Effectiveness of prophylactic intranasal photodynamic disinfection therapy and chlorhexidine gluconate body wipes for surgical site infection prophylaxis in adult spine surgery.

BACKGROUND: Current measures to prevent spinal surgical site infection (SSI) lack compliance and lead to antimicrobial resistance. We aimed to examine the effectiveness of bundled preoperative intranasal photodynamic disinfection therapy (nPDT) and chlorhexidine gluconate (CHG) body wipes in the prophylaxis of spine SSIs in adults, as well as determine our institutional savings attributable to the use of this strategy and identify adverse events reported with nPDT-CHG. METHODS: We performed a 14-year prospective observational interrupted time-series study in adult (age > 18 yr) patients undergoing emergent or elective spine surgery with 3 time-specific cohorts: before rollout of our institution's nPDT-CHG program (2006-2010), during rollout (2011-2014) and after rollout (2015-2019). We used unadjusted bivariate analysis to test for temporal changes across patient and surgical variables, and segmented regression to estimate the effect of nPDT-CHG on the annual SSI incidence rates per period. We used 2 models to estimate the cost of nPDT-CHG to prevent 1 additional SSI per year and the annual cumulative cost savings through SSI prevention. RESULTS: Over the study period, 13 493 patients (mean 964 per year) underwent elective or emergent spine surgery. From 2006 to 2019, the mean age, mean Charlson Comorbidity Index (CCI) score and mean Spine Surgical Invasiveness Index (SSII) score increased from 48.4 to 58.1 years, from 1.7 to 2.6, and from 15.4 to 20.5, respectively (p < 0.001). Unadjusted analysis confirmed a significant decrease in the annual number (74.6 to 26.8) and incidence (7.98% to 2.67%) of SSIs with nPDT-CHG (p < 0.001). After adjustment for mean age, mean CCI score and mean SSII score, segmented regression showed an absolute reduction in the annual SSI incidence rate of 3.36% per year (p < 0.001). The estimated annual cost to prevent 1 additional SSI per year was about $1350-$1650, and the estimated annual cumulative cost savings were $2 484 856-$2 495 016. No adverse events were reported with nPDT-CHG. CONCLUSION: Preoperative nPDT-CHG administration is an effective prophylactic strategy for spinal SSIs, with significant cost savings. Given its rapid action, minimal risk of antimicrobial resistance, broad-spectrum activity and high compliance rate, preoperative nPDT-CHG decolonization should be the standard of care for all patients undergoing emergent or elective spine surgery.

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures.

INTRODUCTION: A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention? MATERIALS AND METHODS: Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention. RESULTS: At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004). CONCLUSION: A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

Practice Variation between Salaried and Fee-for-Service Surgeons for Lumbar Surgery.

OBJECTIVE: To examine differences in surgical practices between salaried and fee-for-service (FFS) surgeons for two common degenerative spine conditions. Surgeons may offer different treatments for similar conditions on the basis of their compensation mechanism. METHODS: The study assessed the practices of 63 spine surgeons across eight Canadian provinces (39 FFS surgeons and 24 salaried) who performed surgery for two lumbar conditions: stable spinal stenosis and degenerative spondylolisthesis. The study included a multicenter, ambispective review of consecutive spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network registry between October 2012 and July 2018. The primary outcome was the difference in type of procedures performed between the two groups. Secondary study variables included surgical characteristics, baseline patient factors, and patient-reported outcome. RESULTS: For stable spinal stenosis (n = 2234), salaried surgeons performed statistically fewer uninstrumented fusion (p < 0.05) than FFS surgeons. For degenerative spondylolisthesis (n = 1292), salaried surgeons performed significantly more instrumentation plus interbody fusions (p < 0.05). There were no statistical differences in patient-reported outcomes between the two groups. CONCLUSIONS: Surgeon compensation was associated with different approaches to stable lumbar spinal stenosis and degenerative lumbar spondylolisthesis. Salaried surgeons chose a more conservative approach to spinal stenosis and a more aggressive approach to degenerative spondylolisthesis, which highlights that remuneration is likely a minor determinant in the differences in practice of spinal surgery in Canada. Further research is needed to further elucidate which variables, other than patient demographics and financial incentives, influence surgical decision-making.

