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Reduction of Aerosol Exposure to Orthopedic Surgeons while Drilling Bone in COVID-19 Era: An Innovative Technique


 Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Date of Submission05-Feb-2021
Date of Decision25-Jul-2021
Date of Acceptance26-Jul-2021
Date of Web Publication14-Oct-2021

Correspondence Address:
Nishant Bhatia,
Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_8_21

  Abstract 


Operating in coronavirus disease times has become a challenge as it risks the frontline task force. Till now, no definitive and clear-cut guidelines for reducing aerosol generating procedures using the orthopedic power tools have been issued by the World Health Organization. We describe a technique to reduce aerosol generation in orthopedic procedures especially during drilling while inserting a screw or pin. We tooled a piece of polycarbonate plastic glass into a cup-shaped configuration and made two working portals, one through which a drill bit/sleeve could be advanced and the other through which a suction catheter could be inserted to suck out the dangerous fumes while drilling.

Keywords: Aerosol containment, aerosol may have viruses, exposure reduction, surgeon safety



How to cite this URL:
Dutt S, Bhatia N, Singh P, Sehrawat R. Reduction of Aerosol Exposure to Orthopedic Surgeons while Drilling Bone in COVID-19 Era: An Innovative Technique. MAMC J Med Sci [Epub ahead of print] [cited 2021 Dec 3]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=328360




  Introduction Top


Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has become the greatest global health concern in recent times. The number of cases being diagnosed on daily basis in India is the highest so far in the world and this number is expected to increase even further as the country makes its way out of lockdown to sustain its economy.[1],[2] This double-edged sword, of rising number of coronavirus disease 2019 (COVID-19) cases on one hand and increased number of orthopedic emergencies during the pandemic on the other, has put a tremendous burden on our already over pressured healthcare system.

Drilling is one of the main sources of aerosol generation in orthopedic procedures. Kucukdurmaz et al. demonstrated that the use of power drills in orthopedic surgery produced statistically significantly higher levels of particles than the ambient air.[3] It is a skillful step in almost every orthopedic surgery requiring adequate vision and considerable maneuverability and hence the exposure to orthopedic surgeons is intricate during drilling.

Aerosols are known to have live viruses as their contents.[4],[5] Transmission of SARS-COV-2 through blood aerosols generated during operative procedures has been postulated but there still remains a deficit of significant studies proving this. However, it is only rational that we act vigilantly about this mode of spread and take appropriate measures to reduce aerosol generation in operation theatres (OTs).

Operating in COVID times has become a challenge as it risks the frontline task force. Till now, no definitive and clear-cut guidelines for reducing aerosol-generating procedures (AGPs) using the orthopedic power tools have been issued by the World Health Organization. The current recommendations for orthopedic surgeons include level 4 gowns, N-95-99 masks, face shields or airtight goggles, and double gloves; however, their costs and availability are issues far from resolved yet in the country.[6]

We describe a technique to contain aerosols generated during orthopedic drilling and reduce its exposure to operating surgeon. Practice of this technique will definitely add to safety profile of the procedure toward the operating team.

Technique

We used polycarbonate plastic glass cut diametrically and longitudinally into cup-shaped and half cylinder configurations, respectively. This plastic is the same material used in protective goggles supplied with personal protective equipment (PPE) kits. Two portals were created in the glass piece by making appropriately sized holes. The tooling of such a device was accomplished at a local implant manufacturer. One gauged portal was used to pass the sleeves and drill bits, whereas the other larger portal was used to pass suction catheter to clear out the fumes while drilling [Figure 1]. The gauged portal was made according to the standard sizes of sleeves and drill bits. One piece was used for one drill bit size. Several glasses were tooled to have an inventory of multiple-sized pieces that could be used with different drill bits [Figure 2]a,b. This process of “tooling” the polycarbonate glass is a one-time procedure, as this material is autoclavable and can be reused after proper sterilization.[7] The glass pieces are placed and secured over the drilling site forming a closed chamber, the suction catheter is inserted through the larger portal, and the drill bit can be advanced in/out through the other hole [Figures 3],[Figures 4],[Figures 5]. Proper sizing of the portals is important to prevent aerosol leakage, while at the same time, allowing some maneuverability of the drill bit. We were able to greatly reduce our exposure to the drill fumes using this technique.

Figure 1: Polycarbonate shield with different-sized holes allow for use
of drill bit along with suction tip.


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,
Figure 2: Finished models after tooling the polycarbonate plastic glass
into (a) cup-shaped and (b) half cylinder (cut longitudinally)
configurations


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,
Figure 3: Usage during drilling for distal locking in femur nail.

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,
Figure 4: Usage during drilling for proximal tibial plating

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,
Figure 5: Usage during drilling for Schanz screw insertion for external
fixator application


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Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent: Informed consent was obtained from all individual participants included in the study.


  Discussion Top


The recent consensus has been to shift to conservative principles and decrease the number of indications for surgery.[8],[9] However, accidental emergencies are inevitable and performing a surgery in emergent conditions puts the whole operating team including nursing staff at grave risk of catching the infection through blood aerosols which are now postulated to be a significant source of infection.[5],[10],[11]

Orthopedic surgeries involve elaborate use of power tools such as electrocautery, drills, reamers, and saws which have shown to produce virus-containing aerosols and droplets.[8] There is clear cut evidence to support SARS-COV-2 transmission through aerosols generated during anesthetic procedures like intubation,[12] but studies proving disease transmission through blood and tissue aerosols generated by power tools are still lacking. However, it is only wise to take every possible step to contain these aerosols for surgeon and staff safety.

