Objectives. Surgeons face a substantial risk of infection because of the occupational exposure to blood-borne pathogens (BBPs) from patients undergoing high-risk orthopaedic procedures. This study aimed to determine the seroprevalence of four BBPs among patients undergoing joint arthroplasty in Shanghai, China. In addition, we evaluated the significance of pre-operative screening by calculating a cost-to-benefit ratio. Methods. A retrospective observational study of pre-operative screening for BBPs, including hepatitis B and C viruses (HBV and HCV), human immunodeficiency virus (HIV) and Treponema pallidum (TP), was conducted for sequential patients in the orthopaedic department of a large urban teaching hospital between 01 January 2009 and 30 May 2016. Medical records were analysed to verify the seroprevalence of these BBPs among the patients stratified by age, gender, local origin, type of surgery, history of previous transfusion and marital status. Results. Of the subjects who underwent arthroplasty surgery in our institution, pre-operative screening tests were available for 96.1% (11 609 patients). The seroprevalence of HBV, HCV, HIV and TP was 5.47%, 0.45%, 0.08% and 3.6%, respectively. A total of 761 seropositive cases (68.4%) were previously undiagnosed. Pre-operative screening for HIV resulted in a low cost to benefit ratio, followed by HCV and HBV. Conclusion. Routine HCV and HIV screening prior to joint arthroplasty is not a cost-effective strategy. Considering the high rate of undiagnosed patients and the shortage of protective options, targeted pre-operative screening for HBV and syphilis should be considered for the protection of healthcare workers in China who have not been vaccinated. Cite this article: Bone Joint Res 2017;6:566–571

Purpose. The consequences of infection in orthopedic oncology patients are well known. Methicillin sensitive- and resistant Staphylococcus aureus (MSSA and MRSA, respectively) are common infecting organisms which may colonize patients pre-operatively. The prevalence of colonization in orthopedic oncology patients is unknown. We sought to prospectively establish the prevalence of MSSA and MRSA colonization in an orthopedic oncology patient population. Method. Beginning in September 2009, all oncology patients of a single surgical service were prospectively screened pre-operatively for MSSA and MRSA colonization using PCR nasal swabs as part of an infection control protocol. Patients identified as carriers underwent decolonization treatment peri-operatively. Results. One hundred thirty-nine oncology patients underwent 143 independent procedures with orthopedics as the primary service from September 1, 2009 August 31, 2010. MSSA/MRSA screening capture rate was 93%. Prevalence of MSSA colonization was 22% and MRSA colonization was 3.8%. MSSA colonization was not associated with malignant diagnosis (p=1.0), or recent chemo- or radiotherapy treatment (p>0.50 for both). All MRSA colonized patients had undergone inpatient oncology treatment or had occupational exposure to MRSA in the last year. Post-operative infection developed in 4/124 patients with type I surgical incisions (3.2%). Infecting organisms were coagulase negative Staphylococcus (n=2), MSSA (n=1), and Streptococcus (n=1). Conclusion. MSSA colonization rates in orthopedic oncology patients are similar to reported population values. MRSA colonization rates are low. Patient diagnosis or adjuvant treatments do not appear to influence colonization rates. MRSA colonization was only seen in patients with inpatient or occupational exposure to MRSA

Abstract. INTRODUCTION. With increasing use of fluoroscopy in Orthopaedic theatres in recent years, the occupational radiation exposure to the surgeons and the theatre staff has increased significantly. Thyroid is one of the most radio-sensitive tissues in the body, but there is a clear lack of awareness among theatre staff of risks of radiation to thyroid. METHODS. We prospectively reviewed the use of thyroid shield by the theatre staff in the orthopaedic theatre for two weeks period. We also recorded the number of fluoroscopic images taken and total radiation dosage for each case. RESULTS. Our results showed that of 249 staff in the theatres of which, only 35 people (14.2%) wore thyroid shields during fluoroscopy, whereas 100% were complaint with body protection shield. We noticed that only 30% of the surgeons, 40% of the scrub nurses and 5% anaesthetist use this, while 95% of the radiographers uses thyroid protection in theatre. Average total radiation during upper-limb procedures was 1.25 cGy, during lower-limb procedures it was 43.48 cGy. Total radiations were very high particularly during lower-limb nailing procedures (80.98 cGy). CONCLUSION. Extensive use of fluoroscopy has a stochastic effect (accumulative effect) on thyroid gland particularly, if the dose in higher than 65 cGy. Despite its availability, only 14% people use the thyroid protection shield. We must emphasise the use of thyroid protection shield to the Orthopaedic surgeons, particularly during lower-limb procedures

