Exploring versatile applications of a vacuum-assisted bone harvester in orthopedic surgery.
Debridement
Infection
Oncology
Orthopedic surgery
Vacuum-assisted bone harvester
Journal
BMC musculoskeletal disorders
ISSN: 1471-2474
Titre abrégé: BMC Musculoskelet Disord
Pays: England
ID NLM: 100968565
Informations de publication
Date de publication:
31 Aug 2024
31 Aug 2024
Historique:
received:
24
04
2024
accepted:
16
08
2024
medline:
1
9
2024
pubmed:
1
9
2024
entrez:
31
8
2024
Statut:
epublish
Résumé
Orthopedic procedures often require removing bone or pathological tissue, with traditional methods involving instruments like curettes and rongeurs. However, these methods can be time-consuming and lead to increased blood loss. To mitigate these side effects, vacuum-assisted tools have been developed to aid in tissue removal. These devices enable surgeons to suction tissue without discarding it, potentially improving outcomes in conditions such as osteomyelitis or tumor removal while enabling collection of the material for downstream applications. Despite limited research, vacuum-assisted devices show promise beyond bone marrow harvesting. This study assesses infection and clearance rates, estimated blood loss, and total procedure time associated with the use of vacuum-assisted tissue removal, with a goal to understand if these devices can be used for tissue removal across a variety of pathologic conditions. A retrospective cohort study was conducted on patients undergoing orthopedic procedures with the Avitus® Bone Harvester repurposed from its original design from December 1, 2021, to July 1, 2023. Procedures were categorized into oncology, and debridement for infection cases. Infection cases were further categorized into those secondary to trauma and those involving primary infections (osteomyelitis and periprosthetic joint infection). Clinical variables, including demographics, intraoperative details, complications, and follow-up, were reviewed. Statistical analysis included descriptive statistics computed with R Studio. The study included 44 patients, with debridement for infection cases being the most common (primary infection: 45.5%; infection secondary to trauma: 18.1%), followed by oncology cases (36.4%). In all oncology cases, a definitive diagnosis was established using the device, and no post-operative infections were reported. The infection clearance rate was 85.0% for primary infection cases and 50.0% for cases of infection following trauma. Across the entire cohort, the average blood loss was 314.52 mL (sd: 486.74), and the average total procedure time was 160.93 min (sd: 91.07). The overall reoperation rate was 47.7%, with an unplanned reoperation rate of 11.4%. The vacuum-assisted bone harvester was effectively utilized in a wide range of debridement and curettage procedures across diverse orthopedic surgeries. In oncology cases, the device enabled effective tissue removal with comparable recurrence rates, demonstrating its potential to minimize contamination while preserving tissue for accurate diagnoses. Additionally, a high rate of osteomyelitis eradication was observed in debridement for primary infection cases (85%). Despite the relatively high reoperation rate of 47.7%, it is crucial to interpret this figure within the context of the varied reasons for reoperation. Many of these reoperations were planned as part of a staged approach to treatment or were unrelated to the device's performance. It is crucial to acknowledge that isolating the device's contribution to these results can be difficult. The utilization of the device should be guided by considerations of cost-effectiveness and patient-specific risk factors.
Sections du résumé
BACKGROUND
BACKGROUND
Orthopedic procedures often require removing bone or pathological tissue, with traditional methods involving instruments like curettes and rongeurs. However, these methods can be time-consuming and lead to increased blood loss. To mitigate these side effects, vacuum-assisted tools have been developed to aid in tissue removal. These devices enable surgeons to suction tissue without discarding it, potentially improving outcomes in conditions such as osteomyelitis or tumor removal while enabling collection of the material for downstream applications. Despite limited research, vacuum-assisted devices show promise beyond bone marrow harvesting. This study assesses infection and clearance rates, estimated blood loss, and total procedure time associated with the use of vacuum-assisted tissue removal, with a goal to understand if these devices can be used for tissue removal across a variety of pathologic conditions.
