Is there value in the routine practice of discarding the incision scalpel from the surgical field to prevent deep wound contamination with Cutibacterium acnes? An update

BACKGROUND

Cutibacterium acnes is the most common microbe implicated in periprosthetic infection in shoulder arthroplasty. We present an update of a previous pilot study in which we demonstrated the persistence of C acnes on the skin and contamination of the scalpel used for the initial skin incision despite a robust presurgical skin preparation protocol.

METHODS

We collected a consecutive case series of patients undergoing primary or revision anatomic or reverse total shoulder arthroplasty performed by a single fellowship-trained surgeon at a tertiary referral hospital from November 2019 to December 2022. The scalpel blade used for the initial skin incision in each patient was swabbed, with cultures being held for 21 days according to a C acnes-specific protocol. Demographic data, medical comorbidities, surgical information, culture results, and infections were documented.

RESULTS

We identified 100 patients (51 men and 49 women) who met the inclusion criteria (mean age, 66.91 years; age range, 44-93 years). Cultures returned positive findings for C acnes in 12 patients (12%), 11 of whom were men (odds ratio, 13.2; 95% confidence interval, 1.73-194.87). No association was found between positive culture findings and age, body mass index, medical comorbidities, or procedure type. No postoperative infections occurred in this patient cohort, and the patients will continue to be monitored for the development of infection.

CONCLUSION

Despite stringent presurgical preparation and scrub protocols, a significant portion of patients undergoing shoulder arthroplasty have C acnes in culturable quantities on their skin at the time of incision. C acnes contamination is much more common in male patients. These findings should be taken into consideration regarding preventive measures such as discarding the initial scalpel and avoiding unnecessary dermal contact during the procedure.

Surgeon-Directed Arthroscopic Infiltration Between the Popliteal Artery and Capsule of the Knee (IPACK) Block: Technical Description

Advances in regional anesthesia techniques for knee surgery have led to drastic improvements in postoperative pain control and have reduced reliance on perioperative opioid analgesics. The infiltration between the popliteal artery and capsule of the knee (IPACK) block has been a useful tool for providing posterior knee analgesia as an adjuvant to traditional femoral or adductor canal blocks in knee surgery. We present a simple and reproducible technique for the arthroscopic administration of this block.

Unpacking the Tibial Tubercle-Trochlear Groove Distance: Evaluation of Rotational Factors, Trochlear Groove and Tibial Tubercle Position, and Role of Trochlear Dysplasia

BACKGROUND

The tibial tubercle to trochlear groove (TT-TG) distance is often utilized for determining the surgical treatment for patients with patellar instability (PI). It is thought to directly represent the position of the TT on the tibia. Recent work has shown that the measurement of the TT-TG distance is multifactorial.

PURPOSE

To investigate the relationship between relative tibial external rotation (rTER) and trochlear dysplasia (TD), as well as the location of the TG and TT in patients with and without PI, and to correlate these and other anatomic measurements with the TT-TG distance.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 89 patients with PI who underwent magnetic resonance imaging were identified with 92 matched control patients. A standardized measurement protocol on axial magnetic resonance imaging determined rTER, the proximal and distal TG lateralization (pTGL and dTGL, respectively) ratios, and the TT lateralization (TTL) ratio. Other measures of interest included the lateral trochlear inclination angle, sulcus angle, and lateral patellar inclination angle. Univariate regression was used to determine the associations of TD (lateral trochlear inclination angle, sulcus angle) with rTER and the TG position, and multivariate regression was used to model associations among all the variables with the proximal and distal TT-TG distances.

RESULTS

rTER was significantly higher in the study group (P < .001), and univariate regression showed a significant association between dysplasia measures and rTER (P < .001). The pTGL ratio was lower in the study group (P = .025), but there was no difference in the dTGL ratio (P = .090) or the TTL ratio (P = .098) between the groups. There were no associations between dysplasia measures and the pTGL and dTGL ratios (P > .05). Multivariate regression showed that the proximal TT-TG distance is predicted by the sulcus angle, pTGL ratio, rTER, and TTL ratio (P < .05) and that the distal TT-TG distance is predicted by the lateral patellar inclination angle, dTGL ratio, sulcus angle, rTER, and TTL ratio (P < .05).

CONCLUSION

rTER had a significant association with TD. The position of the proximal TG was more medial in patients with PI. There was no significant difference in the TTL ratio between patients with and without PI. The TT-TG distance was associated with multiple anatomic measures and was not solely predicated on the position of the TT.

Loss to follow-up in orthopaedic clinical trials: a systematic review

PURPOSE

The rate of patients lost to follow-up may contribute to bias in randomized controlled trials (RCTs).

METHODS

We systematically reviewed orthopaedic RCTs from 2008 to 2011, including 559 RCTs with 131,836 enrolled subjects. The loss to follow-up rates and minimum follow-up times were recorded for each trial. Orthopaedic subspecialty, country of origin, number of enrolled patients, patient age, follow-up strategy, and funding type were also recorded.

RESULTS

Loss to follow-up was not reported in 111 of these studies (20 %). Mean loss to follow-up was 10.4 %. No orthopaedic subspecialty demonstrated significantly different follow-up rates. Remote follow-up strategies did not reduce the loss to follow-up rate. Studies with a minimum follow-up length of three years showed significantly higher loss to follow-up rates compared with studies with shorter minimum follow-up time (14.8 % versus 9.8 %, p = 0.01). Studies performed in the United States had a significantly higher rate of loss to follow-up compared with non-United States studies (13.8 % versus 9.4 %; p = 0.01).

CONCLUSIONS

Loss to follow-up rates in published orthopaedic randomized controlled trials is overall relatively low. A substantial portion of publications does not adequately report follow-up data. Studies performed in the United States and studies with longer follow-up periods seem to be at higher risk for loss to follow-up.