The use of exhaust suit systems is commonplace in arthroplasty surgery where isolation of the surgical team is desirable in an attempt to reduce the risk of infection transmission. Elevated carbon dioxide levels have been reported in the non-clinical setting with such systems the consequences of which can include fatigue, diapho-resis, nausea, headache and irritability. The aim of our study was to determine the levels of carbon dioxide present within an exhaust suit system during hip arthroplasty and to compare these with the recommended occupational exposure limit levels published by the Health and Safety Executive (HSE). Data was collected during ten primary hip replacements performed by the same surgeon whilst wearing the Stryker Steri-Shield Helmet Exhaust System. This is a self-contained unit with an integrated blower used in conjunction with a full-length gown. In addition the helmet was fitted with an air-sampling probe connected to a portable infrared CO2 monitor and also a temperature probe. Thus continuous monitoring of both CO2 and temperature level during surgery was possible. The mean initial CO2 concentration in the helmet at the beginning of surgery was 3 000 parts per million (ppm) and the mean maximum CO2 level recorded was 13 000 ppm. The mean time the surgeon was within an exhaust suit to perform a primary hip replacement was 1 hr 54 mins and for 86% of this time period the CO2 level within the helmet exceeded the recommended level of 5 000 ppm as stipulated by the HSE. In conclusion we have demonstrated significantly elevated CO2 levels within the Stryker Steri-shield Exhaust Suit System during hip surgery. Surgeons who use this system should be aware of this together with the physical symptoms that may result

The use of exhaust suit systems is commonplace in arthroplasty surgery where isolation of the surgical team is desirable in an attempt to reduce the risk of infection transmission. Elevated carbon dioxide levels have been reported in the non-clinical setting with such systems the consequences of which can include fatigue, diaphoresis, nausea, headache and irritability. The aim of our study was to determine the levels of carbon dioxide present within an exhaust suit system during hip arthroplasty and to compare these with the recommended occupational exposure limit levels published by the Health and Safety Executive (HSE). Data was collected during ten primary hip replacements performed by the same surgeon whilst wearing the Stryker Steri-Shield Helmet Exhaust System. This is a self-contained unit with an integrated blower used in conjunction with a full-length gown. In addition the helmet was fitted with an air-sampling probe connected to a portable infrared CO. 2. monitor and also a temperature probe. Thus continuous monitoring of both CO. 2. and temperature level during surgery was possible. The mean initial CO. 2. concentration in the helmet at the beginning of surgery was 3000 parts per million (ppm) and the mean maximum CO. 2. level recorded was 13,000 ppm. The mean time the surgeon was within an exhaust suit to perform a primary hip replacement was 1 hr 54 mins and for 86% of this time period the CO. 2. level within the helmet exceeded the recommended level of 5000 ppm as stipulated by the HSE. In conclusion we have demonstrated significantly elevated CO. 2. levels within the Stryker Steri-shield Exhaust Suit System during hip surgery. Surgeons who use this system should be aware of this together with the physical symptoms that may result

