Marking Pen Bacterial Contamination During Shoulder Surgery.

BACKGROUND: Equipment used to guide surgical incisions has been shown to be a source of bacterial contamination during surgery. PURPOSE/HYPOTHESIS: To compare the culture-positive rates of sterile marking pens used before and after skin preparation for shoulder surgery. It was hypothesized that there will be no difference in culture-positive rates from marking pens used after skin preparation compared with before skin preparation. STUDY DESIGN: Controlled laboratory study. METHODS: Overall, 43 consecutive patients undergoing elective shoulder surgery were enrolled prospectively into this study. Each patient provided 2 samples: study pens (from marking the surgical site incision after skin preparation) and positive control pens (from marking the surgical site incision before skin preparation). In addition, there were 43 negative control pens evaluated (straight from the packaging without any patient contact). Cultures were evaluated at 4 and 21 days, and all positive cultures were further evaluated for speciation, if able. Standard descriptive summaries and Fisher exact tests were used to compare the study samples. RESULTS: The average age of the 43 patients was 54 years (range, 18-76 years). There were 29 (67%) female patients, and 30 (70%) procedures were on the right shoulder. Of the 43 procedures performed, 29 (67.4%) were arthroscopic, 12 (27.9%) were open, and 2 (4.7%) were closed. Of the 43 study pens, 1 culture was positive for Propionibacterium acnes (2.3%). Of the 43 positive control pens, 2 cultures were positive for bacterial growth (4.7%): P. acnes and Gram-positive bacilli (no speciation could be obtained). Of the 43 negative control pens, none of the cultures were positive for bacterial growth (0%). There was no statistical difference in the culture-positive rate between the study pens and the positive or negative control pens (P ≥ .999). CONCLUSION: Study results indicated that sterile surgical marking pens used to plan incisions and to outline anatomic landmarks did not have a higher culture-positive rate compared with pens used on unprepared skin or pens straight from the packaging. CLINICAL RELEVANCE: As a precaution, sterile surgical marking pens should be discarded after use on the skin surface and not placed on the sterile field.

Low-Cost Earmuff Shown to Significantly Reduce Cast-Saw Noise.

Hearing protection devices reduce cast-saw noise. It would be helpful to identify the devices that are both effective and economical. Prior studies have shown that expensive noise-reduction headphones significantly reduced the anxiety associated with cast removal with a powered oscillating saw. The cost of such headphones, however, is a drawback for some practices and hospitals. It would be helpful to determine whether lower cost ear protection can provide effective cast-saw noise reduction. In addition, it is unclear whether the noise reduction ratings (NRRs), the average sound-level reduction provided by a hearing protection device in a laboratory test, provided by manufacturers accurately characterize the effectiveness for reducing cast-saw noise. Note that noise-cancelling devices do not carry an NRR because they are not designed as hearing protectors. Five ear protection devices with different NNRs were tested. The devices varied greatly in cost and included earplugs, low-cost earmuffs, and noise-cancelling headphones. To standardize the evaluation, each device was fitted to an acoustic mannequin with high-fidelity ear microphones while a fiberglass spica cast was cut. An additional test was run without hearing protection as a control. The low-cost devices significantly reduced the saw noise, with the exception of earplugs, which had highly variable performance. The noise reduction was similar between low-cost earmuffs and the high-cost earphones when the noise-cancelling feature was not active. Active noise cancelling provided further reductions in the noise level. Patients can experience high anxiety during cast removal. The current study shows that low-cost earmuffs significantly reduce cast-saw noise. Patient care settings may be more likely to offer hearing protection that is one twenty-fifth the cost of noise-cancelling headphones. An NRR appears to be a reliable guide for selecting hearing protection that reduces cast-saw noise.

The Effect of Booster Seat Use on Pediatric Injuries in Motor Vehicle Frontal Crashes.