Technical Considerations and Fluoroscopy in Percutaneous Fixation of the Pelvis and Acetabulum.

Surgical treatment of the pelvic ring and acetabulum continues to evolve. Improved imaging technology and means for closed reduction have meant that percutaneous techniques have gained popularity in the treatment of the pelvic ring and, more recently, in the acetabulum. Potential benefits include decreased soft-tissue dissection, blood loss, and surgical time. However, these are technically demanding procedures that require substantial expertise from both the surgeon and the radiographer. This article details the necessary fluoroscopic views and general methods used in percutaneous techniques around the pelvis and acetabulum. Despite most studies reporting good-to-excellent clinical and radiographic results, further work is needed to facilitate standardization and optimization of these outcomes.

High-energy trauma patients with pelvic fractures: Management trends in Ontario, Canada.

INTRODUCTION: Although fractures of the pelvic ring account for only 2-3% of all fractures, they are present in approximately 7-20% of patients with high-energy polytrauma. High-energy pelvic fractures are life-threatening injuries, with mortality estimates ranging from 6 to 35%. The purpose of this study was to examine trends in the incidence, diagnosis, treatment, and mortality rates of high-energy pelvic fractures in Ontario, Canada over a 10-year period. METHODS: A cohort of 3915 patients who sustained a high-energy pelvic fracture in Ontario between 01 April 2005 and 31 March 2015 was identified using the Ontario Trauma Registry and administrative healthcare data linked by the Institute for Clinical Evaluative Science (ICES). Severely injured patients (defined as having an Injury Severity Score (ISS) of ≥16) with pelvic fractures following high-velocity mechanisms of injury were identified using applicable ICD-10 codes. Trends were assessed statistically using the Poisson and the Cochrane-Armitage tests for trend. Modified Poisson regression was used to model the adjusted risk ratio of mortality by pelvic fracture treatment. RESULTS: The incidence of pelvic fracture remained constant at approximately 4.6 cases per 100,000 population annually between 2005 and 2011. From 2012, there was a decrease in patients with ISS ≥ 16 due to changes in the calculation of the ISS. The proportion of patients presenting with ISS > 50 increased from 8.2% to 14.1% (p = 0.008) over the study period. Automobile collisions or pedestrians struck by vehicles accounted for over half of injuries. Approximately 6% of patients underwent angioembolisation. Treatment with external fixation (15.5%-20.2%) or no surgical intervention (46.2%-61.3%) increased from 2005 to 2015. Mortality remained constant (11% at 30 days), and laparotomy was the only major intervention not associated with decreased risk of death. CONCLUSIONS: Stable mortality despite increasing injury severity suggests that the quality of care provided to patients with high-energy pelvic fractures has improved over time. However, unchanged incidence suggests the need for ongoing efforts aimed towards injury prevention. ISS at presentation was the most significant predictor of mortality in this patient population.

Virtual Reality Compared with Bench-Top Simulation in the Acquisition of Arthroscopic Skill: A Randomized Controlled Trial.

