COMPARISON OF DIFFERENT APPROACHES FOR HIP REPLACEMENT, DIFFERENT ASPECTS OF OVERLAPPING SURGERIES IN TKR AND TEST FOR CONTAMINATION IN OPERATION THEATER

1. (1)
(2)
(3)
(4)

2. Pongcharoen B
Chaichubut K
JBJS Open Accessed 2019:e0043.

3. Introduction
• Limping following total hip replacement is an adverse clinical
outcome that affects patient satisfaction
• Posterior approach results in a low rate of limping* but more
prone for hip dislocation**
• Modified Watson-Jones approach: Increasingly adopted to
reduce limp but difficult for inexperienced surgeons#
*Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res. 2002 Dec;405:46-53.
** Barber TC, Roger DJ, Goodman SB, Schurman DJ. Early outcome of total hip arthroplasty using the direct lateral vs the posterior surgical approach. Orthopedics. 1996
Oct;19(10):873-5.
# Bertin KC, R¨ottinger H. Anterolateral mini-incision hip replacement surgery: a modified Watson-Jones approach. Clin Orthop Relat Res. 2004
Dec;429:248-55.

4. Introduction…
 Direct lateral approach :
 Allows good exposure*
 May be associated with limping** as it involves
cutting anterior part of gluteus medius muscle#
*Horwitz BR, Rockowitz NL, Goll SR, Booth RE Jr, Balderston RA, Rothman RH, Cohn JC. A prospective randomized comparison of two
surgical approaches to total hip arthroplasty. Clin Orthop Relat Res. 1993 Jun;291:154-63.
**Ji HM, Kim KC, Lee YK, Ha YC, Koo KH. Dislocation after total hip arthroplasty: a randomized clinical trial of a posterior approach
and a modified lateral approach. J Arthroplasty. 2012 Mar;27(3):378-85. Epub 2011 Jul 28.
# Mukka SS, Sayed-Noor AS. An update on surgical approaches in hip arthoplasty: lateral versus posterior approach. Hip Int. 2014 Oct
2;24(24)(Suppl 10):S7-11.

5. Aim
 To determine rate of limping following primary THR
performed through different approaches

6. METHODOLOGY
Type of study: Retrospective
Study subjects:
Consecutive patients who had undergone unilateral primary
THR during 2005 to 2015 at Thammasat University Hospital
Duration of follow up: 2 years (2nd,6th weeks; 3rd , 6th,12th and
24th months)

7. METHODOLOGY…
• Inclusion:
Osteonecrosis of femoral head
Osteoarthritis of hip
Inflammatory joint disease
Femoral neck fracture
Exclusion:
Infectious arthritis
Hip arthrodesis
Neglected femoral neck fracture
Posttraumatic arthritis
Limping due to abnormal hip biomechanics

8. METHODOLOGY…
 Data collected with use of a standardized case report
 Patients classified into 3 groups according to the surgical
approach:
(1) Group I (posterior approach)
(2) Group II (direct lateral approach)
(3) Group III (modified anterolateral Watson-Jones
approach)

9. METHODOLOGY…???
 Posterior approach for obese and/or muscular patients
 Direct lateral approach for patients with femoral neck fractures
to prevent hip dislocation
 Modified anterolateral Watson- Jones approach for non-obese
patients (BMI <30 kg/m2) and/or non-muscular patients
 All procedures performed by same surgeon

10. METHODOLOGY…
Limping assessment: Harris hip score*
Limping severity level:
0- No limp, 11 points
1- Slight limp detected by observer and
unnoticed by patient, 8 points)
2- Moderate limp with abnormal pelvic motion
such as pelvic drop noticed by patient, 5 points
3- Severe limp with pronounced lateral sway of
body and trunk, 0 points
* Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result
evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737-55.

11. METHODOLOGY…
 Acetabular component assessed for inclination and
anteversion according method described by Lewinnek et al*
 Variables:
Operative time
Postoperative Harris hip scores
Complications
Hip abductor muscle strength
Revision rates
*Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978 Mar;60(2): 217-20.

