Surgical Irrigation Research Articles

Wound Irrigation in Orthopedic Open Fractures: A Review.

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

How Successful Is Antibiotic Treatment for Superficial Surgical Site Infections After Open Fracture? A Fluid Lavage of Open Wounds (FLOW) Cohort Secondary Analysis.

Although many studies report the incidence and prevalence of surgical site infections (SSIs) after open fractures, there is limited information on the treatment and subsequent outcomes of superficial SSIs in patients with open fractures. Additionally, clinical studies describing the factors that are associated with persistent infection after nonoperative treatment with antibiotics for patients with superficial SSIs are lacking. Therefore, we asked: (1) What proportion of patients with superficial SSIs after open fracture treatment developed persistent infection after nonoperative treatment (that is, treatment with antibiotics alone)? (2) What risk factors are associated with SSIs that do not resolve with nonoperative (antibiotic) treatment? As a secondary objective, we planned to analyze the microbiological information about participants wound cultures, when these were available, and the proportion of positive cultures for patients whose SSIs were not resolved by antibiotics alone. This is a secondary analysis of the Fluid Lavage of Open Wounds (FLOW) trial dataset. The FLOW trial included 2445 patients with operatively managed open fractures. FLOW participants who had a nonoperatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Superficial SSIs were diagnosed in 168 participants within 12 months of their fracture. Of these, 83% (139) had their superficial SSI treated with antibiotics alone. Participants were grouped into two categories: (1) 97 participants whose treatment with antibiotics alone resolved the superficial SSI and (2) 42 participants whose treatment with antibiotics alone did not resolve the SSI (defined as undergoing surgical management or the SSI being unresolved at latest follow-up [12-months post-fracture for the FLOW trial]). Of the participants whose treatment with antibiotics alone resolved the SSI, 92% (89 of 97) had complete follow-up, 6% (6 of 97) were lost to follow-up before 12 months, 1% (1 of 97) withdrew consent from the study before 12 months, and 1% (1 of 97) experienced mortality before 12 months. Of the participants whose treatment with antibiotics alone did not resolve the SSI, 90% (38 of 42) had complete follow-up, 7% (3 of 42) were lost to follow-up before 12 months, and 2% (1 of 42) withdrew consent from the study before 12 months. A logistic binary regression analysis was conducted to identify factors associated with persistent infection despite superficial SSI antibiotic treatment. Based on biologic rationale and previous evidence, we identified a priori 13 potential factors (corresponding to 14 levels) to be included in the regression model. The antibiotic treatment resolved the superficial SSI in 70% (97 of 139) of patients and did not resolve the SSI in 30% (42 of 139). After controlling for potential confounding variables, such as age, fracture severity, and time from injury to initial surgical irrigation and débridement, superficial SSIs diagnosed later in follow-up were associated with antibiotics not resolving the SSI (odds ratio 1.05 [95% CI 1.004 to 1.009] for every week of follow-up; p = 0.03). Sex, fracture pattern, and wound size were not associated with antibiotics not resolving the SSI. Our secondary analysis of prospectively collected FLOW data suggests that antibiotics alone can be an appropriate treatment option when treating superficial SSIs after an open fracture wound, especially when promptly diagnosed. Further research with longer follow-up time is needed to better identify the natural history of superficial SSIs and possibly some dormant or subclinical infections to help clinicians in the treatment decision-making process. Level III, therapeutic study.

MON-334 Severe Hypercalcemia Following Hip Joint Implantation of Stimulan® Calcium Sulfate Antibiotic Beads

