Abstract

The Montgomery ruling advocates patients be informed of ‘material risks’ of a procedure. With no guidelines for patients wishing to return to high activity levels after knee arthroplasty, we explore patient and surgeon perceptions in climbers.

Ethical approval was granted by the University of Central Lancashire. Anonymous questionnaires were sent via email and social media to consultant knee arthroplasty surgeons and to climbers/mountaineers across the UK. Consultants were asked about advice given for patients who participate in climbing. Climbers were asked about their experiences of knee arthroplasty and return to activity.

Of 33 knee arthroplasty surgeons, 11(33%) were firmly against any return to climbing, 10(30%) counselled against it, and 12(36%) were open to return to previous activity. Of 11(33%) surgeons who do not gather information about levels of climbing, 8 would not provide specific advice regarding risks of returning to sport. Of 28 climbers, only 5(18%) were informed to cease completely, with 11(39%) cautioned against and 12(43%) permitted to return. There was no correlation between the advice received and climbing ability post-operatively, (kappa=0.143,p=0.058), with a substantial agreement between ability 1-year post-operatively and currently, (kappa=0.689,p<0.001).

There is a discrepancy between the advice given and received by climbers/mountaineers prior to knee arthroplasty, with ability post-operatively having no relationship to advice given. Climbing is possible at high level with no reported complications following knee arthroplasty. The 1-year time point is predictive of longer-term outcome. This information should help surgeons better inform their patients preoperatively.

Climbers and mountaineers will present to arthroplasty surgeons in need of hip replacement surgeries. There is a lack of guidance for both parties with a paucity in the literature. Climbing is often considered a high-risk activity to perform with a total hip replacement, due to the positions the hip is weighted in, and the potential austere environment in which an injury may occur.

The aim was to assess levels of climbing and mountaineering possible following hip arthroplasty, and any factors affecting these levels.

Ethical approval was obtained from the University of Central Lancashire. An anonymous online questionnaire was disseminated via email, social media and word-of-mouth to include all climbers, hill-walkers or mountaineers across the UK. This was used to collect climbing and mountaineering ability at various timepoints, along with scores such as the Oxford Hip Score and UCLA Score. The Kappa statistic was used to assess for correlations.

Of the responders, 28 had undergone right hip arthroplasty surgery, with 11 having left hips and 22 receiving bilateral hips. A total of 67 of the replaced hips were total hip replacements, with 16 having undergone hip resurfacing. There is a fair agreement in level of climbing ability 3 months pre- and 3 months post-operatively (kappa=0.287, p<0.001), and a substantial agreement between 1 year post-operatively and currently for both climbing (kappa=0.730, p<0.001) and mountaineering (kappa=0.684, p<0.001). Impressively, 17 participants are climbing at more than E1 trad or 6c sport at one or more time points post operatively, which is regarded as an advanced level within the climbing community. Out of those 17 participants, 8 were climbing at this level within 3 months post-operatively.

The level of climbing possible following hip arthroplasty surgery is above what is expected and perhaps desired by the operating surgeon. It is essential to take the individual patient into account when planning an operative intervention such as arthroplasty. The one year post-operative time point is highly predictive of longer term outcomes for both climbing and mountaineering.

