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Persson A, Atroshi I, Tyszkiewicz T, Hailer NP, Lazarinis S, Eisler T, Brismar H, Mukka S, Kernell PJ, Mohaddes M, Sköldenberg O, Gordon M. Effect of Plasma Air Purifiers on Infection Rates in Orthopedic Surgery. NEJM EVIDENCE 2025; 4:EVIDoa2400289. [PMID: 40130977 DOI: 10.1056/evidoa2400289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2025]
Abstract
BACKGROUND Surgical site infection (SSI) following orthopedic surgery impacts patient outcomes. Airborne transmission is one potential route of infection. Despite their high cost and resource demands, modern ventilation systems have shown limited efficacy in reducing SSI rates. This trial investigated the effectiveness of a low-cost air purifier in reducing SSI rates after orthopedic surgery. METHODS In a nationwide, multicenter, double-blind, cluster-randomized crossover, placebo-controlled superiority trial, we included all patients undergoing orthopedic surgery during the trial period. The intervention group underwent surgery in operating rooms with active Novaerus NV800 air purifiers, while the control group underwent surgery in operating rooms with the same air purifiers that were inactive. The primary end point was SSI within 12 weeks post surgery, defined as a postsurgery infection marker (PSIM), a custom composite outcome based on registry codes for prescribed antibiotics, diagnoses, and surgical procedures. Logistic regression was performed to evaluate the primary outcome. RESULTS Of the 40,547 patients analyzed, 19,869 were in the intervention group and 20,678 in the control group. The PSIM rate was 9.2% in the invention group, and 9.4% in the control group, with an odds ratio of 0.98 (95% confidence interval, 0.91 to 1.05) for the intervention group. This finding remained consistent across various subgroups based on diagnoses, hospital levels, and ventilation types. CONCLUSIONS In modern operating rooms equipped with standard, midrange airflow ventilation systems, the addition of wall-mounted plasma air purifiers did not reduce the PSIM rate after orthopedic surgery. (Funded by the Swedish Research Council; grant number, 2017-00198; ClinicalTrials.gov number, NCT02695368.).
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Affiliation(s)
- Anders Persson
- Division of Orthopaedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Sweden
- Capio Ortho Center Stockholm, Löwenströmska Hospital, Stockholm
| | - Isam Atroshi
- Orthopaedics, Department of Clinical Sciences, Lund University, Sweden
- Department of Orthopedics, Hässleholm Hospital, Hässleholm, Sweden
| | - Thomas Tyszkiewicz
- Department of Orthopedics, Hässleholm-Kristianstad Hospitals, Kristianstad, Sweden
| | - Nils P Hailer
- Orthopaedics, Department of Surgical Sciences, Uppsala University Hospital, Uppsala University, Sweden
| | - Stergios Lazarinis
- Orthopaedics, Department of Surgical Sciences, Uppsala University Hospital, Uppsala University, Sweden
| | - Thomas Eisler
- Division of Orthopaedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Sweden
| | - Harald Brismar
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Sweden
| | - Sebastian Mukka
- Orthopaedics, Department of Diagnostics and Intervention, Umeå University Hospital, Umeå University, Sweden
| | | | - Maziar Mohaddes
- Orthopaedics, Department of Clinical Sciences, Lund University, Sweden
- Department of Orthopedics, Hässleholm Hospital, Hässleholm, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olof Sköldenberg
- Division of Orthopaedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Sweden
| | - Max Gordon
- Division of Orthopaedics, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Sweden
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Wellauer H, Gautier E, Rieker C, Pourzal R, Wahl P. Design features of the rotating head total hip arthroplasty by Weber-Huggler- a forgotten technical solution to reduce wear. Arch Orthop Trauma Surg 2025; 145:140. [PMID: 39849197 DOI: 10.1007/s00402-025-05768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Accepted: 01/15/2025] [Indexed: 01/25/2025]
Abstract
Total hip arthroplasty (THA) is a very successful operation. Once the problem of implant fixation was solved with the use of bone cement, the next development steps focused on improving the bearing. Weber, a Swiss surgeon, introduced the first modular heads in THA. His design improved reconstruction of the patients' anatomy using various neck lengths, eased revision as well-fixed stems could be preserved, and also reduced wear due to a cylindrical, rotating connection between the head and neck. The features and results of this exceptional design are reviewed. However, as newer material combinations greatly mitigated the problem of wear and as the dimensions of the cylindrical connection limit range of motion, it was supplanted by the nowadays well-established Morse taper connection, which also is less complex to manufacture. As Weber's design was associated with good long-term results, the technical features of this technical solution should not be forgotten.
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Affiliation(s)
- Hanna Wellauer
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Emanuel Gautier
- Department of Orthopaedic Surgery, HFR Fribourg- Cantonal Hospital, Fribourg, Switzerland
| | | | - Robin Pourzal
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, USA
| | - Peter Wahl
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland.
- Faculty of Medicine, University of Bern, Bern, Switzerland.
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Fernández-Rodríguez D, Tarabichi S, Golankiewicz K, Zappley N, Parvizi J. Operating Room Air May Harbor Pathogens: The Role of an Ultraviolet Air Filtration Unit. J Arthroplasty 2024; 39:2857-2862. [PMID: 38823518 DOI: 10.1016/j.arth.2024.05.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND One important factor for the prevention of surgical site infections is ultraclean air in the operating room (OR). Still, the direct sterilization potential of most technologies, especially in a dynamic clinical setting, is not well understood. We aimed to determine and compare the microbial presence from the inlet and outlet flow of a filtration unit with crystalline ultraviolet-C (C-UVC) light. METHODS A prospective study was conducted at a single institution, where primary total joint arthroplasty and spine surgeries were performed. The OR was fitted with a positive ventilation system. In addition, a filtration unit with a C-UVC sterilizing light was placed in the OR. The inlet and outlet air flows were swabbed simultaneously and compared. Swabs were processed for culture and next-generation sequencing. RESULTS The mean length of the surgical procedures sampled was 68 ± 13 minutes. Overall, 19 out of 200 (9.5%) swabs isolated microorganisms. Inlet air swabs were positive at a higher rate (16 versus 3%; P < .01) compared to the outlet air swabs. A wide variety of Gram-positive, Gram-negative, and anaerobic bacteria were isolated, but fungi were only recovered from inlet air swabs. The detection of microorganisms was also higher when more door openings were performed (32.5 ± 7.1 versus 27.9 ± 5.6; P < .01). CONCLUSIONS Air swabs mainly isolated microorganisms from the inlet flow to the filtration unit with a C-UVC light. The sterilizing unit counteracted factors affecting the air quality in the OR, namely door openings, surgical personnel, and tissue combustion.
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Affiliation(s)
- Diana Fernández-Rodríguez
- Rothman Institute, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; Plan de Estudios Combinados en Medicina (PECEM) MD/PhD, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Saad Tarabichi
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Krystal Golankiewicz
- Rothman Institute, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicolina Zappley
- Rothman Institute, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Tateiwa T, Masaoka T, Takahashi Y, Ishida T, Shishido T, Yamamoto K. Unveiling the dynamics of intraoperative contamination in total hip arthroplasty: the discrepancy between particulate and microbial contamination in surgical site infection risk. ARTHROPLASTY 2024; 6:49. [PMID: 39350209 PMCID: PMC11443724 DOI: 10.1186/s42836-024-00272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/22/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Surgical site infection (SSI) is a major problem following total hip arthroplasty (THA). This study investigated the impact of a standard intraoperative routine where the surgical team wears full-body exhaust suits (space suits) within a laminar airflow (LAF)-ventilated operating room (OR) on environmental contamination. Our primary objective was to identify potential modifiable intraoperative factors that could be better controlled to minimize SSI risk. METHODS We implemented an approach involving simultaneous and continuous air sampling throughout actual primary cementless THA procedures. This method concurrently monitored both airborne particle and microbial contamination levels from the time the patient entered the OR for surgery until extubation. RESULTS Airborne particulate and microbial contamination significantly increased during the first and second patient repositionings (postural changes) when the surgical team was not wearing space suits. However, their concentration exhibited inconsistent changes during the core surgical procedures, between incision and suturing, when the surgeons wore space suits. The microbial biosensor detected zero median microbes from draping to suturing. In contrast, the particle counter indicated a significant level of airborne particles during head resection and cup press-fitting, suggesting these procedures might generate more non-viable particles. CONCLUSIONS This study identified a significant portion of airborne particles during the core surgical procedures as non-viable, suggesting that monitoring solely for particle counts might not suffice to estimate SSI risk. Our findings strongly support the use of space suits for surgeons to minimize intraoperative microbial contamination within LAF-ventilated ORs. Therefore, minimizing unnecessary traffic and movement of unsterile personnel is crucial. Additionally, since our data suggest increased contamination during patient repositioning, effectively controlling contamination during the first postural change plays a key role in maintaining low microbial contamination levels throughout the surgery. The use of sterile gowns during this initial maneuver might further reduce SSIs. Further research is warranted to investigate the impact of sterile attire on SSIs.
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Affiliation(s)
- Toshiyuki Tateiwa
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Toshinori Masaoka
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yasuhito Takahashi
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
- Department of Bone and Joint Biomaterial Research, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Tsunehito Ishida
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takaaki Shishido
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kengo Yamamoto
- Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Buchanan WW, Hogan MG, Kean CA, Kean WF, Rainsford KD. Surgery of joints. Inflammopharmacology 2024; 32:45-50. [PMID: 37195498 DOI: 10.1007/s10787-023-01224-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/27/2023] [Indexed: 05/18/2023]
Abstract
Crude forms of musculoskeletal surgery have been performed through history for the treatment of deformity, pain and the horrors of battle. In more modern times Muller is credited with the first synovectomy in rheumatoid arthritis in 1884, and a Synovectomy was first performed by Richard von Volkmann (1830-1889) for joint tuberculosis. Chemical synovectomy consisting of the intra-articular injection of various agents was popular for a while but is now largely discarded. Joint resection for sepsis and tuberculosis has been documented since the early 1800s, and also joint arthrodesis, and osteotomy. Modern arthroscopic techniques have added the utility of faster intra-joint inspection and treatment while reduced surgical time exposure and often applied with the use of limb regional anaesthetic nerve blocks, to avoid general anaesthetic. Joint arthroplasty has been developed since1800s, with the use of many artificial joint components. There have been many notable pioneers of this work who are documented in this text, among them Austin T. Moore (1899-1963), George McKee (1906-1991) and Sir John Charnley (1911-1982). The success of joint arthroplasty to the hip, knee, shoulder and other joints has resulted in life-changing benefit for hundreds of arthritis and injury sufferers.
