A prospective randomized controlled clinical investigation comparing two post-operative wound dressings used after elective hip and knee replacement; Mepilex® Border Post-Op versus Aquacel® surgical.

BACKGROUND: Post-operative wound complications, including blistering and surgical site infections, can increase recovery times, costs associated with hospital stay and morbidity. AIM: To compare two post-operative wound dressings (Mepilex Border Post-Op and Aquacel Surgical), in patients undergoing elective hip or knee arthroplasty. METHODS: International, open-label, prospective, superiority, multicentre, randomised, parallel-group, controlled trial. Primary outcome was dressing failure, a composite endpoint assessing four factors weighted from highest to lowest in relation to the risk of surgical site infection. RESULTS: Mepilex Border Post-Op was comparable or superior to Aquacel® Surgical in all parameters investigated. Dressing failure rates, skin redness, itching under the dressing, pain during dressing removal and number of patients requiring a dressing change were low in both groups. Mepilex® Border Post-Op outperformed Aquacel Surgical for ease of application (p<0.0001) and removal (p<0.0001), ability to handle blood (p<0.0001), prevention of dressing residuals (p=0.0167), patient satisfaction of wearing the dressing during rehabilitation training (p=0.0037) and patients' overall experience with the dressing (P=0.0025). CONCLUSION: Both dressings performed well in terms of minimizing post-operative wound complications. However, in relation to clinician satisfaction, minimization of pain and facilitation of patient comfort, Mepilex® Border Post-Op outperformed Aquacel Surgical.

An interprofessional initiative aimed at creating a common learning resource for the operating room ward.

Every semester, the operating room (OR) ward receives students from different educational programmes. Although interprofessional knowledge is essential for OR teamwork, students have traditionally been prepared in an uniprofessional manner, with no focus on interprofessional learning outcomes. This report describes the work process of an interprofessional initiative undertaken to create a common learning resource aimed at preparing students for OR practice. With a focus on interprofessional learning, shared and profession-specific learning outcomes, which are needed to prepare for practice, were identified by an interprofessional faculty. To avoid timetabling and geographic barriers, learning outcomes and constructed learning activities were packaged into an e-module and delivered on-line as an adjunct to existing lectures and workshops. A survey was administered to 4th year medical (n = 42) and 1st year OR nurse students (n = 4) to evaluate their perceptions of the e-module. We found that most learning outcomes from the different syllabuses were common for all professions. The overall response rate of the survey was 59% (27 of 46 students). Eighteen of the 27 responding students had used the learning resource, of which 15 students considered it to be of 'high' or 'very high' value. In summary, this interprofessional initiative resulted in a new common learning resource for the OR, which was used and perceived valuable by a majority of the students. The learning outcomes needed to prepare students from different educational programmes for OR practice are, to a great extent, generic and interprofessional and we thus argue that the interprofessional nature of the faculty was essential for the success of the initiative.

Tourniquet cuff pressure and nerve injury in knee arthroplasty in a bloodless field: a neurophysiological study.

BACKGROUND AND PURPOSE: Tourniquet-related nerve injuries remain a concern in orthopedic surgery. The cuff pressures used today are generally lower, and therefore a decreasing incidence of peripheral nerve injuries might also be expected. However, there have been few neurophysiological studies describing the outcome after bloodless field surgery. We describe the results of neurophysiological examinations and report the incidence of nerve injuries after total knee arthroplasty (TKA) in a bloodless field. PATIENTS AND METHODS: This study was part of a prospective, randomized controlled clinical trial in patients scheduled for TKA in a bloodless field. 20 consecutive patients were enrolled. Electroneurography (ENeG) and quantitative sensory testing (QST) of thermal thresholds were performed on day 3. These tests were repeated 2 months after surgery when electromyography (EMG) with a concentric-needle electrode was also performed. RESULTS: The mean tourniquet cuff pressure was 237 (SD 33) mmHg. Electromyographic signs of denervation were found in 1 patient, who also had the highest cuff pressure in the study population (294 mmHg). The sensory nerve response amplitudes were lower in the operated leg on day 3; otherwise, the neurophysiological examinations showed no differences between the legs. INTERPRETATION: When low tourniquet cuff pressures are used the risk of nerve injury is minor.

Tourniquet time affects postoperative complications after knee arthroplasty.