BACKGROUND: Work-hour restrictions as set forth by the Accreditation Council for Graduate Medical Education (ACGME) and other governing bodies have forced training programs to seek out new learning tools to accelerate acquisition of both medical skills and knowledge. As a result, competency-based training has become an important part of residency training. The purpose of this study was to directly compare arthroscopic skill acquisition in both high-fidelity and low-fidelity simulator models and to assess skill transfer from either modality to a cadaveric specimen, simulating intraoperative conditions. METHODS: Forty surgical novices (pre-clerkship-level medical students) voluntarily participated in this trial. Baseline demographic data, as well as data on arthroscopic knowledge and skill, were collected prior to training. Subjects were randomized to 5-week independent training sessions on a high-fidelity virtual reality arthroscopic simulator or on a bench-top arthroscopic setup, or to an untrained control group. Post-training, subjects were asked to perform a diagnostic arthroscopy on both simulators and in a simulated intraoperative environment on a cadaveric knee. A more difficult surprise task was also incorporated to evaluate skill transfer. Subjects were evaluated using the Global Rating Scale (GRS), the 14-point arthroscopic checklist, and a timer to determine procedural efficiency (time per task). Secondary outcomes focused on objective measures of virtual reality simulator motion analysis. RESULTS: Trainees on both simulators demonstrated a significant improvement (p < 0.05) in arthroscopic skills compared with baseline scores and untrained controls, both in and ex vivo. The virtual reality simulation group consistently outperformed the bench-top model group in the diagnostic arthroscopy crossover tests and in the simulated cadaveric setup. Furthermore, the virtual reality group demonstrated superior skill transfer in the surprise skill transfer task. CONCLUSIONS: Both high-fidelity and low-fidelity simulation trainings were effective in arthroscopic skill acquisition. High-fidelity virtual reality simulation was superior to bench-top simulation in the acquisition of arthroscopic skills, both in the laboratory and in vivo. Further clinical investigation is needed to interpret the importance of these results.

Anatomical Evaluation of the Proximity of Neurovascular Structures During Arthroscopically Assisted Acromioclavicular Joint Reconstruction: A Cadaveric Pilot Study.

PURPOSE: The purpose of this study was to examine the safety of an arthroscopic technique for acromioclavicular joint (ACJ) reconstruction by investigating its proximity to important neurovascular structures. METHODS: Six shoulders from 4 cadaveric specimens were used for ACJ reconstruction in this study. The procedure consists of performing an arthroscopic acromioclavicular (AC) reduction with a double button construct, followed by coracoclavicular ligament reconstruction without drilling clavicular tunnels. Shoulders were subsequently dissected in order to identify and measure distances to adjacent neurovascular structures. RESULTS: The suprascapular artery and nerve were the closest neurovascular structures to implanted materials. The mean distances were 8.2 (standard deviation [SD] = 3.6) mm to the suprascapular nerve and 5.6 (SD = 4.2) mm to the suprascapular artery. The mean distance of the suprascapular nerve from implants was found to be greater than 5 mm (P = .040), while the distance to the suprascapular artery was not (P > .5). Neither difference was statistically significant (P = .80 for artery; P = .08 for nerve). CONCLUSIONS: Mini-open, arthroscopically assisted ACJ reconstruction safely avoids the surrounding nerves, with no observed damage to any neurovascular structures including the suprascapular nerve and artery, and may be a viable alternative to open techniques. However, surgeons must remain cognizant of possible close proximity to the suprascapular artery. CLINICAL RELEVANCE: This study represents an evaluation of the safety and feasibility of a minimally invasive ACJ reconstruction as it relates to the proximity of neurovascular structures.

Global Rating Scales and Motion Analysis Are Valid Proficiency Metrics in Virtual and Benchtop Knee Arthroscopy Simulators.