METHODS
METHODS
A retrospective cohort study was conducted on patients undergoing orthopedic procedures with the Avitus® Bone Harvester repurposed from its original design from December 1, 2021, to July 1, 2023. Procedures were categorized into oncology, and debridement for infection cases. Infection cases were further categorized into those secondary to trauma and those involving primary infections (osteomyelitis and periprosthetic joint infection). Clinical variables, including demographics, intraoperative details, complications, and follow-up, were reviewed. Statistical analysis included descriptive statistics computed with R Studio.
RESULTS
RESULTS
The study included 44 patients, with debridement for infection cases being the most common (primary infection: 45.5%; infection secondary to trauma: 18.1%), followed by oncology cases (36.4%). In all oncology cases, a definitive diagnosis was established using the device, and no post-operative infections were reported. The infection clearance rate was 85.0% for primary infection cases and 50.0% for cases of infection following trauma. Across the entire cohort, the average blood loss was 314.52 mL (sd: 486.74), and the average total procedure time was 160.93 min (sd: 91.07). The overall reoperation rate was 47.7%, with an unplanned reoperation rate of 11.4%.
CONCLUSION
CONCLUSIONS
The vacuum-assisted bone harvester was effectively utilized in a wide range of debridement and curettage procedures across diverse orthopedic surgeries. In oncology cases, the device enabled effective tissue removal with comparable recurrence rates, demonstrating its potential to minimize contamination while preserving tissue for accurate diagnoses. Additionally, a high rate of osteomyelitis eradication was observed in debridement for primary infection cases (85%). Despite the relatively high reoperation rate of 47.7%, it is crucial to interpret this figure within the context of the varied reasons for reoperation. Many of these reoperations were planned as part of a staged approach to treatment or were unrelated to the device's performance. It is crucial to acknowledge that isolating the device's contribution to these results can be difficult. The utilization of the device should be guided by considerations of cost-effectiveness and patient-specific risk factors.
Identifiants
pubmed: 39217301
doi: 10.1186/s12891-024-07786-3
pii: 10.1186/s12891-024-07786-3
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
688Informations de copyright
© 2024. The Author(s).
Références
Diefenbeck M, Haustedt N, Schmidt HG. Surgical debridement to optimise wound conditions and healing. Int Wound J. 2013;10 Suppl 1(Suppl 1):43–7.
pubmed: 24251843
doi: 10.1111/iwj.12187
Piccioli A, Ventura A, Maccauro G, Spinelli MS, Del Bravo V, Rosa MA. Local adjuvants in surgical management of bone metastases. Int J Immunopathol Pharmacol. 2011;24(1 Suppl 2):129–32.
pubmed: 21669151
doi: 10.1177/03946320110241S224
Anastasio AT, Wu KA, Kim BI, Nunley JA, DeOrio JK, Easley ME, Adams SB. A propensity score matched exploration of infection in primary total ankle arthroplasty. Foot Ankle Int. 2023;44(11):1158–65.
pubmed: 37772926
doi: 10.1177/10711007231198429
Schreuder HW, Pruszczynski M, Veth RP, Lemmens JA. Treatment of benign and low-grade malignant intramedullary chondroid tumours with curettage and cryosurgery. Eur J Surg Oncol. 1998;24(2):120–6.
pubmed: 9591027
doi: 10.1016/S0748-7983(98)91459-7
Steffner R. Benign bone tumors. Cancer Treat Res. 2014;162:31–63.
pubmed: 25070230
doi: 10.1007/978-3-319-07323-1_3
Rossi G, Mavrogenis AF, Angelini A, Rimondi E, Battaglia M, Ruggieri P. Vascular complications in orthopaedic surgery. J Long Term Eff Med Implants. 2011;21(2):127.
pubmed: 22043971
doi: 10.1615/JLongTermEffMedImplants.v21.i2.30
Yenigül AE, Sofulu Ö, Erol B. Treatment of locally aggressive benign bone tumors by means of extended intralesional curettage without chemical adjuvants. SAGE Open Med. 2022;10:20503121221094200.
pubmed: 35481245
pmcid: 9036382
doi: 10.1177/20503121221094199
Coleman BE. A Clinical Review of Autogenous Bone Grafting for Orthopaedics and the Avitus® Bone Harvester. Avitus® Orthopaedics, Inc.; 2018. White Paper.
