Glove perforation in hip and knee arthroplasty

Background  

The transmission of blood-borne pathogens during surgery is a major concern. Surgical gloves are the primary barrier between the surgeon and the patient. Surgical procedures that need manual handling of bony surfaces or sharp instruments have the highest risk of glove perforations. The frequencies and the sites of surgical glove perforations in arthroplasty procedures were assessed.     

A comparison of the effect of different surgical gloves on objective measurement of fingertip cutaneous sensibility

INTRODUCTION

The prudent selection of surgical gloves can deliver significant efficiency savings. However, objective data are lacking to compare differences in cutaneous sensibility between competing gloves. Therefore, the present study examined the use of a single comparable model of sterile surgical glove from two competing providers, Gammex PF HyGrip® (Ansell Limited, Red Bank, NJ, USA) with Biogel® (Mölnlycke Health Care AB, Göteborg, Sweden).

SUBJECTS AND METHODS

Cutaneous pressure threshold, static and moving two-point discrimination were measured as indices of objective surgical glove performance in 52 blinded healthcare professionals.

RESULTS

The mean cutaneous pressure threshold was 0.0680 ± 0.0923 g for skin, 0.411 ± 0.661 g for Ansell gloves and 0.472 ± 0.768 g for Biogel gloves. Skin was significantly more sensitive than Ansell (P< 0.0001) or Biogel (P< 0.0001) gloves (Wilcoxon signed rank test). There was no statistical difference between Biogel and Ansell gloves (P = 0.359). There was no significant difference between static or moving 2-point discrimination of skin and Ansell gloves (P= 0.556, P = 0.617; Wilcoxon signed rank test), skin and Biogel gloves (P= 0.486, P= 0.437; Wilcoxon signed rank test) or Ansell and Biogel gloves (P= 0.843, P= 0.670; Wilcoxon signed rank test).

CONCLUSIONS

No demonstrable objective difference was found between competing gloves in the outcome measures of cutaneous sensibility and two-point discrimination. However, a difference in subjective preference was noted. Untested factors may underlie this discrepancy, and further research should employ more sophisticated measurements of surgical performance using competing models of surgical glove.     

Effects of experience on force perception threshold in minimally invasive surgery

Background

Distorted haptic feedback by the surgical instrumentation is a major problem in minimally invasive surgery (MIS). Friction force generated by the rubber seal in the trocars masks the haptic information needed to perceive the properties and structure of the target tissue, resulting in an increased haptic perception threshold in naïve subjects. This can lead to over application of forces in surgery.

Objective

This paper examines the effect of surgical experience on the psychophysics of force perception and force application efficiency in MIS.

Method

A controlled experiment was conducted using a mixed design, with friction and vision as independent within-subjects factors, experience as a between-subjects factor, and applied force and detection time as dependent measures. Fourteen subjects (eight novices and six experienced surgeons) performed a simulated tissue probing task. Performance data were recorded by a custom-built force-sensing system.

Results

When friction was present, higher thresholds and longer detection times were observed for both experienced and inexperienced subjects. In all cases, experienced surgeons applied a greater force than novices, but were quicker to detect contact with tissue, resulting in higher force application efficiency.

Conclusion

Surgeons seem to have adapted to the higher threshold in haptic perception by reacting faster, even while applying more force to the tissue, keeping within the limits of safety.     

Does the Method of Sterile Glove-Opening Influence Back Table Contamination? A Fluorescent Particle Study

