Decision-making in the treatment of radial head fractures: Delphi methodology.

BACKGROUND: The treatment of partially displaced radial head fractures is determined not only by the type of fracture but also by patient characteristics such as age, occupation, hand dominance, mechanism of injury, and concomitant injuries and comorbidities. The goal of this study was to employ the Delphi method to achieve consensus on the management of patients with radial head fractures, utilizing the experience of the ASES Elbow Fracture-Dislocation Multicenter Study Group and Mayo Elbow Club surgeons. METHODS: The initial survey was sent to participants, which included consent to participate in the study and questions about their experience, knowledge, and interest in participating in the Delphi method. We used both open-ended and category-based questions. The second questionnaire generated 76 variables, and individual questions with mean Likert ratings of <2.0 or >4.0 were deemed significant and merged to form multifactorial clinical scenarios relating to both nonoperative and operative management, respectively. RESULTS: Of the surgeons who responded to the questionnaire, 64% were from the United States, while the remainder were from overseas practices. Years in practice on average were 12.4 years (range, 1-40). Seven of the 76 factors met the criteria of a mean Likert score of <2.0 or >4.0. These factors were as follows: age, block to the range of motion (ROM) after aspiration/injection, crepitation with ROM, tenderness over the distal radioulnar joint and/or interosseous membrane (dorsal forearm), gap and/or displacement >2 mm on imaging, complete loss of contact of the head with the rest of the radius on imaging, and fracture head involvement 30% on imaging. Twenty-two (46%) of the 96 clinical scenarios gained >90% consensus in favor of surgical treatment, whereas 8 (17%) reached >90% consensus in favor of nonoperative treatment. CONCLUSION: Obtaining expert consensus on the treatment of radial head fractures remains challenging. Certain factors such as gap/displacement ≥2 mm without complete loss of contact, ≥30% head involvement with a block to an ROM regardless of tenderness over distal radioulnar joint or interosseous membrane (dorsal forearm), or crepitation when the patient was <80 years of age led to a recommendation of operative treatment in 100% of the surveyed surgeons. Patients older than 80 years with no block to ROM after aspiration/injection, no crepitation with ROM, and no tenderness on distal radioulnar joint/interosseous membrane (dorsal forearm) were recommended for nonoperative treatment regardless of the size of the radial head involvement on imaging.

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis.

BACKGROUND: The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis. METHODS: We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates' heterogeneity with I2 index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns. RESULTS: After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20-0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations. CONCLUSION: The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery. LEVEL OF EVIDENCE: II - Systematic Review with Meta-Analysis.