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Affiliation(s)
- W Watson Buchanan
- Department of Medicine, McMaster University, Hamilton, ON, L8N 3Z5, Canada
| | | | - Colin A Kean
- Medicine Rheumatology, Haldimand War Memorial Hospital, 400 Broad Street, Dunnville, ON, N1A 2P7, Canada
| | - Walter F Kean
- Department of Medicine, McMaster University, Hamilton, ON, L8N 3Z5, Canada.
- Medicine Rheumatology, Haldimand War Memorial Hospital, 400 Broad Street, Dunnville, ON, N1A 2P7, Canada.
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Stålfelt F, Svensson Malchau K, Björn C, Mohaddes M, Erichsen Andersson A. Can particle counting replace conventional surveillance for airborne bacterial contamination assessments? A systematic review using narrative synthesis. Am J Infect Control 2023; 51:1417-1424. [PMID: 37182760 DOI: 10.1016/j.ajic.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/08/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Bacterial airborne contamination in the operating room during surgery indicates an increased risk for surgical site infection. The conventional surveillance method for bacteria in the air is by air sampling, plating, and counting of colony-forming units (CFU). Particle counting measures particles in the air, typically in sizes of 1-20 µm, and has been suggested as an alternative to CFU measurements. The primary aim was to investigate the correlation between the number of airborne CFU and particles during surgery. The secondary aim was to explore whether different ventilation settings influence the correlation between CFU and particles. METHODS The databases Cochrane, Embase, and Medline were searched for relevant publications. Due to the heterogeneity of the data, meta-analysis was not possible and a narrative analysis was performed instead. RESULTS The review included 11 studies. Two of the studies (n = 2) reported strong correlation between particles and CFU (Rp = 0.76 and Rc = 0.74). The remaining studies observed moderate correlation (n = 3), low correlation (n = 3), or no correlation (n = 3). Based on the primary results from this study, ventilation attribution to distinguish the correlation between particles and CFU had no or little contribution. CONCLUSIONS Due to the lack of convincing evidence of correlation and lack of high-quality studies performing measurements in a standardized way, the studies could not provide the necessary evidence that show that particle counting could be used as a substitution for conventional air bacterial assessment. Further studies are warranted to strengthen the conclusion.
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Affiliation(s)
- Frans Stålfelt
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Karin Svensson Malchau
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Camilla Björn
- RISE Research Institutes of Sweden, Division Materials and Production, Methodology, Textiles and Medical Technology, Gothenburg, Sweden
| | - Maziar Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annette Erichsen Andersson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Heinke TL, Joseph A, Carroll D. Safety in Health Care: The Impact of Operating Room Design. Anesthesiol Clin 2023; 41:789-801. [PMID: 37838384 DOI: 10.1016/j.anclin.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
The science of operating room design has grown over the past 20 years due to the realization that the physical environment influences health care provider performance and patient outcomes. Medical errors occur when the normal workflow in an operating room is disrupted as providers must overcome sub-optimal conditions. All aspects of the physical environment can impact operating room flow. Studying the layout, contents, ergonomics, and environmental parameters of the operating can lead improved work conditions resulting improved patient and provider safety. At the forefront of operating room design science is the use of simulation and the evaluation of new technologies.
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Affiliation(s)
- Timothy L Heinke
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Suite 4200, MSC 240, Charleston, SC 29425, USA.
| | - Anjali Joseph
- Center for Health Facilities Design and Testing, School of Architecture, 2-141 Lee Hall, Clemson University, Clemson, SC 29631, USA
| | - David Carroll
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Suite 4200, MSC 240, Charleston, SC 29425, USA
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Gemayel A, Flikkema K, Fritz G, Blascak D. Are Intra-operative Forced Air Warming Devices a Possible Source for Contamination During Hand Surgery? Cureus 2023; 15:e46287. [PMID: 37915875 PMCID: PMC10615902 DOI: 10.7759/cureus.46287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/03/2023] Open
Abstract
Background Forced air warming (FAW) devices are routinely utilized in operating rooms for patient temperature control. However, there have been some controversy and conflicting evidence on whether they are a possible source of surgical site infections (SSIs) and contamination. Methods A total of 144 petri dishes were randomized to either a control or experimental group (72 in each group). Each trial consisted of six petri dishes in three locations (floor, table, and operative limb). Two dishes at each location were closed sequentially at one hour, two hours, and three hours. Two control and two experimental trials were performed in two separate operating suites with two different FAW devices. The petri dishes were then analyzed for growth for 48 hours. Two culture swabs from each FAW device hose were obtained and analyzed. Results None of the culture swabs analyzed showed any growth on blood or chocolate agar culture media. There was no significant difference in bacterial colony-forming units per cubic meter (CFU/m3) air between the trial and control groups in each location at one hour of exposure. At two hours of exposure, there was a significantly higher bacterial CFU/m3 air in the experimental group in the operative limb. At three hours of exposure, there was a significantly higher bacterial CFU/m3 air in the experimental group on the floor. However, overall, there was no difference in bacterial CFU/m3 air in both study groups at different times of exposure, incubation, or location. Conclusion Our study was unable to identify any statistically significant risk of contamination associated with the use of FAW devices. However, our study design was limited due to the absence of operating room staff during testing. For this reason, we recommend further research into this topic with the use of an active operating room, which includes simulated movement from the surgeon, anesthesia, scrub technician, nursing, and any other operating room staff who may be present during a real operation.
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Affiliation(s)
- Anthony Gemayel
- Orthopedic Surgery, New York University (NYU) Langone, New York, USA
| | - Kyle Flikkema
- Orthopedic Surgery, Beaumont Health, Farmington Hills, USA
| | - Germaine Fritz
- Orthopedic Surgery, Beaumont Health, Farmington Hills, USA
| | - Daniel Blascak
- Orthopedic Surgery, Beaumont Health, Farmington Hills, USA
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Brothers KM, Parker DM, Taguchi M, Ma D, Mandell JB, Thurlow LL, Byrapogu VC, Urish KL. Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection. Sci Rep 2023; 13:4593. [PMID: 36944677 PMCID: PMC10030625 DOI: 10.1038/s41598-023-30951-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/03/2023] [Indexed: 03/23/2023] Open
Abstract
Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.
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Affiliation(s)
- Kimberly M Brothers
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana M Parker
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Taguchi
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Ageo Medical Clinic, 3133 Haraichi, Ageo-Shi, Saitama, Japan
| | - Dongzhu Ma
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Mandell
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lance L Thurlow
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC, USA
| | - Venkata C Byrapogu
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Arthritis and Arthroplasty Design Group, and The Bone and Joint Center, Department of Orthopaedic Surgery, Department of Bioengineering, Department of Biomedical Engineering, and Clinical and Translational Science Institute, Magee Womens Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, 15219, USA.
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Najafi F, Fernández-Rodríguez D, Parvizi J. Sterile Setup Table in the Operating Room Is Not So Sterile. J Arthroplasty 2023; 38:562-566.e3. [PMID: 36154865 DOI: 10.1016/j.arth.2022.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND One of the important factors for surgical site infection prevention is the implementation of an ultraclean operating room. This study was designed to evaluate back-table sterility during total joint arthroplasty. METHODS This prospective study includes 52 patients undergoing primary total joint arthroplasty between November 2021 and January 2022. A total of 4 swabs (2 air swabs and 2 table swabs) were obtained for each case, at the conclusion of surgery and prior to the takedown of drapes. One swab from each set was sent for culture, and the other was sent for next-generation sequencing (NGS) analysis. RESULTS Among 104 back-table swabs, a total of 13 (12.5%) organisms were isolated. Of these, 7 organisms were isolated by culture and 6 by NGS. No microorganisms were isolated by both culture and NGS from back-table swabs. Among 104 air swabs, a total of 11 (10.6%) organisms were isolated. Of these, 6 microorganisms were isolated by culture and 5 by NGS. In 4 of the 104 swabs, both culture- and NGS-isolated organisms were from air swabs. Of the 104 (12.5%) back-table and air swabs, 13 were culture positive. While more than 1 pathogen was identified in 2 air swabs, all back-table swabs were monomicrobial by culture. Pathogens were identified from 11 of 104 (10.6%) swabs by NGS, while more than 1 pathogen was identified in 4 swabs (2 air and 2 back table). CONCLUSION The findings of this study raise an important issue that the surgical field including the sterile table setup for instruments is not "sterile" and can harbor pathogens.
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Affiliation(s)
- Farideh Najafi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Many Common Pathogens are Present in the Operative Room Air During Surgery. J Arthroplasty 2022; 37:2427-2430. [PMID: 35843378 DOI: 10.1016/j.arth.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The main objective of this study was to assess the sanitary measures of operating theaters using next-generation sequencing. METHODS Air was sampled from the operating room for the whole duration of 10 surgical days of "clean" (no infection cases) procedures (6 hip/knee arthroplasty and 4 spine cases). Controls consisted of samples at the beginning of the day (1 hour before the surgery started) and at the end of the day after terminal cleaning. One additional control sample, consisting of a culture swab that was opened and exposed to the air for 5 seconds, was collected at each time point. All samples were sent for next-generation sequencing analysis (16S rRNA sequencing) for bacterial identification. RESULTS Overall, 306 samples were collected (159 controls and 147 experimental). Microbial DNA was detected in only 1 control sample, while 18 (12.2%) experimental samples were positive for microbial DNA. The most common organisms retrieved were Escherichia coli (6/18, 30%), Cutibacterium acnes (3/18, 15%), and Pseudomonas aeruginosa (2/18, 11.1%). There was no difference in positive samples between arthroplasty and spine cases (P > .05). CONCLUSION Microbial organisms are not uncommonly present in the operating room air during hip and knee arthroplasties and spine procedures.