Introduction: The diagnosis and management of hypercalcemia in hospitalized patients can be challenging. Hypercalcemia is often associated with significant morbidity and end-organ damage which may delay a patient’s recovery. Case report: A 63-years-old female presented for evaluation of left hip pain and was found to have an infection of the prosthetic joint. Past medical history was significant for type 2 diabetes and atrial fibrillation. No known history of malignancy or excess calcium, vitamins A or D intake. Past surgical history was significant for multiple left hip fixation surgeries and a left hip arthroplasty 4 months prior. Patient’s serum calcium on admission was 8.4 mg/dL (corrected 9.5 mg/dL, range 9.5-10.5 mg/dL), serum creatinine 1.2 mg/dL (range, 0.5 - 1.2 mg/dL). Three days later, she underwent surgical irrigation and debridement of the left hip with placement of 30 cc STIMULAN® antibiotic beads with vancomycin. On postoperative day (POD) 5, patient was found to be confused. Laboratory workup revealed serum calcium 13 mg/dL, ionized calcium 1.91 mmol/L (range, 1.12-1.32 mmol/L), serum creatinine 1.6 mg/dL, intact PTH 10 (range, 15- 65 pg/mL), PTH-rp 15 pg/mL (range, 14-27 pg/mL), 25-OH-vitamin D 18 ng/mL (range, 30-60 ng/mL), 1,25-OH2-vitamin D <8 ng/mL (range, 18-72 ng/mL). Clinical challenge: The differential diagnosis of non-PTH mediated hypercalcemia includes malignancy, granulomatosis and/or excess calcium intake. The patient’s history and laboratory data were not consistent with these etiologies. The temporal nature of the hypercalcemia in relation to implantation of antibiotic beads suggest causality of exogenous calcium sulfate and development of the patient’s hypercalcemia. Mild renal insufficiency, as well as immobilization in the setting of surgery, were likely also contributory. Treatment and outcome: This patient was first treated with aggressive intravenous saline and calcitonin. Serum calcium rose to 13.7 mg/dL and pamidronate 30 mg was administered. Hypercalcemia resolved on POD 11 with improvement in patient functional status. Discussion: Hypercalcemia due to implanted calcium sulfate antibiotic beads is not well described outside of case reports. Kallala found hypercalcemia in less than 0.01% of patients who underwent bead implantation, with all the affected patients presenting with preoperative renal failure. Conclusion: Hypercalcemia in the setting of calcium sulfate antibiotic beads implantation may contribute to a patient’s confusion and increase length-of-stay. We recommend serum calcium and creatinine to be closely monitored during the perioperative period in patients who receive calcium sulfate antibiotic beads. Risk factors for the development of hypercalcemia require additional study, though patients with pre-existing renal insufficiency may not be good candidates for the mechanism of antibiotic administration.

Relationship between Burr-Hole position and pneumocephalus in patients operated for chronic subdural hematoma

ObjectiveChronic subdural hematoma (CSDH) is one of the most frequent neurosurgical conditions in people aging between 70 and 80 years. The cranial burr-hole (CBH) with surgical cavity irrigation through the burr hole and closed drainage system is the treatment of choice but -post-operative outcome can be influenced by pneumocephalus. In this study, we aimed to explore the relationship between the anterior-posterior (AP) burr-hole position and the volume of post-operative pneumocephalus. Patients and MethodsWe identified 153 consecutive patients who underwent BHC for CSDH at our institution. Baseline and post-operative data were retrospectively collected from medical records. The linear regression model was used to estimate the association between the volume of post-operative subdural air collection and burr-hole position along with other baseline patients and hematoma variables. ResultsThe AP position of the burr-hole was independently associated with the volume of post-operative pneumocephalus: lower volume of subdural air was observed in patients with more anterior cranial burr-hole. ConclusionsIn patients operated for CSDH, the cranial burr-hole should be performed anteriorly to grant a lesser amount of subdural post-operative air collection.

Intra-Cavity Lavage and Wound Irrigation for Prevention of Surgical Site Infection: Systematic Review and Network Meta-Analysis.

Background: Surgical site infections (SSIs) are costly and associated with poorer patient outcomes. Intra-operative surgical site irrigation and intra-cavity lavage may reduce the risk of SSIs through removal of dead or damaged tissue, metabolic waste, and site exudate. Irrigation with antibiotic or antiseptic solutions may further reduce the risk of SSI because of bacteriocidal properties. Randomized controlled trials (RCTs) have been conducted comparing irrigation solutions, but important comparisons (e.g., antibiotic vs. antiseptic irrigation) are absent. We use systematic review-based network meta-analysis (NMA) of RCTs to compare irrigation solutions for prevention of SSI. Methods: We used Cochrane methodology and included all RCTs of participants undergoing a surgical procedure with primary site closure, in which method of irrigation was the only systematic difference between groups. We used a random effects Bayesian NMA to create a connected network of comparisons. Results are presented as odds ratios (OR) of SSI, where OR <1 indicates a beneficial effect. Results: We identified 42 eligible RCTs with 11,726 participants. Most were at unclear or high risk of bias. The RCTs included groups given no irrigation or non-antibacterial, antiseptic, or antibiotic irrigation. There was substantial heterogeneity, and a random effects model was selected. Relative to non-antibacterial irrigation, mean OR of SSI was 0.439 (95% credible interval: 0.282, 0.667) for antibiotic irrigation and 0.573 (0.321, 0.953) for antiseptic agents. No irrigation was similar to non-antibacterial irrigation (OR 0.959 [0.555, 1.660]). Antibiotic and antiseptic irrigation were ranked as most effective for preventing SSIs; this conclusion was robust to potential bias. Conclusions: Our NMA found that antibiotic and antiseptic irrigation had the lowest odds of SSI. There was high heterogeneity, however, and studies were at high risk of bias. A large RCT directly comparing antibiotic irrigation with both antiseptic and non-antibacterial irrigation is needed to define the standard of care for SSI prevention by site irrigation.