BACKGROUND: Motor vehicle crashes are a significant source of pediatric mortality and morbidity. Studies indicate that booster seats significantly improve seat belt fit for children who have not attained a height of 145 cm (4' 9"). This study examined injuries occurring in booster age children up to age 12, as the majority of children do not attain 145 cm until this age. The purpose of the study was to identify differences in injuries due to the type of restraint used, with attention to musculoskeletal injuries. METHODS: Vehicle and occupant data were obtained from a publically available statistical sample of tow-away crashes. Frontal crashes over an 8-year period were examined. A data set of cases was created involving children ages 5 to 12 years who were unrestrained, restrained using the vehicle's lap and shoulder belt, and restrained using a booster seat with the vehicle's lap and shoulder seat belt. Injury severity, frequency, and patterns of distribution were compared. RESULTS: Unrestrained children experienced moderate to severe injuries 3.8 to 19 times more frequently than children using restraints. There were more injuries to the head and face in unrestrained versus restrained children, but the head and face was the most frequently injured region for all groups. There were no serious cervical spine injuries reported for any group. Lower extremity fractures were not observed in booster seat users but occurred at similar rates in both unrestrained and seat belt restrained children. These fractures occurred in older children who were involved in more severe crashes. CONCLUSIONS: Unrestrained children were more likely to experience moderate and severe injuries than restrained children. The data sample suggests that booster use may reduce the risk of extremity fracture, as there were no extremity fractures in children restrained with booster seats. CLINICAL RELEVANCE: This work provides evidence for the efficacy of booster use for preventing orthopaedic injury in children. This evidence can be used to inform parents and establish recommendations for best practices in transporting children.

Evaluation of 3 Fixation Devices for Tibial-Sided Anterior Cruciate Ligament Graft Backup Fixation.

We conducted a study to biomechanically evaluate 3 methods of tibial-sided fixation for anterior cruciate ligament reconstruction: fully threaded interference screw only, interference screw backed with 4.75-mm SwiveLock anchor, and fully threaded bio-interference screw backed with 4.5-mm bicortical screw (all Arthrex). Thirty skeletally mature porcine tibiae were used. The first group was prepared by graft fixation within the tibial tunnel using only an interference screw. The second and third groups included an interference screw with 2 types of secondary fixation: 4.5-mm bicortical post and SwiveLock anchor. Mechanical testing consisted of 500 cycles between 50 and 250 N at 1 Hz, followed by a pull to failure conducted at 20 mm per minute. Ultimate load-to-failure testing demonstrated the largest mean (SD) load tolerated in the post/washer group, 1148 (186) N, versus the SwiveLock group, 1007 (176) N, and the screw-only group, 778 (139) N. There was no statistical difference between the 2 backup fixation groups. Use of a SwiveLock anchor as backup fixation at the tibial side in soft-tissue anterior cruciate ligament reconstruction is a safe, effective alternative to a bicortical post and provides statistically equivalent pullout strength with unlikely requirement for future hardware removal.

Increasing alpha angle is predictive of athletic-related "hip" and "groin" pain in collegiate National Football League prospects.

PURPOSE: The first purpose was to evaluate radiographic pathomorphology/abnormalities in a cohort of high-level collegiate football players screened with hip radiographs. The second purpose was to define the radiographic predictors of athletic-related "hip" and "groin" symptoms in this cohort of high-level athletes. METHODS: The study population included all male collegiate football players undergoing evaluation and hip radiography at the National Football League (NFL) Scouting Combine in 2009 and 2010. All radiographs were evaluated with a detailed evaluation for hip pathomorphology. Symptoms were recorded as symptomatic or asymptomatic with respect to athletic-related groin/hip pain for comparative purposes. RESULTS: There were 125 players (239 hips) who had hip radiographs and were included in the final cohort. Ninety percent of players (87% of hips) in this cohort had at least 1 finding consistent with cam-type and/or pincer-type femoroacetabular impingement (FAI). There were 75 hips in the symptomatic group and 164 hips in the asymptomatic group. Although the symptomatic group had a greater prevalence of cam-type FAI (P = .009), combined-type FAI (P < .001), and osteitis pubis (P = .014), increasing alpha angle (larger cam deformities) was the only independent predictor of athletic-related groin pain (P = .01). There was no correlation, however, between FAI and body mass index (P = .659), player position (P = .166), or whether a player was drafted by an NFL team (P = .430). CONCLUSIONS: Radiographic signs of FAI were frequently seen in collegiate NFL prospects who were screened with hip radiographs. Although patients with radiographic evidence of osteitis pubis, cam- and combined-type FAI, and larger cam deformities showed a statistically higher prevalence of symptoms, increasing alpha angle (larger cam deformity) was the only independent predictor of athletic-related hip/groin pain. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Functional elbow range of motion for contemporary tasks.