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Veletić M, Apu EH, Simić M, Bergsland J, Balasingham I, Contag CH, Ashammakhi N. Implants with Sensing Capabilities. Chem Rev 2022; 122:16329-16363. [PMID: 35981266 DOI: 10.1021/acs.chemrev.2c00005] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.
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Affiliation(s)
- Mladen Veletić
- Department of Electronic Systems, Norwegian University of Science and Technology, 7491 Trondheim, Norway.,The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Ehsanul Hoque Apu
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States.,Division of Hematology and Oncology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan 48105, United States
| | - Mitar Simić
- Faculty of Electrical Engineering, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | - Jacob Bergsland
- The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Ilangko Balasingham
- Department of Electronic Systems, Norwegian University of Science and Technology, 7491 Trondheim, Norway.,The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Christopher H Contag
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States
| | - Nureddin Ashammakhi
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States.,Department of Bioengineering, University of California, Los Angeles, California 90095, United States
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13
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Hijji FY, Schneider AD, Reeves JT, Wilson ML, Nye L, Lyons JG, Prayson MJ, Rubino LJ. Reduction in Operating Room Airborne Particle Burden and Time-Dependent Contamination of Sterile Instrument Trays With the Use of a Novel Air Filtration System. Cureus 2022; 14:e26864. [PMID: 35974851 PMCID: PMC9375117 DOI: 10.7759/cureus.26864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Postoperative infections represent a substantial burden to patients and healthcare systems. To improve patient care and reduce healthcare expenditures, interventions to reduce surgical infections must be employed. The crystalline C-band ultraviolet (UV-C) air filtration technology (Aerobiotix Inc., Miamisburg, OH, USA) has been designed to reduce airborne bioburden through high-quality filtration and germicidal irradiation. The purpose of this study was to assess the ability of a novel UV-C air filtration device to reduce airborne particle counts and contamination of surgical instrument trays in an operating room (OR) setting. Materials and methods Thirty sterile instrument trays were opened in a positive-air-flow OR. The trays were randomly assigned to one of two groups (UV-C or control, n=15 per group). In the UV-C group, the UV-C filtration device was used and in the control, it was not. All trays were opened with the use of a sterile technique and left exposed in the OR for four hours. Air was sampled by a particle counter to measure the numbers of 5µm and 10µm particles. Culture specimens were obtained from the trays to assess for bacterial contamination. Outcome data were collected at 30-minute intervals for the duration of the four-hour study period. Results Use of the UV-C device resulted in statistically significant reductions in the numbers of 5µm (average of 64.9% reduction when compared with the control, p<0.001) and 10µm (average of 65.7% reduction when compared with the control, p<0.001)-sized particles detectable in the OR. There was no significant difference in the overall rates of contamination (33.3% in the control group vs. 26.7% in the UV-C group, p=1.0) or the time to contamination (mean survival of 114 minutes in the control group vs. 105 minutes in the UV-C group, p=0.72) of surgical instrument trays with the use of the UV-C device. Conclusions The results demonstrate that the UV-C filtration device can successfully reduce airborne bioburden in standard ORs, suggesting that it may have the potential to reduce the risk for wound and hardware infections. Further clinical trials are necessary to better determine the effect of this air filtration system on postoperative infection rates.
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Castel-Oñate A, Marín-Peña O, Martínez Pastor J, Guerra Farfán E, Cordero Ampuero J. Proyecto PREVENCOT: ¿Seguimos las recomendaciones internacionales para la prevención de la infección del sitio quirúrgico en cirugía ortopédica programada? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:306-314. [DOI: 10.1016/j.recot.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/04/2021] [Accepted: 10/17/2021] [Indexed: 11/30/2022] Open
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Castel-Oñate A, Marín-Peña O, Martínez Pastor J, Guerra Farfán E, Cordero Ampuero J. [Translated article] PREVENCOT project: Do we follow international guidelines to prevent surgical site infection in orthopaedic elective surgery? Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Persson A, Atroshi I, Tyszkiewicz T, Hailer N, Lazarinis S, Eisler T, Brismar H, Mukka S, Kernell PJ, Mohaddes M, Sköldenberg O, Gordon M. EPOS trial: the effect of air filtration through a plasma chamber on the incidence of surgical site infection in orthopaedic surgery: a study protocol of a randomised, double-blind, placebo-controlled trial. BMJ Open 2022; 12:e047500. [PMID: 35115346 PMCID: PMC8814745 DOI: 10.1136/bmjopen-2020-047500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION There is controversy regarding the importance of air-transmitted infections for surgical site infections (SSIs) after orthopaedic surgery. Research has been hindered by both the inability in blinding the exposure, and by the need for recruiting large enough cohorts. The aim of this study is to investigate whether using a new form of air purifier using plasma air purification (PAP) in operating rooms (ORs) lowers the SSI rate or not. METHODS AND ANALYSIS Multicentre, double-blind, cluster-randomised, placebo-controlled trial conducted at seven hospitals in 2017-2022. All patients that undergo orthopaedic surgery for minimum 30 min are included. Intervention group: patients operated in OR with PAP devices turned on. CONTROL GROUP patients operated in OR with PAP devices turned off. Randomisation: each OR will be randomised in periods of 4 weeks, 6 weeks or 8 weeks to either have the devices on or off. PRIMARY OUTCOME any SSI postoperatively defined as a composite endpoint of any of the following: use of isoxazolylpenicillin, clindamycin or rifampicin for 2 days or more, International Classification of Diseases codes or Nordic Medico-Statistical Committee codes indicating postoperative infection. In a second step, we will perform a chart review on those patients with positive indicators of SSI to further validate the outcome. Secondary outcomes are described in the Methods section. Power: we assume an SSI rate of 2%, an SSI reduction rate of 25% and we need approximately 45 000 patients to attain a power of 80% at a significance level of 0.05. ETHICS AND DISSEMINATION The study is approved by the Swedish Ethical Review Authority. The interim analysis results from the study will be presented only to the researchers involved unless the study thereafter is interrupted for whatever reason. Publication in a medical journal will be presented after inclusion of the last patient. TRIAL REGISTRATION NUMBER NCT02695368.
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Affiliation(s)
- Anders Persson
- Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Danderyd, Sweden
| | - Isam Atroshi
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Kristianstad, Sweden
| | - Thomas Tyszkiewicz
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Kristianstad, Sweden
| | - Nils Hailer
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Orthopaedics, Uppsala University Hospital, Uppsala, Sweden
| | - Stergios Lazarinis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Orthopaedics, Uppsala University Hospital, Uppsala, Sweden
| | - Thomas Eisler
- Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Danderyd, Sweden
| | - Harald Brismar
- Department of Clinical Science Intervention and Technology, Karolinska Institute, Huddinge, Sweden
- Department of Orthopaedics and Biotechnology, Karolinska Universitetsjukhuset i Huddinge, Huddinge, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
- Umeå University Hospital, Umeå, Sweden
| | - Per-Juan Kernell
- GHP Ortho Center Stockholm, Löwenströmska Hospital, Upplands Väsby, Sweden
| | - Maziar Mohaddes
- Swedish Hip Arthroplasty Register, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University Of Gothenburg, Gothenburg, Sweden
| | - Olof Sköldenberg
- Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Danderyd, Sweden
| | - Max Gordon
- Karolinska Institutet Institutionen för kliniska vetenskaper Danderyds sjukhus, Danderyd, Sweden
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Duan MY, Zhang HZ. Vancomycin lavage for the incidence of acute surgical site infection following primary total hip arthroplasty and total knee arthroplasty. World J Clin Cases 2022; 10:71-78. [PMID: 35071507 PMCID: PMC8727268 DOI: 10.12998/wjcc.v10.i1.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/21/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical site infection is a rare but serious complication associated with total joint arthroplasty (TJA). There are limited data on the effectiveness of intrawound irrigation with vancomycin solution (1000 mg/L; 2 L) before wound closure for preventing acute surgical site infection following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).
AIM To investigate the effectiveness of prophylactic intraoperative application of vancomycin (1000 mg/L; 2 L) solution vs. plain irrigation in reducing the incidence of acute surgical site infection following primary THA and TKA.
METHODS A retrospective review of 2725 consecutive patients undergoing THA or TKA from January 2012–December 2019 was performed. These patients received either intrawound irrigation with normal saline before wound closure between January 2012 and December 2015 (group 1, 1018 patients; 453 undergoing THA and 565 undergoing TKA) or intrawound irrigation with vancomycin solution (1000 mg/L) before wound closure between January 2016 and December 2019 (group 2, 1175 patients; 512 undergoing THA and 663 undergoing TKA). The outcomes were the incidences of postoperative surgical site infection and wound healing complications within 3 mo of primary TJA.
RESULTS There were no significant demographic differences between the 2 groups. There was a significantly higher incidence of acute infection at the surgical site in patients who received intrawound irrigation with normal saline before wound closure than in those who received intrawound irrigation with vancomycin solution (1000 mg/L; 2 L) before wound closure (overall incidence of infection: group 1, 2.46% vs group 2, 0.09%, P < 0.001). There was no significant difference in the incidence of wound healing complications between the two groups.
CONCLUSION Prophylactic irrigation with vancomycin solution (1000 mg/L; 2 L) significantly decreases the incidence of acute surgical site infection after primary TJA. This strategy is a safe, efficacious, and inexpensive method for reducing the incidence of acute surgical site infection after TJA.