Lukasiewicz AM, Bagi PS, Yu KE, Tyagi V, Walls RJ. Novel Vacuum-assisted method for harvesting autologous cancellous bone graft and bone marrow from the proximal tibial metaphysis. Foot Ankle Orthop. 2021;6(1):2473011420981901.
pubmed: 35097423
pmcid: 8702698
doi: 10.1177/2473011420981901
Greco VE, Hammarstedt JE, O’Connor S, Regal S. Masquelet technique and proximal tibial autograft utilizing avitus® bone harvester for severely comminuted open distal radius fracture with extensive bone loss: a case report. J Orthop Case Rep. 2022;12(4):49–53.
pubmed: 36381007
pmcid: 9634387
doi: 10.13107/jocr.2022.v12.i04.2762
Wu KA, Cardona DM, Eward WC: Novel Technique for biopsying osteofibrous dysplasia using a vacuum-assisted bone harvester: a case report. J Orthopaedic Case Rep. 2024;14(11).
Godoy G. Mycobacterial complicated distal femoral osteomyelitis treated with aggressive radical debridement utilizing avitus® suction curettage and distal femoral replacement-a case study. Avitus® Orthopaedics, Inc.; 2023. White Paper.
Jardaly A, Torrez TW, Kothari EA, Andrews NA, Gilbert SR. Over-Reaming the Humerus to Place an IM Lengthening Nail: Don’t Do This Case Report. JPOSNA. 2022;4(2):1–7.
Wu KA, Kugelman DN, Seidelman JL, Seyler TM. Native Joint Septic Arthritis. Antibiotics. 2024;13(7):1–14.
doi: 10.3390/antibiotics13070596
Goud AL, Harlianto NI, Ezzafzafi S, Veltman ES, Bekkers JEJ, van der Wal BCH. Reinfection rates after one- and two-stage revision surgery for hip and knee arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2023;143(2):829–38.
pubmed: 34595545
doi: 10.1007/s00402-021-04190-7
Horvath MM, Rusincovitch SA, Brinson S, Shang HC, Evans S, Ferranti JM. Modular design, application architecture, and usage of a self-service model for enterprise data delivery: the Duke Enterprise Data Unified Content Explorer (DEDUCE). J Biomed Inform. 2014;52:231–42.
pubmed: 25051403
pmcid: 4335712
doi: 10.1016/j.jbi.2014.07.006
Adams OE, Cruz SA, Balach T, Dirschl DR, Shi LL, Lee MJ. Do 30-day reoperation rates adequately measure quality in orthopedic surgery? Jt Comm J Qual Patient Saf. 2020;46(2):72–80.
pubmed: 31899155
Keating ME, Meding JB. Perioperative blood management practices in elective orthopaedic surgery. JAAOS. 2002;10(6):393–400.
pubmed: 12470041
doi: 10.5435/00124635-200211000-00003
Camilleri-Brennan J, James S, McDaid C, Adamson J, Jones K, O’Carroll G, Akhter Z, Eltayeb M, Sharma H. A scoping review of the outcome reporting following surgery for chronic osteomyelitis of the lower limb. Bone Jt Open. 2023;4(3):146–57.
pubmed: 37051853
pmcid: 10041339
doi: 10.1302/2633-1462.43.BJO-2022-0109.R1
Panteli M, Giannoudis PV. Chronic osteomyelitis: what the surgeon needs to know. EFORT Open Rev. 2016;1(5):128–35.
pubmed: 28461939
pmcid: 5367612
doi: 10.1302/2058-5241.1.000017
Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB. Single-stage orthoplastic reconstruction of Gustilo-Anderson Grade III open tibial fractures greatly reduces infection rates. Injury. 2015;46(11):2263–6.
pubmed: 26391592
doi: 10.1016/j.injury.2015.08.027
Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg Am. 2004;86(10):2305–18.
pubmed: 15466746
doi: 10.2106/00004623-200410000-00028
Suh YS, Nho JH, Choi HS, Ha YC, Park JS, Koo KH. A protocol avoiding allogeneic transfusion in joint arthroplasties. Arch Orthop Trauma Surg. 2016;136(9):1213–26.
pubmed: 27450193
doi: 10.1007/s00402-016-2516-7
Nelson CL, Bowen WS. Total hip arthroplasty in Jehovah’s Witnesses without blood transfusion. J Bone Joint Surg Am. 1986;68(3):350–3.
pubmed: 3949830
doi: 10.2106/00004623-198668030-00006
Kamel C, McGahan L, Mierzwinski-Urban M, Embil J. CADTH Rapid Response Reports. In: Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines. edn. Ottawa: Canadian Agency for Drugs and Technologies in Health Copyright © CADTH (June 2011); 2011.
