Detection of Surgical Wrap Defects in the Operating Room Setting.

Surgical site infection is a challenging complication that places a significant burden on the patient and the health care system. Emphasis is being placed on the prevention and treatment of surgical site infections. We evaluated the accuracy of identifying surgical wrap defects based on defect size, location, and operating room staff experience. Forty sterilization wraps were divided into 4 separate groups based on the size of the puncture defects created. Defects measuring 1.2 mm, 3.7 mm, and 6.8 mm were compared with a control group of surgical wraps with no defects. Defects were randomly placed on an inner or outer line with circumference of 7 cm or 14 cm, respectively. Twenty operating room staff of varying levels of experience evaluated each wrap for defects. The detection rates for the 1.2-mm, 3.7-mm, and 6.8-mm wraps and the wraps with no defects were 3%, 73%, 80%, and 99%, respectively. A significant difference was seen between the detection rates for the small defects vs all other size defects. No significant difference was seen in detection rate based on the location of defects. The detection rate was higher among staff members with greater than 1 year of experience vs those with less than 1 year of experience. Sterilization wrap defects of all sizes went undetected at very high rates. Small defects of 1.2 mm, which have been shown to allow bacterial contamination, were missed 97% of the time. Operating room staff with more experience detected more defects than those with less than 1 year of experience. Wrap defects may be a source of bacterial contamination that may frequently go unnoticed. [Orthopedics. 2021;44(6):735-e738.].

Operating Room and Hospital Air Environment.

One method of preventing surgical-site infection is lowering intraoperative environmental contamination. The authors sought to evaluate their hospital's operating room (OR) contamination rate and compare it with the remainder of the hospital. They tested environmental contamination in preoperative, intraoperative, and postoperative settings for a total joint arthroplasty patient. A total of 190 air settle plates composed of trypsin soy agar were placed in 19 settings within the hospital. Locations included the OR with light and heavy traffic, with and without masks, jackets, and shoe covers; the substerile room; OR hallways; the sterile equipment processing center; preoperative areas; post-anesthesia care units; orthopedic floors; the emergency department; OR locker rooms and restrooms; a resident's home; and controls. The trypsin soy agar plates were incubated at 36 °C for 48 hours. Colony counts were performed for each plate. Average colony-forming units (CFUs) were calculated in each setting. The highest CFUs were in the OR locker room, at 28 CFUs per plate per hour. Preoperative and post-anesthesia care unit holding areas were 7.4 CFUs and 9.6 CFUs, respectively. The main orthopedic surgical ward had 10.0 CFUs per plate per hour, whereas the VIP hospital ward had 17.0 CFUs per plate per hour. All OR environments had low CFUs. A live OR had slightly higher CFUs than settings without OR personnel. In comparison with the local community household, the OR locker room, restrooms, hospital orthopedic wards, emergency department, preoperative holding, post-anesthesia care unit, and OR hallway all had higher airborne contamination. On the basis of these results, the authors recommend environmental sampling as a simple, fast, inexpensive tool for monitoring airborne contamination. [Orthopedics. 2021;44(3):e414-e416.].

Implications of positive urine toxicology screening in trauma patients.

BACKGROUND: Pain management in trauma patients can be difficult due to their varied injuries and presence or absence of illicit substances in their systems. Additionally, trauma patients have variable lengths of stay. Limiting length of stay to what is medically necessary and preventing long-term dependence on narcotic medications are important in trauma patient care. METHODS: We performed a retrospective review of 385 consecutive trauma activations at a Level II trauma center with urine toxicology screens from 2015. Main outcome measures recorded were urine toxicology results, average daily morphine milligram equivalents (MME), length of stay (LOS), injury severity score (ISS). We also recorded patient demographic information. Statistical analysis compared outcomes and demographics between trauma patients with positive urine toxicology screens to those with negative screens. Significance was set at p < 0.05. RESULTS: Positive urine toxicology screens were present in 230/385 (59.7%) patients. The median (interquartile range (IQR)) daily MME usage in the positive urine toxicology group was 25.2 (12.0-48.6) versus 12.4 (2.5-27.5) for those with a negative drug screen (p < 0.001). Median LOS was 3 (1-6) days versus 2 (1-4) days for the positive and negative groups, respectively (p = 0.004). There were no differences in age, gender distribution, or ISS between the two groups. Subgroup analysis showed urine toxicology positive for opiates, benzodiazepines, and tetrahydrocannabinol (THC) were associated with increased daily MME. Benzodiazepines and amphetamines were associated with increased LOS. CONCLUSION: This study identifies a positive toxicology screening as a risk factor for increased narcotic demands and longer length of stay in trauma patients. These findings may assist in developing treatment plans and setting expectations in this population. This information can also lead to proactive interventions aimed at minimizing narcotic use and shortening LOS in this population.

