Optimisation of perioperative procedural factors to reduce the risk of surgical site infection in patients undergoing surgery: a systematic review.

Surgical site infections (SSI) are the leading cause of hospital readmission after surgical procedures with significant impact on post-operative morbidity and mortality. Modifiable risk factors for SSI include procedural aspects, which include the possibility of instrument contamination, the duration of the operation, the number of people present and the traffic in the room and the ventilation system of the operating theatre.The aim of this systematic review was to provide literature evidence on the relationship between features of surgical procedure sets and the frequency of SSI in patients undergoing surgical treatment, and to analyse how time frames of perioperative processes and operating theatre traffic vary in relation to the features of the procedure sets use, in order tooptimise infection control in OT. The results of the systematic review brought to light observational studies that can be divided into two categories: evidence of purely clinical significance and evidence of mainly organisational, managerial and financial significance. These two systems are largely interconnected, and reciprocally influence each other. The decision to use disposable devices and instruments has been accompanied by a lower incidence in surgical site infections and surgical revisions for remediation. A concomitant reduction in post-operative functional recovery time has also been observed. Also, the rationalisation of traditional surgical sets has also been observed in conjunction with outcomes of clinical significance.

Guidelines for improvement of the procedural aspects of devices and surgical instruments in the operating theatre.

Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments.

Influence of posterior tibial slope on postoperative outcomes after postero-stabilized and condylar-stabilized total knee arthroplasty.

PURPOSE: To compare clinical outcomes and surgical times of two different types of total knee arthroplasty(TKA), postero-stabilized(PS) and condylar-stabilized(CS), in relation to posterior tibial slope(PTS) values and the deviation of these values from the surgical technique. METHODS: 168 patients undergoing TKA surgery between 2016 and 2020 met our inclusion criteria. For each case, gender, age at surgery, operating time, type of implant and preoperative PTS(preop-PTS) and postoperative PTS(postop-PTS) measurements were collected; difference(∆PTS) between preop-PTS and postop-PTS was also calculated. Short Form 12 Mental and Physical scores(SF-12 M and P) and functional Knee Society Score(fKSS) were collected preoperatively and at a minimum of 12 months postoperatively. Four subgroups were thus created in relation to PS or CS system and postop-PTS value(≤ 5°and > 5°). RESULTS: Of the 168 patients, 96 had a PS system and 72 CS system. Performing a CS-TKA took less time than a PS-TKA(p < 0.05). SF-12P showed better results(p < 0.05) in CS-TKA group than PS-TKA, probably because of the younger age of CS-TKA patients(p < 0.05). In the PS > 5° all examined postoperative scores were better(p < 0.05) than PS ≤ 5°, while only fKSS was better(p < 0.05) in CS > 5° than CS ≤ 5°. No significant difference(p > 0.05) in terms of postoperative outcomes between the PS > 5° and CS > 5° was noted, whereas only SF-12P was better in the CS ≤ 5° compared with PS ≤ 5°. Highest values of SF-12 M and fKSS were obtained in the PS ≤ 5°, in which postop-PTS was closer to technique. CONCLUSION: When performing a PS-TKA, the best result was obtained with a postop-PTS > 5°, but comparable outcomes between the two systems were evident with postop-PTS > 5°. It is crucial to come as close as possible to the indications reported in surgical technique regardless ∆PTS.

Bone remodelling and integration of two different types of short stem: a dual-energy X-ray - absorptiometry study.

PURPOSE: Different kinds of bone preserving hip stems have been created to assure a more physiological distribution of the strengths on the femur. The aim of this research is to evaluate the density reaction of the periprosthetic bone while changing the conformation of the prosthetic implant on dual-energy X-ray - absorptiometry (DXA). METHODS: This is a prospective, single-centre study assessing bone remodelling changes after implantation of two short hip stems, dividing the patients in two groups according to the implant used: 20 in group A, Metha (B-Braun), and 16 in group B, SMF (Smith and Nephew). All participants had a pre-operative and a post-operative (24 months) DXA evaluating the changes in bone mass density (BMD) occurred in the five Gruen's zones. RESULTS: Compared to the pre-operative value, differences in BMD percentage were statistically significant only in ROI 4 (p < 0.05), with an increase in both groups (9 and 18%, respectively). The average increase in BMD was of 7.3% and 7.2% in the 2 groups. CONCLUSION: According to our study, both stems have proved able to provide good load distribution across the metaphyseal region favouring proper system integration. Nonetheless, is certainly needed to perform other studies with longer follow-up and bigger populations to give strength to these conclusions.

