November 17, 2022

The science says they can as some facilities respond with enhanced technology to stop them from harming patients.

STERILE PERIL? Despite the many precautions facilities take to ensure infection-free ORs, concerns remain about the presence of airborne contaminants.

Efforts to protect patients from avoidable harm should include a focus on the space surrounding the sterile field, suggests a recent study.

Publishing in the journal Surgery, the researchers say that although the accepted standard on the ventilation of ORs requires a minimum of 20 air changes per hour with a minimum of four outdoor air exchanges, externally sourced air can still present microbial and chemical contaminates to the OR.

According to the study, 70% of the pathogens responsible for surgical site infections are potentially airborne, making them difficult to address through traditional infection control practices. "Although it has been historically accepted that pathogens responsible for healthcare-acquired infections (HAIs) originate primarily from surfaces, recent literature indicates that airborne microbial burden constitutes a significant portion of the overall pathogens responsible for HAIs," note the authors.

For this reason, many healthcare facilities are utilizing high-efficiency particulate air (HEPA) filters to help remove particulates and reduce the levels of biological contamination. But those are not panaceas either. "Because HEPA devices are designed to capture particulates, any retained particulates are likely to remain inside the filter and the viable matter [such as] bacteria, viruses, mold and fungi may continue to grow and multiply," notes the study.

Some providers are responding by positioning portable units next to the surgical table to direct a sterile airflow across patients and instruments. Robert Osher, MD, a professor of ophthalmology at the University of Cincinnati and medical director emeritus of the Cincinnati Eye Institute, has been using such a device since 2017. "I won't perform surgery without it," he says. "I use it in every one of my cases, and it gives me a great sense of security. It makes me feel that I am creating the safest possible field in which to perform surgery."

As more surgeries migrate to ASCs, the benefits of 3M^™ Prevena^™ Therapy offer options in patient selection and post-op care.

3M
3M^™ Prevena^™ Peel and Place Dressing being applied to a hip.

Total joints replacement surgery is on a continued growth pattern into the ambulatory surgical center (ASC) setting with no signs of stopping. Elective orthopedic surgeries are becoming more common in ASCs as surgeons adapted to the ebb and flow of case volumes that have been impacted by the last two-and-half years of the pandemic. In fact, the trend of transitioning elective total joint replacement cases to the ambulatory surgery center rose dramatically during that time as orthopedic surgeons became more comfortable performing TJA surgery in the ASC setting.

An additional force driving total joint arthroplasty (TJA) to the ASC setting is physician reimbursement, which is now being linked to the cost associated with the episode of care in "bundles. " If surgeons can find ways to provide care for less cost, they are incentivized by increased reimbursements. TJAs performed in an ASC setting are often less expensive than a hospital setting. Entrepreneurial orthopedic surgeons, who often own part or all of an ASC, may benefit financially by doing more TJA surgeries in their ASC. Additionally, previous restrictions placed by Medicare regarding where TJAs can be performed have been lifted.¹

In general, total hip arthroplasty (THA) and total knee arthroplasty (TKA) are very successful operations.² Unfortunately, complications (e.g., surgical site infections [SSI], seromas and dehiscence) can occur. These complications have been extensively studied and many risk factors have been identified.³ Some risk factors, such as smoking, diabetes and obesity, are considered modifiable. Patients are often required to quit using tobacco, control their blood sugar and lose weight before they are offered TJA.

Other risk factors, such as hypercoagulability or autoimmune disease, are not modifiable and must be managed around the time of surgery. A great deal of time and effort is spent optimizing patients before elective TJA.² However, one tool that has become available to help decrease the risk of postoperative complications is 3M^™ Prevena^™ Therapy. Clinical studies have been published supporting the use of Prevena Therapy after TJA surgery to reduce postoperative complications.^4-6 Additional studies have shown significant improvement in reducing rates of SSI, dehiscence and reoperations after hip and knee replacement revision surgery and after fixation of periprosthetic fractures.^7,8

When patient optimization before surgery is not feasible, Prevena Therapy can be especially useful. Significant benefits are being reported in these patient populations in the literature. A recent randomized controlled clinical trial showed reduced rates of 30-, 45- and 90-day surgical site complications and 90-day readmissions with Prevena Therapy after knee revision surgeries and was stopped at the mid-study evaluation point due to the remarkable differences between the two treatment arms and the obvious benefit with the use of Prevena Therapy.⁶

Many orthopedic surgeons are now using Prevena Therapy in their primary hip and knee replacement patients in selective, higher risk clinical situations and have observed clinical improvements as a result.⁹

Support for Prevena Therapy

3M^™ Prevena^™ 125 and 3M^™ Prevena^™ Plus Therapy Units manage the environment of closed surgical incisions and remove fluid away from the surgical incision via the application of -125 mmHg continuous pressure to the closed incision. When used with legally marketed compatible dressings, Prevena 125 and Prevena Plus Therapy Units are intended to aid in reducing the incidence of seroma; in patients at high risk for postoperative infections, the therapy units aid in reducing the incidence of superficial surgical site infection in Class I and Class II wounds. Furthermore, Prevena Therapy is the first medical device indicated by the FDA to help reduce superficial SSIs in high risk patients with Class I and Class II wounds*.

