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Evidence-based Sterility: The Evolving Role of Field Sterility in Skin and Minor Hand Surgery


Abstract and Figures

Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.
Content may be subject to copyright. 1
Since Louis Pasteur discovered that microorganisms
caused infections, the evolution of sterility has had the
pattern of the following: “If some sterility is good, more
must be better.”1 Applying evidence-based medicine
and common sense to sterility will allow us to evolve
into the practice of the following: “What level of steril-
ity do we actually need in this particular circumstance?”
The American Hospital Association estimated that two-
thirds of all surgeries are performed in the ambulatory
setting with eld sterility.2 In Canada, typical outpatient
procedures include laceration repair, skin lesion excision
and reconstruction, and simple hand surgery, such as K
wiring hand fractures, carpal tunnel decompression, and
trigger nger release. In this paper, we arbitrarily dene
eld sterility to include a mask, sterile gloves, and sterile
draping of an area of 40 cm by 40 cm or less around a
wound. Full standard sterility used in the main operating
room (OR) involves the additional use of head covers,
neck to knee sterile surgeon gowns, shoe covers, laminar
airow, and full patient body sterile draping.
The aim of aseptic technique is to prevent surgical
site infections (SSIs), which is dened by the Centers for
Disease Control and Prevention as a skin or subcutaneous
tissue infection around the incision site occurring within
30 days after a procedure.3 There is a growing body of
evidence indicating that SSI does not differ signicantly
between main OR sterility and eld sterility for many sur-
gical procedures.4–8,10–15 However, the difference in cost
and garbage production is immense (Figs.1–3).
The authors hypothesize that there is insufcient sci-
entic evidence to support the costs and garbage produc-
tion of main OR sterility practices such as head covers,
sterile gowns, full patient draping, laminar airow, and
footwear for skin and minor hand surgery procedures. In
this paper, we therefore look at both current evidence and
common sense behind the use of techniques and apparel
designed to prevent SSI. We will focus on the evidence
behind the ability of gloves, masks, gowns, drapes, head
covers, footwear, and ventilation systems to prevent SSIs.
We will also introduce the concept that SSIs are not equal
in their impact to a patient’s well-being and cost to the
health-care system.
Hand/Peripheral Nerve
From the *Faculty of Medicine, University of Calgary, Calgary, AB,
Canada; †Faculty of Medicine, University of British Columbia,
Vancouver, BC, Canada; ‡Dalhousie University, Saint John, NB,
Canada; and §Saint John Regional Hospital, Saint John, NB,
Received for publication May 16, 2019; accepted August 13, 2019.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000002481
Disclosure: The authors have no nancial interest to declare
in relation to the content of this article.
Janelle Yu, MD*
Tianshu Angela Ji, MD
Michael Craig, MD
Daniel McKee, MD
Donald H. Lalonde, MD‡§
Summary: Field sterility is commonly used for skin and minor hand surgery per-
formed in the ambulatory setting. Surgical site infection (SSI) rates are similar for
these same procedures when performed in the main operating room (OR). In this
paper, we aim to look at both current evidence and common sense logic support-
ing the use of some of the techniques and apparel designed to prevent SSI. This
is a literature review of the evidence behind the ability of gloves, masks, gowns,
drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used
MEDLINE, EMBASE, and PubMed and included literature from the inception of
each database up to March 2019. We could not nd substantial evidence to sup-
port the use of main OR sterility practices such as head covers, gowns, full patient
draping, laminar airow, and footwear to reduce SSIs in skin and minor hand
surgery. Field sterility in ambulatory minor procedure rooms outside the main
OR is appropriate for most skin and minor hand surgery procedures. SSIs in these
procedures are easily treatable with minimal patient morbidity and do not justify
the cost and waste associated with the use of main OR sterility. (Plast Reconstr Surg
Glob Open 2019;XXX:e2481; doi: 10.1097/GOX.0000000000002481; Published online
25 November 2019.)
Evidence-based Sterility: The Evolving Role of Field
Sterility in Skin and Minor Hand Surgery
PRS Global Open 2019
A review of the literature was conducted using 3 medi-
cal databases (Ovid MEDLINE, EMBASE, and PubMed).
Literature from the inception of each database up to
March 2019 was searched. Keywords and MeSH terms
related to “surgical wound infection,” “drapes,” “gar-
ments,” “protective clothing,” “gloves,” “shoes,” “surgical
attire,” “ventilation system,” “HEPA,” “operating room,”
Fig. 1. Main OR sterility to remove an accessory auricle. This is a minor skin procedure that could very
safely be performed with eld sterility.
Fig. 2. The waste produced from main OR sterility to remove an accessory auricle. Main OR carpal tun-
nel surgery produces similar waste.
Yu et al. Evidence-based Sterility
“head covering,” and “surgical cap” were used. Animal
studies and non-English articles were excluded.
The use of surgical gloves has become standard prac-
tice to protect health-care providers and prevent SSI.16–20
Much of the recent relevant research has focused upon
the efcacy of sterile gloves versus clean boxed gloves.