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Affiliation(s)
- Ming-Yi Duan
- Department of Orthopedics, Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Hang-Zhou Zhang
- Department of Orthopedics, Joint Surgery and Sports Medicine, First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Operating room ventilation systems: Recovery Degree, Cleanliness Recovery Rate and Air Change Effectiveness in an ultra-clean area. J Hosp Infect 2021; 122:115-125. [PMID: 34974079 DOI: 10.1016/j.jhin.2021.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Entrainment test methods are described in most European standards and guidelines to determine the protected area for Ultra-Clean Ventilation (UCV) systems. New UCV systems, such as temperature-controlled airflow (TcAF) and controlled-dilution ventilation (cDV) claim the whole Operating Room (OR) to be ultra-clean. Current test standards are not developed for assessing ventilation effectiveness outside the standard protected area. AIM To assess and compare the ventilation effectiveness of four types of OR ventilation systems in the ultra-clean area by using a uniform test grid. METHODS In this study the ventilation effectiveness (VE) of four ventilation systems is evaluated for three different ultra-clean (protected) areas; standard protected area (A), area outside standard protected area (B) and large protected area (AB). The VE is defined as the recovery degree (RD), cleanliness recovery rate (CRR) and air change effectiveness (ACE). FINDINGS RD, CRR and ACE were significantly higher for the Uni Directional Air Flow (UDAF) system when compared to the other systems in area A. In area B, UDAF and cDV were comparable regarding RD and CRR and UDAF and Conventional Ventilation (CV) were comparable regarding ACE. In area AB the UDAF and cDV were comparable regarding CRR and ACE but are significantly different in RD. CONCLUSION In area A the ventilation effectiveness of the UDAF ventilation system is outperforming other ventilation systems. In area B, cDV is performing the best followed by UDAF, TcAF and CV. In area AB, UDAF is performing the best followed by cDV, TcAF and CV.
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Diagnosis of Chronic Infection at Total Hip Arthroplasty Revision Is a Question of Definition. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8442435. [PMID: 34840982 PMCID: PMC8626185 DOI: 10.1155/2021/8442435] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022]
Abstract
Purpose Contradicting definitions of periprosthetic joint infection (PJI) are in use. Joint aspiration is performed before total hip arthroplasty (THA) revision. This study investigated the influence of PJI definition on PJI prevalence at THA revision. Test quality of prerevision aspiration was evaluated for the different PJI definitions. Methods 256 THA revisions were retrospectively classified to be infected or not infected. Classification was performed according to the 4 different definitions proposed by the Musculoskeletal Infection Society (MSIS), the Infectious Diseases Society of America (IDSA), the International Consensus Meeting (ICM), and the European Bone and Joint Infection Society (EBJIS). Only chronic PJIs were included. Results PJI prevalence at revision significantly correlated with the applied PJI definition (p = 0.01, Cramer's V = 0.093). PJI prevalence was 20.7% for the MSIS, 25.4% for the ICM, 28.1% for the IDSA, and 32.0% for the EBJIS definition. For synovial fluid white blood cell count, the best ROC-AUC for predicting PJI was 0.953 in combination with the MSIS definition. Conclusion PJI definition significantly influences the rate of diagnosed PJIs at THA revision. Synovial fluid white blood cell count is a reliable means to rule out PJI. In cases with a borderline high synovial white blood cell count before THA revision as the only sign of chronic PJI, an extended diagnostic work-up should be considered.
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Improve Integration of In Vitro Biofilm Body of Knowledge to Support Clinical Breakthroughs in Surgical Site Infection. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202111000-00002. [PMID: 34748523 PMCID: PMC8575432 DOI: 10.5435/jaaosglobal-d-20-00217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 09/17/2021] [Indexed: 01/28/2023]
Abstract
Prosthetics increase the risk of deep surgical site infections in procedures intended to restore function. In orthopaedics, prosthetic joint infections can lead to repetitive surgeries, amputation, or worse. Biofilm formation both in vitro and in vivo involves stages of attachment, accumulation, and maturation. The level of maturation affects susceptibility to antibiotics, the immune system, and the success of surgical interventions. A review of the literature indicates that orthopedic publications are less likely to mention biofilm. We have reviewed animal models of infection to assess in vivo models of prosthetic infection. Although most prosthetic infections seem to originate from local skin microbiota, clinically representative biofilm inocula are unusual. Biofilm-related end points are more widely adopted, but studies rarely include both quantification of adherent microbial burden and imaging of the in vivo biofilm. Failure to differentiate between planktonic and biofilm infections can skew research away from needed chronic disease models. In this review, we address prosthetic joint infections as an important model for chronic biofilm infection research, identify critical requirements for in vivo models of chronic infection, and propose that resistance to the terminology of biofilm research exists within both research and regulation, which could limit progress toward important orthopaedic targets.
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21
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Source strength as a measurement to define the ability of clean air suits to reduce airborne contamination in operating rooms. J Hosp Infect 2021; 119:9-15. [PMID: 34619268 DOI: 10.1016/j.jhin.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical site infections after total hip and knee replacement are linked to the quality of the operating room (OR) air. Applying tight occlusive clothing, effective ventilation and correct working methods are key concepts to obtain low bacterial concentrations in the OR air. The dry penetration test referred to in European standard EN 13795-2:2019 is a screening method for materials used in surgical clothing. Source strength, defined as the dispersal of bacteria-carrying particles from persons during activity, is a functional test of clothing systems and has been calculated in a dispersal chamber and in ORs. Results from both tests can be used when comparing surgical clothing systems. AIM This study relates results of dry penetration tests to source strength values for five surgical clothing systems available on the Swedish market. METHODS Experimental data are reported on the function of these products, expressed as source strength calculated from results in a dispersal chamber and in ORs during orthopaedic operations. FINDINGS All materials tested with dry penetration ≤50 colony-forming units (cfu) had source strength values <3 cfu/s for one person in the dispersal chamber, whereas the material of one product when laundered >50 times had source strength in the dispersal chamber of up to 8 cfu/s. CONCLUSION The dry penetration test could predict the performance of clean air suits of the same design, but more studies are needed to obtain a more valid correlation. Requirements of source strength should be included in standards.
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22
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Knudsen RJ, Knudsen SMN, Nymark T, Anstensrud T, Jensen ET, La Mia Malekzadeh MJ, Overgaard S. Laminar airflow decreases microbial air contamination compared with turbulent ventilated operating theatres during live total joint arthroplasty: a nationwide survey. J Hosp Infect 2021; 113:65-70. [PMID: 33932555 DOI: 10.1016/j.jhin.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/05/2021] [Accepted: 04/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preventing surgical site infections and prosthetic joint infections is crucial for patient safety after total joint arthroplasty. Microbial air contamination has been suggested as a risk factor. Therefore, the ventilation system that will reduce air contamination most effectively in operating theatres (OTs) has been discussed. AIM To determine whether laminar airflow (LAF) ventilation is superior to turbulent airflow (TAF) ventilation by looking at the colony forming units (cfu) count during live total hip and knee arthroplasties. Furthermore, to explore whether the number of OT personnel, door and cabinet lock openings and technical parameters of the ventilation systems have an impact on the number of cfu. METHODS Active air sampling and passive sedimented bacterial load were performed in 17 OTs, equipped with either LAF or TAF ventilation, during 51 live surgeries while observations were noted. FINDINGS LAF OTs reduced cfu counts compared with TAF OTs during live surgery (P<0.001). All LAF OTs provided ultraclean air whereas TAF had nine procedures exceeding the threshold of 10 cfu/m3. Door and cabinet lock openings and number of personnel did not influence the cfu count, while it decreased with increasing volume and total air change per hour (P<0.05). CONCLUSION All LAF OTs had cfu counts within recommendations and provided lower cfu counts compared with TAF OTs. The number of OT personnel and total openings did not have an influence on cfu counts. Increased volume of the OT and total air change per hour showed a decrease in active cfu counts.
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Affiliation(s)
- R J Knudsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - S M N Knudsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.
| | - T Nymark
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | | | - E T Jensen
- National Center for Infection Control, Statens Serum Institut, Denmark
| | | | - S Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Aganovic A, Cao G, Fecer T, Ljungqvist B, Lytsy B, Radtke A, Reinmüller B, Traversari R. Ventilation design conditions associated with airborne bacteria levels within the wound area during surgical procedures: a systematic review. J Hosp Infect 2021; 113:85-95. [PMID: 33930488 DOI: 10.1016/j.jhin.2021.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Without confirmation of the ventilation design conditions (typology and airflow rate), the common practice of identifying unidirectional airflow (UDAF) systems as equivalent to ultra-clean air ventilation systems may be misleading, but also any claims about the ineffectiveness of UDAF systems should be doubted. The aim of this review was to assess and compare ventilation system design conditions for which ultra-clean air (mean <10 cfu/m3) within 50 cm from the wound has been reported. Six medical databases were systematically searched to identify and select studies reporting intraoperative airborne levels expressed as cfu/m3 close to the wound site, and ventilation system design conditions. Available data on confounding factors such as the number of persons present in the operating room, number of door openings, and clothing material were also included. Predictors for achieving mean airborne bacteria levels within <10 cfu/m3 were identified using a penalized multivariate logistic regression model. Twelve studies met the eligibility criteria and were included for analysis. UDAF systems considered had significantly higher air volume flows compared with turbulent ventilation (TV) systems considered. Ultra-clean environments were reported in all UDAF-ventilated (N = 7) rooms compared with four of 11 operating rooms equipped with TV. On multivariate analysis, the total number of air exchange rates (P=0.019; odds ratio (OR) 95% confidence interval (CI): 0.66-0.96) and type of clothing material (P=0.031; OR 95% CI: 0.01-0.71) were significantly associated with achieving mean levels of airborne bacteria <10 cfu/m3. High-volume UDAF systems complying with DIN 1946-4:2008 standards for the airflow rate and ceiling diffuser size unconditionally achieve ultra-clean air close to the wound site. In conclusion, the studied articles demonstrate that high-volume UDAF systems perform as ultra-clean air systems and are superior to TV systems in reducing airborne bacteria levels close to the wound site.
