Keywords
orthopedic surgeons - gloves, surgical - protection - traumatology
Introduction
Orthopedic surgeries have a greater possibility of perforations in gloves, with handling
of blunt and sharp instruments (drills, screws, metal wires, among others),[1] in addition to bone spicules that can injure the surgeon's hand and offer risk of
contamination.
Some studies have evaluated the hypothesis of increased infection in procedures in
which the surgeon's glove loses integrity, but the results indicated no correlation.[1]
[2]
[3]
[4]
The perforation of gloves occurs in 3.5[5] to 56.8%[3] of surgeries; in up to 89% of these, the surgeon may not be aware of the contamination.[6] In addition, perforations are concentrated in the index finger and in the thumb
of the non-dominant hand.[1]
Using two gloves decreases the chance of contamination of the surgeon in cases of
tears by 87%, and, in the case of perforation of the surgeon's hand with a solid needle,
there is a retention of up to 95% of the blood in the gloves, thus minimizing a possible
transmission of diseases.[1] The additional pair of gloves decreases the possibility of perforation of the inner
glove, reducing the risk of contamination by up to 13 times fold.[7]
There are no studies in the literature that evaluated glove tears only in orthopedic
traumatology and fracture correction procedures. Our objective is to evaluate the
exposure of the patient and surgeon, determining the prevalence of glove perforations
in this type of surgery.
Materials and Methods
Two orthopedic surgeons with specialization in orthopedic trauma, M. B. and T. G.,
with 4 and 5 years of training, respectively, both right-handed, inspected the gloves
during and after the surgeries, in the period of 4 months, from July 1, 2019 to October
30, 2019, in the hospitals where they undergo surgical routine (Hospital Santa Cecilia,
Hospital Sancta Maggiore Mooca, Hospital Salvalus and General Hospital of Carapicuíba).
The inclusion criteria were orthopedic trauma surgeries, in which one of the two surgeons
involved in this study participated as the main surgeon; procedures for correction
and fixation of fractures; removal of synthesis materials (plates or rods); revisions,
and pseudarthrosis.
The exclusion criteria were soft-tissue surgeries (tendon or ligament repairs), without
the use of orthopedic implants, or removal of percutaneous synthesis materials.
Both surgeons routinely use two pairs of gloves (inner glove and outer glove). All
gloves used in the services and hospitals frequented by our team are natural rubber
latex, of brands authorized by the quality regulatory body for sterile surgical use.
At the end of the surgery (if there was no perceived perforation throughout the procedure
and the change was already made), the outer glove of each hand was removed separately
and inspected visually and thoroughly for signs of blood stains in the inner glove
([Figure 1]). The same procedure was repeated with the internal glove, in search of contamination
in the surgeon's hands ([Figure 1]).
Fig. 1 Internal glove showing loss of integrity of the left index finger perceived at the
end of surgery.
The surgeries were divided into duration greater than or lower than 60 minutes. In
addition, we separated them into three groups regarding the type of surgery: percutaneous
(such as fixation of distal radius with Kirchner wire); closed-focus surgeries (such
as intramedullary tibia or femur stems with indirect reduction), and open focus surgeries
(direct reduction and manipulation of bone fragments, such as forearm or joint fractures)
Regarding the loss of integrity of the gloves, we divided them into two groups: according
to perforation and details; these were subdivided as follows:
Regarding perforation, the outcomes may be: Group A: “No tears”: unidentified perforation
during the procedure and, at the end, without stains on the internal gloves. Group
B “one glove during”: loss of integrity only of the external glove noted during the
procedure, but without damage to the inner glove. Group C “two gloves during”: loss
of integrity of both gloves perceived during the procedure, with stains on the inner
glove and hand of the surgeon. Group D “one glove in the end”: only at the end of
the surgery there was staining on the inner glove, and the moment at which the perforation
occurred was not identified. Finally, Group E “two gloves in the end”: damage to the
internal and external glove, with contamination including the surgeon's hand, not
noticed during the procedure.