BACKGROUND: Elbow range of motion for functional tasks has been previously studied. Motion arcs necessary to complete contemporary tasks such as using a keyboard or cellular telephone have not been studied and could have implications on what is considered to be a functional arc of motion for these tasks. The purpose of this study was to determine elbow range of motion, including flexion-extension, pronation-supination, and varus-valgus angulation, with use of three-dimensional optical tracking technology for several previously described positional and functional tasks along with various contemporary tasks. METHODS: Twenty-five patients performed six positional and eleven functional tasks (both historical and contemporary). Elbow flexion-extension, varus-valgus, and forearm rotation (pronation and supination) ranges of motion were measured. RESULTS: Positional tasks required a minimum (mean and standard deviation) of 27° ± 7° of flexion and a maximum of 149° ± 5° of flexion. Forearm rotation ranged from 20.0° ± 18° of pronation to 104° ± 10° of supination. Varus and valgus angulations ranged between 2° ± 5° of varus to 9° ± 5° of valgus. For functional tasks, the maximum flexion arc was 130° ± 7°, with a minimum value recorded as 23° ± 6° and a maximum value recorded as 142° ± 3°. All of these were for the cellular telephone task. The maximum pronation-supination arc (103° ± 34°) was found with using a fork. Maximum pronation was found with typing on a keyboard (65° ± 8°). Maximum supination was found with opening a door (77° ± 13°). Maximum varus-valgus arc of motion was 11° ± 4°. Minimum valgus (0° ± 6°) was found with cutting with a knife, while maximum valgus (13° ± 6°) was found with opening a door. CONCLUSIONS: Functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks.

Distances to the subacromial bursa from 3 different injection sites as measured arthroscopically.

PURPOSE: The purpose of this study was to assess the distance for a standard needle to reach the subacromial bursa through 3 commonly used approaches. METHODS: Thirty patients without associated rotator cuff tears underwent arthroscopic evaluation of the shoulder. The bursa was entered without shaving or altering of the bursa. By use of standard arthroscopic portals, a spinal needle was inserted from an anterior, lateral, and posterior position and measured to define the distance to the subacromial bursa from the skin. RESULTS: The mean distance with anterior needle placement was 2.9 +/- 0.6 cm. The mean distance with lateral needle placement was 2.9 +/- 0.7 cm. The mean distance with posterior needle placement was 5.2 +/- 1.1 cm. The mean body mass index for the group of patients was 27.5. The minimum was 18.7, and the maximum was 42.8. CONCLUSIONS: The distance to the subacromial bursa from the anterior and lateral approaches appears to be consistent and within reach of a standard 22- or 25-gauge needle. The distance to the subacromial bursa from a posterior approach appears to be almost double that of the anterior and lateral approaches and may not be reachable by standard 22- and 25-gauge needles in all patients. There appears to be no correlation between distances to the subacromial bursa from the anterior, lateral, or posterior approaches and the patient's body mass index. CLINICAL RELEVANCE: Given the relative distances measured to the subacromial bursa from the anterior, lateral, and posterior positions, clinicians may choose a longer needle to improve the accuracy of placement when approaching the subacromial bursa from a posterior position. Use of a standard-length needle will provide reasonable accuracy from the anterior and lateral positions.