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Purpose: Serum cobalt and chromium levels after metal-on-metal implantations are not well known. There has been little data on the correlation with clinical and radiological surveillance. This prospective analysis followed the changes in serum cobalt, chromium, and titanium levels in order to ascertain the behaviour of the femoral implant and the bearing. Material and methods: The series included 292 patients followed for 27–72 months who were free of kidney failure, were not given vitamin B12 supplementation, and did not have occupational exposure. The same cemented implants were used in all patients: titanium femoral stem, Metasuly heads (28 mm). Serum samples were drawn preoperatively and at three, six and twelve months then annually (systematic activity questionnaire). The limit for detection of serum cobalt and chromium was 1 nmol/l (0.05μg/l); for titanium it was 30 nmol/l (1.4m/l). Results: The main problems encountered were two impingements and two femoral loosenings. Four patterns were identified in the time courses of serum cobalt and chromium. In decreasing order, they were: type 1, low initial level (< 50 nmol/l) then no change; type 2, high initial level (> 50 nmol/l) then decrease; type 3 low initial level then progression; type 4, high initial level then further elevation. Bilateral prostheses showed a particular pattern with elevation after the second implantation. The serum levels rapidly returned to normal after revision in the two impingement cases. The titanium levels were correlated with femoral problems which were not initially detected on the x-rays. Discussion: Correlation between serum cobalt level and wear is difficult to establish. There was no specific pattern after dislocation. The kinetics showed certain patterns with possible prognostic significance: groups 1 (metallic silence) and 2 (breaking-in) would correspond to favourable evolution; type 3 would be difficult to interpret (missed impingement, foreign body, articular decoaptation or major change in activity level); type 4 is highly suggestive of premature wear or a biological problem (excepting bilateral implants). It is important to monitor serum cobalt and titanium simultaneously to detect an interface problem and or femoral loosening

Purpose of the study: Long-term outcome of Charnley low-friction arthroplasty in young active patients is impaired worldwide due to wear of the polyethylene (PE) component and osteolysis. In the late eighties, reports of possible low wear with some former metal on metal total hip arthroplasties led to the reintroduction of metallic bearings. The aims of this work were to examine the rationale for using metal on metal bearings in primary total hip arthroplasty (THA) and report preliminary results obtained with cementless Metasul™-Alloclassic™ hips. Materials and methods: From January 1994 to March 1997, 64 cementless primary Alloclassic-THA (grit-blasted titanium SL stems and CSF treaded cups) with 28 mm Metasul bearings were performed. Mean age at surgery was 60 years (range, 36–73). Diagnoses were usual, mainly primary osteoarthrosis in 70 p. 100 of the hips. Two bearing surfaces were exchanged for late dislocation at 2.6 and 2.9 years. Thus, 62 hips in 58 active patients (4 bilateral) were reviewed after a minimum 2-year follow-up (mean 3.2 years, range 24–66 months). Results: Clinical results according to the Merle d’Aubigne and Charnley rating system were graded excellent or good in all 62 hips. Radiologically, calcar, atrophy and spot welds were noted in 93 p. 100 and 82 p. 100 of hips respectively. Proximal reactive and lucent lines and mild proximal stress shielding were observed in 8 p. 100 and 4.8 p. 100 of hips respectively. No osteolysis granuloma has thus far been observed in the vicinity of any component. Cobalt blood level remained normal, except in 6 cases due to occupational exposure (n = 1), possible impingement (n = 1) or an unknown cause (n = 4). All elevated cobalt levels (range 7 to 25 mg/l) were nevertheless far below the toxic limit. Discussion: Dislocation may be due either to the posterolateral surgical approach and/or early impingement with the first Metasul bearing design (head sleeve). Metasul acetabular component fixation is not restricted to only cementless metal-backing, unlike alumina-ceramic cups. The concern about the toxicity of metallic wear debris dissemination and the hematocarcinogenic risk must be taken into consideration as for any metallic THA. Follow-up is too short for the new polys for significant comparisons. Conclusion: Metal on metal tribology is well known in vitro and Metasul™ bearings have functioned in vivo for 12 years (120 000 Metasul hips worldwide) as was expected from laboratory tests. Obviously, this friction couple is not the unique answer to PE-wear and THA longevity, but, in light of current data, appears as a trustworthy solution available today

