Perioperative Skin Preparation and Draping in Modern Total Joint Arthroplasty: Current Evidence

Skin preparation

Skin preparation with antiseptic fluids has been one of the cornerstones of surgery at least for the last 100 years. In most elective arthroplasty operations, scrubbing is a detailed and meticulous task performed by assistants and the operating room personnel. Charnley recognized the importance of deep infection in joint replacement surgery and declared that the reason that prostheses became infected and failed in the first six months after operation was infection in the operating room, so he mandated the use of a sterile hood and a body-exhaust system, and the use of an ultra-clean air-flow system [4]. Brown et al. suggested that the leg should be held by a scrubbed and gowned member of the team, and most importantly, instrument packs should be opened only after skin preparation and draping have been completed in order to reduce the time of exposure of instruments in possible contaminated air [5].

Skin preparation prior to surgery includes skin decolonization and hair removal, antisepsis, and hand washing by the surgeon. Ample evidence exists in support of the role of pre-operative cleansing in reduction of skin bacteria counts, but it is unclear how this contributes to infection prevention [6]. Pre-operative showering or cleansing with an antiseptic agent at least the night before the surgical procedure has been recommended by the U.S. Centers for Disease Control and Prevention (CDC) [7]. However, Jakobsson et al. suggested that there is no clear evidence for how many times pre-operative disinfection showers should be performed to minimize the risk of perioperative infection, but they recommend three to five pre-operative showers nonetheless [8].

Zywiel et al., in a non-randomized study with 136 patients out of 912 total, showed that the patient-directed use of chlorhexidine- (CHG) impregnated cloth the evening before surgery, and the morning of surgery, appeared to decrease substantially the incidence of deep incisional surgical site infection in TKR (there were no surgical site infections among those patients, compared with a 3.0% rate of infection for patients who used the in-hospital preparation only) [9].

In addition, Eiselt used a similar approach in orthopedic patients undergoing total joint procedures. Patients who used CHG-impregnated wipes the night before, and the morning of the surgery, had a lower incidence of deep infection as compared with those who did not adhere to the protocol in both THA and TKA procedures [10].

Climo et al. showed that the use of daily chlorhexidine bathing may reduce the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) among intensive care unit patients [11]. Bleasdale et al. [12] also identified the effectiveness of chlorhexidine daily bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients.

Johnson et al. suggested that a pre-admission CHG protocol seems to be effective to prevent surgical site infections in TKR procedures, and to release the incidence of deep periprosthetic THR infections [13,14]. In their studies, two groups were compared, on using the CHG protocol. A statistically lower incidence of surgical site infection and periprosthetic hip infection rates was found in patients using the CHG cloths compared with patients undergoing in-hospital perioperative skin preparation only.

Noorani et al. showed in their meta-analysis that CHG should be used preferentially for pre-operative antisepsis in clean-contaminated surgery [15]. Their systematic review identified six eligible studies, containing 5,031 patients. Chlorhexidine reduced post-operative surgical-site infection compared with povidone-iodine.

In another study, Kapadia et al. confirmed prior studies using an advanced pre-admission cutaneous surgical preparation protocol, suggesting this as an effective method to prevent periprosthetic hip arthroplasty infections [16]. In their systematic review, newer infection prevention techniques, such as pre-operative antiseptic scrubbing, may help to reduce the infection rate, whereas traditionally accepted methods of prophylaxis, such as laminar-flow operating rooms and body exhaust suits, may increase the infection rate.

In a systematic review, Banerjee et al. suggested that pre-operative baths or CHG-impregnated wipes can diminish the colonization of pathogenic organisms on the skin. Furthermore, the additional application of CHG topically, or even advanced pre-operative whole-body cleaning with CHG-containing cloths, may contribute even more in the reduction of infectious organisms [17]. This study concerned patients who underwent lower extremity total joint arthroplasty. A meta-analysis of 13 randomized trials (Cochrane review database) concluded that pre-operative skin preparation with chlorhexidine in methylated spirits was associated with lower rates of surgical site infection following clean surgery, compared with alcohol-based povidone-iodine paint [18].

On the other hand, Farber et al. suggested that the introduction of CHG-impregnated wipes in the pre-surgical setting was not associated with a reduced deep infection incidence. Their analysis suggests that CHG wipes before THR and TKR are unnecessary as an adjunct skin antiseptic, as suggested by previous smaller studies [19]. Their retrospective cohort study reviewed all 3,715 patients who underwent primary TJA in two years at their institution. Despite conflicting data, the simplicity and cost-effectiveness of CHG-impregnated wipes supports its application prior to TKR and THR.

Regarding skin pre-operative disinfection, the main debate concerns the selection of an optimal antiseptic agent. The most widely used types of antiseptic agents are alcohol-based solutions, povidone-iodine, and CHG. The comparison of CHG and povidone-iodine remains ambiguous and conflicting [8]. Darouiche et al. demonstrated that CHG in alcohol was superior in reducing the rate of intra-operative contamination in comparison to aqueous povidone-iodine. However, the iodine preparation in the study did not use an alcohol solvent, hence raising the question of whether alcohol plays a role in the efficacy of the solution [20]. In fact, in a study by Swenson et al. involving general surgery patients, povidone-iodine-prepped patients had a lower rate of contamination when alcohol was used (either as a solvent or scrub) [21]. The literature suggests the importance of the combination of alcohol with antiseptic agents, and that CHG combined with alcohol may be superior to other combinations, but this last hypothesis remains to be proved [3].