12. Operative procedure
Posterior approach:
Skin incision extended 5 cm above and below tip of greater trochanter
Gluteus maximus identified and cut along it’s fibers
Short external rotators identified and were cut from their insertion points
Posterior capsule identified and incised in a T shape
Femoral neck excised as per the preoperative template
Posterior capsule and short external rotators were reattached to their insertion

13. Operative procedure…
• Direct lateral approach:
Skin incision curved from ASIS to greater trochanter and down
along femoral shaft
Sheath of TFL cut along its fibers
Anterior border of gluteus medius identified and cut from its insertion
Anterior capsule incised in T shape
Femoral neck excised as per preoperative template
Anterior aspect of gluteus medius muscle repaired to its insertion

14. Operative procedure…
• Modified anterolateral Watson-Jones approach:
Incision extended from tip of greater trochanter to ASIS
TFL and anterior border of gluteus medius muscle were identified
Anterior capsule cut in T shape
Femoral neck cut as per the preoperative template
After replacement anterior capsule was repaired

15. Analysis
Follow-up:
At 2 and 6 weeks; 3, 6, and 12 months; and annually thereafter
Statistical Analysis
• Chi-square test: For limping, sex and dislocation
• ANOVA : for continuous data (e.g., Harris hip score,
acetabular inclination, acetabular anteversion, operative time,
blood loss, and BMI)

16. Results
Baseline characteristics were similar across the 3 groups
except for a higher female:male ratio in the modified anterolateral Watson-Jones approach group

17. Results…
limping scores were also not significantly different between the 3 groups (p = 0.33), and no patient had severe limping

18. Results…
Harris hip score, alignment of the acetabular component,and blood loss were not significantly different between the 3 groups, but the modified
anterolateral Watson-Jones approach was associated with the longest mean operative time

19. Results…
The preoperative and postoperative hip abductor muscle strength was not significantly different between the 3 groups

20. Results…
The preoperative hip abductor muscle strength of patients with femoral neck fractures was excluded because pain precluded its assessment; therefore,
preoperative strength was only assessed for 7 hips that were treated with the direct lateral approach. Patients with femoral neck fractures had the highest
rate of limping, but the limping rates and Harris hip scores were not significantly different from those for patients with osteonecrosis, osteoarthritis, and other
inflammatory joint diseases (p = 0.69 and 0.79, respectively) (

21. Discussion
 Limping after primary THR is controversial as few studies
shown same prevalence across approaches* while others
reported higher rates with direct lateral approach#
 In this study, rate of limping associated with direct lateral
approach (<8%) was similar to posterior approach (<7%) and
modified anterolateral (<4%)
• *Downing ND, Clark DI, Hutchinson JW, Colclough K, Howard PW. Hip abductor strength following total hip arthroplasty: a prospective comparison of
the posterior and lateral approach in 100 patients. Acta Orthop Scand. 2001 Jun;72(3):215-20.
• #Mukka SS, Sayed-Noor AS. An update on surgical approaches in hip arthoplasty: lateral versus posterior approach. Hip Int. 2014 Oct 2;24(24)(Suppl
10):S7-11.

22. Discussion…
 This study has different results as:
• Procedure described in present study involved cutting less of
gluteus medius muscle than Hardinge approach*
• Excluded patients who had other causes of postoperative limp
 Limitations:
 Retrospective cohort study: selection bias
 Patients with femoral neck fractures were managed with direct
lateral approach, which is associated with postoperative
limping#
*Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br. 1982;64(1):17-9.
• #M¨uller M, Tohtz S, Dewey M, Springer I, Perka C. Age-related appearance of muscle trauma in primary total hip arthroplasty and the

24. Introduction
 Practice in which surgeon performs 2 surgeries during
overlapping time frame, surgeon performing critical
components of 1 surgery before starting another
surgery in another operating room*
 An experienced practitioner is delegated to complete
non-critical part of surgery
*American College of Surgeons (ACS) Bulletin of The American College of Surgeons. American
College of Surgeons statements on principles. 2016 Sep 01. ttp://bulletin.facs.org/2016/09/americancollege-
surgeons-statements-principles/. Accessed 2017 Jul 28.

25. Introduction…
 Critical components: Portions of procedure in which surgical
experience and decisions of attending surgeon are required*
 Critical components are left to surgeon to determine, as
permitted by ACS and Centers for Medicare & Medicaid
Services (CMS)
• * Zygourakis CC, Lee J, Barba J, Lobo E, Lawton MT. Performing concurrent operations in academic vascular neurosurgery
does not affect patient outcomes. J Neurosurg. 2017 Nov;127(5):1089-95. Epub 2017 Jan 20.