Contamination of revision procedures in patients with adverse tissues reaction to metal on metal implant.

OBJECTIVE: The aim of this study is to evaluate the incidence of infections in MoM total hip replacement revisions and to propose a therapeutic algorithm that can reduce the onset of this complication. Total hip arthroplasty is one of the most successful procedures performed annually in the world. As the population ages, the number of primary arthroplasty procedures performed each year is rising in conjunction with an increasing revision burden. Metal on Metal (MoM) total hip arthroplasties were reintroduced in over the last fifteen years to meet these needs, larger diameters, improved lubrication, better stability, increased ROM and wear properties of the bearing couple. These advantageous features have led to an exponential diffusion of MoM. Since over last decade, it has become evident that hip replacements with MoM bearing have significantly higher revision rates compared to those with Metal on Polyethylene. The common pathway for this failure mode appears to be increased wear or corrosion with excessive release of metal ions and nanoparticles. Complications such as elevated serum metal ion levels, aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) and pseudotumours have all been well documented, but recent studies suggest increased risk of infection with MoM bearing surfaces. PATIENTS AND METHODS: We collect data from a cohort of 44 patients who underwent revision of total hip arthroplasty between 2014 and 2017 for the complication of MoM bearing. Studied by radiological images, blood tests, and intraoperative clinical status, part of the population was treated with one stage revision, while the other was treated with a two-stage revision. RESULTS: Results showed a difference in the occurrence of infections in the two populations. CONCLUSIONS: We consider it appropriate to perform two-stage revision in all case of failure of MoM replacement so as to allow to minimize the likelihood of infection in patients with damaged tissues by ALVAL, pseudotumour, and necrosis that could create an ideal environment for bacterial development.

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up.

INTRODUCTION: Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications. METHODS: 76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years). RESULTS: Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed. DISCUSSION AND CONCLUSIONS: Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

[Correlation between ICIQ-UI-SF score and personality testing results over a urinary incontinent population]. / Corrélation entre le score de l'ICIQ-UI-SF et les résultats d'un test psychométrique de personnalité d'une population ayant une incontinence urinaire.

OBJECTIVE: We found out the personality pattern of an incontinent population and proceeded to a correlation between the personality inventory and the ICIQ-UI-SF (International Consultation Incontinence Questionnaire Urinary Incontinence Short Form) to demonstrate reliability and sincerity of the answers and to establish that a personality disturbance may impact the physiopathology of micturition. MATERIALS AND METHODS: We performed an observational prospective study. It included patient's answers to a computed questionnaire combining a double ICIQ-UI-SF questionnaire and the 71 questions of the Minimult questionnaire. Forty-seven patients were asked to participate. RESULTS: Over 37 patients included, Wilcoxon-Mann-Whitney non parametric test confirmed agreement of the two ICIQ-UI-SF questionnaires with P=0.1792. Twenty-three patients were validated to the Minimult inventory with F scale<70. We analysed variability of the two global ICIQ-UI-SF score in regard with the validity scale using ROC analysis. We observed an AUC of 0.559 with sensitivity 78.6% and specificity 43.5%. No L score was above 70 demonstrating absence of lie. No personality disturbance was found in 9 cases. We observed six cases with a high hypochondric value, five with a high depressive value, and four with a high hysteric value. This neurotic triad was found in two cases. We noticed five cases with psychopathic deviance relative to antisocial behaviour while values of paranoia and hypomania were high in one case without any association of these personality aspects, which demonstrated absence of behavioural problem. Psychotic profile associating schizophrenia, paranoia, depression and hypomania was not found. We outlined in half of the valid population a significant high psycho-asthenic pattern. CONCLUSION: We conclude that a correlation between the personality inventory and the ICIQ-UI-SF is feasible. The comparative study demonstrate reliability of answers. Sincerity is established by the Minimult L scale. We confirm and precise literature information over clinical personality pattern of this population and observe relevant elements concerning the psycho-asthenic pattern which depicts an anxious personality with an important feeling of the problem. These elements permit to suspect that a personality disturbance may impact the physiopathology of the micturition. LEVEL OF EVIDENCE: 4.