Synovial Cell Count Poorly Predicts Septic Arthritis in the Presence of Crystalline Arthropathy.

Introduction: A synovial cell count greater than 50,000/mm3 is the threshold most commonly used to diagnose septic arthritis. This lab value may be nonspecific in the setting of crystalline arthropathy. The purpose of this study was to evaluate the accuracy of diagnosing septic arthritis using a synovial cell count cut-off of 50,000/mm3 in the setting of crystalline arthropathy.Methods: This was a retrospective review of joint aspirations performed between July 1st, 2013 and June 30th, 2016. Synovial fluid samples were evaluated for cell count, crystals, Gram stain, and culture. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the synovial markers were calculated.Results: During the study period, 738 joint aspirations were sent for testing, of which 358 aspirations in 348 patients met inclusion criteria. There were 49 (13.7%) cases of culture-positive septic arthritis, and 47 patients underwent surgical irrigation and debridement. Gout and pseudogout crystals were present in 163 aspirates (45.5%). Three joints (0.8% overall rate) had concomitant crystalline arthropathy and septic arthritis, each of which had a synovial WBC ≥85,000/mm3. Increasing the WBC count cutoff to 85,000/mm3 demonstrated a specificity of 100%, but a PPV of 12.0%.Conclusions: A cut-off of 85,000/mm3 may be more appropriate to diagnose concomitant septic arthritis and crystalline arthropathy. We recommend medical management and observation in patients with crystal-positive joint aspirations unless the synovial cell count is elevated above 85,000/mm3. Prospective studies using this treatment guideline are needed to evaluate its validity and accuracy.

Methods of local antimicrobic prophylaxis of surgical site infection

Recently, to prevent of surgical site infection, new methods of local antimicrobic prophylaxis have been developed and successfully introduced, which allow to creating high concentrations of antimicrobial drugs in operated tissues and preventing the migration of bacterial flora into the wound. The review describes the main methods used for local impact on microflora and aimed at prophylaxis of surgical site infection. The latter include pre-, intra- and postoperative measures. Optimizing of preoperational methods could be achieved by improving the methods of processing of operating field. Reviews considerable attention is paid to intraoperative measures: the use of surgical gloves with antimicrobial properties, reticulated to implants with antimicrobial properties for tension-free hernioplasty, stage-by-stage surgical wound irrigation with antibacterial drugs during suturing as well as the prospects for the use of bacteriophages in abdominal surgery. To increase the biological tightness of the intestinal suture, some authors propose the use of a biodegradable antibiotic-impregnated implant. The review reflects the possibilities of using biologically active (antimicrobial) sutures, the use of which was very effective at all stages of the operation: from the application of intestinal anastomosis to the skin suture. A wide range of antimicrobial surgical sutures containing antibacterial preparations and made by threads with different biodegradation abilities make, allow us to recommend a differentiated approach to the choice of suture material depending on the stage of surgery and regenerative properties of the sutured tissues. The main measures recommended in the early postoperative period are to cover the wound with special wound coatings preventing the possible contamination and to improve irrigation-aspiration drainage techniques of postoperative wounds.

Traumatic Arthrotomy.

Evaluation of periarticular traumatic wounds for joint penetration is a common clinical concern for orthopaedic surgeons. Wounds that violate the joint capsule can result in deep infection and sepsis. Understanding the anatomic landmarks and capsular extensions of the major joints is key to proper evaluation. Initial evaluation of periarticular wounds includes thorough examination of the wound and plain radiographs. Historically, the saline load test has been the diagnostic test of choice for assessing traumatic arthrotomy; however, CT has recently been shown to have excellent sensitivity and specificity for detecting open knee joint injuries. Current treatment of traumatic arthrotomy includes intravenous antibiotics and surgical irrigation and débridement. Future areas of research must focus on further validation of CT evaluation and its use in other major joints, standardizing antibiotic treatment, and further delineating the role of nonsurgical management in minor injuries.