BackgroundSurgical site infections (SSI) may result from inadvertent intraoperative contamination events. This study investigated the method of opening surgical gloves onto the operative field (OF) and potential contamination rates.MethodsTwenty surgical glove packets were coated with a commercially available fluorescent particle powder. Two methods of glove openings (10 surgical glove packets in each cohort) were investigated: direct drop (DD) onto the OF vs opening and direct hand-off (DH) to a sterile intermediary (SI). Ultraviolet black light was used to quantify fluorescent particles for dispensed glove packets and the OF in both cohorts. The gloves of the SI were inspected in the DH cohort. A previously used contamination scale for fluorescent particle model contamination was employed: 0: no detectable fluorescent particle specks, 1: 1-5 specks, 2: 5-10 specks, 3: 11-100 specks, 4: >100 specks.ResultsThe DD cohort had a median OF contamination of 4 (range, 3-4) vs 3 for the DH trials (range, 1-3; P = .001). Likewise, the median glove contamination was higher in the DD cohort, 3 (range, 2-4) vs 1 for DH (range, 0-3; P = .007). Minimal contamination was found on the hands of the SI. Total fluorescent contamination rates, including the gloves of SI in the DH cohort, revealed greater overall contamination in DD (median, 3.5; range, 2-4) vs DH cohort (median, 1; range, 0-3); (P < .001).ConclusionUsing a fluorescent particle model, there is a greater burden of potential contamination from dispensed glove packets and OF with DD vs DH. The DH method did not show significant fluorescent particle contamination on the SI gloves. These data support the use of the opening of gloves via DH over the DD method in total joint arthroplasty to decrease the risk of potential contamination.     

Unsuitability and high perforation rate of latex-free gloves in arthroplasty: a cause for concern

Introduction  

Any increase in perforations in surgical gloves is a concern. We conducted a prospective study to find a clinically acceptable brand of latex-free gloves suitable for orthopaedic surgery.     

How accurately does a simulation glove reflect function compared to rheumatoid arthritis sufferers?

INTRODUCTION

This study assessed the ability of gloves to simulate rheumatoid arthritis of the hand.

SUBJECTS AND METHODS

Assessments were made in the dominant hand of 24 healthy volunteers with no glove, glove A (simulating stiffness only) and glove B (simulating stiffness and pain). Results were compared to data held on 23 rheumatoid arthritis patients. Sollerman score was used as a standardised measure of hand function and time taken to complete testing was recorded. Grip strength was also measured in volunteers.

RESULTS

Both gloves simulate a reduction in power and prolong time taken to complete Sollerman hand-function testing. The gloves are less able to simulate a matched reduction in function when compared to rheumatoid arthritis sufferers. Sollerman score is 9.7% less in rheumatoid arthritis hands than a healthy volunteer using the glove.

CONCLUSIONS

The glove could, therefore, be used to guide future design of tools and aides that accommodate for hand disorders. More work on the usefulness of such disease simulation in the design of tools for such patients is needed.     

A Randomized Prospective Study of Glove Perforation in Orthopaedic Surgery: Is a Thick Glove More Effective?

We compared perforation rates among operative staff who were randomly assigned either thick latex surgical gloves or conventional gloves for use in performing total knee arthroplasty. A total of 1120 gloves were assessed in 70 total knee arthroplasties. Additionally, the degree of tactile sensitivity provided by the gloves was compared using a two-point discrimination (TPD) test. Perforation occurred in 27 surgeries (38.5%) and in 48 gloves (4.29%). Binary logistic regression analysis revealed that the operator was a risk factor for perforation rate (Odds ratio 14.448, P < .0.01) and that the type of glove was not (P = .896). In the TPD test, tactile sensitivity was lower for a thick outer glove than the conventional double glove (P < .001 for each site). Not only did thick surgical gloves lower tactile sensitivity, they also offered no superior protective effect over conventional gloves.     

A prospective study on the risk of glove fingertip contamination during draping in joint replacement surgery

Introduction

The aim of this prospective study was to investigate the risk of contamination of surgical gloves during preparation and draping in joint replacement surgery.

Methods

During 46 hip and knee replacement procedures, the gloves of orthopaedic consultants (n=5) and registrars (n=3) were assessed for contamination immediately after draping by impression of gloved fingers on blood agar. Contamination was evaluated by the surgeon’s grade, the type of procedure, the role of the assistant and the dominance of the hand.

Results

A total of 125 pairs of top gloves were examined (79 pairs from registrars and 46 pairs from consultants). Bacterial contamination was isolated on 19 pairs (15.2%) (16 pairs from registrars and 3 pairs from consultants, p=0.04). Coagulase negative staphylococci were the main isolates and contamination was considered low in all cases (1–5 colonies). Contamination was seen more on the dominant hand (16 gloves from dominant hands and 6 from non-dominant hands, p=0.04), on the index finger and thumb. More contaminated gloves were seen in hip arthroplasty procedures (16 pairs from total hip replacements vs 3 pairs from total knee replacements, p=0.02).