Validation of the EUMASS Core Set for medical evaluation of work disability.

OBJECTIVE: To perform a content validation of the EUMASS Core Set across six European social insurance systems. The EUMASS Core Set contains 20 categories to describe the functional (in-) capacity of claimants for disability benefits. METHODS: We performed an exploratory, cross-sectional study. We used the EUMASS Core Set, added scales to rate the relevance of the 20 categories and added additional questions concerning comprehensiveness, usefulness and sufficiency of the instrument. Medical examiners from European countries filled in this instrument in 10 consecutive claim assessments. RESULTS: Forty-eight medical examiners in six different countries evaluated 446 claimants. The medical examiners used all categories to describe the claimants' functional (in-) capacity. Medical examiners missed 41 different categories, often mental functions (n = 17). They rated the instrument as useful in 68.4% and as sufficient in 63.2% of the claims. Perceived usefulness varied among countries, but not among disease groups. Perceived sufficiency varied among countries and disease groups. CONCLUSION: The EUMASS Core Set is promising for reporting about functional (in-) capacities. It contains relevant categories for disability evaluation among countries and disease groups. Adding more mental functions might make it more applicable. Medical examiners found it useful and sufficient to evaluate functional (in-) capacity. Implications for Rehabilitation In medical reports of evaluation of work disability, reporting about functional capacity is often unstructured in free text, making the reports difficult to understand. The EUMASS Core Set contains common definitions for expressing functional capacity and is expected to support taking decisions, to improve the quality of decisions and to allow national and international comparisons. Our study suggests the EUMASS core set to be comprehensive, useful and sufficient to express functional capacity in disability evaluation.

Perspectives on metaphyseal conservative stems.

Total hip replacement is showing, during the last decades, a progressive evolution toward principles of reduced bone and soft tissue aggression. These principles have become the basis of a new philosophy, tissue sparing surgery. Regarding hip implants, new conservative components have been proposed and developed as an alternative to conventional stems. Technical and biomechanical characteristics of metaphyseal bone-stock-preserving stems are analyzed on the basis of the available literature and our personal experience. Mayo, Nanos and Metha stems represent, under certain aspects, a design evolution starting from shared concepts: reduced femoral violation, non-anatomic geometry, proximal calcar loading and lateral alignment. However, consistent differences are level of neck preservation, cross-sectional geometry and surface finishing. The Mayo component is the most time-tested component and, in our hands, it showed an excellent survivorship at the mid-term follow-up, with an extremely reduced incidence of aseptic loosening (partially reduced by the association with last generation acetabular couplings). For 160 implants followed for a mean of 4.7 years, survivorship was 97.5% with 4 failed implants: one fracture with unstable stem, 1 septic loosening and 2 aseptic mobilizations. DEXA analysis, performed on 15 cases, showed a good calcar loading and stimulation, but there was significant lateral load transfer to R3-R4 zones, giving to the distal part of the stem a function not simply limited to alignment. Metaphyseal conservative stems demonstrated a wide applicability with an essential surgical technique. Moreover, they offer the options of a "conservative revision" with a conventional primary component in case of failure and a "conservative revision" for failed resurfacing implants.

Hip resurfacing: why does it fail? Early results and critical analysis of our first 60 cases.

Resurfacing replacement represents the most conservative solution available for total arthroplasty of the hip. However, despite the excellent results reported by highly experienced surgeons, a small but not insignificant body of literature has been published on the more controversial aspects of this approach, mainly those related to the biological and mechanical vulnerability of the retained epiphysis. We report here our evaluation of most of the variables inherent to this procedure (surgical exposure, implant design, technical steps). Based on our results, we conclude that the short-term outcome is strongly related to the surgical approach and the relationship between implant design and cementing technique. Even if posterior approaches are currently widely accepted for resurfacing replacement, the ability to preserve the medial circumflex artery has been questioned, and an alternative exposure has been proposed with good results (antero-lateral, lateral and digastric trochanteric osteotomy). Moreover, a minimally invasive posterior approach could increase the risks of vascular damage. Alternatively, inner implant geometry could affect the distribution of cement over the epiphysis when other variables (direct or indirect cementing technique, viscosity) are not properly selected.