Boxed gloves are almost 8 times less expensive than sterile
gloves and generate less sterile packing waste.21
Glove studies examining SSIs have yielded conicting
results. Recent work has failed to clearly demonstrate the
benet of sterile gloves over clean gloves.22 Two observa-
tional studies found no statistical differences in rates of
SSI using sterile gloves versus clean boxed gloves in Mohs
micrographic surgery.23,24 One study found a higher rate
of infection in more complicated ap procedures per-
formed with nonsterile clean boxed gloves but infection
control precautions varied with the procedures.20 A more
recent systematic review and meta-analysis of 14 studies, 8
of which were randomized controlled trials (RCTs), found
no difference in the rate of postoperative SSI in outpatient
cutaneous surgical procedures performed with sterile ver-
sus clean boxed gloves.25 It may be that boxed gloves are
appropriate for minor cutaneous skin procedures.
It should also be noted most of the above studies look
at facial surgery where infection rates may to be lower
than other anatomical areas. The authors speculate that
hand infection rates may be like facial infections because
of high blood ow rates in both sites.
There is currently a lack of evidence supporting the
use of sterile gloves for simple skin surgery. As the theoret-
ical possibility of bacterial contamination of boxed unster-
ile gloves does exist, common sense still guides most of us
to use sterile gloves until stronger evidence is produced,
especially in less vascularized spaces such as the carpal tun-
nel and trigger nger.
Surgical face masks were originally developed to con-
tain bacteria-lled droplets expelled from the nose and
mouth of health-care providers to protect the surgical eld
from contamination. A study by Meleney and Stevens sug-
gested that mask use may reduce the incidence of postop-
erative hemolytic streptococcus wound infections to 5%.26
The practice of wearing masks during surgery subsequently
became more widespread. Interestingly, the same authors
refuted their initial ndings 9 years later and reported
infection rates with consistent mask use to be much higher
than had been anticipated in their initial study.27
Recent studies comparing outcomes with or without
surgical face masks have found little to no difference in
SSIs.28–31 Cochrane reviews have found insufcient evi-
dence for the benet of surgical face masks in clean sur-
gical procedures on reducing wound infection rates.32
Furthermore, large variations exist in the ltering abil-
ity of surgical masks, even from the same manufacturer.
There is currently no standard method of measuring l-
tering capability of masks, and it is not known what effect
the use of surgical masks from different manufacturers
would have on SSIs.
We have not been able to nd good evidence that sur-
gical masks reduce the incidence of SSIs in skin and minor
hand surgery. However, all of us have seen droplets of
saliva or nasal mucous emanating in speech or sneezing.
Spraying an open wound with these bacteria-laden drop-
lets is a difcult problem to disregard. Therefore, until
stronger evidence is available, common sense still guides
us to use a mask with eld sterility in these procedures.
Surgical Gowns and Drapes
Sterile gowns are thought to prevent the surgeon’s skin
or clothing bacteria from shedding onto the patient either
Fig. 3. Field sterility for carpal tunnel surgery. More than 90% of Canadian carpal tunnel operations are
performed this way in minor procedure rooms with an infection rate of 0.39%.14
PRS Global Open 2019
from direct contact or via the air. Gowns are fabricated
from either reusable or single-use materials. Reusable sur-
gical gowns are often made from tightly woven polyester
sheeting or a combination of fabrics with a lm coating.
Single-use surgical gowns consist of nonwoven materials
such as wood pulp and polyester bers with plastic lms
for liquid protection. Due to the wide variety of gowns
used, interpretation of the literature regarding their ef-
cacy is difcult.
Eisen reviewed prospective studies comparing woven
cotton gown material with nonwoven ones and found con-
icting evidence.22 Three prospective crossover studies
showed a benet of disposable gowns over reusable gowns
whereas 2 RCTs and 1 prospective crossover study showed
no difference. Notably, the only level I evidence paper
showed no difference in gown material on SSI rates.33 In
a separate study, the release of airborne bacteria from
dedicated main OR scrub suits compared with personal
clothing worn outside the hospital was not signicantly
Most surgeons wear unsterile scrubs or regular cloth-
ing when performing eld sterility procedures outside of
the main OR. We could not nd any studies that compared
the rate of SSI when surgeons used sterile surgical gowns
with when surgeons did not use sterile surgical gowns.