Drampalos E, Mohammad HR, Pillai A. Augmented debridement for implant related chronic osteomyelitis with an absorbable, gentamycin loaded calcium sulfate/hydroxyapatite biocomposite. J Orthop. 2020;17:173–9.
pubmed: 31879500
doi: 10.1016/j.jor.2019.08.017
Jiang N, Ma YF, Jiang Y, Zhao XQ, Xie GP, Hu YJ, Qin CH, Yu B. Clinical characteristics and treatment of extremity chronic osteomyelitis in southern china: a retrospective analysis of 394 consecutive patients. Medicine (Baltimore). 2015;94(42):e1874.
pubmed: 26496345
doi: 10.1097/MD.0000000000001874
Lam A, Richardson SS, Buksbaum J, Markowitz J, Henry MW, Miller AO, Rozbruch SR, Fragomen AT. Chronic osteomyelitis of the tibia and ankle treated with limb salvage reconstruction. J Bone Jt Infect. 2019;4(6):306–13.
pubmed: 31966963
pmcid: 6960027
doi: 10.7150/jbji.40337
Li J, Zhang H, Qi B, Pan Z. Outcomes of vacuum sealing drainage treatment combined with skin flap transplantation and antibiotic bone cement on chronic tibia osteomyelitis: a case series study. Med Sci Monit. 2019;25:5343–9.
pubmed: 31320603
pmcid: 6660807
doi: 10.12659/MSM.915921
Lindfors N, Geurts J, Drago L, Arts JJ, Juutilainen V, Hyvönen P, Suda AJ, Domenico A, Artiaco S, Alizadeh C, et al. Antibacterial bioactive glass, S53P4, for chronic bone infections - a multinational study. Adv Exp Med Biol. 2017;971:81–92.
pubmed: 28050878
doi: 10.1007/5584_2016_156
Opara KO, Nwagbara IC. The use of sural island musculo fasciocutaneous flap, in the management of chronic osteomyelitis of the tibia. Niger J Clin Pract. 2018;21(6):698–702.
pubmed: 29888714
doi: 10.4103/njcp.njcp_173_17
Rod-Fleury T, Dunkel N, Assal M, Rohner P, Tahintzi P, Bernard L, Hoffmeyer P, Lew D, Uçkay I. Duration of post-surgical antibiotic therapy for adult chronic osteomyelitis: a single-centre experience. Int Orthop. 2011;35(11):1725–31.
pubmed: 21318568
pmcid: 3193950
doi: 10.1007/s00264-011-1221-y
Zhou CH, Ren Y, Ali A, Meng XQ, Zhang HA, Fang J, Qin CH. Single-stage treatment of chronic localized tibial osteomyelitis with local debridement and antibiotic-loaded calcium sulfate implantation: a retrospective study of 42 patients. J Orthop Surg Res. 2020;15(1):201.
pubmed: 32487197
pmcid: 7268519
doi: 10.1186/s13018-020-01721-7
Debnath UK, Thakral R, Burrow ZP. Techniques of Bone Grafting and Bone Augmentation. In: Handbook of Orthopaedic Trauma Implantology. edn.: Springer; 2023: 405–422.
Saikia KC, Bhattacharyya TD, Bhuyan SK, Bordoloi B, Durgia B, Ahmed F. Local recurrences after curettage and cementing in long bone giant cell tumor. Indian J Orthop. 2011;45(2):168–73.
pubmed: 21430873
pmcid: 3051125
doi: 10.4103/0019-5413.77138
Şirin E, Akgülle AH, Topkar OM, Sofulu Ö, Baykan SE, Erol B. Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series. Acta Orthop Traumatol Turc. 2020;54(5):524–9.
