Image-derived instrumentation vs. conventional instrumentation with 3D planning for glenoid component placement in reverse total shoulder replacements: a randomized controlled trial.

Hypothesis: Glenoid baseplate positioning for reverse total shoulder arthroplasty (rTSA) is important for stability and longevity, with techniques such as image-derived instrumentation (IDI) developed for improving implant placement accuracy. We performed a single-blinded randomized controlled trial comparing glenoid baseplate insertion accuracy with 3D preoperative planning and IDI jigs vs. 3D preoperative planning and conventional instrumentation. Methods: All patients had a preoperative 3D computed tomography to create an IDI; then underwent rTSA according to their randomized method. Repeat computed tomography scans performed at six weeks postoperatively were compared to the preoperative plan to assess for accuracy of implantation. Patient-reported outcome measures and plain radiographs were collected with 2-year follow-up. Results: Forty-seven rTSA patients were included (IDI n = 24, conventional instrumentation n = 23). The IDI group was more likely to have a guidewire placement within 2mm of the preoperative plan in the superior/inferior plane (P = .01); and exhibited a smaller degree of error when the native glenoid retroversion was >10° (P = .047). There was no difference in patient-reported outcome measures or other radiographic parameters between the two groups. Conclusion: IDI is an accurate method for glenoid guidewire and component placement in rTSA, particularly in the superior/inferior plane and in glenoids with native retroversion >10°, when compared to conventional instrumentation.

Efficacy of surgeon-directed suprascapular and axillary nerve blocks in shoulder arthroscopy: a 3-arm prospective randomized controlled trial.

Background: The use of regional anesthesia in shoulder arthroscopy improves perioperative pain control, thereby reducing the need for opioids and their recognized side effects. Occasionally one type of block is not suitable for a patient's anatomy or comorbidities or requires a specially trained anesthetist to safely perform. The primary aim of this study is to compare the efficacy of 3 different nerve blocks for pain management in patients undergoing shoulder arthroscopy. Methods: A 3-arm, blinded, randomized controlled trial in patients undergoing elective, unilateral shoulder arthroscopic procedures between August 2018 and November 2020 was conducted at a single center. One hundred and thirty participants were randomized into 1 of 3 regional anesthesia techniques. The first group received an ultrasound-guided interscalene block performed by an anesthetist (US + ISB). The second group received an ultrasound-guided suprascapular nerve block and an axillary nerve block by an anesthetist (US + SSANB). The final group received a suprascapular nerve block without ultrasound and an axillary nerve block under arthroscopic guidance by an orthopedic surgeon (A + SSANB). Intraoperative pain response, analgesia requirements, and side effects were recorded. Visual analogue pain scores and opioid doses were recorded in the Post Anaesthesia Care Unit (PACU) and daily for 8 days following the procedure. Results: Twelve patients withdrew from the study after randomization, leaving 39 participants in US + ISB, 40 in US + SSANB, and 39 in A + SSANB. The US + ISB group required significantly lower intraoperative opioid doses than US + SSANB and A + SSANB (P < .001) and postoperatively in PACU (P < .001). After discharge from hospital, there were no differences between all groups in daily analgesia requirements (P = .063). There was significantly more nerve complications with 6 patient-reported complications in the US + ISB group (P = .02). There were no reported differences in satisfaction rates between groups (P = .41); however, the A + SSANB group was more likely to report a wish to not have a regional anesthetic again (P = .04). Conclusion: The US + ISB group required lower opioid doses perioperatively; however, there was no difference between groups after discharge from PACU. The analgesia requirements between the US + SSANB and A + SSANB were similar intraoperatively and postoperatively. A surgeon-administered SSANB may be a viable alternative when an experienced regional anesthetist is not available.

Contamination Associated With Glove Changing Techniques in the Operating Theatre.

Background: Sterility of the operative field during surgery is imperative in reducing the risk of infection. Most commonly, double gloves are worn by surgeons. When contamination occurs, the top gloves are changed intra-operatively. No studies have investigated which glove changing technique is best. Therefore, in this study, we aim to identify which top glove changing technique causes the least surface contamination. Methods: Glitterbug™ (UV fluorescent powder) was applied to the top gloves of 3 individuals who changed their top gloves according to a randomised method - Method 1: 3 pairs worn, remove the outer pair; Method 2: 2 pairs worn, remove the top glove, replace unassisted; and Method 3: 2 pairs worn, remove the top glove, and replace assisted by a scrub nurse. A blinded investigator inspected for Glitterbug™ contamination under UV light. Results: Two hundred and ten trials were performed and two types of contamination were identified, namely, direct contact and airborne spread. For absolute contamination, Method 1 had 59/64 (92%) contaminated trials, Method 2 had 49/65 (75%) contaminated trials, and Method 3 had 64/81 (79%) contaminated trials. This was statistically significant (p = 0.031). For direct contamination only, Method 1 had 38/64 (59%) contaminated trials, Method 2 had 24/65 (37%) contaminated trials, and Method 3 had 20/81 (25%) contaminated trials. This was statistically significant (p < 0.0001). Conclusions: Method 2 had a statistically significant lower contamination rate overall, with Method 3 having the lowest direct contamination rate. We believe that wearing 2 gloves, removing the top glove and replacing it, either assisted or unassisted, could decrease surface contamination of the sterile field.

Sterile stockinette in orthopaedic surgery: a possible pathway for infection.

BACKGROUND: The prevention of infection in joint replacement surgery is important. Preparing and draping the patient is fundamental to maintaining sterility of the operative field. One method of draping for total knee replacement (TKR) surgery involves cleaning the operative leg with antiseptic wash then covering the un-prepped foot with a sterile stockinette to sequester the foot from the sterile field. There are two main methods for applying this stockinette. This randomized, blinded control trial simulates stockinette application to assess if it prevents proximal microbial migration into the sterile field. METHOD: To simulate microbial presence, ultraviolet fluorescent powder Glitterbug Powder™ (Arrow Scientific Pty Ltd, Lane Cove, NSW, Australia) was applied to volunteers' feet to the level where antiseptic wash would routinely stop during preparation. The stockinette was applied. Two methods of application (above and below knee) and two surgeons were used. These were randomized for each application. The drapes were removed and a blinded assistant measured the distance of proximal spread of Glitterbug Powder™. RESULTS: Both methods of application were associated with considerable proximal spread of Glitterbug Powder™. For the below knee method, mean proximal spread distance of 49.19%; for the above knee, mean of 71.8% proximal spread (P = 0.038). Multivariate linear regression analysis demonstrated that method and location of the contamination were predictive of the area of contamination and the percentage of the leg contaminated. No other factors (surgeon, gender, hirsute score) were predictive of either area or percentage contamination. CONCLUSION: The surgical field for TKRs may be contaminated by significant proximal microbial spread from the unprepared foot with the use of a sterile stockinette drape.