The rationale behind using main OR sterile drapes
to cover the entire patient far beyond the surgical eld is
to prevent contact between sterile and unsterile surfaces
and the patient’s wound. The World Health Organization
(WHO) evaluated the most optimal draping material to
prevent SSI in the main OR environment. They recom-
mend either1 sterile, disposable, nonwoven drapes, or2
sterile, reusable, woven drapes, based on a meta-anal-
ysis which found no difference between these draping
Regarding the use of adhesives, a recent Cochrane
review (level I evidence) based on 5 trials found that the
use of adhesive drapes was associated with an increased
SSI risk compared with no drapes.36 This review also found
that iodine-impregnated adhesive drapes likely made no
difference to SSI risk compared with nonadhesive drapes.37
They concluded that adhesives may increase SSI risk by
attracting and promoting the colonization of bacteria.38
We could not nd any evidence to support that sur-
geons’ gowns or full patient draping decreases SSI in skin
and minor hand surgery procedures over eld sterility in
skin and minor hand surgery. Common sense would sug-
gest that, if a difference exists, it would be extremely small
and not worth the cost and garbage of gowns and drapes
given the low eld sterility rates of infection and minimal
patient morbidity in these procedures.10,11,13,14
Head Covers
Summers et al stated that 46% of medical and nursing
personnel carried pathogenic organisms (most commonly
Staphylococcus aureus) in hair and nasal passages.39 Because
bacterial shedding could theoretically occur through the
air from the scalp hair, the authors recommended that
health-care workers completely cover hair during surgical
procedures. This type of infection theory paper spawned
the widespread practice of using head covers over the scalp
and facial hair in the main OR. However, Humphreys et
al found that the use of disposable head coverings in an
experimental setting was not associated with reduced bac-
terial air counts.40
There are currently no studies associating the use of
head covers with a reduction in SSI in skin and simple
hand surgery. Multiple literature reviews have concluded
that there is insufcient evidence to suggest that the use
of head coverings reduces rates of SSI.22,41–43 Furthermore,
no studies have proven superiority of any specic type of
surgical headwear over another, in any clinical capacity.44
Despite the lack of denitive evidence, most organizations
recommend that head coverings be used in the main OR
and perioperative setting given the theoretical benet.45
The fact that different organizations have so many differ-
ent head dress policies is likely reective of the fact that
there is no good evidence that 1 policy is better than the
other. Neither common sense nor the evidence supports
the use of head cover for skin and minor hand surgery.
Amirfeyz et al compared bacterial contamination of
designated theatre-only shoes with street footwear.45 He
found more pathogenic bacteria on all studied shoes at
the end of the day, with street shoes being signicantly
more contaminated than theatre-only shoes at both the
beginning and end of the day. Nagai et al demonstrated
increased rates of bacterial oor contamination with
proximity to areas where footwear is changed.46 Copp and
Copp found increased rates of bacterial transfer to the OR
oor from street shoes than from designated theatre-only
shoes or shoes with covers.47 In these studies, the relation-
ship to SSIs was not studied. A recent systematic review
study conrmed a lack of research exploring the effect of
shoe surfaces as a potential cause of increased infection
We could not nd any evidence that either high bac-
terial counts on the oor or increased concentrations of
bacteria on shoes increase infection rates in skin or minor
hand surgery. The fact that policies vary so widely from
center to center reects this lack of evidence. Unless there
is gross contamination such as large amounts of pus on
the oor, common sense would suggest that footwear or
oor washing between cases makes little to no difference
in minor skin and hand surgery procedures that occur way
above the oor at the surgeons’ elbow height.
Ventilation Systems
Most procedure rooms outside the main OR have no
special ventilation. Most main ORs use laminar airow l-
tration (LAF) and high-efciency particulate air (HEPA)
lters to achieve ultraclean air. Most of the literature on
the effect of ventilation systems relates to major orthope-
dic procedures where infection creates great morbidity for
LAF systems provide unidirectional airow. In theory,
they decrease infection rates by preventing airborne bac-
teria from landing and infecting the wound. A landmark
RCT in the early 1980s showed that LAF reduced deep
Yu et al. Evidence-based Sterility
prosthetic joint infections from 1.5% to 0.6%, spurring
increased use of ultraclean air systems especially in ortho-
pedic surgery.49
However, multiple recent studies failed to reproduce
these results or expand these conclusions to other proce-
dures. A recent systematic review found no difference in
overall SSI between laminar airow and conventional ven-
tilation in abdominal and vascular surgeries.50 The same
study also found a possible increased risk of deep SSI for
hip and knee arthroplasties with LAF.50 Possible explana-
tions for this discrepancy include changes in the modern-
day OR environment with the use of positive pressure
rooms, aws with the original RCT such as lack of random
allocation and heterogenic use of antibiotic prophylaxis,
and a possible harmful effect of ultraclean air systems if
they are not used or maintained properly.51
High-efciency particulate lters can remove 99.97%
of particles >0.3 µm, whereas conventional lters remove
95% of particles >5 µm. However, HEPA lters are signi-
cantly more expensive to purchase and maintain.52 A ret-
rospective cohort study showed that HEPA with laminar
or turbulent ventilation reduced SSI rates in knee arthros-
copy compared with no articial ventilation but failed to
show this benet in hip arthroscopy.53 Another retrospec-
tive comparative study found that HEPA made no differ-
ence in SSI rates in total joint arthroplasty surgeries using
forced air warmers.54
Given the inconclusive evidence of laminar airow sys-
tems and HEPA lters in high infection risk surgeries with
large articial joint replacements, it seems unlikely that
either ventilation system would impact infection for most
skin and minor hand surgery procedures. This is espe-
cially relevant when evidence has shown the low rate of
infections with skin and minor hand surgery in procedure
rooms outside the main OR where there is no laminar air-
ow or HEPA lters10,11,13,14
The Evidence Supporting Field Sterility for Skin and Minor
Hand Surgery
K wire pinning of hand fractures without sterile gowns
and with no full patient draping has been shown to pro-
duce very low infection rates.10,11 Unlike infection after
internal plate xation or prosthetic joint replacement,
the cost of infection after hand fracture K wire pinning
to a patient’s quality of life or to the health-care system
is very low. Most infections after K wire pinning respond
with minimal patient morbidity to removing the K wire
and oral antibiotics. In Canada, eld sterility for K wire
insertion procedure rooms outside the main OR is a well-
accepted long-standing practice in many hospital centers.