Conclusions

Contamination of glove fingertips during draping in joint replacement procedures is more likely to occur among junior surgeons, in hip rather than knee arthroplasty procedures and on the dominant hand. It is therefore essential that surgeons of different grades replace gloves used in draping to avoid exposing patients to the risk of infection.     

Effectiveness of a Surgical Glove Port for Single Port Surgery

Background  

A new surgical concept, such as single port surgery (SPS), usually raises many questions regarding safety, usefulness, appropriateness, applicability, and cost. Because many new port devices have been developed, choosing the type of port device for SPS is the most important factor. We herein briefly report our newly developed SPS port made using a standard surgical glove.     

Hearing status in children with frequently relapsing and steroid resistant nephrotic syndrome

Background

Children with idiopathic nephrotic syndrome (INS) are at risk of hearing impairment due to nephrotoxic drugs and biochemical impairments.

Methods

Forty children with INS aged 5–16 years [20 patients with frequently relapsing nephrotic syndrome (FRNS)/steroid dependent nephrotic syndrome (SDNS) and 20 with steroid resistant nephrotic syndrome (SRNS)] and 20 normal healthy controls were enrolled in this study. Pure tone audiometry was done using the ALPS AD 2000 audiometer. Sensorineural hearing loss was diagnosed when the bone conduction level was >20 dB and the difference in air to bone gap was ≤15 dB. Based on the air conduction (AC) threshold, deafness was graded into the following categories: mild (26–40 dB), moderate (41–55 dB), moderately severe (56-70 dB), severe (71–91 dB) and profound (>91 dB).

Results

Children with FRNS/SDNS had a higher threshold for hearing at frequencies of 250 and 500 Hz, respectively, than the controls. Of the children in the FRNS/SDNS category, three (15 %) had mild sensorineural hearing impairment. These children had a low serum calcium level (P?<?0.03) and received higher cumulative doses of furosemide (P?<?0.04). Children with SRNS had a higher threshold for hearing at frequencies of 250, 500, 1,000, and 2,000 Hz, respectively, than the controls. Of the 20 children with SRNS, ten (50 %) had sensoineural hearing impairment (8 mild, 2 moderate). Children with SRNS with a hearing defect had received a higher cumulative dose of furosemide (P?<?0.03).

Conclusions

Children with FRNS/SDNS and SRNS are at risk of sensorineural hearing impairment. The risk factors associated with this impairment were higher cumulative doses of furosemide and hypocalcemia. Larger prospective cohort studies are required to evaluate this association.     

Validated risk rule using computerized data to identify males at high risk for fracture

Summary  

Absolute risk assessment is now the preferred approach to guide osteoporosis treatment decisions. Data collected passively during routine healthcare operations can be used to develop discriminative absolute risk assessment rules in male veterans. These rules could be used to develop computerized clinical decision support tools that might improve fracture prevention.     

Comparison in Young Healthy Volunteers of 3 Different Parameters of Constant Current Stimulation Used to Determine Sensory Thresholds in the Lower Urinary Tract

Purpose

We compared different parameters of constant current stimulation used for evaluation of sensation in the lower urinary tract.

Materials and Methods

In 24 healthy male and 9 healthy female volunteers (mean age 24 years) sensory thresholds were determined at the same site on the bladder, urethra and skin with 3 different parameters of constant current stimulation (2.5, 20 and 95 Hz. at pulses 1, 1 and 0.5 msec., respectively) given at random.

Results

Thresholds were highly reproducible at all sites and with the 3 currents. Thresholds obtained with 2.5 Hz. were significantly greater than those obtained with 20 Hz. at all sites or 95 Hz. at the bladder and male urethra. No significant difference was found between thresholds in the bladder or urethra with 20 and 95 Hz. In 2 volunteers no bladder sensation was elicited with 2.5 Hz. even at 33 mA. A reproducible elevated threshold was found with 20 and 95 Hz. No intravesical pressure increase occurred during stimulation.

Conclusions

Absolute values of sensory thresholds vary in relation to the site of stimulus and stimulation parameters in healthy young subjects. Low frequency current (2.5 Hz.) is less easily perceived and, therefore, would seem less suitable for evaluation of electrical sensation in the lower urinary tract. Thresholds obtained with frequences of 20 and 95 Hz. were not statistically different.     