26. Introduction…
Advocacy:
 Allows more efficient use of surgeon’s time
 Improve workload that a single surgeon is able to
accomplish in a day
 Facilitate patient access to experienced surgeon
 Training of medical professionals by allowing more
independence and hands-on experience

27. Aims
 Comparison between overlapping and non-overlapping
surgeries in aspects of:
 Mean operating room time
 Complications within 3 months
 Types of complications leading to reoperation

28. Methodology
 Type of study:
Retrospective
 Study duration: 2010 to 2016
 Inclusion criteria :
Patients who treated with primary total knee or total hip
arthroplasty
 Exclusion:
Procedures performed for fractures
Bilateral or additional THA or TKA

29. Methodology…
 Critical portions :
 Total knee arthroplasty- soft-tissue balancing,
trialing and cementing of component
 Total hip arthroplasty- femoral neck osteotomy,
acetabular reaming, cup impaction, trialing and
stem insertion

30. Data collection and Analysis
 Collected from electronic medical records system
 Statistical analyses done with SPSS (version 24; IBM)
 Pearson chi-square and Fisher exact test: Categorical variables
 Independent t test: Numerical variables

31. Results
ASA: American Society of Anesthesiologists (ASA) physical status score

32. Results…
Mean operating room time: significantly higher for overlapping group than for non-overlapping
Overlapping and non-overlapping groups not differ with regard to e rates of complications

33. Results….
Figure: operating room times for the overlapping and non-overlapping groups
for the entire cohort, obese patients, and patients with an ASA score

34. Results…
Subgroup analyses of overlapping and non-overlapping procedures performed on obese patients or patients with an ASA score of 3 or 4 the mean
operating room time remained significantly higher for the overlapping group
No significant differences in the rates of complications, readmissions, or reoperations.

35. Results…
Figure: Outcomes within 90 days after surgery in overlapping and non-overlapping groups

36. Discussion
 Longer mean operating room time in overlapping group is
contrary to study by Zhang, who found no difference*
 This is probably because of involvement of assistants in
overlapping procedures
*Zhang AL, Sing DC, Dang DY, Ma CB, Black D, Vail TP, Feeley BT. Overlapping surgery in the ambulatory
orthopaedic setting. J Bone Joint Surg Am. 2016 Nov 16; 98(22):1859-67.

37. Conclusions
 Overlapping surgery does not lead to an increase rates of
complications
 Responsible execution of overlapping surgery does not add
unnecessary risk in the setting of total joint arthroplasty
 Further investigations required to evaluate effects of
overlapping procedures on patient-oriented outcome

39. Introduction
• In low-income-countries like sub-Saharan Africa,
numbers of joint arthroplasty are increasing
• Wider availability of resources, expertise and increased
life expectancy can be attributed to such increase
• Malawi National Joint Registry (MNJR) was established
to maintain records of arthrolasty and their outcomes*
• *Graham S, Lubega N, Harrison WJ. The Malawi National Joint Registry. BJJ News.2015 Jun 10;7.

40. Material and methods
 Type of study: Retrospective
 Inclusion:
 All patients who had undergone TKA at single
institution during 2005 to 2015
 Data derived from the MNJR
 Sample size: 177

41. Material and methods …
• Procedures were performed by 6 different surgeons
• None of hospital operating theaters had a laminar-flow system
• Majority (174) of TKA performed for osteoarthritis

42. Material and methods …
• In majority of cases cruciate-retaining prosthesis (DePuy
Orthopaedics)with a metal tray and polyethylene insert used
• None of patients underwent patellar resurfacing
• All of the implants were secured with use of Smart set GHV
cement with gentamicin (DePuy)

43. Material and methods …
 Patient received a single dose of intravenous antibiotic at
start of surgery
 Thromboembolism-deterrent (TED) graduated compression
stockings were used, along with low-dose aspirin, for 6 weeks
 Patients were mobilized on first postoperative day

44. Process of assessments

45. Process of assessments…
 Surgical wounds assessed with use of the ASEPSIS
wound-scoring system*
 Score of >10 was considered to be indicative of an
infection
 Evaluation done at 6 weeks, 3months , 6 months and annually
using Oxford Knee Score (OKS)
• *Wilson AP, Treasure T, Sturridge MF, Gr¨uneberg RN. A scoring method (ASEPSIS) for postoperative wound infections for
use in clinical trials of antibiotic prophylaxis.Lancet. 1986 Feb 08;1(8476):311-3.
• National Institute for Health and Care Excellence. Healthcare-associated infections: prevention and control in primary and community
care: clinical guideline. 2012. https://www.nice.org.uk/guidance/cg139. Accessed 2017 Sep 26.