It has produced very few cases of infection that end up
requiring intravenous antibiotics or producing osteomy-
elitis. Infection after K wire insertion seems more related
to what the patient does after the surgery than the eld
versus man OR sterility with which we insert them.
In a multicenter prospective study of 1,504 cases, eld
sterility for carpal tunnel surgery yielded an infection rate
of 0.39%.14 More than 90% of Canadian carpal tunnels are
performed this way today with the same low infection rate
with no gown, no head gear, no protective footwear no
full patient draping, and no special airow systems.12 This
SSI rate is comparable with those carpal tunnel surgeries
completed in the main OR.55,56
Field sterility is also associated with very low SSI rates
in Mohs micrographic surgery. A 2013 publication of
20,821 cases produced an infection rate of 0.37%.13 This
is remarkably similar to the multicenter study of the
infection rate in carpal tunnel surgery described above.
Another Moh’s series also showed very low infection rates
of more complex skin surgery such as aps (1.9%) and in
full thickness skin grafts (3.1%).39
Both current evidence and common sense therefore
suggest that eld sterility is reasonable in minor proce-
dures such as skin surgery, carpal tunnel surgery, and K
wiring of hand fractures.
Main OR Sterility Is Expensive
Main OR sterility is costly compared with eld steril-
ity.4,6–8,10,11,57 The cost to excise a single skin lesion in the
main OR is twice as expensive as with eld sterility.15 Carpal
tunnel releases are 4 times more costly if performed in the
main OR compared with in the minor procedure room,
even without anesthesiology.8 Trigger nger surgery is 2–3
times more expensive in the main OR.9
It should also be noted that many of the main OR
materials used are for personal protection equipment not
sterility. Part of the costs therefore is consumed by health
personnel protection.
Main OR Sterility Creates Massive Amounts of Unnecessary
Disposable materials consumed in main OR steril-
ity practices create enormous amounts of waste. Recent
Canadian environmental data from 2015 showed that the
health-care sector generated 33 million metric tons of car-
bon dioxide, which is equivalent to 4.6% of Canada’s total
greenhouse gas emissions.17 In the United States, hospitals
produce 4 billion tons of waste annually with ORs being
the highest contributors.58,59 Future studies that evaluate
the safety and efcacy of eld sterility practices could pro-
vide considerable nancial savings for the health-care sys-
tem and environmental benets for everyone.4–8,57
Not All SSIs Are Equal in Patient Impact and Cost
Infection after carpal tunnel surgery usually responds
very well to suture removal or oral antibiotics without signif-
icant harm to the patient or cost to the health-care system.
Infection after a prosthetic knee insertion can be disastrous
to a patient’s life and will generate costly complication man-
agement. Both clinical situations are SSIs, but they have
very different cost and patient harm implications. Common
sense tells us that to use main OR maximal expense “space
suit” style sterility is reasonable for knee replacement but
not for carpal tunnel surgery. It is important to study not
only the rates but perhaps more importantly the patient
impact of SSIs in different operations. We should not treat
all SSIs as having an equal effect on patients.
The senior author currently uses eld sterility outside the
main OR environment for closed K wire insertion and simple
soft tissue dissection surgery such as carpal tunnel, trigger
PRS Global Open 2019
nger, and ulnar nerve decompression at the elbow. He uses
augmented eld sterility (gown for the surgeon and a larger
drape around the hand) for tendon repair and tendon trans-
fer because infection in these circumstances has more grave
consequences than simple closed K wire insertion or carpal
tunnel surgery. He prefers traditional full OR sterility for per-
manent hardware insertion and extensive soft tissue dissec-
tion procedures such as forearm tendon transfers.
Main Weakness of the Study
The principal weakness of this study is that there is
profound lack of good scientic evidence telling us how
much sterility we actually need for different types of proce-
dures. For this reason, the senior author felt compelled to
add the common sense of clinical experience to the analy-
sis of the literature.
We have not been able to nd substantial evidence to
support many of the main OR sterility practices such as
head covers, sterile gowns, full patient draping, laminar
airow, and footwear for skin and minor hand surgery
procedures. Field sterility with a mask, sterile gloves, and
a small sterile wound drape in minor procedure rooms
(outside the main OR) seems appropriate for the majority
of these types of operations.
The cost of an infection after implantation of a syn-
thetic knee implant is very high to a patient’s quality of
life and to our health-care system. All possible measures of
reducing SSIs (theoretical or proven) in this type of pro-
cedure seem justied. On the other hand, most infections
in skin and minor hand surgery respond to the removal
of sutures, K wires, and oral antibiotics. The cost is not
massive to a patient’s quality of life or to the health-care
system. The costs and garbage production of main OR
sterility are not justied with these types of procedures,
especially given their low infection rates with eld sterility.
Donald Lalonde, MD
Division of Plastic Surgery Dalhousie University
Suite C204, 600 Main Street
Saint John, NB E2K 1J5, Canada
The patient provided written consent for the use of her image.