Comparison of Irrigation with Povidone-Iodine Versus Normal Saline on Wound Infection After Open Appendectomy

Objective: Surgical site infections (SSIs) pose a continued problem to operating surgeons. It adds to the healthcare cost, increases morbidity and mortality and sometimes culminates in re-explorations. Rate of SSIs can be ameliorated by removing damaged or non-viable tissue, metabolic waste and wound exudates; this can be achieved by irrigation of surgical wound intraoperatively. Surgical wound irrigation can also be performed postoperatively. Even after giving prophylactic antibiotics and august aseptic measures, post-appendectomy wound infection remains soaring. The efficacy of povidone-io- dine on non-incised skin is well known but its application as an intraoperative irrigation solution in open surgical wounds is not a mundane practice. Likewise prophylactic irrigation with normal saline solution to prevent wound infection has also turned out to be effective in some studies. The objective of this study is to compare the percentage of superficial SSI post-appendectomy, with intraoperative irrigation of subcutaneous plane using 1% povidone-iodine solution versus normal saline.&#x0D; Methods: 200 cases of open appendectomy for acute appendicitis at Baqai Medical University, Kara- chi were randomly distributed into two arms. In group A, 0.9% Normal Saline was employed to irrigate subcutaneous tissue before skin closure while in group B irrigation with 1% diluted povidone-iodine solution was undertaken. The cases were assessed for infection in surgical wounds in line with Southampton wound grading system for five days after surgery and followed for thirty days.&#x0D; Results: Mean age of participants of this study was 18.65 years. There were 100 patients in both groups and the groups were not different statistically in terms of age, gender and operative findings. A total of 38 (19%) out of 200 patients had Southampton grade 2 and above, signifying wound infection. Out of these, 29 (29%) were from Group A and 9 (9%) from Group B (p=0.001).&#x0D; Conclusion: 1% diluted povidone-iodine irrigation of subcutaneous plane after appendectomy remark- ably lowers the rate of SSI when compared with normal saline irrigation.

Clinical Characteristics and Outcomes of Staphylococcus aureus Implant-associated Infections in Children.

Staphylococcus aureus is a significant cause of implant-associated infections (IAIs). Data detailing the optimal treatment of IAIs are lacking in children. We describe the clinical features and outcomes of pediatric patients with S. aureus IAIs seen at Texas Children's Hospital. Patients and their isolates were identified from a S. aureus surveillance database from 2008 to 2016 in Houston, TX. Demographic and clinical data were collected retrospectively. Fisher's exact was used for statistical analysis. Forty-five patients with 47 IAIs were identified. Most patients had an infected orthopedic implant: 22 (47%) spinal rods and 19 (40%) with other orthopedic hardware. Thirty (64%) IAIs developed within 90 days of implant placement. Six patients had polymicrobial infections and 3 patients were bacteremic. Of the 47 IAI isolates, 34 (72%) were methicillin-susceptible S. aureus (MSSA) and 13 (28%) were methicillin-resistant S. aureus. All children underwent surgical irrigation, debridement and antibiotic therapy. Of the 47 IAI episodes, 22 of the implants were removed at time of initial presentation, 7 implants had delayed removal, and 18 implants remained in place. Successful treatment was achieved in all patients with immediate implant removal (22/22) and in 83% of patients with implant retention (15/18), including 10 patients with early postoperative infections (<3 months) and 5 patients with late postoperative infections (>3 months). Four patients had recurrence of infection. The majority of S. aureus IAIs were methicillin-susceptible S. aureus. All children with immediate implant removal and most children with retained implants were treated successfully with surgery and antibiotic therapy.

Wash, Rinse, Repeat: Which Patients Undergo Serial Joint Irrigation in Pediatric Septic Hip Arthritis?