46. Process of assessments
• Antero-posterior and lateral radiographs of knee were made at
each follow-up
• Radiographs were reviewed by author who had not been
involved in surgical procedures
• Images assessed for signs of loosening

47. Results

48. Results
• Data of 127 patients (98 women and 29 men) with a mean age
of 65.3 years were analyzed
• 26 patients had staged bilateral TKA
• Mean duration of follow-up was 4 years

49. Results…
• One patient developed an early postoperative
periprosthetic joint infection within 6 weeks
• One patient developed tibial aseptic loosening at 2 years
and underwent successful revision surgery
• Two patients developed late periprosthetic joint
infections at 1 year and 3 years

50. Results…
• Radiographs demonstrated no evidence of aseptic loosening in
any patient at last visit
• Mean preoperative OKS was 16.81 (4 to 36) while mean
postoperative OKS was 45.61 (range, 29 to 48) after a mean
duration of follow-up of 4 years
• Among HIV-positive, none had complications

51. Discussion

52. Discussion …

53. Discussion
• Study demonstrated good short-term results
• Found similar functional outcomes and low infection rates in
HIV-positive patients
• Findings were comparable to middle and high income
countries

54. Indian context:
National joint registry started in 2006
Indian Society of Hip and Knee Surgeons (ISHKS) facilitates
data collection

55. Discussion…
• Mean OKS (45.61) at 4 years was higher than U.K. National
Joint Registry (39) at 3 yeas: could be due to varying levels of
patient expectations

57. Introduction…
 Basic principles related to microbial air contamination:
 Microbes are dispersed in air by personnel in OT and
usually carried on skin* as microbe-carrying particles
 With size of 2 to 14μm and deposited on surfaces
under the influence of gravity#.
• *Davies RR, Noble WC. Dispersal of bacteria on desquamated skin. Lancet.1962 Dec 22;2(7269):1295-7.
• #Noble WC, Lidwell OM, Kingston D. The size distribution of airborne particles carrying micro-organisms. J Hyg (Lond). 1963 Dec;61:385-
91.

58. Introduction…
• Recommendations:
• Whyte et al. : less than10/m3 at the wound *
• Friberg et al. : 350/m2/hr**
• German : 1 colony/50 cm2/hr#
• Pasquarella et al.21 : 0 to 5 colonies/plate/hr ##
• Diverse methods and data formats make comparisons of
reference values difficult
• *Whyte W, Lidwell OM, Lowbury EJ, Blowers R. Suggested bacteriological standards for air in ultraclean operating rooms. J Hosp Infect. 1983
Jun;4(2):133-9.
• **Friberg B, Friberg S, Burman LG. Inconsistent correlation between aerobic bacterial surface and air counts in operating rooms with ultra clean
laminar air flows:proposal of a new bacteriological standard for surface contamination. J Hosp Infect. 1999 Aug;42(4):287-93.
• ## Pasquarella C, Pitzurra O, Savino A. The index of microbial air contamination. J Hosp Infect. 2000 Dec;46(4):241-56.

59. Introduction…
• Petri dishes:
• Available in triple-wrapped sterile packaging
• With trypticase soy agar media
• Diameter - 9 cm
• Cost -2 USD per plate
• Three plates were exposed on back-table sterile field (back-
table zone) at opening of procedure while one additional plate
on the back table was kept closed as a negative control

60. Introduction…
Test for
contaminants
Direct assessment
Contact sampling
methods**
Wound
washout#
Wound
swabs*
Indirect assessment
Viable
Active
sampling
Passive
sampling
Nonviable