Prevena Therapy may be most beneficial to specific patient populations. Patients with a low or high body mass index (BMI), type 2 diabetes, immunodeficiency, active tobacco use, anticoagulation therapy use and prior surgeries have been found to be at higher risk for developing surgical site complications.⁹

Prevena Therapy in the ASC setting

Bundle payments are present in most major medical systems and a reality facing orthopedic surgeons. If care can be delivered for a lower cost, physician reimbursement can be greater. This motivates orthopedic surgeons to optimize patients before surgery and limit postoperative complications as much as possible. As of May 2021, the Centers for Medicare and Medicaid Services are requiring ASCs to report quality metrics or see a reduction in payment.¹⁰ Complications, such as infections and return admissions to the hospital, will have a significant negative impact on the bundle and have been labeled "bundle busters. " ¹¹

When used in the patient at high-risk for complications, Prevena Therapy may help decrease the chance for postoperative complications and potentially improve patient outcomes and patient satisfaction, thus reducing "bundle busters ", increasing physician reimbursement and decreasing overall cost of care. Orthopedic surgeons may be comfortable increasing the BMI cutoff for their ASC patients if Prevena Therapy is used.

This expands the number of TJA patients seen in the ASC, which may provide opportunities for treating more complex patients. Although there are additional costs associated with utilizing Prevena Therapy, these dressings can potentially decrease complication rates in higher risk patients and "bundle busters " can be avoided. Additionally, Prevena Therapy may positively impact the overall cost of care, which may decrease with TJA patients.

*The effectiveness of Prevena Therapy in reducing the incidence of SSIs and seroma in all surgical procedures and populations has not been demonstrated. See full indications for use and limitations at myKCI.com.

Patients with hidradenitis suppurativa, while relatively rare, could be at elevated risk for surgical site infections.

A relatively rare skin disorder was shown in a recent study to essentially double wound-related issues for patients who received total hip or total knee replacements.

The study, published in Arthroplasty Today, focused on hidradenitis suppurativa (HS), also known as acne inversa. HS is a chronic skin disorder of the hair follicles that causes inflammatory skin lesions, usually in the inguinal and axillary regions. It affects about 1% of the U.S. population and is more prevalent in women than men. Furthermore, African Americans, Hispanics and biracial people are more likely to have HS than white Americans.

When the researchers reviewed results for the first 90 postoperative days of more than 331,000 total hip arthroplasty (THA) patients and more than 274,000 total knee arthroplasty (TKA) patients, HS was noted for 481 (0.15%) of those who had undergone THA and 290 (0.11%) for those who had undergone TKA. They found that the rate of surgical site infections for the TKA patients was 10% for those with HS and 5.4% for those without the condition. For the THA patients, those with HS had a 3.8% incidence of wound dehiscence, compared to 1.5% for those without it.

"These skin lesions are common sites of bacterial growth and are thus a potential risk factor for infection following procedures such as total hip arthroplasty (THA) or total knee arthroplasty (TKA), " says the study.

The data does not mean the long-term outcomes of the joint replacements were impacted, however. "Importantly, despite the increased wound-related issues for those with HS, there was not a difference in five-year implant survival noted for THA or TKA, " notes the study. "This suggests that, once through the short-term wound-related issues, implant survival should be similar for those with HS as those without HS. "

While significant work has been done to optimize outcomes and minimize morbidity following joint replacements, the authors say their study is one of numerous deeper dives that are now being taken into reviewing more specific conditions present in smaller groups of patients. They say investigating how patients with rare conditions such as HS are at risk of complications after total joint procedures can lead to better surgical planning and improved preoperative patient counseling.

Findings include confirmation that arthroplasties are moving to outpatient settings at a rapid pace.

The American Joint Replacement Registry (AJRR), described as the cornerstone of the American Academy of Orthopaedic Surgeons (AAOS) Registry Program, has published its 2022 Annual Report on hip and knee arthroplasty procedural trends and patient outcomes.

The report, available here, includes more than 2.8 million hip and knee procedures since 2012 from more than 1,250 hospitals, ASCs and private practice groups that have submitted data. AJRR, billed as the largest orthopedic Registry by annual procedure count, describes an overall cumulative procedural volume growth of 14% compared to the previous year.

"The AJRR Annual Report puts 10 years of procedural data at our fingertips and allows orthopedic surgeons to develop robust, meaningful analytics that can unlock new insights into patient reported outcomes and support highly informed decision-making and quality improvement, " says Bryan D. Springer, MD, FAAOS, chair of the AJRR Steering Committee.

Among AJRR's most notable findings in this year's report:

• Patient-Reported Outcome Measures (PROMs) are increasingly being utilized to evaluate the success of hip and knee arthroplasties. By the end of 2021, over 400 participating sites submitted PROMs to AJRR, representing a 38% increase over the previous year.
• AJRR evaluated age-stratified patient-reported outcome scores for the first time this year. Patients older than 75 were found to have poorer scores compared to younger groups, most notably when using a quality-of-life assessment tool.
• "ASCs play an increasingly important role in the delivery of total joint arthroplasty care in the U.S., " notes AJRR, which says the number of procedures submitted by ASCs has grown "exponentially " between 2012 and 2020. Even more notably, the number of submitted ASC procedures increased by 57% since last year's annual report.
• Since 2017, the use of robotics in total knees has increased in magnitude by six times, and more than doubled in total hips. "Computer navigation use has remained relatively stable, " adds AJRR.

"This year 's AJRR Annual Report is testament to the commitment of healthcare institutions, clinicians and patients to improving quality musculoskeletal care," says James A. Browne, MD, FAAOS, chair of the AJRR Publications Subcommittee. "As I look ahead, I am optimistic about the future and our ability to provide clinical insights, national trends and risk-stratified outcome analyses for patients who undergo hip and knee arthroplasty procedures."