PURPOSE: Pneumatic tourniquets are frequently used in knee arthroplasty surgery. However, there is a lack of evidence to define safe tourniquet time in lower limb surgery. The primary aim of this study was to investigate whether tourniquet time influences the risk of postoperative complications after primary and secondary knee arthroplasty. METHODS: This study was a prospective register study. Since we wanted dispersion in tourniquet time, we included a consecutive series of 577 primary knee arthroplasties, 46 revision knee arthroplasties, and 18 patellar supplementing knee arthroplasties from a clinical audit database over a period of five years. The following postoperative complications were recorded: superficial wound infections, deep wound infections, deep vein thrombosis, pulmonary embolism, nerve injuries, compartment syndrome, cuff pressure injuries, and bandage injuries. RESULTS: Tourniquet time over 100 minutes was associated with an increased risk of complications after knee arthroplasty surgery (OR 2.2, CI 1.5-3.1). This increase in risk remained after adjusting for cuff pressure, sex, age, American Society of Anesthesiologists (ASA) classification, smoking, diabetes, and surgery indication (OR 2.4, CI 1.6-3.6). CONCLUSIONS: Tourniquet time over 100 minutes increases the risk of complications after knee arthroplasty surgery and special attention is advocated to reduce the tourniquet time.

Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty: a randomized controlled study of 164 patients.

BACKGROUND: Measurement of limb occlusion pressure before surgery might lead to the use of a lower tourniquet cuff pressure during surgery and thereby reduce the risk of postoperative pain and complications. The primary aim of this study was to investigate whether the limb-occlusion-pressure method reduces the tourniquet cuff pressure used during total knee arthroplasty and if this leads to less postoperative pain compared with that experienced by patients on whom this method is not used. The secondary aim was to investigate whether there were any differences regarding the quality of the bloodless field, range of motion, and postoperative wound complications. METHODS: One hundred and sixty-four patients scheduled to be treated with a total knee arthroplasty were randomized to a control group or to undergo the intervention under study (the limb-occlusion-pressure [LOP] group). In the control group, the tourniquet cuff pressure was based on the patient's systolic blood pressure and a margin decided by the surgeon (the routine method). In the LOP group, the tourniquet cuff pressure was based on the measurement of the limb occlusion pressure. The primary outcome measure was postoperative pain, and the secondary outcome measures were the quality of the bloodless field, knee motion, and wound-related complications at discharge and two months after surgery. RESULTS: The tourniquet cuff pressure was significantly lower in the LOP group than in the control group (p < 0.001). We could not demonstrate any differences between the groups regarding postoperative pain or complications, although the number of postoperative complications was relatively high in both groups. However, at discharge forty of the forty-seven patients with a wound complication had had a cuff pressure above 225 mm Hg and at the two-month follow-up evaluation fourteen of the sixteen patients with a wound complication had had a cuff pressure above 225 mm Hg. CONCLUSIONS: The limb-occlusion-pressure method reduces the cuff pressure without reducing the quality of the bloodless field, but there were no differences in outcomes between the groups. An important secondary finding was that patients with a cuff pressure of ≤225 mm Hg had no postoperative infections and a lower rate of wound complications.

Skin protection underneath the pneumatic tourniquet during total knee arthroplasty: a randomized controlled trial of 92 patients.

BACKGROUND: The use of a pneumatic tourniquet to obtain a bloodless field during a total knee arthroplasty (TKA) allows the surgeon to work with greater technical precision in a safe, clear environment. Despite the benefits of surgical tourniquets and many advances in tourniquet equipment, their use is not without risk and complications may still occur. The primary aim of this study was to determine whether there are any differences between an elastic stockinette, cast padding, and no protective material at all regarding skin injuries after a primary TKA in a bloodless field using a pneumatic tourniquet. METHODS: 92 patients were randomized to 1 of 3 groups. In the first group, the limb underneath the pneumatic tourniquet was protected by a two-layer elastic stockinette (E). In the second group, it was protected by cast padding (C), and no protective material (N) was used in the third group. The presence of major skin injuries (blisters) was recorded when the tourniquet was removed after surgery. RESULTS: The two groups with skin protection had fewer skin injuries (p = 0.007). The elastic stockinette was significantly better than having no protective material and there was a trend towards better results in the elastic stockinette group than in the cast padding group. INTERPRETATIONS: Our findings indicate that protective material underneath the tourniquet cuff reduces the risk of skin injuries, i.e. blisters. An elastic stockinette appears to be best.