The purpose of this study is to identify risk factors associated with repeat surgical irrigation in pediatric septic hip arthritis. A single center retrospective case-control study was performed. Patients who underwent ≥2 washouts (cases) were compared with those who had only 1 washout (controls). Demographic, clinical, laboratory, microbial, and magnetic resonance imaging data were compared between cases and controls and a prediction model was developed using logistic regression. A risk score was then constructed by counting the number of risk factors from the model that were present in each patient. We identified 26 patients between 1994 and 2015 who underwent ≥2 washouts for septic hip arthritis, and 63 control patients who had only a single washout. Twenty-two patients had 2 washouts, 3 had 4 washouts, 1 had 5 washouts. Median number of days between first and second washout was 5 (interquartile range, 4 to 8). The most common reason for repeat washout was persistent fever (N=21), followed by persistently elevated laboratory values (N=13), abnormal magnetic resonance imaging findings (N=12), and continued pain (N=12). Repeat washout cases demonstrated higher temperature preoperatively (P<0.001), had more frequent initial misdiagnosis (P=0.002), and had a longer time from symptom onset to surgery (P=0.02). Laboratory values in these cases showed higher C-reactive protein (P=0.003), and more frequent left shift (P=0.03) at presentation, with a greater proportion of positive cultures (P<0.001). Postoperatively, repeat washout cases had higher temperatures (P<0.001), more frequent wound drainage (P=0.02), and complications (P=0.001). A risk score for predicting the likelihood of undergoing repeat washout was constructed by counting the number of the following factors present: presence of left shift in CBC, positive blood or synovial fluid cultures, and postoperative temperature over 39°C. Seventy percent of cases had ≥2 of these risk factors and 80% of controls had ≤1 risk factor. Cases of pediatric septic arthritis which undergo repeat washout are associated with left shift, high postoperative temperatures, and positive cultures. They have more frequent misdiagnosis leading to delayed treatment and subsequent medical complications. Level III.

Iatrogenic hyponatraemia secondary to surgical irrigation during transurethral resection of the prostate

Iatrogenic hyponatraemia secondary to surgical irrigation during transurethral resection of the prostate

Patients treated with surgical irrigation and debridement for infection after ACL reconstruction have a high rate of subsequent knee surgery

ObjectivesThe purpose of this cross-sectional study was to describe the rates of additional surgery and patient-reported outcomes in patients who underwent surgical irrigation and debridement (I&D) for infection following anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that additional surgery is associated with worse patient-reported outcomes.MethodsPatients diagnosed with a postoperative infection following ACLR (defined as one requiring surgical treatment with either a deep or superficial I&D) were identified from a prospective cohort. Both primary and revision ACLRs were included, as well as any graft type (autografts and allografts). Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score [KOOS] and Marx activity level) and subsequent surgeries were collected at 2-year and 6 year follow-up from the initial ACLR surgery. Baseline demographics and 2-year and 6-year outcomes (from initial ACLR) were compared between patients who did or did not undergo additional surgery subsequent to I&D using Wilcoxon rank-sum tests for continuous variables and Fisher’s exact tests for categorical variables.ResultsTwenty-one of 3210 ACLR patients (0.7%) had a postoperative infection requiring surgical I&D. This group consisted of 12 men and 9 women, mean (SD) age of 25.8 (11.3) years, 18 primary and 3 revision ACLRs and 16 autografts and 5 allografts. The mean time from ACLR to the surgical I&D was 39 days. In these patients, IKDC scores improved from 44±17 prior to initial ACLR to 83±16 at 6-year follow-up (p<0.001). While all KOOS scores improved from baseline to final follow-up, activity level decreased from 11±6 to 7±5 points (p<0.001). Follow-up related to subsequent surgery was obtained on 20 of 21 patients (95%). Forty per cent of the infection group (n=8 of 20) underwent additional surgery following their I&D, with three patients (15%) undergoing revision ACLR and one patient (5%) undergoing total knee arthroplasty. Patients who underwent additional surgery had lower Marx activity at 2 years compared with patients who had no subsequent surgeries (4±3vs 9±5 points, p=0.018).ConclusionPatients who undergo I&D for an infection following ACLR have a high rate of additional surgery but still attain reasonable clinical outcomes 6 years after ACLR.Level of evidenceIV

Ex vivo and in vivo evaluation of residual chlorhexidine gluconate on skin following repetitive exposure to saline and wiping with 2% chlorhexidine gluconate/70% isopropyl alcohol pre-operative skin preparations