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Affiliation(s)
- A Aganovic
- Department of Automation and Process Engineering, The Arctic University of Norway, Norway.
| | - G Cao
- Department of Energy and Process Engineering, Norwegian University of Science and Technology - NTNU, Norway
| | - T Fecer
- Department of Computer Aided Engineering and Computer Science, Faculty of Civil Engineering, Brno University of Technology, Czech Republic
| | - B Ljungqvist
- Department of Civil and Environmental Engineering, Chalmers University of Technology, Sweden
| | - B Lytsy
- Department of Medical Sciences, Clinical Microbiology, Uppsala University, Sweden
| | - A Radtke
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Norway
| | - B Reinmüller
- Department of Civil and Environmental Engineering, Chalmers University of Technology, Sweden
| | - R Traversari
- Netherlands Organization for Applied Scientific Research, Netherlands
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Ennis H, Chen CJL, Bondar K, McCormick J, Zieminski C, Hernandez VH. Influential literatures in periprosthetic infection following joint arthroplasty: A bibliometric review. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2021. [DOI: 10.1177/22104917211009777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this bibliometric literature review was to identify and analyze the most frequently cited manuscripts on the topic of periprosthetic joint infection. Periprosthetic infection following joint arthroplasty is a complication leading to rising rates of mortality and increasing economic strain. No prior study has evaluated the most impactful literature on the topic of periprosthetic joint infection (“PJI”) in total hip and knee arthroplasty. Knowledge and appreciation of the most influential publications on this topic can guide and inspire future research endeavors. Using the Clarivate Analytics Web of Science database, the 50 most cited articles related to periprosthetic infection following joint arthroplasty were identified. Numerous metrics including citation frequency, year of publication, country of origin, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. The seven most cited articles (per year) during the past 10 years were also identified. The years of publications of the articles included in the final analysis ranged from 1969 to 2014. “Current concepts: Prosthetic-joint infections” by Zimmerli et al. was the most frequently cited article. Level of Evidence (“LOE”) of 2 and 3 were the most common. Clinical outcomes was the most common article type. Mayo Clinic and Thomas Jefferson University produced the most publications. Hanssen and Parvisi were the most productive authors. 2000–2009 ( n = 25) was the most prolific decade in terms of number of publications. Using citation analysis as an indication of influence, the most influential articles on periprosthetic joint infection were highlighted. Analysis of the most recognized publication on PJI provides an enhanced understanding of the diagnosis, treatment, and future research of PJI. Future studies may combine the search results of multiple databases including Scopus, Web of Science and PubMed to rectify any discrepancies in citation data and to capture additional literature on PJI.
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Affiliation(s)
- Hayley Ennis
- Department of Orthopaedic Surgery, University of Miami Hospital, Miami, FL, USA
| | - Clark Jia-Long Chen
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Kevin Bondar
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Johnathon McCormick
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Colin Zieminski
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
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Morris BJ, Kiser CJ, Laughlin MS, Sheth MM, Dunn WR, Elkousy HA, Edwards TB. A localized laminar flow device decreases airborne particulates during shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg 2021; 30:580-586. [PMID: 32949760 DOI: 10.1016/j.jse.2020.08.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the rate of periprosthetic joint infection following shoulder arthroplasty is low, it is a morbid and costly complication. Airborne particulates have long been recognized as a potential source of wound contamination, and operating room-mounted and smaller localized laminar airflow devices have been developed to minimize airborne particulates. This randomized controlled trial evaluated the effectiveness of a localized laminar flow device in reducing the intrusion of ambient airborne particles and bacteria into the surgery site during shoulder arthroplasty as measured by overall particle counts and colony-forming units (CFUs). METHODS Patients undergoing primary anatomic or reverse shoulder arthroplasty were eligible for participation. After providing informed consent, patients were randomly assigned to the Air Barrier System (ABS) group or control group. For all patients, the ABS was placed on the surgical field; however, it was only turned on by the technician for those randomized to the ABS. Study participants, surgeons, and surgical staff were blinded to group assignment. Bacterial CFUs were collected from within 5 cm of the surgical wound every 10 minutes, whereas airborne particulates were collected every minute. Poisson regression models were used to determine whether differences existed in CFUs and particulate counts between the ABS and control groups. RESULTS A total of 43 patients were randomized into the ABS (n = 21) or control (n = 22) group. Surgical time (P = .53) and the average staff count (P = .16) in the operating room did not differ between groups. Poisson regression showed that the ABS group had significantly lower CFUs (β = -0.583, P < .001) along with surgical time and particulates with a diameter ≥ 5 μm. Staff count and particulates with a diameter < 5 μm were not significant predictors of CFUs. Infection was not a primary outcome; however, no postoperative infections have been reported in either study group with a minimum of 1-year follow-up for all patients. DISCUSSION This double-blinded, randomized trial demonstrated that a localized laminar flow device dramatically reduced the count of CFUs in the air directly above the wound and beneath the ABS (adjusted for the number of operating room personnel and surgical time). The use of the device was not associated with a longer case duration; however, some additional setup time was required prior to surgical incision to place the device. Further study is required to determine the clinical implications of this finding-specifically, whether such devices result in lower rates of periprosthetic joint infection after shoulder arthroplasty.
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Affiliation(s)
- Brent J Morris
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA; Fondren Orthopedic Research Institute, Houston, TX, USA; Texas Education and Research Foundation for Shoulder and Elbow Surgery, Houston, TX, USA
| | - Casey J Kiser
- Orthopaedics and Sports Medicine, Geisinger Holy Spirit, Camp Hill, PA, USA
| | - Mitzi S Laughlin
- Fondren Orthopedic Research Institute, Houston, TX, USA; Texas Education and Research Foundation for Shoulder and Elbow Surgery, Houston, TX, USA.
| | - Mihir M Sheth
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Warren R Dunn
- Fondren Orthopedic Research Institute, Houston, TX, USA; Texas Education and Research Foundation for Shoulder and Elbow Surgery, Houston, TX, USA
| | - Hussein A Elkousy
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA; Fondren Orthopedic Research Institute, Houston, TX, USA; Texas Education and Research Foundation for Shoulder and Elbow Surgery, Houston, TX, USA
| | - T Bradley Edwards
- Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA; Fondren Orthopedic Research Institute, Houston, TX, USA; Texas Education and Research Foundation for Shoulder and Elbow Surgery, Houston, TX, USA
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Metsemakers WJ, Zalavras C, Schwarz EM, Chen AF, Trampuz A, Moriarty TF. Antimicrobial Resistance, the COVID-19 Pandemic, and Lessons for the Orthopaedic Community. J Bone Joint Surg Am 2021; 103:4-9. [PMID: 33259429 DOI: 10.2106/jbjs.20.01214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antimicrobial resistance (AMR) is widely regarded as one of the most important global public health challenges of the twenty-first century. The overuse and the improper use of antibiotics in human medicine, food production, and the environment as a whole have unfortunately contributed to this issue. Many major international scientific, political, and social organizations have warned that the increase in AMR could cost the lives of millions of people if it is not addressed on a global scale. Although AMR is already a challenge in clinical practice today, it has taken on a new importance in the face of the coronavirus disease 2019 (COVID-19) pandemic. While improved handwashing techniques, social distancing, and other interventional measures may positively influence AMR, the widespread use of antibiotics to treat or prevent bacterial coinfections, especially in unconfirmed cases of COVID-19, may have unintended negative implications with respect to AMR. Although the exact number of bacterial coinfections and the rate at which patients with COVID-19 receive antibiotic therapy remain to be accurately determined, the pandemic has revived the discussion on antibiotic overuse and AMR. This article describes why the COVID-19 pandemic has increased our awareness of AMR and presents the immense global impact of AMR on society as a whole. Furthermore, an attempt is made to stress the importance of tackling AMR in the future and the role of the orthopaedic community in this worldwide effort.
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Affiliation(s)
- Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Microbial Monitoring as a Tool for Preventing Infectious Risk in the Operating Room: Results of 10 Years of Activity. ATMOSPHERE 2020. [DOI: 10.3390/atmos12010019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Environmental microbial contamination in the operating room (OR) can favour contamination of the surgical wound, posing the risk of infection of the surgical site. Thus, environmental monitoring is a useful tool for assessing environmental health and the effectiveness and efficiency of the measures adopted to control the risk of infection in the OR. This work aimed to analyse the long term environmental quality of 18 ORs throughout Sardinia, Italy, through the quantitative and qualitative characterisation of the microbial flora present in the air and on surfaces, in order to evaluate the trend over time, including in relation to any control measures adopted. The results of the sampling carried out in the period from January 2010 to December 2019 have been extrapolated from the archive-database of the Laboratory of the Hygiene and Control of Hospital Infections Unit of the University Hospital in Sassari. During the period in question, 188 air evaluations were carried out, both in empty rooms and during surgery, and 872 surface samples were taken. When the air was monitored, it emerged that significant contamination was detectable in a reduced number of examinations and a limited number of rooms. Microbial load values higher than the reference values may have been mainly determined by sub-optimal operation/maintenance of the air conditioning system. Surface testing showed a good level of sanitisation, given the low percentage of non-compliant values detected. The possibility of having data available on environmental quality is a useful educational and training tool both for those responsible for sanitisation procedures and the surgical team, in order to increase awareness of the effects of a lack of compliance with behavioural standards.