Regarding the details, we divided them into finger and side, record as to the region
and laterality of the perforations; and moment and mode, if perceived during the procedure
and reason for the tear, such as contact with bone spicules, Kirchner wires, during
handling of the punch, or when positioning Hohmann-type retractor or reduction calipers.
At the end, a statistical analysis of the variables was performed, using a chi-squared
test to compare the various variables found.
Results
A total of 210 surgical procedures involving internal fixation materials, such as
fractures, revisions, removals of material, were evaluated. Regarding time, 116 (55.2%)
lasted less than 60 minutes, and 94 (44.7%) more than 60 minutes. Regarding the type
of surgery, 20 surgeries were percutaneous, 60 were closed focus, and 130 were open
focus. Regarding the loss of integrity, 41.4% of the procedures had perforations or
damage to the gloves.
Regarding time, procedures with duration greater than 60 minutes presented a higher
rate of tears, with 67%. In surgeries that lasted less than an hour, there was a 20.6%
loss of integrity (p < 0.001) ([Table 1]).
Table 1
|
Surgical time
|
Total
|
|
< 60 minutes
|
> 60 minutes
|
|
|
Total
|
116
|
94
|
210
|
|
Damaged gloves
|
24 (20.6%)
|
63 (67.0%)
|
87 (41.4%)
|
|
Integral gloves
|
92 (79.3%)
|
31 (32.9%)
|
123 (58.5%)
|
Regarding the type of surgery, open focus procedures stood out, with 49.2% of them
presenting perforations. On the other hand, 33.3% of closed focus surgeries and 15%
of percutaneous surgeries had glove damage (p = 0.005) ([Table 2]).
Table 2
|
Type of surgery
|
Total
|
|
Percutaneous
|
Closed focus
|
Open focus
|
|
|
Total
|
20
|
60
|
130
|
210
|
|
Damaged gloves
|
3 (15%)
|
20 (33.3%)
|
64 (49.2%)
|
87 (41.4%)
|
|
Integral gloves
|
17(85%)
|
40 (66.6%)
|
66 (59.7%)
|
123 (58.5%)
|
Regarding the outcomes, considering the 87 surgeries in which there was perforation,
the situation of perceiving the tear only in the external glove (group B) during the
surgery had a higher rate, with 24.2%. On the other hand, the cases in which there
was loss of integrity of two gloves noticed during surgery (group C) accounted for
5.7%. The procedures in which the tear was discovered only at the end of the surgery
corresponded to 9% in the external glove only (group D) and 2.3% with perforation
of both gloves (group E) ([Table 3]).
Table 3
|
Perforations - perception
|
|
|
|
|
Group A
|
Group B
|
Group C
|
Group D
|
Group E
|
|
123 (58.5%)
|
51 (24.2%)
|
12 (5.7%)
|
19 (9.0%)
|
5 (2.3%)
|
|
Total
|
87 (41.4%)
|
|
|
|
Regarding perception, when there were tears, 63 cases were identified at the time
of the surgery. On the other hand, 24 of the perforations were noted only at the end
of the surgery during the inspection. In 80% of the cases in which there was a tear,
the internal glove remained intact, serving as a barrier to direct contact between
patient and surgeon.
The site that had the most perforations was the index finger of the non-dominant hand
(left), with 62.5% of the cases, followed by the right index finger, with 19.2%, and
in third, the left thumb with 9.6% ([Table 4]).
Table 4
|
Perforations - local (finger)
|
Total
|
|
Left index
|
Right index
|
Left thumb
|
Right thumb
|
Left ring finger
|
Left middle finger
|
Palmar region
|
|
|
65 (62.5%)
|
20 (19.2%)
|
10 (9.6%)
|
4 (3.8%)
|
3 (2.8%)
|
1 (0.9%)
|
1 (0.9%)
|
104
|
In cases of loss of integrity in which the reason was identified, the greatest factor
responsible was contact with bone spicules, in 45% of cases, followed by perforations
with Kirchner wires or guide wires, with 22.5%. Tears during handling of the punch
were the causative agent in 12.5%, and the act of positioning a Hohmann-type retractor
or reduction clamp in 10% of cases ([Table 5]).