Non-union in an unnoticed neck fracture in resurfacing total hip arthroplasty.

The renewed popularity of resurfacing hip arthroplasty (RHA) in the last five years has generated a remarkable quantity of scientific contributions based on mid- and short-term follow-up. In spite of some large series with extremely low complication rates, more than one paper has reported a consistent early revision rate as a consequence of biological or biomechanical failure. Two major complications are commonly described with resurfacing implants: avascular necrosis and neck fracture. A close relationship between these two events has been suggested, but not firmly demonstrated, while surgical exposure and implant positioning seem to be better understood as potential causes of failure. However, it may happen that neither avascular necrosis nor neck fracture can be clearly recognised in a failed resurfacing implant: it is what we have directly experienced, with a missed fracture at the head-neck junction, evolved in non-union, beneath the dome of the femoral component. The present report, besides a brief clinical history, tries to give a possible interpretation of such an unusual complication.

Bone remodelling in THA: A comparative DXA scan study between conventional implants and a new stemless femoral component. A preliminary report.

Periprosthetic bone loss is a major cause for concern in patients undergoing total hip arthroplasty (THA). There are many different factors that may determine the pattern of bone loss and bone remodelling following THA, such as the quality of the bone before the hip replacement, skeletal bone mass at the time of the operation, material and method of fixation and implant design. Recent developments in dual-energy X-ray absorptiometry (DXA) have made it possible to quantify bone mineral density (BMD) to evaluate changes around the prosthesis and to measure bone stock and bone density redistribution after a total hip replacement. In this cross-sectional multicentre clinical study the DXA method was used to compare bone mass after uncemented THA of a custom-made stemless design with five groups of conventional cementless implants (Alloclassic, Mayo, CFP, IPS, ABG). The adaptive bone changes of the proximal femur three years after implantation were evaluated. Periprosthetic BMD was measured in 130 subjects in the seven regions of interest (ROI) based on Gruen zones. Significant differences were found between the stemless implant and the other five groups in zones 1, 4 and 7. The CFP, IPS, and ABG groups showed decreased BMD in ROI 1, and the Mayo, IPS and Alloclassic in ROI 7. An increased BMD in ROI 4 was observed in the Mayo, IPS, ABG and Alloclassic groups. The results of the present study suggest that a conservative stemless implant with complete proximal load transfer produces a homogeneous and more physiological redistribution of bone density, allowing maintenance of proximal periprosthetic bone stock.

[Medical certificate in sickness and disability insurance area]. / Le certificat médical en matière d'Assurance Maladie-Invalidité.

Physicians have to complete medical certificates required by the sickness and incapacity insurance in Belgium. Certificate for incapacity for work allows the worker to take a rest needed by his health state. It is a part of the medical treatment. Incapacity for work is defined differently in the two main social legislations in our country: the legal frame concerning employed workers and the other one concerning free workers. In both legislations however, it is important that practitioners give the useful information to the advisor doctor of the insurance sickness fund. Making so, he helps his patient with coping with the controls imposed by the law. Using official forms is not compulsory but helps the physician to complete correctly an incapacity for work certificate. In health care area, certificates are needed to obtain reimbursement of treatments. The same concern will guide the practitioner when he completes these certificates.

Femoral prosthetic heads and their significance in polyethylene wear.

We used scanning electron microscopy to perform an ultrastructural analysis and two optical interferometric profilers to measure roughness on 40 prosthetic femoral heads. We expressed roughness as Ra (roughness average) value and Rsk (roughness skewness) value. Our results show that in order to obtain an ideal surface finish a low or not very high Ra value and a negative Rsk value are needed. The presence of depressions or holes (rather than scratches) with smooth (rather than sharp) edges seems to improve the lubrication and wettability properties.

Intraoperative type 1 proximal femoral fractures: influence on the stability of hydroxyapatite-coated femoral components.