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Wang Q, Xu C, Goswami K, Tan TL, Parvizi J. Association of Laminar Airflow During Primary Total Joint Arthroplasty With Periprosthetic Joint Infection. JAMA Netw Open 2020; 3:e2021194. [PMID: 33064136 PMCID: PMC7568200 DOI: 10.1001/jamanetworkopen.2020.21194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Whether laminar airflow (LAF) in the operating room is effective for decreasing periprosthetic joint infection (PJI) after total joint arthroplasty remains a clinically important yet controversial issue. OBJECTIVE To investigate the association between operating room LAF ventilation systems and the risk of PJI in patients undergoing total joint arthroplasty. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted of 6972 consecutive patients undergoing primary total knee arthroplasty or total hip arthroplasty at 2 surgical facilities within a single institution from January 1, 2013, to September 15, 2017, with a minimum of 1 year of follow-up. All procedures were performed by 5 board-certified arthroplasty surgeons. Statistical analysis was performed from January 1, 2014, to September 15, 2018. EXPOSURE Patients underwent total joint arthroplasty in operating rooms equipped with either LAF or turbulent airflow. MAIN OUTCOMES AND MEASURES Patient characteristics were extracted from clinical records. Periprosthetic joint infection was defined according to Musculoskeletal Infection Society criteria within 1 year of the index arthroplasty. A multivariable logistic regression model was performed to explore the potential association between LAF and risk of PJI at 1 year, and then a sensitivity analysis using propensity score matching was performed to further validate the findings. RESULTS A total of 6972 patients (2797 who underwent total knee arthroplasty and 4175 who underwent total hip arthroplasty; 3690 women [52.9%]; mean [SD] age, 63.9 [10.7] years) were included. The incidence of PJI within 1 year for patients from the facility without LAF was similar to that of patients from the facility with LAF (0.4% [12 of 3027] vs 0.5% [21 of 3945]). In the multivariable logistic regression analysis, after all confounding factors were taken into account, the use of LAF was not associated with a reduction of the risk of PJI (adjusted odds ratio, 0.94; 95% CI, 0.40-2.19; P = .89). After propensity score matching, there was no significant difference in the incidence of PJI within 1 year for patients who underwent total joint arthroplasty at these 2 sites. CONCLUSIONS AND RELEVANCE This study suggests that the use of LAF in the operating room was not associated with a reduced incidence of PJI after primary total joint arthroplasty. With an appropriate perioperative protocol for infection prevention, LAF does not seem to play a protective role in PJI prevention.
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Affiliation(s)
- Qiaojie Wang
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Shanghai Sixth People’s Hospital, Shanghai, China
| | - Chi Xu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
- Department of Orthopaedic Surgery, General Hospital of People’s Liberation Army, Beijing, China
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L. Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Stawicki SP, Wolfe S, Brisendine C, Eid S, Zangari M, Ford F, Snyder B, Moyer W, Levicoff L, Burfeind WR. The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study. Surgery 2020; 168:968-974. [PMID: 32888714 DOI: 10.1016/j.surg.2020.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. METHODS After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. RESULTS The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). CONCLUSION Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.
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Affiliation(s)
- Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA.
| | - Samantha Wolfe
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Chad Brisendine
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Sherrine Eid
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Matthew Zangari
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Frank Ford
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Beverly Snyder
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - William Moyer
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - Lee Levicoff
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
| | - William R Burfeind
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA
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30
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Ball CM, Featherstone PJ. Hygiene and personal protection: The anaesthetist’s journey. Anaesth Intensive Care 2020; 48:258-261. [DOI: 10.1177/0310057x20933801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christine M Ball
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
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31
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Langvatn H, Bartz-Johannessen C, Schrama JC, Hallan G, Furnes O, Lingaas E, Walenkamp G, Engesaeter LB, Dale H. Operating room ventilation-Validation of reported data on 108 067 primary total hip arthroplasties in the Norwegian Arthroplasty Register. J Eval Clin Pract 2020; 26:1022-1029. [PMID: 31599061 DOI: 10.1111/jep.13271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The true effect of laminar airflow (LAF) systems on postoperative infection is disputed, partly due to uncertainty regarding the validity of ventilation data in register studies. The aim of this study was to validate the information on operating room (OR) ventilation reported by the orthopaedic surgeons to the Norwegian Arthroplasty Register (NAR) after primary total hip arthroplasty (THA). METHOD Forty of the 62 public orthopaedic units performing primary THA in Norway during the period 1987-2015 were included. The hospitals' current and previous ventilation systems were evaluated in cooperation with the hospitals head engineer. We identified the type of ventilation system reported to the NAR and compared the information with the factual ventilation in the specific ORs at the time of primary THA. RESULTS A total of 108 067 primary THAs were eligible for assessment. None of the hospitals performed THA in true "greenhouse" (GH) ventilation. Fifty-seven percent of the primary THAs were performed in ORs with LAF and 43% in ORs with conventional, turbulent ventilation (CV). Comparing the reported data with the validated data, LAF was reported with a sensitivity of 86%, specificity of 89%, and positive predictive value (PPV) of 92%, with an accuracy of 88%. CV was reported with a sensitivity of 89%, specificity of 87%, and PPV of 84%, with an accuracy of 88%. The total, mean misreporting rate was 12%. CONCLUSIONS Surgeons were not fully aware of what kind of ventilation system they operated in. This study indicates that conclusions based on ventilation data reported on THA in the NAR should not be interpreted without considering the inaccuracy of the data.
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Affiliation(s)
- Håkon Langvatn
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway.,Department of Orthopedic Surgery, St. Olav University Hospital, Trondheim, 7035, Norway
| | - Christoffer Bartz-Johannessen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway
| | - Johannes Cornelis Schrama
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
| | - Egil Lingaas
- Department of Infection Prevention, Oslo University Hospital, Oslo, 0372, Norway
| | - Geert Walenkamp
- Department of Orthopedic Surgery, Maastricht University, Maastricht, The Netherlands
| | - Lars Birger Engesaeter
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
| | - Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, 5021, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, 5021, Norway
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Langvatn H, Schrama J, Cao G, Hallan G, Furnes O, Lingaas E, Walenkamp G, Engesæter L, Dale H. Operating room ventilation and the risk of revision due to infection after total hip arthroplasty: assessment of validated data in the Norwegian Arthroplasty Register. J Hosp Infect 2020; 105:216-224. [DOI: 10.1016/j.jhin.2020.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/06/2020] [Indexed: 01/25/2023]
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Davis DE, Zmistowski B, Abboud JA, Namdari S. Cost Effectiveness of Laminar Flow Systems for Total Shoulder Arthroplasty: Filtering Money from the OR? THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:38-43. [PMID: 32090144 DOI: 10.22038/abjs.2018.34938.1918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Laminar flow ventilation systems were developed to reduce surgical contamination in joint arthroplasty to avoid periprosthetic joint infection (PJI). The goals of this study are to evaluate the cost-effectiveness and economic viability of installing and maintaining a laminar flow system in an operating room. Methods A Monte Carlo simulation was used to evaluate the cost effectiveness of laminar flow. The variables included were cost to treat PJI, incidence of PJI, cost of laminar flow, years of operating room use, and arthroplasty volume as the dependent variable. Results Laminar flow would be financially-justified when 1,217 (SD: 319) TSA cases are performed annually with assumed 10% reduction in PJI from laminar flow and 487 (SD: 127) with assumed 25% reduction. In a high volume OR, laminar flow costs $25.24 per case (assuming 10% reduction) and $8.24 per case (assuming 25% reduction). Laminar flow would need to reduce the incidence of PJI by 35.1% (SD: 9.1) to be a cost-effective strategy. Conclusion This analysis demonstrates the substantial arthroplasty volume and large reduction in PJI rates required to justify the installation and maintenance costs of this technology. This high cost of implementation should be considered prior to installing laminar flow systems.
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Affiliation(s)
- Daniel E Davis
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Anis HK, Curtis GL, Klika AK, Piuzzi NS, Otiso J, Richter SS, Barsoum WK, Higuera CA. In-Room Ultraviolet Air Filtration Units Reduce Airborne Particles During Total Joint Arthroplasty. J Orthop Res 2020; 38:431-437. [PMID: 31441105 DOI: 10.1002/jor.24453] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/07/2019] [Indexed: 02/04/2023]
Abstract
Reducing airborne bioburden in total joint arthroplasty (TJA) is of critical importance. The efficacy of crystalline ultraviolet-C (C-UVC) filtration in reducing bioburden in a dynamic operating room (OR) environment has not been evaluated. We assessed whether C-UVC filtration reduced (i) total particle counts (TPC); (ii) viable particle counts (VPC); and (iii) colony-forming units (CFUs). Fifty primary TJA cases were performed in a positive-pressure OR; 25 cases with the C-UVC unit and 25 cases without. The air was sampled by a particle counter and an impact air sampler to measure particle counts and CFUs, respectively. To compare TPC, VPC, and CFU/m3 between groups, independent t tests and multivariate regression, adjusted for number of OR staff and door openings, were performed. The C-UVC group had significantly lower TPC (2.6 × 106 vs. 4.7 × 106 particles, p = 0.001) and VPC (18,605 vs. 27,516 particles, p = 0.001). There were fewer CFUs in the C-UVC group (10.9 CFU/m3 vs. 13.7 CFU/m3 , p = 0.163). Multivariate analysis identified C-UVC filtration as a significant predictor of decreased TPC (β = -0.44, p = 0.002) and VPC (β = -0.47, p = 0.001) after accounting for door openings and number of OR staff. The reduction in CFUs was not significant on multivariate analysis. In this prospective pilot study, a C-UVC air disinfection and recirculation unit led to a significant reduction in both TPC and VPC and a non-significant reduction in CFU. Statement of clinical significance: Further studies are needed to investigate the effects of C-UVC filtration units on surgical-site infection rates. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:431-437, 2020.