Transbrachioradialis Approach to the Radial Tunnel: An Anatomic Study of 5 Potential Compression Sites.

BACKGROUND: Recent anatomic studies have failed to demonstrate a single utilitarian approach to intraoperative identification and surgical release of all 5 potential sites of posterior interosseous nerve (PIN) compression in the radial tunnel. This study examines if a single incision brachioradialis-splitting approach without the use of additional anatomic windows is capable of adequately exposing the entire length of the radial tunnel, including all 5 sites of PIN compression to allow for adequate release. METHODS: Ten fresh frozen cadaver forearms (6 female, 4 male) were dissected utilizing a curvilinear 7 cm incision over the brachioradialis. The muscle belly was split via simple blunt retraction, exposing the radial tunnel. The PIN was identified and mobilized at 5 compression sites: radiocapitellar joint (RCJ), radial recurrent vessels (Leash of Henry), fibrous medioproximal edge of extensor carpe radialis brevis, arcade of Frohse, and distal edge of supinator. RESULTS: The PIN was identified and effectively released in all specimens without difficulty from this single approach. All 5 sites of compression were visible and accessible through the brachioradialis-split approach. Specifically, there was no difficulty in identifying and releasing the PIN at the distal edge of supinator. CONCLUSIONS: Radial tunnel syndrome is defined as PIN compression within the radial tunnel spanning from the fibrous RCJ to the distal edge of the supinator. A single brachioradialis-splitting approach is adequate for complete visualization and release of all compression sites of the radial tunnel. Utilizing this technique allows for surgical access and ease as well as minimizing necessity for additional windows or multiple incisions.

Radial axial interosseous load (RAIL) test for essex lopresti type injuries.

BACKGROUND: When approaching radial head and neck fractures, the decision for ORIF, resection, or arthroplasty is often performed intraoperatively. Factors that contribute include ligamentous and bony stability, cartilage injury, mechanical alignment as well as patient factors. Recent data has suggested conventional methods may not be sufficiently sensitive in detecting Essex Lopresti injuries. Here we describe an intraoperative technique that could objectively assess proximal radio-ulnar stability with subsequent disruption of the ligamentous structures. METHODS: Eight cadaveric specimens were used to evaluate amount of radial proximal migration between three groups of forearms. After radial head resection, proximal migration of the radial shaft was measured in three distinct groups. Group A included intact forearms, Group B included forearms with resected interosseous membranes (IOM), and Group C included forearms with resected interosseous membranes and distal radioulnar joint (DRUJ) disruptions. RESULTS: As compared to group A, group B averaged 4 mm of proximal radial migration (p < 0.01), while Group C demonstrated >6 mm of migration (p < 0.01). CONCLUSION: In the setting of a non-repairable radial head, the RAIL test may provide a more objective means of assessing for Essex-Lopresti injuries.

Radiographic Outcomes of Dorsal Distraction Distal Radius Plating for Fractures With Dorsal Marginal Impaction.

Background: The purpose of this study is to compare radiographic outcomes of patients treated with dorsal spanning plates with previously reported normal values of radiographic distal radius anatomy and compare the results with prior publications for both external fixation and internal fixation with volar locked plates. Methods: Patients with complex distal radius fractures including dorsal marginal impaction pattern necessitating dorsal distraction plating at the discretion of the senior authors (M.A.T. and M.A.I.) from May 30, 2013, to December 29, 2015, were identified and included in the study. Retrospective chart and radiograph review was performed on 19 patients, 11 male and 8 female, with mean age of 47.83 years (22-82). No patients were excluded from the study. Results: All fractures united prior to plate removal. The average time the plate was in place was 80.5 days (49-129). Follow-up radiographs showed average radial inclination of 20.5° (13.2°-25.5°), radial height of 10.7 mm (7.5-14 mm), ulnar variance of -0.3 mm (-2.1 to 3.1 mm), and volar tilt of 7.9° (-3° to 15°). One patient had intra-articular step-off greater than 2 mm. Conclusions: Dorsal distraction plating of complex distal radius fractures yields good radiographic results with minimal complications. In cases of complex distal radius fractures including dorsal marginal impaction where volar plating is not considered adequate, a dorsal distraction plate should be considered as an alternative to external fixation due to reduced risk for infection and better control of volar tilt.