61. Introduction
 Presence of airborne microbe-carrying particle*during
surgeries increases risk of periprosthetic joint infection
 No standard technique so far to measure intraoperative
airborne microbe-carrying-particle contamination#
 United Kingdom and Germany specify techniques and
reference values to address Microbe-carrying-particle levels**
• *Whyte W, Hejab M. Particle and microbial airborne dispersion from people. European Journal of Parenteral and Pharmaceutical Sciences.
2007;12(2):39-46.
• #Parvizi J, Barnes S, Shohat N, Edmiston CE Jr. Environment of care: Is it time toreassess microbial contamination of the operatin room air as a risk
factor for surgical site infection in total joint arthroplasty? Am J Infect Control. 2017 Nov 1; 45(11):1267-72. Epub 2017 Aug 14
• **Deutsches Institut f¨ur Normung. DIN 1946-4. Ventilation and air conditioningpart4: VAC systems in buildings and room used in the health care
sector. Berlin: Deutsches Institut f¨ur Normung; 2008..

62. Aims
• (1) To develop an environmental test procedure
• (2) To develop concepts for applications relevant to
orthopaedic surgeons:
• (A) How settle plate data can be used in future studies
investigating the risk of periprosthetic joint infection
• (B) How data can be utilized as a clinical tool to
monitor and control operating room environmental
quality

63. Methodology…

64. Methodology…
Six Petri dishes 3 each for operating table and back table
Plates were closed after closure of fascia
Exposure time was recorded
Plates were incubated for 48 hours
All visible microbial colonies
counted manually
Plates were read with use of a desk-
mounted magnifier

65. Methodology
• Type of study: Pilot study
• Test Procedure
• Sampling zones:
• (1) Extremity drape area: To assess direct contamination of
wound and indirect wound contamination from contact with
gloves and instruments
• (2) Instrument table area: To assess risk of contact
contamination via instruments.

66. Methodology
• Initial phase :
• Evaluated difference in particle levels in TKA with surgical
helmet systems and lower extremity trauma procedures
without helmet systems
• Twenty-eight procedures were monitored over a period of 8
months

67. Methodology
• 47 procedures monitored while 22 were analyzed
• Exclusion from analysis:
• Trauma surgery(14) and robotic unicondylar knee
replacements (7): differences in terms of setup, draping,
and equipment
• TKA (4): As negative control was positive, indicating
possible mishandling of plates

68. Methodology
• Surgery performed in 2 OT built to current U.S.
standards*
• Laminar flow with HEPA (high-efficiency particulate air)
filter was present in all OT
• All surgeons used identical draping, equipment, and
implant systems
• * American Society for Heating. Refrigerating and Air-Conditioning Engineers. ASHRAE 170-2013, ventilation of health care facilities
(ANSI/ASHRAE/ASHE approved). Atlanta: American Society for Heating, Refrigerating and Air-Conditioning Engineers; 2013.

69. Methodology
• Scrubbed personnel used surgical helmet systems , low-
permeability surgical gowns, and double gloving
• Protocol included :
• Prophylactic antibiotics
• Limited room traffic
• Minimal door openings
• Recommendations of Association of peri Operative
Registered Nurses (AORN) #
• # Association of periOperative Registered Nurses. Guidelines for Perioperative Practice, Denver: AORN; 2016.

70. Analysis
• Variables studied:
• Colony count
• Plate area
• Exposure duration
Outcome:
 Measured as microbial deposition total (MDT)
• MDT represents total surface contamination accumulated
during observation period

71. Analysis..
• Statistical Analysis:
• Confidence intervals calculated with use of Wald method
www.graphpad.com/quickcalcs
• Descriptive statistics calculated using Excel

72. Analysis..

73. Results

74. Results

75. Results
• MDT reference: level more than 450 (10 colonies/m3)
taken as upper limit of ultraclean air conditions
• Back table zone MDT exceeded upper limit in 3 cases
while wound zone MDT exceeded in 2 cases
• Majority of wound-zone observations (90 %) showed
levels of <450
• Analysis of excluded cases showed no meaningful
change

76. Discussion
• MDT levels are comparable to previous studies
• Settle plate method can be used as research tool to validate:
• Performance of ultraclean air systems
• Performance of operating room protocols
• Specific equipment such as surgical helmet systems

77. Discussion…

78. Discussion…
• Limitations:
• Not address other sources of contamination like transfer,
strike-through and barrier defects
• Small number of procedures in the study

79. Discussion…Indian context