pubmed: 33155564
pmcid: 7646609
doi: 10.5152/j.aott.2020.19082
Errani C, Tsukamoto S, Ciani G, Donati DM. Present day controversies and consensus in curettage for giant cell tumor of bone. J Clin Orthop Trauma. 2019;10(6):1015–20.
pubmed: 31736607
pmcid: 6844202
doi: 10.1016/j.jcot.2019.09.017
van der Heijden L, Dijkstra PDS, Blay JY, Gelderblom H. Giant cell tumour of bone in the denosumab era. Eur J Cancer. 2017;77:75–83.
pubmed: 28365529
doi: 10.1016/j.ejca.2017.02.021
Ogilvie CM, Cheng EY. What’s New in Primary Bone Tumors. J Bone Joint Surg Am. 2016;98(24):2109–13.
pubmed: 28002375
doi: 10.2106/JBJS.16.00996
Ghert MA, Rizzo M, Harrelson JM, Scully SP. Giant-cell tumor of the appendicular skeleton. Clin Orthop Relat Res. 2002;400:201–10.
doi: 10.1097/00003086-200207000-00025
Wijsbek AE, Vazquez-Garcia BL, Grimer RJ, Carter SR, Abudu AA, Tillman RM, Jeys L. Giant cell tumour of the proximal femur: Is joint-sparing management ever successful? Bone Joint J. 2014;96-b(1):127–31.
pubmed: 24395323
doi: 10.1302/0301-620X.96B1.31763
Filipowska J, Tomaszewski KA, Niedźwiedzki Ł, Walocha JA, Niedźwiedzki T. The role of vasculature in bone development, regeneration and proper systemic functioning. Angiogenesis. 2017;20(3):291–302.
pubmed: 28194536
pmcid: 5511612
doi: 10.1007/s10456-017-9541-1
Zheng K, Yu X, Hu Y, Zhang Y, Wang Z, Wu S, Shen J, Ye Z, Tu C, Zhang Y. Clinical guideline for microwave ablation of bone tumors in extremities. Orthop Surg. 2020;12(4):1036–44.
pubmed: 32776475
pmcid: 7454210
doi: 10.1111/os.12749
Aiba H, Kobayashi M, Waguri-Nagaya Y, Goto H, Mizutani J, Yamada S, Okamoto H, Nozaki M, Mitsui H, Miwa S, et al. Treatment of simple bone cysts using endoscopic curettage: a case series analysis. J Orthop Surg Res. 2018;13(1):168.
pubmed: 29976220
pmcid: 6034211
doi: 10.1186/s13018-018-0869-z
Clark CR, Morgan C, Sonstegard DA, Matthews LS. The effect of biopsy-hole shape and size on bone strength. J Bone Joint Surg Am. 1977;59(2):213–7.
pubmed: 845207
doi: 10.2106/00004623-197759020-00014
Gregoretti S. Suction-induced hemolysis at various vacuum pressures: implications for intraoperative blood salvage. Transfusion. 1996;36(1):57–60.
pubmed: 8607155
doi: 10.1046/j.1537-2995.1996.36196190516.x
Pastorino A, Tavarez MM. Incision and Drainage. StatPearls. 2024.
Pincher B, Fenton C, Jeyapalan R, Barlow G, Sharma HK. A systematic review of the single-stage treatment of chronic osteomyelitis. J Orthop Surg Res. 2019;14(1):393.
pubmed: 31779664
pmcid: 6883574
doi: 10.1186/s13018-019-1388-2
Kim G, Lee KE, Shah A, Seidelman J, Wu KA, Cardona DM, Wahid L. Tuberculosis Osteomyelitis of the Wrist. Perm J. 2024:1–5.