BACKGROUND: Work-hour restrictions and fatigue management strategies in surgical training programs continue to evolve in an effort to improve the learning environment and promote safer patient care. In response, training programs must reevaluate how various teaching modalities such as simulation can augment the development of surgical competence in trainees. For surgical simulators to be most useful, it is important to determine whether surgical proficiency can be reliably differentiated using them. To our knowledge, performance on both virtual and benchtop arthroscopy simulators has not been concurrently assessed in the same subjects. QUESTIONS/PURPOSES: (1) Do global rating scales and procedure time differentiate arthroscopic expertise in virtual and benchtop knee models? (2) Can commercially available built-in motion analysis metrics differentiate arthroscopic expertise? (3) How well are performance measures on virtual and benchtop simulators correlated? (4) Are these metrics sensitive enough to differentiate by year of training? METHODS: A cross-sectional study of 19 subjects (four medical students, 12 residents, and three staff) were recruited and divided into 11 novice arthroscopists (student to Postgraduate Year [PGY] 3) and eight proficient arthroscopists (PGY 4 to staff) who completed a diagnostic arthroscopy and loose-body retrieval in both virtual and benchtop knee models. Global rating scales (GRS), procedure times, and motion analysis metrics were used to evaluate performance. RESULTS: The proficient group scored higher on virtual (14 ± 6 [95% confidence interval {CI}, 10-18] versus 36 ± 5 [95% CI, 32-40], p < 0.001) and benchtop (16 ± 8 [95% CI, 11-21] versus 36 ± 5 [95% CI, 31-40], p < 0.001) GRS scales. The proficient subjects completed nearly all tasks faster than novice subjects, including the virtual scope (579 ±169 [95% CI, 466-692] versus 358 ± 178 [95% CI, 210-507] seconds, p = 0.02) and benchtop knee scope + probe (480 ± 160 [95% CI, 373-588] versus 277 ± 64 [95% CI, 224-330] seconds, p = 0.002). The built-in motion analysis metrics also distinguished novices from proficient arthroscopists using the self-generated virtual loose body retrieval task scores (4 ± 1 [95% CI, 3-5] versus 6 ± 1 [95% CI, 5-7], p = 0.001). GRS scores between virtual and benchtop models were very strongly correlated (ρ = 0.93, p < 0.001). There was strong correlation between year of training and virtual GRS (ρ = 0.8, p < 0.001) and benchtop GRS (ρ = 0.87, p < 0.001) scores. CONCLUSIONS: To our knowledge, this is the first study to evaluate performance on both virtual and benchtop knee simulators. We have shown that subjective GRS scores and objective motion analysis metrics and procedure time are valid measures to distinguish arthroscopic skill on both virtual and benchtop modalities. Performance on both modalities is well correlated. We believe that training on artificial models allows acquisition of skills in a safe environment. Future work should compare different modalities in the efficiency of skill acquisition, retention, and transferability to the operating room.

Mastery versus the standard proficiency target for basic laparoscopic skill training: effect on skill transfer and retention.

BACKGROUND: Little evidence exists to guide educators in the best way to implement simulation within surgical skills curricula. This study investigated whether practicing a basic Fundamentals of Laparoscopic Surgery (FLS) simulator task [peg transfer (PT)] facilitates learning a more complex skill [intracorporeal suturing (ICS)] and compared the effect of PT training to mastery with training to the passing level on PT retention and on learning ICS. METHODS: For this study, 98 surgically naïve subjects were randomized to one of three PT training groups: control, standard training, and overtraining. All the participants then trained in ICS. The learning curves for ICS were analyzed by estimating the learning plateau and rate using nonlinear regression. Skill retention was assessed by retesting participants 1 month after training. The groups were compared using analysis of variance (ANOVA). Effectiveness of skill transfer was calculated using the transfer effectiveness ratio (TER). Data are presented as mean±standard deviation (p<0.05). RESULTS: The study was completed by 77 participants (28 control, 26 standard, and 23 overtrained subjects). The ICS learning plateau rose with increasing PT training (452±10 vs. 459±10 vs. 467±10; p<0.01). Increased PT training was associated with a trend toward higher initial ICS scores (128±107 vs. 127±110 vs. 183±106; p=0.13) and faster learning rates (15±4 vs. 14±4 vs. 13±4 trials; p=0.10). At retention, there were no differences in PT scores (p=0.5). The PT training took 20±10 min for standard training and 39±20 min for overtraining (p<0.01). Overtrained participants saved 11±5 min in ICS training compared with the control subjects (p=0.04). However, TER was 0.165 for the overtraining group and 0.160 for the standard training group, suggesting that PT overtraining took longer than the time saved on ICS training. CONCLUSION: For surgically naïve subjects, part-task training with PT alone was associated with slight improvements in the learning curve for ICS. However, overtraining with PT did not improve skill retention, and peg training alone was not an efficient strategy for learning ICS.