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... Adopting the same standards of an operating room for CSIR procedures may be unnecessary when considering an analogous comparison in the surgical literature: minor hand and skin surgery. In Canada, the most common procedural setting for carpal tunnel surgery is an ambulatory procedure room using "field sterility," defined by the use of a surgical mask, sterile gloves, and small sterile drape [22,23]. No gown or hat is worn. ...
... Considering rising healthcare costs and the production of approximately four billion pounds of medical waste annually in the USA, it behooves proceduralists to weigh the theoretical benefit of infection rate reduction by PPE with the costs, both financially and environmentally. Increased healthcare costs associated with more stringent requirements for operating room attire has been extensively published in the surgical literature [23,25,[29][30][31][32][33]. The healthcare industry is estimated to be responsible for 8% of the greenhouse gas emissions in the USA [7]. ...
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Purpose To determine institutional practice requirements for personal protective equipment (PPE) in cross-sectional interventional radiology (CSIR) procedures among a variety of radiology practices in the USA and Canada. Methods Members of the Society of Abdominal Radiology (SAR) CSIR Emerging Technology Commission (ETC) were sent an eight-question survey about what PPE they were required to use during common CSIR procedures: paracentesis, thoracentesis, thyroid fine needle aspiration (FNA), superficial lymph node biopsy, deep lymph node biopsy, solid organ biopsy, and ablation. Types of PPE evaluated were sterile gloves, surgical masks, gowns, surgical hats, eye shields, foot covers, and scrubs. Results 26/38 surveys were completed by respondents at 20/22 (91%) institutions. The most common PPE was sterile gloves, required by 20/20 (100%) institutions for every procedure. The second most common PPE was masks, required by 14/20 (70%) institutions for superficial and deep procedures and 12/12 (100%) institutions for ablation. Scrubs, sterile gowns, eye shields, and surgical hats were required at nearly all institutions for ablation, whereas approximately half of institutions required their use for deep lymph node and solid organ biopsy. Compared with other types of PPE, required mask and eye shield use showed the greatest increase during the SARS-CoV-2 pandemic. Conclusion PPE use during common cross-sectional procedures is widely variable. Given the environmental and financial impact and lack of consensus practice, further studies examining the appropriate level of PPE are needed. Graphical abstract
... This might not be surprising as these concepts have permeated through everyday life and are easily transferrable into health care. Recent work by Lalonde et al. (Yu et al., 2019) on field sterility and Van Denmark's concept of 'lean and green hand surgery' (Van Demark et al., 2018) have also helped by demonstrating that sustainable hand surgery can be practiced economically while maintaining safe surgical standards. Accordingly, the clinical scenario questions addressing 'waste management & recycling in the theatre setting' and 'reduction/limiting the use of drapes and gowns for simple soft tissue procedures' have achieved the highest support. ...
... 13,14 Utilization of field sterility reduces the environmental impact of theater waste, and numerous studies have found no differences in infection rates between field sterility and theater sterility. [15][16][17] A 2019 study analyzed the economic impact of WALANT surgery for 150 carpal tunnel and trigger finger surgeries performed in an outpatient setting; they found an average saving of over €1,000 per case with superior postoperative pain scores. 18 In a separate A1 pulley release study, WALANT led to a shorter mean turnover time versus regional anesthesia and tourniquet (mean: 31.1 vs. 65.3 ...
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Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.
... With this trend, it is important to consider how the procedure room differs from the traditional operating room. First, the use of field sterility instead of main-operating-room sterility has allowed for considerable cost and waste reductions, without impacting upon the likelihood of surgical site infections ( Figure 1) [29][30][31]. Instead of needing the full standard set-up for main-operating-room sterility (which includes head covers, neck-to-knee sterile surgeon gowns, shoe covers, laminar airflow, and full-patient-body sterile draping), CTR can safely be performed in a clinic's procedure room with nothing more than a mask, sterile gloves, and single drape. Importantly, where CTR is performed in such settings, the absence of costly, specialized ventilation systems such as laminar air filtration or high-efficiency particulate air filters has not been linked to worse outcomes. ...
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As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
... When superficial infections occur, they can be easily treated, with minimal patient morbidity. 15 The ability to minimize surgical waste with minor hand procedures has also been documented by other authors. 6,26,29,41,42 Patients have been pleased with WALANT surgery done in procedure rooms. ...
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Purpose Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room. Methods The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed. Results Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using “lean and green” hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period. Conclusions Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction. Clinical relevance Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.
... Over the past 20 years, several studies have supported that simplified field sterility alone is suitable for many hand procedures. [6][7][8][9][10] To address the patient experience whilst undergoing WALANT, we have applied the developing technology of wide-awake virtual reality. 11 Procedures done in the office are also significantly less costly than those performed in the main operating room. ...
