Leading Orthopaedic Surgeon Advocates for "Clean Air" in the Operating Room

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Somers Orthopaedics Dr. Joel Buchalter offers tips on reducing infection risk with joint replacement surgery.

More than 800,000 joint replacement procedures are done in the United States every year, according to the American Academy of Orthopaedic Surgeons. Total joint replacements, which are done most frequently to relieve the pain and disability caused by severe arthritis, are performed most often on knee and hip joints but also on joints in the ankle, shoulder, fingers, and elbow. “The risk of postoperative infection is present in all surgical procedures but it can be particularly serious in joint replacement,” says Dr. Joel Buchalter of Somers Orthopaedic Surgery & Sports Medicine. “While the infection rate for joint replacement has been reduced to 1-2%, our goal is zero infections. And because airborne contaminants in the operating room are the primary cause of infection, creating an “ultra clean air” environment is an important weapon in our fight against infection.”

Postoperative infection is particularly troublesome in joint replacement because the implant procedure introduces foreign material into the patient's body. Bacteria are usually well controlled by the body's own immune system; when an infection is detected, the immune system responds quickly and attacks the infecting bacteria. But an implanted prosthetic joint cannot defend itself against infection the way other tissues can. When bacteria gain access to the area around the prosthesis, it is harder for the immune system to clear the infection with a foreign body amidst the tissues. If an infected implant persists, the problem can worsen and sometimes the implant may need to be removed in order to cure the infection.

Preventing infection requires careful attention prior to surgery, during surgery and after surgery. Prior to surgery, patients and their doctors must ensure that conditions that might introduce bacteria into the body – such as skin conditions, problems of the teeth and gums, and urinary tract infections – are treated. These bacteria can be carried by the blood from distant sources in the body to the prosthesis. Similarly, after surgery patients must be attentive to treating cuts promptly and consider taking prophylactic antibiotics before invasive dental work or other procedures.

“But blood-borne bacteria do not pose the greatest risk in joint replacement procedures,” Dr. Buchalter says. “The majority of infections are caused by airborne particles that are either present in the operating room – from skin cells shed by the operating room staff and the patient. – or are introduced through the ventilation system or through infiltration (e.g via a door being opened and closed). That's why the most advanced facilities use specialized “clean air” distribution systems that remove these contaminants to reduce the risk of infection.”

Air distribution in a hospital operating room is more complex than in a typical office building, where the primary objective is to quickly mix the air introduced into the room with the air already in the room in order to maintain a comfortable temperature without a draft. In the operating room, this typical system would spread an unacceptable level of airborne contaminants. Clean air environments were developed initially for semiconductor manufacturing and subsequently adapted to operating rooms. They utilize a specialized air distribution system comprised of several components that remove particulate matter from different sources:

  •     A ventilation system using high-efficiency particulate air (HEPA) filters reduces contaminants introduced via incoming air;
  •     Maintaining a positive pressure in the room controls the spread of particles introduced by infiltration;
  •     Contaminants released into the air by the staff and patient are carried away and prevented from mixing with incoming air by increasing the fresh air ventilation rate without causing excessive drafts. This is accomplished with “laminar air flow,” a system that introduces a large volume of fresh air at a uniform low velocity to promote a stable downward flow of air.

“The design of the operating room is only one important factor in our effort to eliminate infection in joint replacement procedures,” says Dr. Buchalter. Additional important measures known to lower the risk of infection are:

  •     Antibiotics before and after surgery: Antibiotics are given within one hour of the start of surgery (usually once in the operating room) and continued for a short period following the procedure.
  •     Minimizing operating time and traffic in the operating room: Efficiency helps to lower the risk of infection by limiting the time the joint is exposed. Limiting the number of operating room personnel entering and leaving the room is thought to decrease risk of infection.
  •     Use of strict sterile technique and sophisticated sterilization techniques: Care is taken to ensure that the operating site is sterile, the instruments have been autoclaved and not exposed to any contamination, and the implants are packaged to ensure their sterility.
  •     Wearing total body exhaust suits: Sterile "space suit" that encloses the surgeon and his/her team in a sterile environment.

“We use every technique known to be effective in reducing infection,” Dr. Buchalter concludes. “A 'clean air' operating room is one that may not be familiar to patients. But they should be fully informed of the availability of these facilities as they contemplate joint replacement. Their use provides an extra measure of confidence that every possible precaution has been taken to ensure a successful outcome and rapid recovery.”

Somers Orthopaedic Surgery and Sports Medicine Group, founded in 1988, is one of the most comprehensive and specialized practices in the region. Highly trained physicians specialize in diagnosing and treating all orthopaedic, rheumatological, and pain management problems in adults and children. All surgeons are board certified and experienced, having completed rigorous training at the finest medical institutions in the country. The staff includes fifteen physicians, five physicians' assistants, three physical therapists and a supporting staff of over 100. The group's physicians perform all types of arthroscopic surgery, ACL reconstruction, minimally invasive joint replacement, computer navigation, revision joint replacement, sports care, spine surgery, fracture care, hand, ankle, and foot surgery. State-of-the-art facilities include digital radiology, MRI and ultrasound. http://www.somersortho.com

Joel S. Buchalter, M.D., F.A.A.O.S., F.A.C.S., a founding partner of Somers Orthopaedic, has been in practice since 1988. He received board certification in Orthopaedic Surgery in 1990. He is a fellow of the American Academy of Orthopaedic Surgeons and a fellow of the American College of Surgeons. Dr. Buchalter graduated from Rensselaer Polytechnic Institute with a bachelors of science in biomedical engineering, earned his medical degree from New York University School of Medicine, and completed his internship in general surgery at Beth Israel Medical Center and his residency in orthopaedic surgery at the Hospital for Joint Diseases. Dr. Buchalter is a clinical assistant professor of orthopaedic surgery at the New York University School of Medicine/Hospital for Joint Disease Orthopaedic Institute. He is also co-director of the Orthopaedic Institute at Putnam Hospital Center. He is on staff at Northern Westchester Hospital Center in Mount Kisco, the Hospital for Joint Diseases in New York City, and Putnam Hospital Center in Carmel where he has served as chairman of the department of orthopaedic surgery.


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