Intraoperative scrub nurse turnover in orthopaedic surgery procedures: An opportunity for improved operating room efficiency.

BACKGROUND: Scrub nurses play a crucial role in facilitating orthopaedic surgeries, and thus intraoperative scrub nurse turnover may disrupt the workflow of the surgical team and prolong duration of surgery (DOS). The purpose of this study was to quantify the impact of intraoperative scrub nurse turnover on operative time of orthopaedic surgeries lasting less than 3h in duration. METHODS: Prospectively collected databases from two institutions were retrospectively queried to identify all orthopaedic procedures of maximum mean duration of 180min from March 4th, 2018 to August 31st, 2022. Cases were divided into two groups, those with scrub nurse turnover and those without. Propensity score matching was conducted to match groups by surgeon, hospital, patient age, gender, and ASA classification. Unpaired t-tests were used to compare mean DOS for each surgical procedure. Average treatment effect on treated (ATET) with 95% confidence intervals (CIs) were calculated. RESULTS: Scrub nurse turnover significantly prolonged DOS for both bone forearm facture open reduction and internal fixation (ORIF) (ATET=21.08, p=0.001), ankle ORIF (ATET=21.26, p<0.001), clavicle ORIF (ATET=16.16, p=0.028), femur intramedullary nail (ATET=11.52, p=0.003), rotator cuff repair (ATET=16.88, p<0.001), partial discectomy (ATET=10.52, p=0.001), total knee arthroplasty (TKA) (ATET=5.69, p<0.001), anterior total hip arthroplasty (THA) (ATET=8.80, p<0.001), lateral THA (ATET=7.02, p<0.001), and uncemented hip hemiarthroplasty (ATET=16.79, p=0.049). CONCLUSION: Intraoperative scrub nurse turnover significantly prolongs surgical times in orthopaedic surgeries lasting up to 3h in duration. This highlights the importance of developing strategies to prevent intraoperative scrub nurse turnover to improve OR efficiency and decrease healthcare costs.

Resident education in orthopaedic trauma: the future role of competency-based medical education.

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees' performance in managing orthopaedic trauma patients. This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320-5.

Reflections on current methods for evaluating skills during joint replacement surgery: a scoping review.

Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons' competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.

Evaporation of ionic liquids at atmospheric pressure: study by ion mobility spectrometry.

A conventional ion mobility spectrometry (IMS) was used to study atmospheric pressure evaporation of seven pure imidazolium and pyrrolidinium ionic liquids (ILs) with [Tf(2)N], [PF(6)], [BF(4)] and [fap] anions. The positive drift time spectra of the as-received samples measured at 220°C exhibited close similarity; the peak at reduced mobility K(0)=1.99 cm(2)V(-1)s(-1) was a dominant spectral pattern of imidazolium-based ILs. With an assumption that ILs vapor consists mainly of neutral ion pairs, which generate the parent cations in the reactant section of the detector, and using the reference data on the electrical mobility of ILs cations and clusters, this peak was attributed to the parent cation [emim]. Despite visible change in color of the majority of ILs after the heating at 220°C for 5h, essential distinctions between spectra of the as-received and heated samples were not observed. In negative mode, pronounced peaks were registered only for ILs with [fap] anion.

Influence of the number of cortices on the stiffness of plate fixation of diaphyseal fractures.

OBJECTIVE: To determine the influence of the number of cortices of fixation on the stiffness of plate fixation of diaphyseal fractures. DESIGN: Canine experimental study. SETTING: Tertiary referral and teaching hospital in Toronto, Canada. PARTICIPANTS: Paired radii from fourteen skeletally mature, cross-bred dogs. MAIN OUTCOME MEASURE: One member of each pair of radii was tested intact as a control, and the other had a transverse osteotomy plated sequentially with five to ten cortices of fixation on either side of the simulated fracture. Dynamic compression plates and limited contact dynamic compression plates were used in two groups with seven paired radii each. Normalized torsional stiffness and four-point bending stiffness were determined in the elastic range for the control and each of the plated constructs in both groups, using a materials testing machine. RESULTS: The authors found no significant difference between the stiffness of the dynamic compression plates and limited contact dynamic compression plates. With either plate of a given length, significantly increased torsional stiffness is achieved with end bicortical screws. For bending stability with the plate at right angles to the bending plane, even short plated constructs have a stiffness exceeding that of intact bone. CONCLUSIONS: For a transverse osteotomy with no fracture interdigitation, the bending rigidity with the plate at right angles to the bending plane is greater than the original stiffness of the bone for all constructs tested, with the exception of the limited contact dynamic compression plate with five cortices of fixation. The torsional rigidity of fixation only approaches the original rigidity of the bone for ten cortices of fixation with the dynamic compression plate and the limited contact dynamic compression plate.

Characterization of exoskeletal proteins from the American lobster, Homarus americanus.

Proteins from the calcified exoskeleton of the lobster, Homarus americanus, were extracted and separated by two-dimensional gel-electrophoresis. Electroblotting the proteins onto polyvinylidene difluoride (PVDF) membranes followed by sequence determination gave 16 N-terminal amino-acid sequences and revealed that further eight proteins were N-terminally blocked. The relative molecular mass, M(r), was obtained for most of the electrophoretically separated proteins by means of matrix-assisted laser desorption mass spectrometry (MALDIMS) after electroelution from Coomassie-stained two-dimensional polyacrylamide gels. Eleven proteins were purified from extracts of the exoskeleton by low pressure ion exchange chromatography and reversed-phase high performance chromatography, and their sequences were determined by combined use of Edman degradation and mass spectrometry. Good agreement was obtained between the M(r)-values measured by mass spectrometry and those calculated from the sequences. Five of the sequenced proteins contain two copies of a previously observed 18-residue sequence motif, while a couple of the remaining sequences show similarity to sequences of exoskeletal proteins from shrimps and spiders. Only limited similarity to insect cuticular proteins was observed.