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Background:. We transitioned our hand practice from the operating room (OR) to our office-based procedure room (OPR) to offer wide-awake, local anesthesia, no tourniquet (WALANT). We have established that using wide-awake virtual reality improves patient comfort and anxiety during wide-awake procedures and helps facilitate our patients’ choice of venue. We aimed to assess the effect of this transition on infection rates for procedures performed by a single surgeon in the OR versus the OPR. Methods:. A retrospective chart review was performed on a single surgeon’s adult patients who underwent elective and closed traumatic upper limb surgeries. A surgical site infection was defined as superficial or deep, based on clinical examination conducted by the surgeon, and was treated with antibiotics within a 4-week postoperative window. Results:. From August 2017 to August 2019, 538 (216 OR and 322 OPR) consecutive cases met inclusion criteria. There were six (2.78%) superficial infections and zero deep space infections in the OR cohort compared with four (1.24%) superficial and zero deep space infections in the OPR cohort with no statistical significance. Two-thirds of cases were converted to WALANT and delivered in the office. Conclusions:. This narrative study concurs with the current literature that WALANT in the office setting is as safe as the hospital OR-based procedures for selected elective cases. By transitioning suitable cases from the OR to the OPR, a surgeon’s overall infection rate should not change.
Waste in medicine can be defined narrowly by including only physical waste. It can be defined widely by including the concept of wasting time, energy, money and waste of materials. We will provide an overview of waste mitigation and how it can be a union between saving money and protecting the environment.
Field sterility for K-wire insertion outside the main operating room is much cheaper and greener (ie, there is less waste). It permits increased access to more affordable surgery because unnecessary sedation and full sterility are eliminated. Early pain-guided protected movement of K-wired finger fractures at 3 to 5 days leads to less stiffness. It will not result in loss of reduction or infection around K-wires if patients avoid "pain" (ie, do not perform movements that hurt). Early protected movement and early removal of K-wires at 2 to 4 weeks contribute to less stiffness after operative hand/finger fracture reduction and stabilization.
Surgeons are familiar with surgical technique articles that provide step-by-step details of various surgical procedures relevant to clinical practice. This article is a communications technique article that provides step-by-step things that a surgeon can say to a wide-awake patient during the surgery to improve outcomes in clinical practice. The absence of anamnestic sedation enables memorable patient education from their surgeon to decrease the risk of postoperative complications.
The aim of this review article is to provide many important tips and tricks for surgeons to start Wide Awake Local Anaesthesia No Tourniquet (WALANT) hand surgery in their practice. The massive cost reduction of this disruptive new approach will enable them to increase access to hand surgery for their patients who cannot afford unnecessary sedation or unnecessary sterility of the expensive main operating room environment. Evidence-based sterility will permit surgeons to move a lot of their surgery out of the main operating room to minor procedure rooms without a significant increase in infection rates. Important pointers on how to inject minimally painful local anaesthesia will have patients thinking the surgeon injector is a bit of a magician. WALANT enables surgeons to improve the outcomes of many hand surgery procedures. Level of Evidence: Level V (Therapeutic)
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Background: Trigger finger release (TFR) is a common surgical procedure, representing a financial burden to the healthcare system. Our null hypothesis is that the choice surgical setting (operating room [OR] versus procedure room [PR]), and anesthetic type (local-only or monitored anesthesia care [MAC]) do not affect surgical encounter costs for TFR. Methods: Adult patients undergoing isolated unilateral TFR between May 2014 and December 2017 by five hand fellowship-trained surgeons at a single academic medical center were identified by CPT code (26055). We excluded patients undergoing revision surgery, tenosynovectomy, or additional procedures. Using our institution’s information technology value tools, we calculated total direct costs for each surgical encounter, which were compared between groups. Univariate and multivariable gamma regression were used to model costs. Results: Of 210 included patients, 54% (113/210) of cases were performed in the PR and 46% (97/210) in the OR. No significant differences in demographics were observed between PR and OR groups. Compared to local-only in the PR, the OR with local-only, and OR with MAC, demonstrated 2.2-fold and 3.2-fold greater median costs. Multivariable models suggested that use of the OR independently led to 221% (95% CI: 137% to 345%; p < 0.01) greater mean costs than the PR, and use of MAC was associated with 30% (95% CI: 13 to 49%; p < 0.01) greater mean costs for OR cases than local-only, while controlling for other confounders. Conclusions: Performing TFR in the procedure room setting under local-only anesthesia minimizes surgical encounter direct costs for this common procedure.
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Background Human health is dependent upon environmental health. Air pollution is a leading cause of morbidity and mortality globally, and climate change has been identified as the single greatest public health threat of the 21st century. As a large, resource-intensive sector of the Canadian economy, healthcare itself contributes to pollutant emissions, both directly from facility and vehicle emissions and indirectly through the purchase of emissions-intensive goods and services. Together these are termed life cycle emissions. Here, we estimate the extent of healthcare-associated life cycle emissions as well as the public health damages they cause. Methods and findings We use a linked economic-environmental-epidemiological modeling framework to quantify pollutant emissions and their implications for public health, based on Canadian national healthcare expenditures over the period 2009–2015. Expenditures gathered by the Canadian Institute for Health Information (CIHI) are matched to sectors in a national environmentally extended input-output (EEIO) model to estimate emissions of greenhouse gases (GHGs) and >300 other pollutants. Damages to human health are then calculated using the IMPACT2002+ life cycle impact assessment model, considering uncertainty in the damage factors used. On a life cycle basis, Canada’s healthcare system was responsible for 33 million tonnes of carbon dioxide equivalents (CO2e), or 4.6% of the national total, as well as >200,000 tonnes of other pollutants. We link these emissions to a median estimate of 23,000 disability-adjusted life years (DALYs) lost annually from direct exposures to hazardous pollutants and from environmental changes caused by pollution, with an uncertainty range of 4,500–610,000 DALYs lost annually. A limitation of this national-level study is the use of aggregated data and multiple modeling steps to link healthcare expenditures to emissions to health damages. While informative on a national level, the applicability of these findings to guide decision-making at individual institutions is limited. Uncertainties related to national economic and environmental accounts, model representativeness, and classification of healthcare expenditures are discussed. Conclusions Our results for GHG emissions corroborate similar estimates for the United Kingdom, Australia, and the United States, with emissions from hospitals and pharmaceuticals being the most significant expenditure categories. Non-GHG emissions are responsible for the majority of health damages, predominantly related to particulate matter (PM). This work can guide efforts by Canadian healthcare professionals toward more sustainable practices.