Latex-Free Gloves : Safer for Whom?

Increasing latex hypersensitivity among patients and health care workers has prompted the development of latex-free surgical gloves. Latex-free gloves must perform equally as the existing latex standard. We analyzed perforation rates in a clinical trial comparing latex and a latex-free alternative during primary hip and knee arthroplasty. The overall latex glove perforation rate was 8.4% compared with 21.6% for the latex-free alternative (χ²P < .001). The operation perforation rate for latex gloves was 34.4% compared with 80% for latex-free gloves (χ²P < .001). We suggest that the latex-free glove tested cannot provide a reliable barrier between the surgeon and the patient. As such, we question the safety of these gloves and the standards sets by the regulators.     

The mechanical and microbiological integrity of surgical gloves

Background: Several manufacturers supply surgical gloves that have been individually tested (IT) for leaks. Other manufacturers supply gloves in which sample gloves from each batch are tested for leaks (batch tested: BT). The latter brands may be rejected by surgeons because of presumed increased risk of wound infection and staff exposure to patient pathogens. The influence of differences between glove brands on performance in surgery has not been extensively studied. The aims of the present study were to test the mechanical and microbiological integrity of IT compared to BT gloves. Methods: A total of 110 unused gloves from each of an IT and a BT brand were tested for leaks, first, by observation of water‐jets from water‐filled gloves and second, by measuring electrical resistance between inside and outside the glove surfaces, to give a baseline measure. A total of 304 IT and 280 BT gloves were then similarly leak‐tested after 98 clean surgical procedures. The hands and gloves of scrub team members were cultured postsurgery. Results: A total of 1/110 BT and 0/110 IT unused gloves contained leaks (NS, Fisher's exact test). Operative perforation rates were lower for BT compared with IT (8/280 cf. 22/304; P < 0.05 Fisher's exact test). There was no bias in types of operations or scrub team members to account for the difference. Growth of normal skin flora was found on virtually every wearer's hands post­operatively. Similar bacteria were frequently cultured from the outside of gloves at the conclusion of surgery (111/152 pairs IT cf. 122/140 pairs BT; P < 0.01, Fisher's exact test). Conclusion: This study provides evidence that the clinical performance of BT gloves is no different to IT gloves. There was no significant difference in mechanical leak rates for unused gloves. Paradoxically, although IT gloves were more likely to show macro­perforations after surgery, the incidence of contamination on the surface of BT gloves was greater, possibly reflecting a qualitative difference in glove material. This study suggests that both types of gloves develop microporosity during use, which may allow transfer of bacteria from the surgeon's skin to the surface of the glove.     

Factors that influence the selection of sterile glove brand: a randomized controlled trial evaluating the performance and cost of gloves

Purpose

To determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand.

Methods

Forty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The manufacturer’s suggested retail price was collected for each glove tested.

Results

There were statistically significant differences in touch sensitivity for all nerve distributions, with all glove types resulting in less sensitivity than a bare hand. When compared with the non-sterile glove, only the thickest glove tested (Ansell Perry Orthopaedic) was found to have less touch sensitivity. Fine motor dexterity testing revealed no statistically significant differences in time to completion amongst glove types or bare handed performance. In hand-eye coordination testing across treatment conditions, the thickest glove tested (Ansell Perry^® Orthopaedic) was the only glove to show a statistically significant difference from a bare hand. There were statistically significant differences in glove comfort ratings across glove types, with latex-free, powder-free (Cardinal Esteem^®), and latex powder-free (Mölnlycke-Biogel^®) rated highest; however, there were no statistically significant differences in subjective performance ratings across glove types.

Conclusions

Given the observed similarities in touch sensitivity and psychomotor performance associated with five different glove types, our results suggest that subjective provider preferences, such as glove comfort, should be balanced against material costs.     

Chest tube insertion is one important factor leading to intercostal nerve impairment in thoracic surgery

Objectives

Chest tube insertion seems to be one important factor leading to intercostal nerve impairment. The purpose of this prospective study was to objectively evaluate intercostal nerve damage using current perception threshold testing in association with chest tube insertion.