Postoperative sepsis is a costly and potentially devastating problem in total joint arthroplasty. Airborne bacteria and other viable microorganisms shed from surgical staff are a source of deep prosthetic infection, and the density of airborne bacteria is correlated with the rate of postoperative joint sepsis in total joint arthroplasty surgery. Previous studies have also reported a positive relationship between the density of nonviable airborne particulate and viable CFU counts, both airborne and in the surgical wound, during surgery. The purpose of this study was to determine the extent to which a system that delivers a small field of local, directed HEPA-filtered air flow over the surgical field reduces airborne particulate and airborne bacteria during total hip arthroplasty. A minimum of 8 subjects per group provided 80% power (a = 0.05) to detect a =75% difference in bacterial density between groups. All patients who consented to undergo primary total hip arthroplasty were eligible. Thirty-six patients were prospectively randomized into three groups: directed air flow, air flow system present but turned off (sham), and control (standard) conditions. Airborne particulate and bacteria were continuously collected in consecutive 10 minute intervals within 5 cm of the surgical wound using an air sampling device. Data were analyzed using a generalized linear model for repeated measures. Particulate counts and bacterial density at the surgical site were 80% lower on average in the directed air flow group compared to the other two groups (p<0.001) (Figure 1). Density of particulate >10 μm in diameter was strongly related to bacterial density at the surgical site (p<0.001), as was staff count (p<0.001) and bacterial density at a control site that was remote from the surgical field (p<0.001). The directed air flow system's effectiveness in reducing bacteria appears to be related to its ability to reduce particulate that may carry and allow proliferation of bacteria. The directed air flow system is relatively simple to use and does not appear to hinder the function of the surgeon or operating room staff, impede access to the surgical site, or interfere with the surgical procedure. The directed air flow system can be used in any operating room environment to provide clean air equivalent to a properly-used, well-functioning laminar air flow system. The directed air flow system was effective in reducing airborne particulate and bacteria in the surgical field during total hip arthroplasty.

Prevention of surgical infection following joint arthroplasty is preferable to treatment.

Prevention requires identification and control of the potential sources of microbial contamination. The purpose of this study was to determine whether the density of airborne particulate in the operating room during total joint arthroplasty could predict the density of viable airborne bacteria at the surgery site.

A standard particle analyzer was used to measure the number and diameters of airborne particulate during 22 joint arthroplasty surgeries performed in non-laminer flow rooms. An impact air sampler and standard culture plates were used to collect airborne particulate and were analysed to identify and count colony-forming units.

Particulate density averaged > 500,000 particles/ft3, and 1,786 colony-forming units were identified, primarily gram-positive cocci. The density of particles ≥10um explained 41% of the variation in colony-forming unit density. Colony-forming units and ≥10 um particle density increased with longer surgery duration and higher staff counts.

This is the first study to the authors knowledge that shows a correlation between the number of persons in the OR and CFUs at the surgical site during total joint arthroplasty procedures. Increasing surgical staff appear to produce both more particulate and more CFUs. These observations support the use of environmental controls that isolate and protect the surgical site from airborne particulate and microbial contamination.

Continuous monitering of particulate larger than 10 um during joint arthroplasty procedures may be warrented.

Introduction The aim of the investigation was to assess the significance of the extent of surgical margin on the chance of death, metastasis and local recurrence in soft tissue sarcoma.

Methods The review consisted of 324 patients. Surgical margin data was unavailable for 21, and of the remaining 303 patients, 10 patients had no residual tumour, margins were not defined for 24 patients and nine patients had radical resections. Wide margins were achieved for the remaining 260 patients. Fifty-four percent had surgical margins of under five millimetres. Cox Proportional Hazards Regression modelling was used to consider the impact of surgical margin with an overall survival, disease-free survival and metastasis-free survival. Results were expressed as survival rate ratios and graphics represented as model based survival curves. All associations that were statistically significant as well as any associations for which the rate ratios were 2.0 or greater were reported. Follow-up ranged from 53 days to 187 months, with a median of 40 months.

Results Overall survival time for the 279 patients with complete information was 124 months. There was a significant association between overall survival and extent of the surgical margin (chi-squared test statistics = 14.7, 8df, p = 0.043). There was a significantly higher death rate in patients who had a wide contaminated margin or a radical resection indicating likely poorer prognostic groups. There was however no difference between any margin from one to 20 mm. With respect to disease relapse, there were 27 local recurrences among 279 patients, and for statistical reasons, 24 local recurrences among 213 patients were reviewed. There was a significant association between the extent of surgical margin and disease-free survival (chi-squared test statistics = 9.5, 4df, p = 0.051). With relation to metastasis, 68 of 257 patients were reviewed, there being no statistical association between metastasis-free survival and margin extent.

Conclusions There is significant statistical evidence to suggest overall and disease-free survival increase with increasing width of surgical margin. The evidence is not convincing in our assessment of metastasis-free survival

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.