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Background: Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. Objectives: To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. Methods: Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. Main results: We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). Authors' conclusions: This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
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Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system.
Deep infection was identified as a serious complication in the earliest days of total hip arthroplasty. It was identified that airborne contamination in conventional operating theatres was the major contributing factor. As progress was made in improving the engineering of operating theatres, airborne contamination was reduced. Detailed studies were carried out relating airborne contamination to deep infection rates. In a trial conducted by the United Kingdom Medical Research Council (MRC), it was found that the use of ultra-clean air (UCA) operating theatres was associated with a significant reduction in deep infection rates. Deep infection rates were further reduced by the use of a body exhaust system. The MRC trial also included a detailed microbiology study, which confirmed the relationship between airborne contamination and deep infection rates. Recent observational evidence from joint registries has shown that in contemporary practice, infection rates remain a problem, and may be getting worse. Registry observations have also called into question the value of “laminar flow” operating theatres. Observational evidence from joint registries provides very limited evidence on the efficacy of UCA operating theatres. Although there have been some changes in surgical practice in recent years, the conclusions of the MRC trial remain valid, and the use of UCA is essential in preventing deep infection. There is evidence that if UCA operating theatres are not used correctly, they may have poor microbiological performance. Current UCA operating theatres have limitations, and further research is required to update them and improve their microbiological performance in contemporary practice. Cite this article: Bone Joint J 2018;100-B:1264–9.
Background: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping. The semisterile technique utilizes minimal prep and draping, which was proven to be a viable alternative when treating pediatric supracondylar humerus fractures. The purpose of this study was to investigate the safety and benefits of the semisterile technique for CRPP of pediatric upper extremity fractures. Methods: A retrospective cohort study was conducted of pediatric patients who underwent CRPP of an upper extremity fracture over a 4-year period. Demographic data, fracture type/location, and the type of prep technique (full-prep vs semisterile) were recorded. Qualities of intraoperative care were assessed, and postoperative care parameters were compared. Patient outcomes for the 2 techniques were compared using bivariate analyses. Results: In total, 219 patient records were reviewed including 160 in the semisterile group and 59 in the full-prep group. When comparing intraoperative parameters between the full-prep and semisterile techniques, the average room setup time was similar (20.6 vs 18.8 minutes, P = .52). However, the procedure times (32.1 vs 26.9 minutes, P = .04) were significantly shorter in the semisterile group. Nearly a 10-minute decrease in total time in the operating room was present while utilizing the semisterile technique (62.8 vs 53.6 minutes, P < .01). There were no statistical differences in complication rates between prep groups ( P = .31), and there were no infections while utilizing the semisterile technique. Conclusions: The semisterile technique is a safe and efficient alternative that may be used when performing CRPP of pediatric upper extremity fractures.
Background: The American College of Surgeons (ACS) guidelines indicate that skullcaps are acceptable, while the Association of periOperative Registered Nurses (AORN) recommends bouffant caps. However, no scientific evidence has shown a significant advantage in surgical site infection (SSI) reduction with either cap. The objective of this study was to determine the influence of surgical cap choice on SSIs. Study design: Data from a previously published prospective randomized trial on the impact of hair clipping on SSI were analyzed. Patients were grouped by the attending surgeons' preferred cap choice into either bouffant or skull cap groups. Results: Overall, 1543 patients were included in the trial. Attending surgeons wore bouffant caps in 39% and skullcaps in 61% of cases. Prevalence of diabetes and tobacco use were similar between the groups. Bouffant caps were used in 71% of colon/intestinal, 42% of hernia/other, 40% of biliary cases and only 1% of foregut cases. Overall, SSIs occurred in 8% and 5% of cases with a bouffant and skull cap, respectively (P=0.016); with 6% vs. 4% classified as superficial (P=0.041), 0.8% vs. 0.2% deep (P=0.12), and 1% vs. 0.9% organ space (P=0.79); however, when adjusting for the type of surgery, no significant differences in SSI rates were observed for skull caps versus bouffant caps. Conclusions: Attending surgeon preference for bouffant versus skull caps does not significantly impact SSI rates after accounting for surgical procedure type. Future guidelines should consider these clinical outcome data and surgeon preference should dictate operating room headwear.
