Efficacy of Intraoperative Antiseptic Techniques in the Prevention of Periprosthetic Joint Infection: Superiority of Betadine.

BACKGROUND: Povidone-iodine (PI), chlorhexidine gluconate (CHG), and vancomycin (VANC) powder are common intrawound prophylactic agents to prevent periprosthetic joint infection during primary total joint arthroplasty. The aims of this study are (1) to determine the minimal inhibitory concentration (MIC) and time to death for PI, CHG, and VANC against multiple bacteria and (2) to determine time to death against bacteria dried on titanium discs. METHODS: A standard quantitative suspension assay was performed to determine the MIC for PI, CHG, and VANC against methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Haemophilus influenzae, Pseudomonas aeruginosa, Burkholderia cepacia, and Escherichia coli. Time to death assay was performed with time points of 0, 3, 30, and 60 minutes. Concentrations of antiseptic agents for time to death assay were 1% PI, 0.05% CHG, and 5 µg/mL VANC. Dry-phase bacteria on titanium discs were treated in a similar fashion. RESULTS: The MIC of PI was 0.63%, CHG was 0.0031%, and VANC was 1.56 µg/mL. All 7 bacterial isolates were completely killed by PI at all times tested. CHG failed to kill MRSA and B cepacia at 0- and 3-minute exposures. Vancomycin completely killed MRSA and S epidermidis isolates between 18-20 hours of exposure. All bacterial isolates dried on titanium discs were eliminated by PI exposure on contact. E coli and S epidermidis were incompletely eliminated by CHG at 0 minutes, with all isolates eliminated at 3, 10, and 30 minutes. CONCLUSION: Our study suggests that PI kills all bacteria tested immediately on contact and that the exposure time is not the key factor.

Does Surgeon Fellowship Training Influence Outcomes in Hemiarthroplasty for Femoral Neck Fracture?

BACKGROUND: The aim of this study is to compare the outcomes (90 days and 1 year) of patients with femoral neck fracture undergoing hemiarthroplasty by surgeons with different fellowship training: trauma, arthroplasty, and general orthopedics. METHODS: This study is a retrospective review of consecutive patients undergoing hip hemiarthroplasty for femoral neck fracture from 2010 to 2018. Comorbidities, perioperative details, demographics, injury variables, and time-to-surgery were compared between the fellowship training cohorts, in addition to outcomes including dislocation, periprosthetic joint infection, and mortality at 90 days and 1 year. RESULTS: A total of 298 hips with an average age of 77.8 years underwent hemiarthroplasty for femoral neck fracture. Arthroplasty surgeons had a significantly shorter operative duration (82 minutes, P = .0014) and utilized the anterior approach more frequently (P < .0001). The general orthopedists had a significantly increased total surgical complication risk compared to both the arthroplasty and trauma fellowship-trained cohorts at both 90 days (11.8% vs 1.6% vs 3.9%, P = .015) and 1 year (18.2% vs 4.9% vs 7.1%, P = .008). The overall mortality risk was 11.7% at 90 days and 22.8% at 1 year. When adjusted for covariates, including comorbidities, gender, age, and preoperative walking capacity, both the arthroplasty fellowship-trained cohort (odds ratio 0.381, 95% confidence interval 0.159-0.912, P = .030) and the general orthopedist cohort (odds ratio 0.495; 95% confidence interval 0.258-0.952, P = .035) had reduced risk of 1-year mortality compared to the trauma fellowship-trained cohort. CONCLUSION: Hemiarthroplasty performed for femoral neck fractures may result in fewer complications when performed by arthroplasty fellowship-trained surgeons. An arthroplasty weekly on-call schedule and adjusted institutional protocols may be utilized to improve outcomes and reduce complications. LEVEL OF EVIDENCE: Level II, retrospective cohort.

Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses.

BACKGROUND: Optimization of surgical instrument trays improves efficiency and reduces cost. The purpose of this study is to assess the economic impact of optimizing orthopedic instrument trays at a tertiary medical center. METHODS: Twenty-three independent orthopedic surgical instrument trays at a single academic hospital were reviewed from 2017 to 2018. Using Lean methodology, surgeons agreed upon the fewest number of instruments needed for each of the procedure trays. Instrument usage counts, cleaning times, room turnover times, tray weight, holes in tray wrapping, wet trays, and time invested to optimize each tray were tracked. Cost savings were calculated. Student's t-test was used to determine statistical significance, with P < .05 considered significant. RESULTS: The mean instrument usage before and after Lean optimization was 23.4% and 54.2% (P < .0001). By Lean methods, 433 of 792 instruments (55%) were removed from 11 unique instrument trays (102 total trays), resulting in a reduction of 3520 instruments. Total weight reduction was 574.3 pounds (22%), ranging from 2.1-16.2 pounds per tray. The number of trays with wrapping holes decreased from 13 to 1 (P < .0001). The process of examining and removing instruments took an average of 7 minutes 35 seconds per tray. The calculated total annual savings was $270,976 (20% overall cost reduction). CONCLUSION: In addition to substantial cost savings, tray optimization decreases tray weights and cleaning times without negatively impacting turnover times. Lean methodology improves efficiency in instrument tray usage, and reduces hospital cost while encouraging surgeon and staff participation through continuous process improvement. LEVEL OF EVIDENCE: Economic Quality Improvement, Level III.