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Metals represent the main components of orthopaedic implants. Being in contact with biological fluids, the metallic alloys used for the fabrication of artificial joints undergo corrosion or degradation, therefore they release ions and molecules. Although these do not have antigenic properties, they bind to protein carriers and may act as haptens eliciting a delayed-type hypersensitivity reaction (DTH). Biomaterial-related hypersensitivity is considered as an immunotoxic effect, although little is known about its clinical incidence and its impact on implant failure. The main question about the sensitivity against metals used in the joint prosthesis concern the cause-effect relation with the implant failure. In metal-exposed workers, the diagnosis of DTH is made in vivo by patch testing. For the occupational exposure standard patch-testing protocols are available, but some concerns exist about their applicability to study the hypersensitivity to metal implants. In this case-control study, a panel of representative haptens was used to assess the incidence of positive patch testing in patients undergoing ‘total hip replacement’ (THR) and ‘total knee replacement’ (TKR). The main goal of this study was to evaluate the validity of this relatively simple and safe procedure in the diagnosis of the hypersensitivity reactions to the implant components. A consecutive series of 286 individuals was enrolled in the study. Five groups of patients were evaluated: Group A included 75 patients (20 M; 55 F; median age 59) candidates to primary THR or TKR; Group B included 98 patients with loosening of THR (27 M; 71 F; median age 67; median follow up: 102 months); Group C included 53 patients with stable THR (13 M; 40 F; median age 68; median follow up: 60 months); Group D included 40 patients with failed TKR (14 M; 26 F; median age 68; median follow up: 24 months); Group E included 20 patients with stable TKR (4 M; 16 F; median age 70; median follow up: 16 months). Osteoarthritis was the most frequent disease that led to joint replacement (59%), followed by hip dysplasia (19%), and trauma (13%). Patients with rheumatoid arthritis were excluded from the study, as well as patients who assumed cortico-steroids or other immunosuppressive drugs. Fifty-eight patients (21%) had an additional implant at another site. Hypersensitivity to metals was tested by using the most relevant components of Cobalt-Chromium based alloys (CoCrMo), Ti-based alloys (TiAlV), and bone cements. A drop of each hapten was smeared on the Haye’s chamber test, which was applied to the dorsum of the patient. After 48–72 hours, skin reactions were evaluated and graded as 0 (no reaction), 1 (erythema), 2 (edema), 3 (vesicles), or 4 (bulla). All patients with a medical history of metal DTH showed positive skin reaction. The incidence of positive patch testing to at least one hapten, as well as the frequency of DTH to metal, resulted significantly higher in patients with TKR, while the incidence of positive skin testing to bone cements was similar in all groups. Group B patients with CoCrMo-THR showed a low frequency of nickel-DTH in comparison to Group A (9% and 22%, respectively). In patients with TiAlV-THR the immune status seemed to be unaffected, and these individuals showed a high incidence of vanadium-DTH (Group A: 8%; Group B: 21%; Group C: 19%; p= 0.04). A high incidence of vanadium hypersensitivity was found also in patients with TKR (Group D: 33%; Group E: 20%). The median duration of the implant resulted significantly lower in patients who had a positive patch testing to metals (71 vs 106 months; p= 0.008). Our results demonstrated the reliability of the panel used for skin testing, which was able to identify a systemic hypersensitivity status. A remarkable finding concerned the prevalence of DTH related to the metal composition of the implant. A significant low frequency of metal DTH, namely nickel, was found in patients with CoCrMo-failed implant. Because nickel is the most common metal sensitizer and its amount in both CoCrMo and TiAlV alloys is very low, we may consider the incidence of nickel DTH as informative for the immune status of the examined group. In the TiAlV group the immune status seems to be unaffected; on the contrary, theese patients showed a high prevalence of vanadium skin reaction. These results confirm the conclusion of previous studies, where the immunocompromised status of patients who had a CoCrMo had been shown and related to the high serum level of chromium and cobalt. Although the cause-effect relation between DTH and implant failure cannot be established, the hypersensitivity should be considered when deciding what type of prosthesis to use. Either if the sensitization precedes or follows the loosening, it participates in the network of events that are responsible for prosthetic loosening, because contributes to mantain the inflammatory process