The Indian Orthopaedic Association has laid down several guidelines pertaining to orthopedic management in this pandemic; however, there are lacunae in recommendations regarding practice modifications of AGPs using orthopedic power tools.[9] Each day new and innovative ways are being reported to reduce AGPs. Surgeons are employing various tools, masks, respirators, etc., for protection. Although our technique “contains” the aerosols generated at bone-drill interface, large amounts of aerosols may still be produced at the level of motor of the drill which is not covered; however, the chances of these aerosols being infective are very less, as this part of the drill does not make contact with any bodily fluids of the patient if the described device is used properly.

Protective goggles are routinely worn by surgeons while operating on HbSAg/HCV/HIV-positive cases. The thick polycarbonate material protects the eyes from aerosols if secured properly. Same principle can be utilized by tightly securing the “tooled pieces” at the surgical site and then working through the portals.

Tooling this material into an innovative device to reduce exposure to aerosols while drilling/reaming can turn out to be an effective technique for enhancing personal protection while operating on COVID status unknown/positive patients. The cost of developing such a device is minimal. Polycarbonate has a glass transition temperature of 147°C and softens above 155°C when compared with acrylic plastic which melts at much lower temperatures.[7] Hence, it can easily bear the sterilization temperatures of autoclaving (121°C) which makes it relevant for use as a medical device. In addition, with recent advances, this material has been strengthened to withstand multiple cycles of sterilization hence making it reusable.[13] The reusability is an added advantage in our economically and socially overburdened Indian scenario.The common opinion is to avoid power instruments during COVID times and so, it may be wiser to use a hand drill instead of a power drill wherever possible.[9] However, using a power drill shortens the duration of surgery thus reducing the total exposure time, and with usage of the above technique of aerosol containment, the overall vulnerability might be further minimized. Through this study, we want to highlight and share this technique to reduce exposure among the front line healthcare providers.


  Conclusion Top


Our technique is an easy and cost-effective way to reduce exposure to dangerous aerosols and droplets in OT settings. Although it involves tooling by local implant manufacturers, but once we have the device ready in our inventory, we can surely have added protection for OT personnel, but obviously in adjunct to PPE kits.

Authors’ Contributions

SD: Conceptualization, methodology, writing – review, and editing. NB: Writing – original draft, data curation. PS: Methodology, supervision, validation, writing – review and editing. RS: Methodology, writing − review and editing.

Authors’ Statement

The manuscript has been read and approved by all the authors, requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organisation. Coronavirus disease (COVID-19): Weekly Epidemiological Update. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200907-weekly-epi-update-4.pdf?sfvrsn=f5f607ee_2. Accessed September 12, 2020.  Back to cited text no. 1
    
2.
Government of India. COVID-19. https://www.mygov.in/COVID-19. Accessed September 12, 2020.  Back to cited text no. 2
    
3.
Kucukdurmaz F, Imren Y, Akkoyunlu Y, Tuncay I, Sen C. Domestic electric drills in the service of orthopaedic surgery: a potential and preventable source of surgical site infections. Acta Orthop Traumatol Turc 2012;46:455e9.20.  Back to cited text no. 3
    
4.
Tran K, Severn M, Pessoa-Silva C-L, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 4
    
5.
Basso T, Dale H, Langvatn H et al. Virus transmission during orthopedic surgery on patients with COVID-19–a brief narrative review. Acta Orthop 2020;91:534-7.  Back to cited text no. 5
    
6.
Hirschmann MT, Hart A, Henckel J, Sadoghi P, Seil R, Mouton C. COVID-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon. Knee Surg Sports Traumatol Arthrosc 2020;28:1690-8.  Back to cited text no. 6
    
7.
City plastics. Materials-polycarbonate. Available at https://web.archive.org/web/20181016161442/http://www.cityplastics.com.au/materials-polycarbonate. Accessed September 16, 2020.  Back to cited text no. 7
    
8.
Neradi D, Hooda A, Shetty A, Kumar D, Salaria AK, Goni V. Management of orthopaedic patients during COVID-19 pandemic in India: a guide. Indian J Orthop 2020;54:402-7.  Back to cited text no. 8
    
9.
Indian Orthopaedic Association. COVID-19 IOA Guidelines. New Delhi: Indian Orthopaedic Association; 2020. https://www.ioaindia.org/COVID19IOA guide lines.pdf. Accessed September 12, 2020.  Back to cited text no. 9
    
10.
Raghavan R, Middleton PR, Mehdi A. Minimising aerosol generation during orthopaedic surgical procedures − Current practice to protect theatre staff during Covid-19 pandemic. J Clin Orthop Trauma 2020;11:506-7.  Back to cited text no. 10
    
11.
Viswanath A, Monga P. Working through the COVID-19 outbreak: rapid review and recommendations for MSK and allied heath personnel. J Clin Orthop Trauma 2020;11:500-3.  Back to cited text no. 11
    
12.
Odor PM, Neun M, Bampoe S et al. Anaesthesia and COVID-19: infection control. Br J Anaesth 2020;125:16-24.  Back to cited text no. 12
    
13.
Chatterjee G, Dhara D, Glasgow K et al. Methods of sterilizing polycarbonate articles and methods of manufacture. United States patent US 7, 638, 091. 2009.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figures 3], [Figures 4], [Figures 5]



 

 
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