Pro-MMP-9 upregulation in HT1080 cells expressing CD9 is regulated by epidermal growth factor receptor.

Degradation of the surrounding extracellular matrix (ECM) by matrix metalloproteinases (MMPs) drives invasion and metastasis of cancer cells. We previously demonstrated that tetraspanin CD9 expression upregulates pro-MMP-9 expression and release and promotes cellular invasion in a human fibrosarcoma cell line (HT1080). These events were dependent upon the highly functional second extracellular loop of CD9. We report here that the epidermal growth factor receptor (EGFR) tyrosine kinase expression and activity are involved in the CD9-mediated increase in pro-MMP-9 release and cellular invasion. Pro-MMP-9 expression was significantly decreased in a dose-dependent manner using first a broad spectrum receptor tyrosine kinase inhibitor and multiple specific EGFR inhibitors in CD9-HT1080 cells. Furthermore, gefitinib treatment of CD9-HT1080 cells reduced invasion through matrigel. EGFR knockdown using short interfering RNA resulted in decreased pro-MMP-9 expression and release into the media and subsequent cellular invasion without affecting CD9 expression or localization. Conclusively, this study points to EGFR as a key mediator between CD9-mediated pro-MMP-9 release and cellular invasion of HT1080 cells.

Intrathecal Morphine Use Improves Postoperative Analgesia and Reduces Opioid Consumption in Patients Undergoing Total Knee Arthroplasty Under Spinal Anesthesia: A Retrospective Study.

Background Intrathecal morphine (ITM) provides effective postoperative analgesia for patients undergoing total knee arthroplasty (TKA) under spinal anesthesia (SA). The management of pain in patients undergoing TKA has remained a challenge for anesthesiologists, as no single regional anesthesia technique is adequate with regard to balancing effective analgesia with minimal side effects. Severe postoperative pain following TKA has been shown to negatively impact patient outcomes and mortality. This study is aimed to describe the effect of intrathecal morphine in patients undergoing total knee arthroplasty. Methods This was a retrospective, descriptive, and single-center study conducted on patients undergoing total knee arthroplasty from June 1, 2022, to June 1, 2023. The sample size consisted of 50 patients who were 18 years and older, American Society of Anesthesiology (ASA) class 1-3, and patients who had received either 150 mcg (experimental) or no ITM dose under spinal anesthesia. Oral morphine requirement (OME) and visual analog pain scale (VAS) were used to assess pain in the first 24 hours after surgery. Results The experimental group had significantly lower OME usage in the post-anesthesia care unit (PACU) (p < 0.001) and at six hours (p = 0.040) postoperatively. At 12 hours and 24 hours postoperatively, the two groups had similar OME use (p > 0.20, for both). The experimental group had significantly less total OME use over the first 24-hour postoperative period. The experimental group had significantly lower pain scores in the PACU (p < 0.001) and at six hours postop (p = 0.002); there were no significant differences between groups at 12- and 24-hours postop. The ambulation distance was clinically significant and better in the ITM group but was not statistically significant (p = 0.080). There was no difference between groups in the incidence of postoperative nausea and vomiting (PONV). Conclusion The careful use of ITM with the optimal dose offers an effective addition to regional anesthesia for improved analgesia with minimal side effects. The 150 mcg ITM dose provided good analgesic effects with longer duration and was not associated with respiratory depression.

COVID-19 and Acute Cervical Spinal Cord Injury-Case Report of 2 Patients: Do We Need to Rethink Our Standard Treatment Strategy?

STUDY DESIGN: This was a case series. OBJECTIVE: The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center. SUMMARY OF BACKGROUND DATA: There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic. METHODS: The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI. RESULTS: Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI. CONCLUSIONS: Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

Comparison Between the Direct Anterior and Posterior Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture.

