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Maintaining the Sterility of the Mobile C-Arm During Intramedullary Nailing: “The Fluffy Stick Technique”

Gandham, Surya MBChB, BSc Hons, MRCS (Ed)*; McNicholas, Mike BSc, MBChB, FRCS (Ed & Glasg), MD, FRCSEd (Tr & Orth), FFSEM, RCSI

doi: 10.1097/BTO.0b013e318290874f
Tips and Pearls

Infection is a major worry for all orthopedic surgeons and measures are taken to minimize surgical site infections. However, with the increasing complexity of orthopedic surgical techniques and the need for intraoperative imaging, there are still no standardized techniques that can ensure the sterility of the operating field while using a C-arm. We have designed a method, which is both inexpensive and user friendly for all theater staff. It involves the use of a sterile bag draped over a drip stand and allows the C-arm to enter the bag from under the operating table when lateral views are needed, thereby maintaining a sterile field.

*Warrington Hospital, Warrington, UK

University Hospital Aintree, Teaching Hospital Major Trauma Centre, NHS Foundation Trust, Longmoor Lane, Liverpool, AL

The authors declare that they have nothing to disclose.

Address correspondence and reprint requests to Surya Gandham, MBChB, BSc Hons, MRCS (Ed), Apartment 5, 5 Alexandra Drive, Liverpool L178TA, AL. E-mail:

Infection is one of the most common complications associated with orthopedic surgery. The Health Protection Agency states that risk of surgical site infections (SSI) was highest in repair of neck of femur procedures, where approximately 1 in 60 patients developed an SSI.1 In addition, approximately 1 in 70 patients undergoing reduction of a long bone fracture also developed an SSI.1

Fluoroscopy is frequently used intraoperatively, to help with trauma procedures as well as in spinal operations. There are currently several different types of image intensifiers that are collectively known as “C-arms.” They enable the surgeon to attain radiographs in different positions and planes by simply moving the adjustable C-arm (Fig. 1).

It is very important to cover the portion of the C-arm closest to the sterile field with sterile drapes, to maintain the sterility of the operating field. It is also important for the surgeon to be aware of the C-arm and try not to handle the machine if its sterility is in question. The use of additional equipments in theater has been proved to increase the risk of infection.2–4 Therefore, the addition of the C-arm in any orthopedic procedure adds an extra source of bacterial infection. Appropriate measures should be taken to try and reduce this.

Biswas et al5 stated that the upper portions of C-arms exhibited the greatest rates of contamination during spinal procedures. This loss in sterility was most likely due to the movement of the undraped portions of the C-arm being rotated under the table to acquire lateral images. Biswas et al5 also state that the top portion of the C-arm drape is unsterile and a possible source of an SSI.

Currently, there are no standardized draping methods for the use of the C-arm and it is for this reason that the risk of contamination from this source has increased. The sterile field is defined as a horizontal plane level with the surgical tabletop.6,7 When the C-arm swings underneath the table, it becomes unsterile and needs to be ideally re-draped as it enters the sterile field (Fig. 2).

This causes a waste of time, resources, and if the C-arm is not properly re-draped, in addition to the increased infection risk. There are manufacturers who have tried to solve this problem. The most notable design is the C-armor drape, which is a sterile pouch and encompasses the C-arm on all 5 sides.8 However, not all theaters have this drape and have surgeons and scrub nurses who have had little experience using this technique. It is also difficult for the radiographer to see the positioning of the C-arm once under the drapes.

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We propose a novel method of keeping the C-arm sterile with the use of a readily available theater equipment. By using a large, clear sterile bag draped over a drip stand with castors, we are able to provide a sterile bag, in which the contaminated C-arm can be positioned into. The top of the drip stand is wrapped with wool, to prevent the pointed hooks from piercing the bag (Fig. 3).

A sterile bag is then safely placed over the drip stand with the bottom rolled up slightly, to allow easy entry of the C-arm (Fig. 4).

After this step, the surgeon can safely maneuver the C-arm into the bottom of the sterile bag when a lateral image is needed. The C-arm enters the bag at the level of the table, thereby maintaining a sterile field (Fig. 5).

As illustrated below, the C-arm has entered the sterile field but is fully covered on 5 sides, thereby maintaining the sterile field. The radiographer is also able to easily view the positioning of the device, which will help obtain the appropriate radiographs quicker (Fig. 6).

An additional advantage of this technique is that the surgeon can handle the C-arm safely, to obtain ideal images quickly, while not jeopardizing his sterility. It is therefore important to use a drip stand with castors to help with this. He is also able to maintain the drill in a position parallel to the floor while tilting the table to help with distal interlocking (Fig. 7).

When an anteroposterior radiograph is needed, the C-arm is simply swung out of the bag and out of the sterile field.

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This is a safe and inexpensive method of using easily obtainable theater equipment to maintain a sterile field while using a C-arm. It has a number of applications such as in intramedullary nailing and spinal surgery, where anteroposterior and lateral images are needed.

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C-arm; sterility; infection; distal locking

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