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Affiliation(s)
- Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave/A41, Cleveland, Ohio, 44114
| | - Gannon L Curtis
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, Michigan
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave/A41, Cleveland, Ohio, 44114
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave/A41, Cleveland, Ohio, 44114
| | - Joshua Otiso
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave/A41, Cleveland, Ohio, 44114
| | - Sandra S Richter
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave/A41, Cleveland, Ohio, 44114
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Stryja J, Sandy-Hodgetts K, Collier M, Moser C, Ousey K, Probst S, Wilson J, Xuereb D. PREVENTION AND MANAGEMENT ACROSS HEALTH-CARE SECTORS. J Wound Care 2020; 29:S1-S72. [DOI: 10.12968/jowc.2020.29.sup2b.s1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jan Stryja
- Vascular Surgeon, Centre of vascular and miniinvasive surgery, Hospital Podlesi, Trinec, The Czech Republic. Salvatella Ltd., Centre of non-healing wounds treatment, Podiatric outpatients’ department, Trinec, The Czech Republic
| | - Kylie Sandy-Hodgetts
- Senior Research Fellow – Senior Lecturer, Faculty of Medicine, School of Biomedical Sciences, University of Western Australia, Director, Skin Integrity Clinical Trials Unit, University of Western Australia
| | - Mark Collier
- Nurse Consultant and Associate Lecturer – Tissue Viability, Independent – formerly at the United Lincolnshire Hospitals NHS Trust, c/o Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire, PE21 9Q
| | - Claus Moser
- Clinical microbiologist, Rigshospitalet, Department of Clinical Microbiology, Copenhagen, Denmark
| | - Karen Ousey
- Professor of Skin Integrity, University of Huddersfield. Institute of Skin Integrity and Infection Prevention, Huddersfield, UK
| | - Sebastian Probst
- Professor of wound care, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Jennie Wilson
- Professor of Healthcare Epidemiology, University of West London, College of Nursing, Midwifery and Healthcare, London, UK
| | - Deborah Xuereb
- Senior Infection Prevention & infection Control Nurse, Mater Dei Hospital, Msida, Malta
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Diagnosis of the failed total hip replacement. J Clin Orthop Trauma 2020; 11:2-8. [PMID: 32001976 PMCID: PMC6985031 DOI: 10.1016/j.jcot.2019.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/28/2019] [Indexed: 12/27/2022] Open
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Teo BJX, Woo YL, Phua JKS, Chong HC, Yeo W, Tan AHC. Laminar flow does not affect risk of prosthetic joint infection after primary total knee replacement in Asian patients. J Hosp Infect 2019; 104:305-308. [PMID: 31877337 DOI: 10.1016/j.jhin.2019.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The role of laminar flow (LAF) is contradictory with several studies failing to replicate risk reduction. The 2016 World Health Organization guidelines identified this lack of good comparative studies. AIM To analyse the use of LAF and the incidence of prosthetic joint infections (PJIs) in Asian patients undergoing total knee replacement (TKR). METHODS Patients who underwent standard cemented posterior-stabilized TKR from 2004 to 2014 were reviewed from a prospectively collected single-surgeon database. Revision, traumatic and/or inflammatory cases were excluded. The type of airflow used was identified. The technique and surgical protocol for all procedures were similar. Tourniquets and inserted drains were routinely used. Patellar resurfacing was not performed. Patients were followed up at the outpatient clinics at regular intervals up to two years. At each visit, the patient was assessed for the occurrence of PJI. FINDINGS Of the 1028 procedures, 453 (44.1%) were performed in an LAF operating theatre (OT) whereas 575 (55.9%) were performed in a non-LAF OT. There were no significant differences between the two groups in terms of age, gender, or side of procedure. The overall incidence of PJI was 0.6% (N = 6). Three (50%) occurred in an LAF OT whereas three (50%) occurred in a non-LAF OT. This was not statistically significant. CONCLUSION Laminar flow systems are costly to procure and maintain. With modern aseptic techniques, patient optimization, and use of prophylactic antibiotics, laminar flow does not appear to further reduce risk of PJI in Asian patients after TKR.
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Affiliation(s)
- B J X Teo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore.
| | - Y L Woo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - J K S Phua
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - H-C Chong
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - W Yeo
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - A H C Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Popp W, Alefelder C, Bauer S, Daeschlein G, Geistberger P, Gleich S, Herr C, Hübner NO, Jatzwauk L, Kohnen W, Külpmann R, Lemm F, Loczenski B, Spors J, Walger P, Wehrl M, Zastrow KD, Exner M. Air quality in the operating room: Surgical site infections, HVAC systems and discipline - position paper of the German Society of Hospital Hygiene (DGKH). GMS HYGIENE AND INFECTION CONTROL 2019; 14:Doc20. [PMID: 32047719 PMCID: PMC6997799 DOI: 10.3205/dgkh000335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In recent years, there has been an ongoing discussion about the value of laminar airflow (LAF=low turbulence displacement ventilation) in the operating room for prevention of surgical site infections (SSI). Some publications, e.g., from the WHO, issued the demand to no longer build LAF ceilings in operating rooms. The present statement deals critically with this position and justifies the use of LAF ceilings in different ways: Many of the papers cited by the WHO and others for the case against LAF do not provide reliable data.The remaining studies which might be used for answering the question give quite different results, also in favor of LAF.The size of the LAF ceiling in many studies is not given or mostly too small in comparison to actual technical requirements.LAF in different countries can mean quite different techniques (e.g., the US in comparison to Germany) so that the results of studies that do not take this into account may not be comparable.LAF has positive effects in terms of reducing particulate and bacterial load, associated with increased airflow in the surgical working area. A reduction of carcinogenic substances in the air may also be assumed, which would increase workers' safety. Thus, this paper recommends building LAF ceilings in the future as well, depending on the operations intended. Further, this paper gives an overview of possible reasons for surgical site infections and highlights the importance of discipline in the operating theatre.
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Affiliation(s)
- Walter Popp
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | | | - Sonja Bauer
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | | | | | - Sabine Gleich
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | - Caroline Herr
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | | | - Lutz Jatzwauk
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | | | | | | | | | - Jörg Spors
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | - Peter Walger
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | - Markus Wehrl
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
| | | | - Martin Exner
- German Society for Hospital Hygiene (DGKH), Berlin, Germany
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Potter BK. From Bench to Bedside: Synthesizing Better Replacements and Reconstructions. Clin Orthop Relat Res 2019; 477:2642-2643. [PMID: 31764326 PMCID: PMC6907320 DOI: 10.1097/corr.0000000000001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K Potter
- B. K. Potter, Directorate for Surgical Services, Walter Reed National Military Medical Center & the Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD USA
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40
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CORR Insights®: What are the Factors Associated With Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study. Clin Orthop Relat Res 2019; 477:2264-2266. [PMID: 31283728 PMCID: PMC6999953 DOI: 10.1097/corr.0000000000000831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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41
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Teo BJX, Yeo W, Chong HC, Tan AHC. Surgical site infection after primary total knee arthroplasty is associated with a longer duration of surgery. J Orthop Surg (Hong Kong) 2019; 26:2309499018785647. [PMID: 30010488 DOI: 10.1177/2309499018785647] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Surgical site infection (SSI) is a serious complication following total knee arthroplasty (TKA) leading to considerable morbidity. The incidence is reported to be up to 2%. Risk factors continue to be an area of intense debate. Our study aims to report the incidence of SSI and identify possible risk factors in our patients undergoing TKA. METHODS Prospectively collected data for 905 patients who underwent elective unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed. Patient demographics and relevant co-morbidities such as diabetes and heart disease were analysed. The presence of superficial wound infections and/or prosthetic joint infections was included. RESULTS The overall infection rate was 1.10% (10 of 905 patients). Six patients (0.66%) were diagnosed with superficial infections and four with PJI (0.44%). The mean operative duration for TKA with SSI was significantly longer at 90.5 ± 28.2 min, compared to 72.2 ± 20.3 min in TKA without SSI ( p = 0.03). All superficial infections occurred within the first month post-surgery and were self-limiting with oral antibiotics. The four patients with PJI required repeated procedures following TKA, including debridement, implant removal and/or revision arthroplasty. None of the 10 patients had a history of diabetes. There were no significant differences in demographics and co-morbidities between those who developed infection after TKA and those who did not. CONCLUSION An overwhelming majority had good outcomes with only four deep infections resulting in revision surgery. We report that the risk of infection in TKA was significantly associated with a longer operative duration.
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Affiliation(s)
- Bryon Jun Xiong Teo
- 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - William Yeo
- 2 Department of Physiotherapy, Singapore General Hospital, Singapore, Singapore
| | - Hwei-Chi Chong
- 2 Department of Physiotherapy, Singapore General Hospital, Singapore, Singapore
| | - Andrew Hwee Chye Tan
- 1 Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
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42
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Persson M. Airborne contamination and surgical site infection: Could a thirty-year-old idea help solve the problem? Med Hypotheses 2019; 132:109351. [PMID: 31421424 DOI: 10.1016/j.mehy.2019.109351] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 11/26/2022]
Abstract
Surgical site infection (SSI) is a most serious postoperative complication, associated with increased morbidity and mortality, as well as extended therapy and elevated healthcare costs. In open clean surgery, e.g. orthopedic and cardiothoracic operations, the risk of SSI is strongly correlated with the amount of airborne bacteria being present in the operating room and the surgical field. The source of these bacteria is the surgical team itself, as we all emit thousands of bacteria-carrying skin particles every minute into the air. Although the risk of airborne contamination has decreased over the years, thanks to modern surgical clothing and advanced operating room ventilation, airborne bacteria are still detected and cause SSI. However, during the past thirty years there has been a simple and potentially effective preventive method waiting to be noticed. In 1986 Hall, Mackintosh and Hoffman found in a controlled experimental study that the application of regular unperfumed skin lotion to a person's body reduced the emission of airborne bacteria-carrying particles by approximately 90%. Moreover, the effect lasted at least 4 hours, which corresponds to a major surgical procedure. Thus, in the light of those results the present paper puts forth the hypothesis that this method can decrease the incidence of airborne bacterial contamination and SSI in open clean surgery. The paper also discusses the rationale and advantages of the method, and questions why it has escaped scientific attention for so long. In healthcare, difficult problems rarely have a simple and cheap solution. However, the use of ordinary skin lotion in open surgery may just be one, as it could potentially help prevent surgical site infection, and thereby increase patient safety and reduce healthcare costs.
