C-arm contamination of the surgical field: Can contamination be reduced with an intervening drape?

INTRODUCTION: Contamination of the surgical field by the C-arm in orthopaedic procedures is a significant potential source for surgical site infections. The purpose of this study was to explore the utility of a split sheet to aid in prevention of secondary contamination from the C-arm on the C-arm side of the operative field. METHODS: A C-arm and a surgical table were draped by standard techniques. The surgical table was split in thirds: the surgeon's side, the C-arm side of the operative field, and the middle for contamination analysis. Fluorescent powder was used to simulate a contaminant and placed on the C-arm, floor and lower portions of drapes. The C-arm was cycled between PA and Lateral positions. Powder transfer to the field was visualized with a camera under uniform UV light. Photographs were taken to measure fluorescent pixels prior to cycling the C-arm and at 5, 10 and 15 cycles. This protocol was repeated using a split sheet (U-drape) to isolate the C-arm below the operative field. Image J was utilized to calculate differences in the number of pixels brighter than the control image. RESULTS: Using standard draping techniques, there was contamination of the surgical field with the C-arm side of the operative field having the highest level of fluorescent pixels. The number of fluorescent pixels was linearly correlated with the number of PA to Lateral cycles. At the end of 15 cycles, the average number of fluorescent pixels for the intervening draping technique was 2.9 pixels compared to the standard draping technique of 3939 pixels (p = 0.0078). DISCUSSION: The addition of a U-drape between the C-arm and the table results in a statistically significant reduction in surgical field contamination as a result of secondary transfer from the C-arm. LEVEL OF EVIDENCE: II.

Resident Training and the Assessment of Orthopaedic Surgical Skills.

Medical knowledge and technical skills are foundations of surgical competency. The American Board of Orthopaedic Surgery (ABOS) and the Resident Review Committee for Orthopaedic Surgery recently mandated simulation training to improve surgical skills, listing 17 surgical skills modules to improve residents' technical skills. However, there is no established tool to measure the effectiveness of these modules. The Global Index for Technical Skills (GRITS) tool has been previously validated for evaluating general surgery residents. The aim of this study was to determine whether the GRITS tool is valid, practical, and reliable in evaluating the skills of orthopaedic residents in a simulation setting, whether the outcomes correlate to performance in the operating room, and to what extent these simulation modules are valued by residents. METHODS: Simulation performance was assessed longitudinally on 5 residents using the GRITS assessment through postgraduate years (PGY) 1 to 5 (n = 25 evaluations) in a simulated volar forearm approach using cadaveric specimens. An additional 20 PGY-1 residents were evaluated cross-sectionally in this same time frame. Written, open-ended feedback on the simulation experience was sought and analyzed via a thematic analysis. For correlative data, evaluations (n = 65 evaluations) of a variety of authentic surgical procedures were compiled on PGY-2 through PGY-5 orthopaedic residents and compared with the simulated experiences. RESULTS: GRITS scores were averaged for each group of residents, and validity and reliability were assessed using R-software. PGY-1 residents' mean GRITS evaluation score (expressed as a value from 1 to 5) was 3.4. Longitudinally, this mean score increased over the PGY years 2-5 to 4.4, 4.7, 4.9, and 4.8, respectively. Of the parameters measured by GRITS, the lowest average scores were "flow of operation" and "time and motion" across all levels, although these did improve over PGY years 2 to 5. Findings were consistent between simulation and "real-world" procedures. Open-ended responses evaluating the module were positive. CONCLUSIONS: Our study suggests that the GRITS tool shows promise as an effective and reliable method for assessing orthopaedic resident's technical skills based on an ABOS module system.