Orthopedic surgery: Beware of 10 intra operative nightmare situations other than common medico-surgical complications

Orthopedics is considered an art of jugglery and carpentry. There are so many technical and situational difficulties other than medico-surgical complication and still challengingly unique of surgeries pertaining to orthopedics. We have reviewed orthopedic literature to conclude 10 nightmare situations which are though less common but discussed even lesser. They include IITV (Image Intensifier), Suction, Cauterization, Lighting, Drilling, Implants, Cooling and ventilation, Patient positioning, Wrong side/site and Accidental prick or injuries related issues. Considering all this problems as a single issue, its prevalence is sometime comparable with the known complication like infection and other morbidity and mortality. The liability of non-biological issues on doctor or hospital and narrow margin between technical error and negligence has made reporting of such situation even in front of medical fraternity a rarity. Appropriate pre-operative planning and keeping the backups available can dramatically reduce the encounter with these preventable situations. These situations are definitely like a ‘nightmare’ for any orthopedic surgeon, now it is up to us when we are going to take the ‘wake-up call


Introduction
As orthopedic surgeons, we utilize more technology, more implantable devices, more industry support, and more mechanical innovations than any other branch of medicine according to Capozzi JD et al [1]. This has made us more vulnerable to many technical nightmare situations, of which most other medical fields are unaware. The use of fluoroscopy has increased tremendously in field of orthopedics [2]. The image intensifiers have enabled orthopedic surgeons to become technically more proficient and decrease the morbidity of the patient by minimizing area of operative field and decreasing operative time [3].
Old machines, voltage and wiring related problems, nonmaintenance are the reasons behind failure. Improper handling by non-qualified person and multiple frequent shoot outs demanded by operating surgeon may lead to hanging problems. AMC (Annual Maintenance Contract) and CMC (Comprehensive Maintenance contract) with the manufacturer are important in preventing problems.
The risk of an orthopedic surgeon contracting cancer is significantly higher than that of a non-orthopedic professional and eight times more than that of an unexposed worker [4].
Qualified technician only should operate the machine rather than learning or trainee doctors and it also help in radiation reduction [5]. Unfortunately once it stops working during surgery, there is less we can do except converting a closed surgery into an open one if possible.
(2) Suction: Operation field suctioning catheter allows the suctioning of blood, flushing solutions, and discharges from the operation field. Invent of suction catheter was once considered as new era of surgical drainage by suction applicable to every surgical field [6].
Proper suctioning of oozing blood is mandatory for any open surgery nowadays. Kelly EA et al emphasized that adequate surgical field visualization is imperative for successful outcomes in their study [7]. (3) Cauterization: Electro-cautery, also known as thermal cautery, refers to a process in which a direct or alternating current is passed through a resistant metal wire electrode, generating heat. The heated electrode is then applied to living tissue to achieve hemostasis or varying degrees of tissue destruction [8].
Bloodless field is the basic requirement of a meticulous surgery. Yang Y et al observed that electro cautery is now more commonly adopted to not only achieve intraoperative hemostasis but cutting and dissecting out many structures during surgical exposure [9].
Spine and micro surgery is almost impossible without cauterization especially bipolar. Excessive blood loss is also a life-threatening complication prevented by cautery.
Back up machine along with the use of prophylactic tourniquet (without inflating) is recommended. Takeshi Ide et al reveled that LED lights are superior due to less heat radiation, pure white illumination, improved shadow control and more accurate color rendition in comparison to halogen with even lesser power consumption [11]. High quality stabilizers should be used along with to deal with voltage related fluctuations. Moreover, to achieve a competent level of performance for bicortical bone, trainees should learn how to optimize their drilling through the bone rather than just plunge (technical error) prevention [13]. Pre-operative implant should be checked by operating surgeon with labeling and backup instruments before autoclaving. Accidental fall of implant during surgery is also not as uncommon as thought of. Khan S at al in their study of 120 random orthopedic surgeries, rate of accidental fall of implant or instruments was found as high as 30 percent [14].
It happens more commonly during emergency surgery than elective surgery and mostly by operating surgeon followed by assistant and staff nurse. In their study from 1990 to 2005 using the Nationwide Inpatient Sample (NIS), Ong KL et al found out that hospitalisations due to accidental falls on level surfaces or from stairs increased by 306% or 310% respectively with overall increase in incidence upto 35%.
Falls involving orthopedic revision surgery (re-operation) were relatively rare, but cost 50% (median) more than those that did not involve re-operation in 2005 [15].  and pressure sores and well leg compartment syndrome [18].
Operating surgeon should confirm the adequate position, traction and reduction by himself before getting scrubbed. Properly equipped operating table, self-retaining retractors and trained assistants aid a lot. routinely take some action to prevent wrong-site surgery [21].
In an unfortunate incident of Wrong Side Surgery, that author himself has come a crossed involved a pediatric patient, minimally displaced forearm fracture, general anesthesia prior to surgeon's arrival in operating room, wrong sided painting-draping by assistant, pre-operative X-ray on the view box without side marker and false sense of perfect reduction during nailing by under training orthopedic surgeon without any supervision. So many things to be learn from just one case.

Conclusion
Considering all this problems as a single issue, its prevalence is sometime comparable with the known complication like infection and other morbidity and mortality. Because of many other challenging situations which we haven't reviewed and lack of proper reporting fashion, these intra operative technical problems other than medico-surgical complications might be just a tip of an iceberg in actual sense. An honest reporting system without the fear of vicarious liability and dedicated research in this field is the need of time.
We firmly believe that pre-operative planning with the backups is the solution of these preventable situations.
Campaigns like Universal Precautions or Mark Your Site have definitely had their impact but still many more to be done.
Sharing the unforgivable complications by the fraternity and becoming advanced not only in terms of surgical skills but also in sharing the responsibilities is the need of time before it's too late. Very few surgeons' 'nightmare' can become a 'wake up call' for many.

Conflict of interest: None declared.
Funding: Nil, Permission from IRB: Yes