Skin antisepsis is performed before surgery to minimize the risk of surgical site infections. Chlorhexidine gluconate (CHG) is routinely used in this application, but it may be removed during surgery when prepped areas are exposed to fluid and repeated blotting. This work evaluated the effect of adding a film-forming acrylate copolymer to a CHG-containing skin preparation on minimizing CHG loss during a simulated surgical irrigation and wiping procedure. The results were compared with those obtained with a commercially available water-soluble CHG preparation. Two studies using excised porcine skin and one study on human volunteers were performed. In each study, the CHG preparations were applied and the treated sites were challenged with repetitive saline soaks and gauze dabbing to simulate surgical conditions. Challenged and unchallenged sites were analysed either for CHG content by high-performance liquid chromatography, or for bacterial log recovery after seeding an indicator organism (reflecting remaining CHG activity). After irrigation and wiping, skin treated with the film-forming CHG preparation had more CHG remaining both on excised pig skin and in the human model. In the pig model, there was a lower recovery of inoculated bacteria with the CHG preparation containing the film-forming copolymer. No skin irritation or adverse events were reported in the human study. The addition of a film-forming copolymer has the potential to improve the retention of CHG on skin throughout a surgical procedure compared to a water-soluble preparation. This improved retention may lead to better antimicrobial activity.

Effect of Postoperative Xylitol Nasal Irrigation on Patients with Sinonasal Diseases.

To examine the effect of xylitol nasal irrigation in a large sample size of patients who had undergone nasal surgery. Double-blinded randomized controlled crossover study. Tertiary referral center. The study included 100 patients with sinonasal disease who underwent endoscopic sinus surgery (ESS), septoplasty, or both concurrently. To identify patients with allergic sensitization, serum-specific immunoglobulin E levels were measured. Nasal symptoms were evaluated with the NOSE (Nasal Obstruction Symptoms Evaluation) and SNOT-20 (Sino-Nasal Outcome Test-20) and via visual analog scale (VAS) scores. In the ESS group (n = 34), the general nasal symptom score evaluated by the SNOT-20 showed significantly greater improvement in the xylitol group versus the saline group ( P = .022). VAS symptom scores for sneezing ( P = .003), headache ( P = .02), and facial pain ( P = .037) were also more improved in the xylitol group. In the septoplasty group (n = 39), the VAS score for nasal stuffiness showed a significantly greater improvement in the xylitol group when compared with the saline irrigation group ( P = .001). Among the patients with allergic sensitization (n = 31), rhinorrhea symptoms improved significantly more in the xylitol group than in the saline group ( P = .024). The preference survey showed that more than half of the patients in each surgical group preferred xylitol irrigation. We found that xylitol nasal irrigation was useful in postoperative ESS and septoplasty care. For patients with allergic sensitization, rhinorrhea showed greater improvement in the xylitol group than in the saline group.

Predictability of Clinical Knowledge Through Mobile App-based Simulation for the Treatment of Pediatric Septic Arthritis: A Pilot Study.

Recently the American Board of Orthopaedic Surgery and the Accreditation Council of Graduate Medical Education have identified the treatment of septic arthritis of the hip in children as a milestone skill for all US orthopaedic residents. The purpose of this study was to test correlation between clinical knowledge and examination score on a mobile app-based training module for the treatment of pediatric septic hip arthritis. A 4-part simulation model on surgical decision-making associated with the treatment of pediatric septic arthritis was developed through expert consensus. Orthopaedic trainees participating in the "Top Gun" program of the 2015 and 2016 International Pediatric Orthopaedic Symposiums were recruited to participate in this pilot study. Trainees completed a presimulation quiz on their knowledge of diagnosis, arthrocentesis, and surgical irrigation and debridement on a pediatric patient presenting with septic arthritis of the hip. Trainees then completed the 4-part simulation on the mobile app. Pearson correlation analysis was used to assess the relationship between the quiz and the simulation. A total of 53 orthopaedic residents and fellows participated in the simulation. Median quiz score was 87 points [interquartile range (IQR), 81 to 94] before the intervention and 100 points (IQR, 94 to 100) postintervention. The median simulation test score was 89 (IQR, 81 to 92) which demonstrated a positive correlation with the postintervention quiz (r=0.44, P<0.001). The preintervention metrics demonstrated a positive correlation with postintervention metrics (r=0.53, P<0.001). This study revealed a statistically significant positive correlation between the mobile app simulation and the clinical knowledge of the participants, as well as the ability to improve knowledge about a procedure during the testing period. These findings support the ability for the mobile app to test clinical knowledge. In the current environment of decreased work hours and patient exposure for orthopaedic trainees, mobile app-based simulation has the potential to safely aid in assessment of orthopaedic residents and fellows.

