rates of contamination. Our hospital has since increased environmental cleaning and monitoring of these areas with improved effect. Based on our results, we can recommend environmental sampling as a simple, fast, inexpensive tool to monitor airborne contamination

Purpose of the study: Increasing the number of times the operating room doors open increases the number of airborne bacteria and consequently the rate of postoperative infections with sometimes disastrous results, particularly for prosthesis surgery. Material and methods: An observer counted the number of times the door to the operating room were opened during orthopaedic operations. The study was conducted in a teaching hospital (hospital A) during scoliosis surgery then repeated for a similar operation after posting dissuasive signs and delivery of information to the personnel concerning the risk of contaminating the patient. A study was then conducted for total hip arthroplasty (THA) in another teaching hospital (hospital B) and in a private clinic (hospital C). The same protocol as used in South Australia was applied for these studies. Results: The mean rate of door opening in hospital A was 0.52/min. This rate was 0.45/min (13.5% less) in the same hospital A after posting dissuasive signs on the doors and providing information to the personnel. In hospital B, the rate was 0.67/min. In hospital C, the rate was 0.42/min (i.e. 37% less). In Australia, the mean rate was 1/min in hospital A before sign posting and information delivery and 0.65 (−35%) after. In hospital B, the rate was 0.87/min and in hospital C 0.47/min (i.e. 46% less). Discussion: Nearly 50 years ago Sir John Charnley demonstrated that airborne contamination must be controlled in prosthetic orthopaedic surgery. In France airborne contamination is regulated by a series of standards (NF EN ISO 14644 established in 1999) and partially controlled during the design phase of operating rooms with the installation of laminar flow ventilation. Door opening, and particularly swinging doors, causes turbulent airflow increasing bacterial contamination. Conclusion: Circulation in the operating room should be limited to necessary organisation (prior transport of instruments and consumables, fluoroscope, nursing staff turnover, etc.) and by information and education of all participants. The presence of observers is inevitable in the operating rooms of teaching hospitals. Their entrance and exit should however be limited and their movement within the room controlled. It is also recommended to use cell phones

Background. Sterile Surgical Helmet System (SSHS) are used routinely in hip and knee arthroplasty in order to decrease the risk of infection. It protects surgeon from splash and also prevents contamination of surgical field from reverse splash by virtue of its perceived sterility. A prospective study was conducted to confirm if SSHS remain sterile throughout the procedure in Hip (THA) and Knee (TKA) Arthroplasty. We also evaluated if type of theatre had any effect on degree of contamination. Material and Methods. Visor area of 40 SSHS was swabbed at half hourly interval until the end of the procedure. Two groups of 20 each were made on the basis of theatre used for performing surgery. Group 1 (Gp1) had surgery performed in laminar flow and Group 2 (Gp2) in non-laminar flow theatre. Swabs collected were processed to compare the time dependent contamination of the SSHS and identify the organisms responsible for contamination. Results. Overall 80% (70% laminar, 90% non-laminar) of masks were contaminated by end of the procedure. There was a statistically significant difference in degree of contamination after direct inoculation while there was no statistical difference after 24 hrs of incubation. Coagulase negative Staphylococcus was the most common bacteria grown in both the groups. Conclusion. SSHS lose their sterility peroperatively due to airborne contamination, mandating prompt change of gloves in case of active contact with them to avoid the bacterial transmission into surgical wound and catastrophic joint infection

