Quality of lower limb preoperative skin preparation using colorless versus colored disinfectants-results of an experimental, randomized study in a close to reality setting.

BACKGROUND: Appropriate preoperative skin cleansing is important to control surgical site infections. Both colored and colorless skin disinfectants are available, however certain types of skin preparation, such as octenidine-dihydrochloride with alcohol have a long residual antimicrobial effect but are available only in colorless form. We hypothesized that colorless skin disinfectants lead to more incomplete skin preparation of lower limbs compared to colored agents. METHODS: We randomly assigned healthy volunteers to undergo a determined skin cleansing protocol for total hip arthroplasty in the supine position to either a colored or colorless skin cleansing protocol. The adequacy of skin preparation was compared between orthopedic consultants and residents. The colorless disinfectant was mixed with a fluorescent dye and missed skin areas were visualized using UV lamps. Both preparations were photo-documented following standardized protocols. The primary outcome of interest was the number of legs with an incomplete scrubbed area. The secondary outcome was the cumulative skin area not disinfected. RESULTS: Fifty-two healthy volunteers (104 legs; 52 colored and 52 colorless) underwent surgical skin preparation. The number of legs incompletely disinfected was significantly higher in colorless compared to colored disinfectant group (38.5% (n = 20) vs. 13.5% (n = 7); p = 0.007). Regardless of the disinfectant, consultants performed better than the residents. When using colored disinfectant, residents incompletely prepared the site in 23.1% (n = 6) compared with 57.7% (n = 15) with a colorless disinfectant (p = 0.023). Conversely consultants using colored disinfectant incompletely prepared the site in 3.8% (n = 1) compared with 19.2% (n = 5) for colorless disinfectant (p = 0.191). The total amount of uncleansed skin was significantly higher using colorless skin disinfectant (mean ± standard deviation: 8.78 cm2± 35.07 vs. 0.65 cm2 ± 2.66, p = 0.002). CONCLUSIONS: Application of colorless skin disinfectants for hip arthroplasty cleansing protocol led to decreased skin coverage among consultants and residents compared to colored preparations. Colored disinfectants remain the gold standard in hip surgery, however we should be aiming to develop newer colored disinfectants with long residual antimicrobial effects to enable visual control during the scrubbing process.

A Rare Case of Complex Pelvic Injury and Associated Intrathecal Fat Embolism due to Spinopelvic Dislocation with Sacral Burst Fracture.

INTRODUCTION: Pelvic and lumbar spine injuries are very common especially in multiple trauma patients. The usual mechanism in young patients leading to pelvic fractures is a high-energy trauma such as traffic accidents. In elderly patients, low energy traumas are causal for such injuries. Compared to the high number of patients with pelvic or lumbar spine injuries, cerebral fat embolism is a quite rare finding but it needs to be considered to not misinterpret the radiological findings. CASE: We present the case of a 41-year-old patient, who got hit and trapped in the lumbar region by a hydraulic arm in a car repair shop. The patient was primarily admitted to a level II trauma center. The radiological and clinical examinations revealed an open pelvic type C injury in terms of a spinopelvic dissociation, dislocation of the left hip joint, rupture of the mesentery of the rectum and colon sigmoideum, and a complex injury to the left ureter. Additionally, CT scan showed fluid with higher density than cerebro spinal fluid (CSF) in the lateral ventricles indicating an intracranial bleeding. After an immediate surgery to stabilize the patient, he was admitted to a level I trauma center. The reanalysis of the existing CT datasets combined with a new head CT leads to the conclusion that the high density fluid in the lateral ventricles is not a intracranial bleeding but rather fat deriving from the complex pelvic and lumbar spine fracture into the CSF system. Therefore, an immediate operation was performed to stabilize the spinopelvic dissociation and to close the injured dural sheath. Additionally, a ventricle drainage has been placed, which confirmed the diagnosis of intrathecal fat embolism. Afterwards, complex plastic surgery was necessary to restore the soft tissue damage. CONCLUSIONS: Intrathecal fat embolism in muliple trauma patients is a rare condition, which should be considered in patients with complex spine or pelvic injuries. It is important to distinguish this rare condition from intracranial bleedings, which are much more common because the consequent therapeutic strategy is quite different. In case of intrathecal fat embolism, a ventricle drainage system should be placed immediately, and the underlying spine or pelvic injuries need to be stabilized combined with closure of the dural sheath to prevent continuous fat embolism and meningeal infection.