Perioperative anaphylaxis — Time for a NAP… 6!

Perioperative anaphylaxis — Time for a <scp>NAP</scp>… 6!

Impact of a Novel Surgical Wound Protection Device on Observed versus Expected Surgical Site Infection Rates after Colectomy Using the National Surgical Quality Improvement Program Risk Calculator.

Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator. A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study. A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device. These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.

Percutaneous suction and irrigation for the treatment of recalcitrant pyogenic spondylodiscitis

BackgroundThe primary management of pyogenic spondylodiscitis is conservative. Once the causative organism has been identified, by blood culture or biopsy, administration of appropriate intravenous antibiotics is started. Occasionally patients do not respond to antibiotics and surgical irrigation and debridement is needed. The treatment of these cases is challenging and controversial. Furthermore, many affected patients have significant comorbidities often precluding more extensive surgical intervention. The aim of this study is to describe early results of a novel, minimally invasive percutaneous technique for disc irrigation and debridement in pyogenic spondylodiscitis.Materials and methodsA series of 10 consecutive patients diagnosed with pyogenic spondylodiscitis received percutaneous disc irrigation and debridement. The procedure was performed by inserting two Jamshidi needles percutaneously into the disc space. Indications for surgery were poor response to antibiotic therapy (8 patients) and the need for more extensive biopsy (2 patients). Pre- and postoperative white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Oswestry disability index (ODI), and visual analogue score (VAS) for back pain were collected. Minimum follow-up was 18 months, with regular interval assessments.ResultsThere were 7 males and 3 females with a mean age of 67 years. The mean WBC before surgery was 14.63 × 109/L (10.9–26.4) and dropped to 7.48 × 109/L (5.6–9.8) after surgery. The mean preoperative CRP was 188 mg/L (111–250) and decreased to 13.83 mg/L (5–21) after surgery. Similar improvements were seen with ESR. All patients reported significant improvements in ODI and VAS scores after surgery. The average hospital stay after surgery was 8.17 days. All patients had resolution of the infection, and there were no complications associated with the procedure.ConclusionsOur study confirms the feasibility and safety of our percutaneous technique for irrigation and debridement of pyogenic spondylodiscitis. Percutaneous irrigation and suction offers a truly minimally invasive option for managing recalcitrant spondylodiscitis or for diagnostic purposes. The approach used is very similar to discography and can be easily adapted to different hospital settings.Level of EvidenceLevel III

Surgical Breast Pocket Irrigation With Hypochlorous Acid (HOCl): An In Vivo Evaluation of Pocket Protein Content and Potential HOCl Antimicrobial Capacity.

Hypochlorous acid (HOCl) demonstrates rapid and broad antimicrobial activity against planktonic and biofilm phenotype bacteria in vitro. To identify the protein content present in breast pockets in vivo and calculate the estimated active concentration of HOCl, (PhaseOne, Integrated Healing Technologies, Franklin, TN) following HOCl-protein interactions. Fluid samples were collected prior to implant insertion in 18 consecutive patients, representing 36 pocket samples, with all cases being bilateral primary breast augmentations. Samples were evaluated by an independent CLIA approved laboratory for albumin and total protein concentration in g/dL. Results were compared to HOCl solution concentration and protein binding potential to determine availability of free HOCl. The mean tissue sample concentration (right and left breast) was 31.6 mg/dL which translates to 0.0001 mmol per 20 cc of interstitial fluid. Mean total protein levels (right and left breast) were 62.3 mg/dL or 0.000187 mmol per 20 cc interstitial fluid. Based upon potential stoichiometric neutralization of HOCl by proteins in either a 1:1 or 3:1 ratio, using 115 cc of HOCl solution (per breast) at a concentration of 250 ppm/mL or 0.025% HOCl or = 0.48 mmol HOCl/dL, there would be 2950 times the amount of active HOCl at a 1:1 reaction ratio, or 983 times more HOCl assuming a 3:1 reaction ratio. Based on the range of identified levels of protein in individual surgical pockets in the study, there is an estimated 242 to 12,500 times more HOCl molecules than protein at a 3:1 molar ratio of binding or reactive protein. n estimated range of 983-2950 times more HOCl molecules are present during irrigation with 230 cc of PhaseOne® (115 cc for each breast) than available protein. This supports the antimicrobial and anti-biofilm activity as described in previous in vitro studies when using PhaseOne® as part of pocket irrigation.