OBJECTIVES: To compare 90-day and 1-year outcomes, including mortality, of femoral neck fracture patients undergoing total hip arthroplasty (THA) by direct anterior approach (DAA) versus posterior approach (PA). DESIGN: Retrospective cohort. SETTING: Level I Trauma Center. PATIENTS: One hundred forty-three consecutive intracapsular femoral neck fractures treated with THA from 2010 to 2018. The minimum follow-up was 12 months, and the average follow-up was 14.6 months (12-72 months). MAIN OUTCOME MEASURES: Postoperative outcomes, including discharge ambulation, dislocation, periprosthetic joint infection, revision THA, and mortality at 90 days and 1 year after THA. RESULTS: Of the 143 THA included, 44 (30.7%) were performed by DAA while 99 (69.3%) were performed by PA. In-hospital outcomes were similar between the cohorts. Compared with DAA patients, PA patients were more likely to ambulate without assistance preinjury (88.9% vs. 72.7%, P = 0.025) and be nonambulatory at the time of discharge (27.3% vs. 11.4%, P = 0.049). There were no significant differences in 90-day and 1-year postoperative outcomes between the DAA and PA groups, including dislocation, periprosthetic joint infection, periprosthetic fracture, mechanical complications, and revision surgery. Although there was no difference in mortality rate at 90 days, at 1-year follow-up the mortality rate was lower in the DAA group (0% vs. 11.1%, P = 0.018). CONCLUSIONS: Performing THA by DAA provides similar benefits in regards to medical and surgical outcomes compared with the PA for displaced femoral neck fracture. However, the DAA may lead to decreased 1-year mortality rates, possibly, because of improved early ambulation capacity that is an important predictor of long-term mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A prospective study of platelet function in trauma patients.

BACKGROUND: Exsanguination associated with acute traumatic coagulopathy is a leading cause of death following injury. While platelets occupy a pivotal role in clot formation, clinical research has been scant because of complexities resulting from the need for rapid handling and complex testing of platelet functions. While the thrombin pathway has been proposed as a mediator of platelet dysfunction in trauma, it has not been systematically investigated. The purpose of this study was to evaluate the thrombin pathway in platelet dysfunction. METHODS: Forty trauma patients and 20 noninjured controls were enrolled in the study at a Level I trauma center. Platelet aggregation was tested by light transmission aggregometry with two agonists, adenosine diphosphate (ADP) and thrombin receptor agonist peptide (TRAP). Mean fluorescence intensity and percent positivity of CD62 on ADP-activated platelets were evaluated using flow cytometry. Enzyme-linked immunosorbent assays were performed to evaluate the concentrations of D-dimer, thrombin-antithrombin complex (TAT), and prothrombin fragment 1 + 2 (PF 1 + 2) in each sample. RESULTS: Compared with healthy controls, trauma patients had significantly decreased ADP- and TRAP-mediated platelet aggregation and ADP-mediated CD62 expression. In trauma patients, TRAP-mediated aggregation was inversely proportional to head Abbreviated Injury Scale (AIS) score. Glasgow Coma Scale (GCS) score was directly proportional to TRAP- and ADP-mediated aggregation. When compared with controls, significant differences of D-dimer, TAT, and PF 1 + 2 were found. Measures of shock, including admission blood pressure, pulse, base deficit, and lactate level, did not correlate with platelet dysfunction. CONCLUSION: Trauma patients have significantly lower levels of platelet activation and aggregation compared with healthy controls. Severity of head injury was significantly correlated with platelet dysfunction in a stepwise fashion. Trauma patients also have significantly increased levels of D-dimer, TAT, and PF 1 + 2 when compared with healthy controls. Our data suggest that the thrombin receptor pathway plays an important role in platelet dysfunction in trauma. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Tetraspanin CD9 regulates cell contraction and actin arrangement via RhoA in human vascular smooth muscle cells.

The most prevalent cardiovascular diseases arise from alterations in vascular smooth muscle cell (VSMC) morphology and function. Tetraspanin CD9 has been previously implicated in regulating vascular pathologies; however, insight into how CD9 may regulate adverse VSMC phenotypes has not been provided. We utilized a human model of aortic smooth muscle cells to understand the consequences of CD9 deficiency on VSMC phenotypes. Upon knocking down CD9, the cells developed an abnormally small and rounded morphology. We determined that this morphological change was due to a lack of typical parallel actin arrangement. We also found similar total RhoA but decreased GTP-bound (active) RhoA levels in CD9 deficient cells. As a result, cells lacking a full complement of CD9 were less contractile than their control treated counterparts. Upon restoration of RhoA activity in the CD9 deficient cells, the phenotype was reversed and cell contraction was restored. Conversely, inhibition of RhoA activity in the control cells mimicked the CD9-deficient cell phenotype. Thus, alteration in CD9 expression was sufficient to profoundly disrupt cellular actin arrangement and endogenous cell contraction by interfering with RhoA signaling. This study provides insight into how CD9 may regulate previously described vascular smooth muscle cell pathophysiology.