Background Operating rooms (ORs), combined with labour and delivery suites, account for approximately 70% of hospital waste. Previous studies have reported that recycling can have a considerable financial impact on a hospital-wide basis; however, its importance in the OR has not been demonstrated. Objective To propose a method of decreasing cost through judicious selection of instruments and supplies, and initiation of recycling in plastic and hand surgery. Methods The authors identified disposable supplies and instruments that are routinely opened and wasted in common plastic and hand surgery procedures, and calculated the savings that can result from eliminating extraneous items. A cost analysis was performed, which compared the expense of OR waste versus single-stream recycling and the benefit of recycling HIPAA documents and blue wrap. Results Fifteen total items were removed from disposable plastic packs and seven total items from hand packs. A total of US$17,381.05 could be saved per year from these changes alone. Since initiating single-stream recycling, the authors' institution has saved, on average, US$3,487 per month at the three campuses. After extrapolating at the current savings rate, one would expect to save a minimum of US$41,844 per year. Discussion OR waste reduction is an effective method of decreasing cost in the surgical setting. By revising the contents of current disposable packs and instrument sets designated for plastic and hand surgery, hospitals can reduce the amount of opened and unused material. Conclusions Significant financial savings and environmental benefit can result from this judicious supply and instrument selection, as well as implementation of recycling.
Purpose: Treatment patterns of carpal tunnel surgery by members of the American Society of Surgery of the Hand (ASSH) have recently been published. The majority of cases in this study were performed in the general operating room with intravenous (IV) sedation or a Bier block. Patients were most commonly prescribed hydrocodone for postoperative pain. The majority of carpal tunnel releases at our center are performed under local anesthesia alone, with plain acetaminophen (Tylenol) or codeine prescribed for postoperative pain. The authors were interested in determining whether these differences were specific to our center or whether there were nationwide differences among the Canadian Society of Plastic Surgery (CSPS) members compared to the ASSH members. We aimed to conduct a similar study to assess current trends across members of the CSPS to assess similarities and differences compared with current practices by members of the ASSH. Methods: A 10-question survey, modeled after a previously published study, was sent electronically to Canadian plastic surgeons (n = 400). A description and a link to the survey was sent via e-mail and data were anonymously submitted and analyzed using descriptive statistics. Results: The online survey was completed by 183 surgeons (46%). The local procedure room is used by 161 (surgeons 88%), whereas 15 surgeons (8%) used the general operating room. Subcutaneous local anesthetic is used by 98 surgeons (54%), a median nerve block by 68 (7%), a full wrist block used by 6 (3%), local anesthesia with IV sedation used by 6 (3%), a Bier block used by 3 (2%), and a general anesthetic used by 1 (0.5%). After surgery, 70 surgeons (38%) prescribed codeine, 49 (27%) prescribed plain paracetamol, 24 (13%) prescribed nonsteroidal anti-inflammatories, 21 (12%) prescribed tramadol, and 21 (12%) prescribed a narcotic stronger than codeine. Conclusions: Compared with data obtained from ASSH members, differences in practice by Canadian plastic surgeons responding to this survey appear to be related to type of anesthetic used and postoperative analgesia provided. The majority of procedures in this study were performed in a local procedure room under local anesthetic alone and the majority of patients are discharged with codeine or paracetamol. Clinical relevance: This study draws comparisons between Canadian plastic surgeons and members of the ASSH with respect to carpal tunnel surgery and adherence to the American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Diagnosis and Treatment of Carpal Tunnel Syndrome.
Background Studies have suggested that forced-air warmers (FAW) increase contamination of the surgical site. In response, FAWs with high efficiency particulate air filters (FAW-HEPA) were introduced. This study compared infection rates following primary total joint arthroplasty (TJA) using FAW and FAW-HEPA. Methods Primary TJA patients at a single health care system were retrospectively reviewed. A total of 5,405 THA (n=2,419) and TKA (n=2,986) consecutive cases in 2013 and 2015 were identified. Patients in 2013 (n=2,792) had procedures using FAW, while FAW-HEPA was used in 2015 (n=2,613). Primary outcome was overall infection rate within 90-days. A stratified analysis sub-categorizing infections as periprosthetic joint infection (PJI) or surgical site infection (SSI) was conducted. PJI was defined as reoperation with arthrotomy or meeting Musculoskeletal Infection Society (MSIS) criteria. SSI was defined as wound complications requiring antibiotics or irrigation/debridement. The χ²-test and t-test were used for univariate analysis, while logistic regression models adjusted for potential confounders. Results The FAW and FAW-HEPA groups had similar rates of overall infection (1.65% [n=46] vs. 1.61% [n=42]; P>0.99), SSI (1.18% [n=33] vs. 0.84% [n=22]; P=0.27), and PJI (0.47% [n=13] vs. 0.77% [n=20]; P=0.22). Regression models did not show FAW to be an independent risk factor for increased overall infection (odds ratio [OR]=1.00; 95% confidence interval [CI] 0.65–1.57; P=0.97), SSI (OR=1.47; 95% CI 0.83 –2.58; P=0.18), or PJI (OR=0.53; 95% CI 0.25–1.13; P=0.09). Conclusion FAW were not correlated with a higher risk of overall infection, SSI, or PJI during TJA when compared to FAW-HEPA devices.