Introduction. Deep prosthetic joint infection is a major cause of morbidity. Previous work has shown that infected skin scales shed by members of staff in the operating theatre are the key source of infection. Much attention has been given to the design of ultra clean operating theatres but remarkably little attention has been given to factors controlling skin scale shedding. The aim of this study was to develop a novel method of direct visualisation and quantification of skin scales and to assess the effect of a simple skin care regimen on skin scales. Patients/Materials & Methods. Direct visualisation of the skin surface at high power is difficult due to the depth of surface contours in relation to microscope depth of field. A Zeiss stereo compound Axio-Zoom microscope was used containing a stage on which subjects’ upper or lower limbs could be comfortably placed. A reflected light source allowed direct visualisation of a magnified image of the skin surface. Real-time digital manipulation of multiple z-stacked images on a linked computer created a composite three dimensional image of the skin surface. Density of skin scales was then calculated from this image. We tested the effect of a standardised skincare regime consisting of washing, exfoliation and moisturisation on skin scale density at multiple sites and contralateral controls. Results. The z-stack images provided excellent visualisation of the skin. There was considerable variation in skin scale density between individuals. Our data demonstrated a reduction in skin scale density at a study site during each successive stage of the skin care regimen. This effect was sustained even when the regimen was performed 12 hours prior to image acquisition. There was a marked reduction in skin scale density in treated compared to untreated contralateral sites, which was maintained over a period of hours. Discussion. This study demonstrates a practical reproducible method of direct visualisation of the skin and quantification of skin scales. The method is suitable for a larger scale study of orthopaedic theatre staff during a working day and to measure the effect of the simple skin care regimen in this population. We have also conducted a pilot study in a clean room and we use surface microscopy to help study the relationship between skincare, clothing and contamination measured in CFU/cubic meter of air. Conclusion. It is hypothesised that a daily skin care regimen comprising washing, exfoliating and moisturising for operating theatre staff would be expected to reduce intraoperative skin scale shedding and consequently prosthetic joint infection rates. Regular exfoliation by surgical staff is likely to substantially reduce airborne contamination in clean air theatres

Purpose: Wound dressing is the last phase of any surgical intervention. The purpose is to isolate the surgical wound to reduce the risk of airborne contamination. In certain situations such as skin trauma, burns, acute or chronic loss of skin cover, or open fractures, wound dressings can however have a deleterious effect (maceration, adherence). Prevention of secondary infection of surgical wounds and spread of infection from septic patients is an integral part of our routine practice. We have developed a specific system useful in certain situations to isolate a septic or “at-risk” limb. Material and methods: Our system is composed of a closed 100-cm polyvinyl chloride isolator measuring 40 cm in diameter. Two “absolute” filters allow internal ventilation with a variable flow filtered-air generator. Sterile products are introduced into the isolator via a shuttle chamber. With this system, the wound can be isolated without isolating the patient. We have used this system for more than 250 patients since 1986. A dedicated chart has been used to monitor results obtained with the system since 1993. Results: The isolator was used for 258 patients, 185 men (71%), with 271 limb wounds on 227 lower limbs (83%) (63% legs and ankles). Half of the patients had open fractures associated with loss of skin cover. The clinical course was satisfactory in 75% of the patients (complete healing or complementary skin graft). The system was psychologically unacceptable for seven patients. There was only one case of a new germ isolated from a wound. Conclusion: This dressing isolator requires a significant “logistic” investment but provides considerable bacteriological safety for difficult cases