Methods

Sixteen patients were enrolled in this study. Intercostal nerve function was assessed with a series of 2000-Hz (Aβ fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C^®). Current perception threshold values at chest tube insertion were measured before surgery, during chest tube insertion and after removal of the chest tube. Intensities of ongoing pain were also assessed using a numeric rating scale (0–10).

Results

Current perception thresholds at each frequency after surgery were significantly higher than before surgery. Numeric rating scale scores for pain were significantly reduced from 3.3 to 1.9 after removal of the chest tube (p = 0.004). The correlation between current perception threshold value at 2000 Hz and intensity of ongoing pain was marginally significant (p = 0.058).

Conclusions

This is the first study to objectively evaluate intercostal nerve damage at chest tube insertion. The results confirmed that chest tube insertion has clearly deleterious effects on intercostal nerve function.     

Vinyl glove ingestion in children: a word of caution

BackgroundVinyl gloves when ingested will harden and develop sharp edges producing gastric bezoars; bowel obstruction; and, ultimately, perforation. We report 4 children with complications secondary to vinyl glove ingestion who required surgical intervention.MethodsA 3-year-old boy, a 13-year-old adolescent girl with Down syndrome, a 14-year-old adolescent girl, and a 15-year-old adolescent boy presented with bowel obstruction secondary to a bezoar caused by a vinyl glove. The adolescent girl with Down syndrome presented again at age 17 years with a large vinyl glove gastric bezoar. Three of the children had mental retardation, and 1 was a victim of child abuse. Three had laparoscopic-assisted removal of the vinyl glove bezoar, and 1 had laparotomy.ResultsThe 4 children recovered uneventfully. Two of the patients had unsuspected intestinal perforation. The caretakers denied awareness of the vinyl glove ingestion.ConclusionsVinyl glove ingestion can cause intestinal obstruction and perforation. Vinyl gloves should be removed from the immediate proximity of mentally retarded patients or patients with pica. Most of the time, the finding of vinyl gloves as etiology of the obstruction or perforation is incidental. If the event is known or witnessed, prompt surgical intervention is generally recommended.     

Five year neurodevelopment outcomes of perinatally HIV‐infected children on early limited or deferred continuous antiretroviral therapy

Introduction

Early antiretroviral therapy (ART) has improved neurodevelopmental outcomes of HIV‐infected (HIV‐positive) children; however, little is known about the longer term outcomes in infants commencing early ART or whether temporary ART interruption might have long‐term consequences. In the children with HIV early antiretroviral treatment (CHER) trial, HIV‐infected infants ≤12 weeks of age with CD4 ≥25% were randomized to deferred ART (ART‐Def); immediate time‐limited ART for 40 weeks (ART‐40W) or 96 weeks (ART‐96W). ART was restarted in the time‐limited arms for immunologic/clinical progression. Our objective was to compare the neurodevelopmental profiles in all three arms of Cape Town CHER participants.

Methods

A prospective, longitudinal observational study was used. The Griffiths mental development scales (GMDS), which includes six subscales and a global score, were performed at 11, 20, 30, 42 and 60 months, and the Beery‐Buktenica developmental tests for visual motor integration at 60 months. HIV‐exposed uninfected (HEU) and HIV‐unexposed (HU) children were enrolled for comparison. Mixed model repeated measures were used to compare groups over time, using quotients derived from standardized British norms.

Results

In this study, 28 ART‐Def, 35 ART‐40W, 33 ART‐96W CHER children, and 34 HEU and 39 HU controls were enrolled. GMDS scores over five years were similar between the five groups in all subscales except locomotor and general Griffiths (interaction p < 0.001 and p = 0.02 respectively), driven by early lower scores in the ART‐Def arm. At 60 months, scores for all groups were similar in each GMDS scale. However, Beery visual perception scores were significantly lower in HIV‐infected children (mean standard scores: 75.8 ART‐Def, 79.8 ART‐40W, 75.9 ART‐96W) versus 84.4 in HEU and 90.5 in HU (p < 0.01)).

Conclusions

Early locomotor delay in the ART‐Def arm resolved by five years. Neurodevelopmental outcomes at five years in HIV‐infected children on early time‐limited ART were similar to uninfected controls, apart from visual perception where HIV‐infected children scored lower. Poorer visual perception performance warrants further investigation.