Does bacteremia occur during high pressure lavage of contaminated wounds?

The risk of bacteremia secondary to high pressure lavage of contaminated wounds was assessed. Twenty canines were divided randomly into four treatment groups. A 10-cm incision was made over the left shoulder of each dog. The deltoideus muscle was disrupted and traumatized. Groups A and B (n = 8) had wound contamination with 1.4 x 10(9) Staphylococcus aureus followed 75 minutes later by high pressure lavage or bulb syringe irrigation, respectively. Groups C and D (n = 2) had no contamination, followed by the same treatment. Bacterial counts were obtained before and after wound irrigation. Blood cultures were obtained before, during, and 15 minutes after irrigation. Positive control cultures were obtained during injection of bacteria into the antecubital vein. A detectable bacteremia did not occur during or after high pressure lavage or bulb syringe irrigation of acute contaminated wounds but did occur in 18 of 20 positive controls. Bacterial levels were reduced by an average of 70% +/- 10% by high pressure lavage and 44% +/- 50% by bulb irrigation. Reduction of wound bacteria was achieved more consistently with high pressure lavage than with bulb syringe irrigation.

Moisture and mould problems in schools and respiratory manifestations in schoolchildren: clinical and skin test findings.

OBJECTIVE: We performed a clinical study in 99 children attending schools with moisture problems and compared the findings with those of 34 children from a reference school. The aim of the study was to evaluate the possible association between respiratory or allergic diseases in the pupils and moisture or mould problems in the school buildings. RESULTS: Asthma was diagnosed in nine (6.7%) children: eight of them came from the moisture-problem schools and all were over 10 y old. In addition, 17 non-asthmatic children had suffered from wheezing and 21 from long-term cough, both symptoms being suggestive of occult asthma. If moisture problems were observed both at home and in the school, the frequency of asthma was 21% and the combined frequency of asthma and wheezing was 43%. The presence of allergic rhinoconjuntivitis or atopic dermatitis had no association with moisture or mould problems. We performed skin-prick tests to 13 moulds in all the 133 children. A positive reaction (> 3 mm) was observed in only six (5%) of them. All six positive children reacted to at least one moisture-indicative mould, Fusarium roseum, Aspergillus fumigatus, Phoma herbarum or Rhodotorula rubra. None of these cases came from the reference school. There was a significant association between positive reactions to moisture-indicative moulds and asthma; four (44%) of the nine children with asthma had such reactions. In addition, all the 6 reactive children had either asthma or wheezing. CONCLUSIONS: We report preliminary evidence for an association between moisture or mould problems in the school building and the presence of manifest and occult asthma in the pupils. Our results show that skin-test positivity to moulds is rare in children. However, reactivity to moisture-indicative moulds seems to be associated with the occurrence of asthma or wheezing.

Calcium hydroxide ameliorates tobramycin toxicity in cultured chick tibiae.

Results from this laboratory have shown that bone metabolism is directly related to extracellular pH and that high concentrations of tobramycin released from impregnated polymethylmethacryrate (PMMA) beads has pH-dependent toxic effects on bone. In the present study, beneficial effects of calcium hydroxide-impregnated PMMA were investigated regarding tobramycin toxicity and bone metabolism in chick embryo tibiae in vitro. Also using Ca(OH)2 as a pH regulator, the antibiotic efficacy of tobramycin-impregnated PMMA was evaluated with respect to inhibition of Staphylococcus aureus growth. When Ca(OH)2 was added to PMMA beads containing tobramycin, the beads released hydroxyl and calcium ions into the culture medium and released more antibiotic than beads containing only tobramycin. Bone metabolism (glycolysis, total protein synthesis, and collagen synthesis) was enhanced by Ca(OH)2-impregnated beads with or without tobramycin. Additionally, bacterial growth was inhibited more strongly when S. aureus was incubated with tobramycin- and Ca(OH)2-impregnated PMMA disks than with disks containing only tobramycin. This study demonstrates the feasibility of adding Ca(OH)2 to tobramycin-impregnated PMMA beads as a regulator of local pH and a promoter of bone metabolism for protection of bone when high concentrations of tobramycin are used to treat osteomyelitis. It also suggests that lower concentrations of antibiotic may be effective if Ca(OH)2 and tobramycin are administered simultaneously.

Internalization of Staphylococcus aureus by cultured osteoblasts.

Staphylococcus aureus is the most common cause of both acute and chronic osteomyelitis; however, the pathogenesis of osteomyelitis is poorly understood. We investigated the ability of S. aureus to associate with chick osteoblasts in culture and have demonstrated internalization of bacteria by the osteoblasts. Two strains of S. aureus were examined that were ingested by osteoblasts to different extents, suggesting strain differences in uptake. Initial association of S. aureus strains with osteoblasts was independent of the presence of matrix collagen produced by the osteoblasts. Internalization of bacteria required live osteoblasts, but not live S. aureus, indicating osteoblasts are active in ingesting the organisms. The bacteria were not killed by the osteoblasts, since viable bacteria were cultured several hours after ingestion.