Nasser AAH, Fenton P, Bose D. Single stage versus two-stage orthoplastic management of bone infection. Injury. 2022;53(3):984–91.
pubmed: 35063261
doi: 10.1016/j.injury.2022.01.020
Cheng H, Chen BP, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration increases risk of surgical site infections: a systematic review. Surg Infect (Larchmt). 2017;18(6):722–35.
pubmed: 28832271
doi: 10.1089/sur.2017.089
Wu KA, Helmkamp J, Levin JM, Hurley ET, Goltz DE, Cook CE, Pean CA, Lassiter TE, Boachie-Adjei YD, Anakwenze O, et al. Association between radiographic soft-tissue thickness and increased length of stay, operative time, and infection rate after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2024;33(6):1267–75.
pubmed: 38036256
doi: 10.1016/j.jse.2023.10.017
Leong G, Wilson J, Charlett A. Duration of operation as a risk factor for surgical site infection: comparison of English and US data. J Hosp Infect. 2006;63(3):255–62.
pubmed: 16698117
doi: 10.1016/j.jhin.2006.02.007
Wu KA, Anastasio AT, Krez AN, Kutzer KM, DeOrio JK, Easley ME, Nunley JA, Adams SB. Association of radiographic soft tissue thickness with revision total ankle arthroplasty following primary total ankle arthroplasty: a minimum of 5-year follow-up. Foot Ankle Orthop. 2024;9(2):24730114241255350.
pubmed: 38803651
pmcid: 11129576
doi: 10.1177/24730114241255351
Heinz NR, Clement ND, Young RN, Duckworth AD, White TO, Molyneux SG. Rate and factors associated with surgical site infection following aseptic revision fixation of orthopaedic trauma injuries. Eur J Orthop Surg Traumatol. 2023;33(8):3511–7.
pubmed: 37202609
pmcid: 10651543
doi: 10.1007/s00590-023-03573-3
Koval KJ, Helfet DL. Tibial plateau fractures: evaluation and treatment. J Am Acad Orthop Surg. 1995;3(2):86–94.
pubmed: 10790657
doi: 10.5435/00124635-199503000-00004
Knight R, Spoors LM, Costa ML, Dutton SJ. Wound Healing In Surgery for Trauma (WHIST): statistical analysis plan for a randomised controlled trial comparing standard wound management with negative pressure wound therapy. Trials. 2019;20(1):186.
pubmed: 30922364
pmcid: 6438006
doi: 10.1186/s13063-019-3282-y
Melvin SJ, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: I. evaluation and initial wound management. JAAOS. 2010;18(1):10–9.
pubmed: 20044487
doi: 10.5435/00124635-201001000-00003
Komori A, Iriyama H, Kainoh T, Aoki M, Naito T, Abe T. The impact of infection complications after trauma differs according to trauma severity. Sci Rep. 2021;11(1):13803.
pubmed: 34226621
pmcid: 8257796
doi: 10.1038/s41598-021-93314-5
Coombs J, Billow D, Cereijo C, Patterson B, Pinney S. Current concept review: risk factors for infection following open fractures. Orthop Res Rev. 2022;14:383–91.
pubmed: 36385752
pmcid: 9651069
Tornetta PI, Della Rocca GJ, Morshed S, Jones C, Heels-Ansdell D, Sprague S, Petrisor B, Jeray KJ, Del Fabbro G, Bzovsky S, et al. Risk factors associated with infection in open fractures of the upper and lower extremities. J Am Acad Orthop Surg Glob Res Rev. 2020;4(12):e20.00188.
pubmed: 33986214
pmcid: 7725249
Burnham JM, Meta F, Lizzio V, Makhni EC, Bozic KJ. Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment. Curr Rev Musculoskelet Med. 2017;10(2):233–9.
pubmed: 28421386
pmcid: 5435638
doi: 10.1007/s12178-017-9407-6
Chambers JD, Silver MC, Berklein FC, Cohen JT, Neumann PJ. Are medical devices cost-effective? Appl Health Econ Health Policy. 2022;20(2):235–41.
pubmed: 34820784
doi: 10.1007/s40258-021-00698-6
Wu KA, Anastasio AT, Krez AN, O'Neill C, Adams SB, DeOrio JK, Easley ME, Nunley JA. Diabetic management and infection risk in total ankle arthroplasty. Foot Ankle Surg. 2024.
Chauveaux D. Preventing surgical-site infections: measures other than antibiotics. Orthop Traumatol Surg Res. 2015;101(1):S77–83.
pubmed: 25623269
doi: 10.1016/j.otsr.2014.07.028
Ramdas K, Saleh K, Stern S, Liu H. Variety and experience: learning and forgetting in the use of surgical devices. Manage Sci. 2018;64(6):2590–608.
doi: 10.1287/mnsc.2016.2721