Nonunion of a Nondisplaced Radial Neck Fracture: A Case Report.

CASE: We describe the case of a 66-year-old man who sustained a nondisplaced radial neck fracture and subsequently developed a symptomatic nonunion. After a period of unsuccessful conservative treatment, a radial head resection was performed. CONCLUSION: Radial neck fractures, unlike their radial head counterparts, have a low rate of nonunion. Our patient's only positive risk factor was age, but he developed a nonunion. At the 2-year follow-up after excision of the radial head, there was a lack of proximal migration of the radius during axial loading, demonstrating a positive outcome without the need for replacement of the radial head.

Failure of Wrist Hemiarthroplasty.

BACKGROUND: Wrist hemiarthroplasty has emerged as a motion-sparing option for severe wrist arthritis. It is technically easy with advantages of limited bone resection and no risk of nonunion. Given the relative infancy of the procedure in clinical practice, there are limited data on patient outcomes. METHODS: Eleven patients were treated with wrist reconstructive hemiarthroplasty. Indications included 1 patient with scaphoid nonunion advanced collapse, 9 patients with scapholunate advanced collapse, and 1 patient with capitolunate arthritis. Average age was 63 years; average follow-up was 4 years. Objective parameters included Disabilities of the Arm Shoulder and Hand (DASH), grip strength, and range of motion. Implant failure defined by necessity of revision procedure. RESULTS: DASH scores initially improved postoperatively but were not statistically significant. Grip strength was 60% of contralateral side. Postoperative range of motion at 6 months was flexion 40.3°, extension 39.3°, supination 87.0°, pronation 77.8°, radial deviation 14.5°, and ulnar deviation 13.8°. A 45% failure rate was observed. Complications included failure with conversion to Total Wrist Arthroplasty (TWA; n = 2) or wrist fusion (n = 3) secondary to development of ulnar-sided wrist pain. One additional patient experienced severe wrist pain but declined additional surgery. CONCLUSIONS: Wrist hemiarthroplasty in our series had a significant failure rate. In each case of failure, the patient developed ulnar-sided wrist pain. In the presence of more reliable procedures, wrist hemiarthroplasty is not indicated in its current incarnation.

The Clinical Application of Kaplan's Cardinal Line as a Surface Marker for the Superficial Palmar Arch.

We feel the original description of Kaplan's cardinal line provides a more accurate reference point to the superficial palmar arterial arch. We sought to anatomically correlate the relationship of Kaplan's cardinal line to the superficial palmar arch. Sixty hands (30 cadavers) were dissected after Kaplan's original description was drawn on each hand. Measurements we made from Kaplan's cardinal line to the superficial palmar arch at both the radial and ulnar borders of the ring finger. The superficial palmar arterial arch was an average of 10.4 and 11.8 mm from the radial and ulnar borders of the ring finger with standard deviations of roughly 4 mm for each measurement. Clinically, Kaplan's cardinal line is a more predictable landmark for the superficial palmar arch. In referencing this landmark as the distal most extent of an open or endoscopic carpal tunnel release, the superficial palmar arch should be free of transection.

Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics.

Staphylococcus aureus (S aureus) remains one of the most common pathogens for skin and soft-tissue infections encountered by the orthopaedic surgeon. Community-acquired methicillin-resistant S aureus (CA-MRSA) has become increasingly prevalent, particularly among athletes, children in day care, homeless persons, intravenous drug users, men who have sex with men, military recruits, certain minorities (ie, Alaskan Natives, Native Americans, Pacific Islanders), and prison inmates. Risk factors include antibiotic use within the preceding year, crowded living conditions, compromised skin integrity, contaminated surfaces, frequent skin-to-skin contact, shared items, and suboptimal cleanliness. When a patient presents with a skin or soft-tissue infection, the clinician should determine whether an abscess or other infection needs to be surgically incised and drained. Cultures should be performed. When the patient is a member of an at-risk group or has any of the risk factors for CA-MRSA, beta-lactam antibiotics (eg, methicillin) are no longer a reasonable choice for treatment. Empiric treatment should consist of non-beta-lactam antibiotics active against CA-MRSA.

Nonoperative treatment for a double dislocation of the thumb metacarpal: a case report.

Double dislocations of the thumb are rare injuries. Those reported in the English literature have all been treated operatively except one. We report the second case of a double dislocation of a thumb involving the metacarpophalangeal joint and carpometacarpal joint treated nonoperatively. Two-year results reveal a stable, pain free thumb with no evidence of arthritis or subluxation.