Intraoperative fluoroscopy has facilitated improvements in surgical procedures across various subspecialties but has resulted in increased radiation exposure to the patient and surgeon. The results of a survey administered to 447 orthopedic surgeons and radiological technologists show that there is no standard universal c-arm language, that significant confusion and miscommunication exists between surgeons and technologists because of this, that unnecessary radiation exposure occurs as a direct consequence of this miscommunication, and that the vast majority of respondents would accept a standardized language similar to the one proposed in this study. This could potentially lead to less miscommunication and radiation exposure.

Introduction: Ganglion cysts represent the most common benign soft-tissue masses of the hand and wrist, most are treated nonoperatively, with relatively few local recurrences. Few studies have identified risk factors for recurrence in the pediatric population. The aim of this study is to identify risks of cyst recurrence and to establish if ultrasonographic imaging aids in the prediction of recurrence. Methods: A single-center retrospective chart review was performed, identifying patients diagnosed with a ganglion cyst of the hand or wrist. Demographic information, cyst characteristics, and ultrasound examination reports were documented. Standard statistical and logistic regression analyses were performed. Results: A total of 132 cysts were identified in 126 patients and the average age was 8.5 years old. The most common location was the dorsal wrist (57/132, 43.2%). There were 14 recurrences [11/14, (79%) dorsal wrist, 3/14 (21%) volar wrist, 0/14 (0%) in nonwrist locations]. The risk of recurrence was significantly greater for dorsal wrist cysts than nonwrist locations (odds ratio=18.1; 95% confidence interval: 1.02, 316.65; P=0.048); there was no statistical difference in recurrence rates between dorsal and volar cysts (P=0.15). Recurrence was noted in older patients (12.2 vs. 8.1 y, P<0.001) and those patients with painful masses (P=0.02). Patients undergoing surgical excision had a higher risk of recurrence than those who did not undergo surgical excision (P<0.001). Cyst volume as measured by ultrasound was performed in 37 cysts, with repeat ultrasounds in 12 cases demonstrating a decreased volume of 0.85 cm3 at baseline to 0.35 cm3 with repeat examination (P=0.40). In patients that received at least 1 ultrasound, there were no differences in cyst volume between those that recurred and those that did not (P=0.40). Conclusions: Risk factors for recurrence in pediatric patients with a ganglion cyst include older age, symptomatic masses, cysts located around the wrist, and those requiring surgical excision. Ultrasound examination of cyst volume did not predict recurrence. Level of Evidence: Level III—therapeutic.

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AIMTo define a ten-step protocol that reduced the incidence of surgical site infection in the spine surgery practice of the senior author and evaluate the support for each step based on current literature.METHODSIn response to unexplained increased infection rates at our institution following spine surgery, a ten-step protocol was implemented: (1) preoperative glycemic management based on hemoglobin A1c (HbA1c); (2) skin site preoperative preparation with 2% chlorhexidine gluconate disposable cloths; (3) limit operating room traffic; (4) cut the number of personnel in the room to the minimum required; (5) absolutely no flash sterilization of equipment; (6) double-gloving with frequent changing of outer gloves; (7) local application of vancomycin powder; (8) re-dosing antibiotic every 4 h for prolonged procedures and extending postoperative coverage to 72 h for high-risk patients; (9) irrigation of subcutaneous tissue with diluted povidone-iodine solution after deep fascial closure; and (10) use of DuraPrep skin preparation at the end of a case before skin closure. Through an extensive literature review, the current data available for each of the ten steps was evaluated.RESULTSUse of vancomycin powder in surgical wounds, routine irrigation of surgical site, and frequent changing of surgical gloves are strongly supported by the literature. Preoperative skin preparation with chlorhexidine wipes is similarly supported. The majority of current literature supports control of HbA1c preoperatively to reduce risk of infection. Limiting the use of flash sterilization is supported, but has not been evaluated in spine-specific surgery. Limiting OR traffic and number of personnel in the OR are supported although without level 1 evidence. Prolonged use of antibiotics postoperatively is not supported by the literature. Intraoperative use of DuraPrep prior to skin closure is not yet explored.CONCLUSIONThe ten-step protocol defined herein has significantly helped in decreasing surgical site infection rate. Several of the steps have already been shown in the literature to have significant effect on infection rates. As several measures are required to prevent infection, instituting a standard protocol for all the described steps appears beneficial.

Osteomyelitis in children commonly affects long bones such as the femur, tibia, and humerus. There have been relatively few documented studies of osteomyelitis at unusual locations, such as the calcaneus. The objective of this study is to systematically review information on the diagnostic and treatment methods of calcaneal osteomyelitis as well as associated complications. Methods included research database searches using primarily PubMed and EMBASE databases. Results of the review show no clear approach to diagnosis and treatment of calcaneal osteomyelitis in children. Clinical presentation of refusal to bear weight was the most common clinical symptom. Magnetic resonance imaging was 100% diagnostic in studies that used this modality, compared with X-rays, which were 14%-71.4% diagnostic. Blood cultures were diagnostic in 27% to 55% of cases, and erythrocyte sedimentation rate was elevated in 79% to 97% of cases. Methicillin-sensitive Staphylococcus aureus was the most common cultured organism. Treatment involved either antibiotics alone or in combination with surgical debridement/evacuation. Penicillin, penicillin derivatives, cephalosporins, clindamycin, and chloramphenicol were the most commonly used antibiotics, with duration varying from 5 days to 10 weeks. The most common complication was recurrent osteomyelitis. Levels of Evidence: III