Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Norman A. Johanson, MD, and Martin J. Morrison III, MD*,
Drexel University College of Medicine, Philadelphia, Pennsylvania
Posted May 2009 (updated May 21, 2009)
During the 1980s, the senior author of this Commentary & Perspective (N.A.J.) regularly
performed surgery on patients and/or families with hemophilia. On one
particular occasion, he was performing an osteotomy for hip dysplasia on the
HIV-positive wife of a hemophiliac. There was more than usual blood loss during
the procedure, and, although he was wearing prescription glasses, a good deal
of blood, fat, and particulate debris made contact with his glasses, face, and
even his eyes. He took part in the HIV testing that was conducted during the 1991
Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) and, to
his relief, the test result was negative. The overwhelming lack of HIV
prevalence among the sample of orthopaedic surgeons who were tested at that
meeting was striking. The only two positive results out of a total of 3420
participants were found in individuals who reported "nonoccupational risk
factors for HIV infection."1 On the basis of his own exposure while working
in a regional hemophilia clinic as well as on the basis of the apparently very
low observed rate of HIV penetration into the orthopaedic community, it seemed
that the airborne spread of this particular virus was not as common as was
being suggested in some of the contemporary literature2,3. However, there
continues to be concern regarding other pathogens, such as hepatitis B and C,
which may be more easily acquired by splashed or sprayed material from a wound4.
It should be emphasized that, during the 1980s, the expanding but nonuniform use
of body exhaust suits for performing total joint arthroplasty and trauma
surgery also offered the near certainty of complete facial protection for the
surgeon and his or her assistants.
Twenty years later, in the era of Occupational Safety and
Health Administration (OSHA) regulations regarding the use of eye protective
devices, Mansour et al. have shown us that there may still be work to be done
on defining "adequate eye protection" in orthopaedic surgery. Utilizing
operating-room simulation, including the positioning of life-size mannequin
heads around the surgical field, the authors were able to determine the
relative protective properties of a control (no protective device) plus five
commonly used types of eye protection: (1) modern prescription glasses, (2)
standard surgical telescopic loupes, (3) hard plastic contoured glasses, (4)
disposable plastic glasses, and (5) a combination facemask and eye shield. Paper
targets placed over the eyes were used to measure splash contamination for each
trial. A femoral osteotomy was selected for this cadaver study because of the attendant
probability of substantial blood loss and the spray of wound contents via the
action of an oscillating saw. Saline solution with red-dye additive was placed
in the wound to simulate blood. Only 10 mL of saline solution was initially
placed in the wound, which seems to be a low estimate of blood loss. Therefore
the results (the percentage of positive hits) that were reported may actually
underestimate the danger of a positive hit on the surface of the eye.
Nevertheless, this study provides a scientifically valid comparison of commonly
used eyewear.
The results demonstrate significant variation in the
performance of the devices. None offered 100% protection. Modern prescription
glasses were no better than the control (no protective device). Both the
control and prescription glasses allowed positive hits to the simulated
conjunctival surface in 83% of the trials. Surprisingly, standard loupes were
only marginally more effective. The clear winners were disposable plastic
glasses and hard plastic contoured glasses. The combination facemask/eye shield
did not offer enough protection from above the face to be equivalent to the
more closely fitting eye protection.
The question that emerges from this well-executed study is,
"What defines adequacy of eye protection in high-risk orthopaedic surgery?" First,
for every preventative strategy that may be considered, the magnitude of the actual
clinical problem to be prevented needs to be kept in mind, and, in that regard,
we need good, contemporary, orthopaedic-specific epidemiological information on
transmission of disease. Second, in this era of scarce resources in health
care, the cost of preventative measures should be weighed against the real
benefit conferred. The authors acknowledge that a full head mask for every
orthopaedic procedure is "impractical." However, because of the potential
benefits to both the patient and the surgical team, it may make sense to
establish the body exhaust suit, which includes a full head mask, as the
standard of care for total joint replacement and related procedures. For other
procedures, the trade-offs may cause problems, particularly when considering
the visual acuity required for executing certain surgical procedures. A surgeon
who wears prescription glasses for surgery may have visual difficulties when wearing
additional closely overlying glasses. While a logical choice might be a
combination facemask/eye shield, the results of this study showed that option
to be less effective than more contoured and closely fitting protective
devices. If loupes are required to successfully perform the procedure, there
are limited means for improving the observed 50% hit rate. Perhaps new designs in
magnification eyewear that integrate these scientific findings will be necessary.
In any case, it is more desirable for the surgeon to be aware of these findings
and proactively make the necessary changes than to wait for the government to
impose more unwieldy regulations.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
1. Preliminary analysis: HIV serosurvey of orthopedic surgeons, 1991. MMWR Morb Mortal Wkly Rep. 1991;40:309-12.
2. Duthie GS, Johnson SR, Packer GJ, Mackie IG. Eye protection, HIV, and orthopaedic surgery. Lancet. 1988;1:481-2.
3. Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. J Med Virol. 1991;33:47-50.
4. Giachino A, Profitt A, Taine W. Contamination of the conjunctiva of the orthopaedic surgeon. A technical note. J Bone Joint Surg Am. 1988;70:126-7.
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