Purpose: With the growing risk of nosocomial infections, one might expect to see a reinforcement of septic isolation wards in orthopaedics and traumatology units. The question is however being revisited because of several factors. 1st: General Orthopaedics Units are practically the only hospital units caring for a minority of septic patients with often resistant germs and a majority of non-septic patients in the same setting. 2nd: The growing number of single-patient rooms procures confidence (whether justified or not). 3rd: Hygiene specialists are particularly wary of occult carriers of resistant bacteria and apply a single set of protective measures for all patients. 4th: Economic performance is given priority. Material and methods: We studied 1) the current situation in Orthopaedic units in University Hospitals in France and 2) the statistics from the Besançon University Hospital Hygiene Unit and from data in the literature. Results: 1) Interrogation of the 71 University Orthopaedics Units in France revealed that: 11 units have strict isolation wards; 40 have incomplete isolation wards; 20 make no distinction between septic and non-septic patients. 2) According to the Hygiene Unit statistics, the epidemiological load of S. aureus meti-R (SAMR), strains often implicated in orthopaedic infection, is much higher in the University Hospital polyvalent wards than in the Orthopaedic septic ward. Contamination between septic patients is low. Furthermore, hand-borne and airborne contamination are not controlled in wards other than septic wards. Data in the literature are not in agreement concerning this new trend in prevention by isolation. Discussion: a) One argument retained by all is that septic wards have an advantage in terms of efficacy and concentration of preventive measures. b) The growing workload in mixed units hinders strict application of preventive measures. c) A large number of temporary personnel (trainees, temporary employees, personnel untrained in sepsis prevention) are present in polyvalent units. d) Standardisation of preventive measures leads to an average level of prevention which lengthens the duration of care for non-septic patients and simplifies care for septic patients. e) The financial argument is impertinent compared with the consequences of contamination. Furthermore, a departmental structure would allow common use of the septic ward. Conclusion : Septic isolation wards (or a septic department) should be preserved. The orthopaedic surgeon, as a responsible actor in the fight against nosocomial infections, should in concert with the consulting hygienist, oppose purely administrative decisions

Aims

The survival of humeral hemiarthroplasties in patients with relatively intact glenoid cartilage could theoretically be extended by minimizing the associated postoperative glenoid erosion. Ceramic has gained attention as an alternative to metal as a material for hemiarthroplasties because of its superior tribological properties. The aim of this study was to assess the in vitro wear performance of ceramic and metal humeral hemiarthroplasties on natural glenoids.

The February 2024 Research Roundup³⁶⁰ looks at: If you use a surgical helmet, you should seal your gown-glove interface; The use of iodophor-impregnated drapes in patients with iodine-related allergies: a case series and review of the literature; Location of the ovaries in children and efficacy of gonadal shielding in hip and pelvis radiography; Prehospital tranexamic acid administration does not improve outcomes in severe trauma patients; Silver-coated distal femur megaprosthesis in chronic infections with severe bone loss: a multicentre case series.

Aims

The surgical helmet system (SHS) was developed to reduce the risk of periprosthetic joint infection (PJI), but the evidence is contradictory, with some studies suggesting an increased risk of PJI due to potential leakage through the glove-gown interface (GGI) caused by its positive pressure. We assumed that SHS and glove exchange had an impact on the leakage via GGI.

The contemporary practice of orthopaedic surgery requires an evidence-based approach to support all medical and surgical interventions. In this essay, the author expresses a forthright, personal and somewhat prejudiced appeal to retain the legitimacy of clinical decision making in conditions that are rare, contain multiple variables, have a solution that generally works or has an unpredictable course.

Cite this article: Bone Joint J 2014;96-B:1002–4.

We have investigated whether the use of laminar-flow theatres and space suits reduced the rate of revision for early deep infection after total hip (THR) and knee (TKR) replacement by reviewing the results of the New Zealand Joint Registry at ten years.

Of the 51 485 primary THRs and 36 826 primary TKRs analysed, laminar-flow theatres were used in 35.5% and space suits in 23.5%. For THR there was a significant increase in early infection in those procedures performed with the use of a space suit compared with those without (p < 0.0001), in those carried out in a laminar-flow theatre compared with a conventional theatre (p < 0.003) and in those undertaken in a laminar-flow theatre with a space suit (p < 0.001) when compared with conventional theatres without such a suit. The results were similar for TKR with the use of a space suit (p < 0.001), in laminar-flow theatres (p < 0.019) and when space suits were used in those theatres (p < 0.001). These findings were independent of age, disease and operating time and were unchanged when the surgeons and hospital were analysed individually.

The rate of revision for early deep infection has not been reduced by using laminar flow and space suits. Our results question the rationale for their increasing use in routine joint replacement, where the added cost to the health system seems to be unjustified.

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated.

Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.