We reviewed a series of 120 uncemented total hip replacements using the Omniflex stem with hydroxyapatite coating. Twenty minor intraoperative proximal fractures occurred. All fractures were treated with cerclage wiring after removal of the stem. Radiographic and clinical results of these 20 patients were compared with the remaining 100 implants in which this complication did not occur. In 20% of the cases of both groups, a migration of less than 2 mm was observed. No differences were detected in Harris Hip Scores, subsidence of the stem, and radiographic behavior. We concluded that a properly stabilized proximal femoral fracture above the lesser trochanter did not influence the clinical and radiographic results at more than 3 years follow-up.

Arthroscopic treatment of bilateral Freiberg's infraction.

Freiberg's disease is a relatively rare disorder with a multifactorial cause. The condition has a definite predilection for the second metatarsal head, and it is rare to find a bilateral involvement, especially of the first metatarsal head described in the literature. The results of different methods of surgical treatment have been reported, but no single procedure has produced uniformly good results. We describe a case of a 28-year-old man, a lawyer with a 4-year history of bilateral intermittent forefoot pain on weightbearing without any recollection of specific trauma to his feet. Radiographic and magnetic resonance imaging investigations were performed and the patient underwent a bilateral arthroscopic treatment with joint debridement and drilling of the metaphyseal portion of both distal metatarsal head. Three months after surgery, the patient returned to unrestricted activity without pain. At last evaluation, 2 years postoperatively, he is symptom free and new magnetic resonance examination has shown satisfactory restructuring of the lesions.

Conversion of the arthrodesed hip to a total hip arthroplasty. Indications and limitations.

Arthrodesis of the hip is thought to achieve satisfactory clinical and functional results in the adult despite the loss of articular mobility involved (Santori et al., 1986; Russel, 1987; Weber, 1987). Over the long term, however, most patients develop secondary degenerative arthritis in the spine, contralateral hip, and knees due to overloading. The deteriorating condition of these joints eventually causes the onset of pain, which often requires further intervention. Surgery on these joints may yield satisfactory short-term results, but these will not last if the arthrodesed hip is not converted to total hip arthroplasty either prior to or at the same time as such operations.

The cementless PCA primary total hip system. Medium-term follow-up of 235 cases.

The Porous Coated total hip Arthroplasty (PCA), used by the authors since August 1984, represents a considerable advancement in the field of prosthetic replacement. Its original design and biological fixation give it long-lasting stability not only in young patients, but also patients with initial osteoporosis. Its use in cases of advanced osteoporosis, however, is more controversial. The 8-year results are quite satisfactory from both a clinical and radiographic standpoint, confirming, as other authors have reported, that the medium and long-term results of cementless total hip replacement tend to stabilize because there is a lack of late reactions, which are more common in cemented implants.

Third-degree lesions of the external compartment of the ankle: results of conservative treatment.

Ankle sprains are one of the most common lesions of the musculo-skeletal system. In some sports they are the most common reason that athletes seek medical care. For this reason many publications are dedicated to this subject, and specifically to the treatment of lesions of the external compartment, which account for about 85% of all ligamentous lesions of the ankle (O'Donoghue, 1958). The treatment of these lesions is very controversial. Some orthopedists propose early surgical treatment to restore normal healing with minimal functional lengthening. Others favor conservative treatment, while still others recommend functional treatment with the objective of accelerating the recovery of proprioceptive reflexes affected by the ligamentous lesion as well as stimulating healing by movement. The authors' diagnostic and therapeutic approach to lesions of the external compartment of the ankle is explained with special reference to lesions in athletes, who must be guaranteed perfect joint stability in order to tolerate the intense stress of sports activity without danger of relapse.

[The prevention and treatment of skeletal deformities in fibrous dysplasia]. / Prevenzione e trattamento delle deformità scheletriche nella displasia fibrosa.

Fibrous dysplasia generally leads to skeletal deformity over time, particularly when the lower extremities are affected. The authors describe their experience in this field, proposing mainly preventive treatment of progressive deformities and pathological fractures. They prefer intramedullary nailing, which by strengthening the affected bone allows free and early mobilization of the limb. Moreover, full weight-bearing prevents the onset of "ex non usu" osteoporosis, which is quite often responsible for pathological fractures.