Table 5
|
Perforations - reason (when) identified
|
Total
|
|
Bone spicules
|
Kirchner wire/ guide wire
|
Punch
|
Positioning Hohmann or reduction caliper
|
Awl
|
Palpar screw to fit key
|
|
|
18 (45%)
|
9 (22.5%)
|
5 (12.5%)
|
4 (10%)
|
2 (5%)
|
2 (5%)
|
40
|
Discussion
In the literature, we found different analyses on the subject. Some authors, like
Nicolai et al.[8] and Chan et al.,[5] evaluated the gloves of the surgical team, reaching percentages of 14.6% and 3.5%,
respectively. Laine and Aarnio[7] and Sanders et al.[2] obtained larger numbers analyzing only surgeons' gloves, with 31.4% and 52% of perforations,
respectively. In our study, we found a perforation prevalence of 41.4%.
Surgical time is a factor clearly related to the loss of glove integrity. Louis et
al.[9] indicated that 90% of perforations are concentrated in procedures with more than
2 hours. Enz et al.[10] also found more perforations in arthroplasty reviews, which last an average of 116 minutes.
Laine and Aarnio[7] indicated a difference of 3.6% of tears in surgeries with less than 1 hour to 14.6%
in those of more than 1 hour. Sanders et al.[2] also stated that in the analysis of gloves in procedures with more than 3 hours,
100% presented perforations. Our article indicated a difference of 20.6% of tears
in shorter procedures to 67% in long surgeries.
Although not including only orthopedic trauma procedures in their study, Chan et al.,[5] analyzed their results, also dividing by type of surgery. The result was a higher
perforation rate in fixation procedures with intramedullary nail, indicating 33% of
perforations, followed by 19% of tears in surgeries with open reduction. Diverging
from this information, our work in internal fixations with open focus presented 49.2%
of perforations, and in closed focus procedures with intramedullary stems, the result
was similar to that of Chan et al.,[5] 33.3%.
Loius et al.[9] and Mafulli et al.[6] had 80% and 89% of the perforations noted only at the end of the surgery; Laine
and Aarnio[7] indicated 23% of intraoperative perception when using only one glove and 36% with
two gloves. Nicolai et al.[8] presented perception in 10.2% in the group with conventional gloves. Our article
obtained an inverse result in relation to these values; we obtained 72.4% intraoperative
identification of perforations. In addition, we concluded that the use of double gloves
protected the surgeon's hands in 80.4% of the procedures in which there was loss of
integrity of the glove, in these cases the inner glove remained undamaged; just as
Tanner and Parkinson's[1] indicated as a protective factor.
Regarding the location of the perforations, Nicolai et al.[8] and Laine and Aarnio[7] indicated the occurrence of 73.6 and 70% of tears in the non-dominant hand; our
analysis found a similar value, with 76.6%. Lee et al.[11] found a higher prevalence distribution of holes in the non-dominant index, followed
by the dominant index finger and the non-dominant thumb, which agreed with our results.
Our article identified 62.5% of the tears located in the index finger of the left
hand, 19.2% in the right index finger, and 9.6% in the left thumb.
As a limitation of the present work, the method of detecting the loss of integrity
differs from that recognized and standardized in the United States and in Europe (The
American Society for Testing and Materials and The European Standards Committee),
which consists in filling the glove with 1,000 ml of water and suspending it with
a clamp by the collar, thus allowing water to flow through possible perforations.
Another option found in the literature is to fill the glove with 500 ml of water and
squeeze it to evaluate water leakage.[12] Another limitation was the non-detailing of the population or type of surgery.
Conclusion
Our study indicated 67% of perforations in longer surgeries against 20.6% in surgeries
with duration of less than 1 hour. Open reduction surgeries showed loss of integrity
in 49.2% of cases, closed reduction surgeries, in 33.3%, while percutaneous surgeries
only showed loss of integrity in 15% of cases. The most affected finger was the index
of the non-dominant hand, responsible for 62.5% of the perforations. In addition,
in 72.4% of the times, the tear was perceived throughout the surgery, and the most
frequent reason was contact with bone spiculae.