Introduction: Fluoroscopy is routinely used for real-time intra-operative localization of patient anatomy and surgical instrument positioning. Using this radiographic information the orthopedic surgeon inserts different implants into bone. Despite its utility, however, fluoroscopy does have disadvantages. The most notable is potential occupational radiation exposure. Conventional fluoroscopy usually provides only one plane at a time, whereas at least two planes are needed for optimal placement of an implant. By combining a standard C-arm fluoroscopy with computer aided surgical technology, radiation exposure can be eliminated and four different planes can be visualized simultaneously. This study presents data of preliminary clinical experience using this new technology. Material and methods: The Stealth Station Treatment Guidance Platform System by Medtronic was used. The calibration target was attached to a C-arm fluoroscope. The static reference arc which was attached to the patient and various surgical tools. All with affixed light emitting diodes (LEDs) which were seen by the Infra Red camera. After a short registration process in which the relevant anatomy images were acquired, the C-arm was withdrawn and the entry point to the operated anatomy was determined using the navigation capabilities of the system. During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well. Results: Excellent correlation between the virtual fluoroscopic imaging and live fluoroscopy was observed, thus the placement of the wire in all cases was satisfactory and there was no need to change the position of the wire following the live fluoroscopic confirmation. The number of fluoroscopic buttoning was smaller than the average number in similar surgery using conventional fluoroscopy. Discussion: According to our preliminary clinical experience it seems that virtual fluoroscopy offers several advantages over conventional fluoroscopy while providing acceptable targeting accuracy. Our impression is that its saves fluoroscopic radiation exposure and improves exactness of the procedure. However, since currently only one reference arc can be detected at a time by the guidance system it can be used only in a stable anatomical situations (such as non-displaced fractures or pedicular screw placements). The use of better-oriented surgical instrumentation and more than one reference point detection will significantly improve the clinical potential of this method

Introduction: Fluoroscopy is routinely used for real-time intra-operative localization of patient anatomy and surgical instrument positioning. Using this radiographic information the orthopedic surgeon inserts different implants into bone. Despite its utility, however, fluoroscopy does have disadvantages. The most notable is potential occupational radiation exposure. Conventional fluoroscopy usually provides only one plane at a time, whereas at least two planes are needed for optimal placement of an implant. By combining a standard C-arm fluoroscopy with computer aided surgical technology, radiation exposure can be eliminated and four different planes can be visualized simultaneously. This study presents data of preliminary clinical experience using this new technology. Material and methods: The Stealth Station Treatment Guidance Platform System by Medtronic was used. The calibration target was attached to a C-arm fluoroscope. The static reference arc which was attached to the patient and various surgical tools. All with affixed light emitting diodes (LEDs) which were seen by the Infra Red camera. After a short registration process in which the relevant anatomy images were acquired, the C-arm was withdrawn and the entry point to the operated anatomy was determined using the navigation capabilities of the system. During a period of six months, 31 patients underwent different surgical procedures in which a guided wire was used for: percutaneous fixation of unstable pelvis and hip fractures (13 patients), inserting and locking of an intrameduallry nail (12 patients), inserting pedicular screws (2 patients), or removing foreign-bodies or internal fixations (4 patients). In all cases the placement of the hardware was approved by conventional fluoroscopy as well. Results: Excellent correlation between the virtual fluoroscopic imaging and live fluoroscopy was observed, thus the placement of the wire in all cases was satisfactory and there was no need to change the position of the wire following the live fluoroscopic confirmation. The number of fluoroscopic buttoning was smaller than the average number in similar surgery using conventional fluoroscopy. Discussion: According to our preliminary clinical experience it seems that virtual fluoroscopy offers several advantages over conventional fluoroscopy while providing acceptable targeting accuracy. Our impression is that its saves fluoroscopic radiation exposure and improves exactness of the procedure. However, since currently only one reference arc can be detected at a time by the guidance system it can be used only in a stable anatomical situations (such as non-displaced fractures or pedicular screw placements). The use of better-oriented surgical instrumentation and more than one reference point detection will significantly improve the clinical potential of this method

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.

Objectives

The objective of this study was to characterize the effect of rifampin incorporation into poly(methyl methacrylate) (PMMA) bone cement. While incompatibilities between the two materials have been previously noted, we sought to identify and quantify the cause of rifampin’s effects, including alterations in curing properties, mechanical strength, and residual monomer content.