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Affiliation(s)
- Mikael Persson
- Department of Quality Management and Mechanical Engineering, Mid Sweden University, Östersund, Sweden.
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: rationale and methods of the shoulder subgroup. J Shoulder Elbow Surg 2019; 28:S4-S7. [PMID: 31196515 DOI: 10.1016/j.jse.2019.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/19/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Albrektsson T, Becker W, Coli P, Jemt T, Mölne J, Sennerby L. Bone loss around oral and orthopedic implants: An immunologically based condition. Clin Implant Dent Relat Res 2019; 21:786-795. [DOI: 10.1111/cid.12793] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/29/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Tomas Albrektsson
- Department of BiomaterialsUniversity of Gothenburg Gothenburg Sweden
- Department of ProsthodonticsUniversity of Malmö Malmö Sweden
| | - William Becker
- Department of PeriodonticsUniversity of Southern California School of Dentistry Los Angeles California
- Department of PeriodonticsUniversity of Washington School of Dentistry Seattle Washington
| | | | - Torsten Jemt
- Department of ProsthodonticsUniversity of Gothenburg Gothenburg Sweden
| | - Johan Mölne
- Department of Pathology and GeneticsInstitute of Biomedicine, Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
| | - Lars Sennerby
- Department of Oral & Maxillofacial SurgeryUniversity of Gothenburg Gothenburg Sweden
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Cook TM, Piatt CJ, Barnes S, Edmiston CE. The Impact of Supplemental Intraoperative Air Decontamination on the Outcome of Total Joint Arthroplasty: A Pilot Analysis. J Arthroplasty 2019; 34:549-553. [PMID: 30600122 DOI: 10.1016/j.arth.2018.11.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/07/2018] [Accepted: 11/29/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND During the early era of arthroplasty, the concept of ultraclean operating room (OR) was introduced based on the principle that the number of airborne particles in the OR directly influences incidence of device-related infections. The hypothesis of this pilot study was that use of an innovative UV-C air decontamination technology would lead to a reduction in the incidence of periprosthetic joint infection (PJI) following total joint arthroplasty. METHODS A retrospective, observational, surveillance study was conducted with a consecutive series of patients who underwent total joint arthroplasty (n = 496) between January 2016 and August 2017. All perioperative and postoperative care protocols were identical for both groups, only study variable was that in 231 arthroplasty patients (OR B), an innovative supplemental UV-C air decontamination technology was used, whereas in the remaining 265 patients, arthroplasty was performed with standard turbulent HVAC (OR A). RESULTS There was no significant difference between patient groups regarding age, body mass index, diabetes diagnosis, smoking status, length of surgery, or revision status. The rate of PJI was documented to be 1.9% in the turbulent air group, and no infections were documented in the cohorts operated under UV-C air decontamination, which was statistically significant (P < .044). CONCLUSION While PJI is multifactorial in nature, the present retrospective pilot study suggests that use of an intraoperative supplemental air decontamination significantly reduced the overall risk of PJI. The findings of this study are encouraging and should be examined in a larger-scale, prospective, multicenter study.
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Affiliation(s)
- Thomas M Cook
- Division of Orthopedic Surgery, Grandview Medical Center, Dayton, OH
| | - Caleb J Piatt
- Division of Orthopedic Surgery, Grandview Medical Center, Dayton, OH
| | - Sue Barnes
- Clinical Infection Prevention Consultant, San Mateo, CA
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46
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Al-Houraibi RK, Aalirezaie A, Adib F, Anoushiravani A, Bhashyam A, Binlaksar R, Blevins K, Bonanzinga T, Chih-Kuo F, Cordova M, Deirmengian GK, Fillingham Y, Frenkel T, Gomez J, Gundtoft P, Harris MA, Harris M, Heller S, Jennings JA, Jiménez-Garrido C, Karam JA, Khlopas A, Klement MR, Komnos G, Krebs V, Lachiewicz P, Miller AO, Mont MA, Montañez E, Romero CA, Schwarzkopf R, Shaffer A, Sharkey PF, Smith BM, Sodhi N, Thienpont E, Villanueva AO, Yazdi H. General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S157-S168. [PMID: 30360978 DOI: 10.1016/j.arth.2018.09.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Aalirezaie A, Akkaya M, Barnes CL, Bengoa F, Bozkurt M, Cichos KH, Ghanem E, Darouiche RO, Dzerins A, Gursoy S, Illiger S, Karam JA, Klaber I, Komnos G, Lohmann C, Merida E, Mitt P, Nelson C, Paner N, Perez-Atanasio JM, Reed M, Sangster M, Schweitzer D, Simsek ME, Smith BM, Stocks G, Studers P, Talevski D, Teuber J, Travers C, Vince K, Wolf M, Yamada K, Vince K. General Assembly, Prevention, Operating Room Environment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S105-S115. [PMID: 30348570 DOI: 10.1016/j.arth.2018.09.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
BACKGROUND Surgical site infection is associated with a substantial healthcare burden and remains one of the most challenging complications to treat. Airborne particles carrying contaminating micro-organisms are responsible for the majority of these infections. METHODS Various operating theater ventilatory systems have been developed to prevent direct airborne bacterial inoculation of the surgical wound. Laminar air flow uses positive pressure air currents through filtration units to direct air streams away from the operative field in order to create an ultraclean zone around the operative site. DISCUSSION Early studies reported lower infection rates with laminar air flow and therefore it became the accepted standard for implant-related surgery. However, more recent evidence has questioned its clinical importance. The purpose of this article is to review contemporary laminar air flow handling systems and the current evidence behind their use.
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Affiliation(s)
- Sameer Jain
- 1 Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Northumberland, United Kingdom
| | - Mike Reed
- 1 Northumbria Healthcare NHS Foundation Trust, Wansbeck Hospital, Northumberland, United Kingdom.,2 Department of Health Sciences, University of York, Seebohm, Heslington, York, United Kingdom
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49
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Harp JH. A Clinical Test to Measure Airborne Microbial Contamination on the Sterile Field During Total Joint Replacement: Method, Reference Values, and Pilot Study. JB JS Open Access 2018; 3:e0001. [PMID: 30533587 PMCID: PMC6242324 DOI: 10.2106/jbjs.oa.18.00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Airborne microbe-carrying particles in the operating-room environment during total joint replacement are a risk factor for periprosthetic joint infection. The present study focuses on a simple environmental test, based on practices used in aseptic cleanrooms, to quantify the deposition of microbe-carrying particles onto the sterile field. Methods Settle plates are exposed Petri dishes. A settle plate test system and sampling plan were developed from current practices used in aseptic manufacturing. A pilot study evaluated this system in an orthopaedic operating room during 22 total knee and hip arthroplasties. The microbial deposition total (MDT), expressed in colonies/m2, is proposed as an outcome variable to report airborne sterile-field contamination as measured with settle plates. Two reference MDT levels were developed: (1) an upper limit of 450, corresponding with the ultraclean air definition of 10 colonies/m3, and (2) a target level of 100, corresponding with 1 colony/m3. These levels also correspond with widely used limits in aseptic cleanrooms and controlled environments. Results High MDT standard deviations were noted. Ninety-one percent (95% confidence interval, 71.0% to 98.7%) of wound zone MDT levels were within the upper limit. Twenty-seven percent (95% confidence interval, 12.9% to 48.4%) of wound zone levels were within the target level. Conclusions Settle plates are a feasible technique to test environmental levels of microbe-carrying particles on sterile fields during total joint replacement for scientific and environmental quality studies. Clinical Relevance This settle plate operating-room environmental test can be used in future research to validate the presence of actual ultraclean-air conditions during periprosthetic joint infection outcome studies. Surgeons also can use this test to measure intraoperative airborne microbe-carrying-particle sterile-field contamination and compare it with ultraclean-air reference levels for environmental quality-control programs.
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Affiliation(s)
- John H Harp
- Sparks Regional Medical Center, Fort Smith, Arkansas
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50
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Smith JO, Frampton CMA, Hooper GJ, Young SW. The Impact of Patient and Surgical Factors on the Rate of Postoperative Infection After Total Hip Arthroplasty-A New Zealand Joint Registry Study. J Arthroplasty 2018; 33:1884-1890. [PMID: 29455937 DOI: 10.1016/j.arth.2018.01.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA). The potential to define and modify risk factors for infection represents an important opportunity to reduce the incidence of PJI. This study uses New Zealand Joint Registry data to identify independent risk factors associated with PJI after primary THA. METHODS Data on 91,585 THAs performed between 2000 and 2014 were analyzed. Factors associated with revision for PJI within 12 months were identified using univariate and multivariate analyses. RESULTS Revision rates for PJI were 0.15% and 0.21% at 6 and 12 months, respectively. Multivariate analysis showed significant associations with the American Society of Anesthesiologists grade (odds ratio [OR] 6.13, 95% confidence interval [CI] 1.28-29.39), severe or morbid obesity (OR 2.15, CI 1.01-4.60 and OR 3.73, CI 1.49-9.39), laminar flow ventilation (OR 1.98, CI 1.38-2.85), consultant-supervised trainee operations (OR 1.94, CI 1.22-3.08), male gender (OR 1.68, CI 1.23-2.30) and anterolateral approach (OR 1.62, CI 1.11-2.37). Procedures performed in the private sector were protective for revision for infection (OR 0.68, CI 0.48-0.96). CONCLUSIONS The PJI risk profile for patients undergoing THA is constituted of a complex of patient and surgical factors. Several patient factors had strong independent associations with revision rates for PJI. Although surgical factors were less important, these may be more readily modifiable in practice.
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Affiliation(s)
- James O Smith
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
| | | | - Gary J Hooper
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Simon W Young
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
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