With regard to pre-operative hair removal, the CDC recommends that it be done immediately before the procedure with the use of electric clippers preferred over razor blades [7]. The meta-analysis of Tanner et al. showed that electric clippers and depilatory creams should be used preferentially, as they were associated with lower infection rates over shaving with razor blades. In the same study, the authors concluded that there was no difference concerning infection rates if patients have had hair removed or not prior to surgery. By contrast with other studies, the authors believed it is of no importance if the shaving or clipping occurs one day before surgery or on the day of surgery [22].

Hand washing by the surgeon and medical personnel is a difficult topic to evaluate because of the ambiguity of the literature regarding duration and optimal antiseptic agent. Wheelock et al., in an effort to examine surgical scrub time and subsequent bacterial growth, pinpointed a duration of scrubbing for 2–3 min [23]. Currently the CDC recommendation for scrubbing lies between 2–5 min [7]. Data suggest that an alcohol-based hand rub and the usual hand scrub agents are equivalent for microbe removal. Parenti et al., in a trial of 4,387 patients who underwent clean, and clean-contaminated surgery using either traditional hand scrubbing techniques or waterless, alcohol-based antiseptics, showed no difference in infection rates [24]. On the basis of the current literature, all medical personnel should practice surgical hand antisepsis of no less than 2–3 min. The use of either hand rub or hand scrub solution remains discretionary.

It is important to emphasize the fact that each of the prevention measures mentioned above is considered to be relative, and there is no absolute intra-operative protocol to prevent infection during surgery. Therefore, in the hope that all these measures act accuretively, each department should have its own protocol and education program.

Draping

The passage of bacteria through drapes is a potential source of surgical site contamination. Therefore, adequate draping should be considered of the highest priority. Drapes should be tested rigorously with regard to their resistance to bacterial penetration. According to Blom et al., disposable non-woven drapes are superior to reusable woven cotton/linen drapes in resisting bacterial penetration [25–28].

Blom et al. established an acceptable and sound for most surgeons' and researchers' methodology of assessing bacterial penetrability of drapes. They use agar plates and each disposable drape is placed between a round agar plate and an inverted square agar plate filled with blood agar. After a standardized period of time, the square agar plates are removed and incubated for 48 h and inspected for microbe growth. Bacterial penetration is time-dependent. Certain brands of drapes are more impenetrable than others; none is impenetrable at all time points, but most remain impenetrable or allowed passage of fewer than 100 colony-forming units at 90 min. They recommend that drapes should be tested thoroughly for their microbial permeability by every department and hospital [25–28].

Ha'eri et al. showed that non-woven fabrics, drapes, and gowns made of woven fabrics are ineffective barriers against penetration by microorganisms. Additionally, they demonstrated that contamination of woven fabrics increased relative to the length of the operation, the extent of surgical manipulation, and the distance between particles and the surgical site infection. To the contrary, non-woven fabrics prevent this route of contamination [29]. Gary et al. demonstrated that skin prepared with 0.7% iodine povacrylex/74% isopropyl alcohol solution has significantly greater drape adhesion (almost three times greater adhesion strength) compared with skin prepared with 2% chlorhexidine gluconate/70% isopropyl alcohol [30]. Although maintaining good adhesion is important, an incise drape that has excessive adhesion may cause skin irritation during the removal of drapes. Regardless of the skin preparation used, the skin reaction at the application site of the drape does not seem to create problems of excessive contamination, infection, or other post-operative complications. These data imply that choosing skin preparation type affects drape adhesion. Therefore, when incise drapes are used, the selection of skin preparation should take into account optimal drape adhesion in order to reduce drape lifting and prevent any possible surgical site contamination because of that.

The use of plastic adhesive drapes for the prophylaxis of surgical site infections following orthopedic operations was investigated by Breitner et al. in 1986 in a randomized study. In order to carry out qualitative bacteriologic examinations, smears were taken prior to, 1, and 2 h after the beginning, and after the end of the operation. Bacterial infestation in the operation area was found in 54.5% of patients operated on without a drape, and in 44.1% in patients when the plastic drape was employed (p=NS). Most of the bacteria found were coagulase-negative staphylococci, in some cases Corynebacterium and aerobic spore-forming organisms. There were no post-operative surgical site infections. The use of incision drapes for the prophylaxis of post-operative surgical site infections was therefore considered not necessary in orthopedic surgery [31].

According to a study by Gilliam et al., comparison of a traditional two-step method of pre-operative skin preparation using aqueous iodophors with a one-step method using an iodophor-in-alcohol solution proved that the one-step application of a water-insoluble iodophor-in-alcohol solution is equally as effective as the traditional scrub-and-paint preparation in reducing the number of bacteria about the operative site. In the same study, the water-insoluble preparation also resulted in significantly improved drape adhesion as compared with the standard scrub-and-paint procedure. The one-step water-insoluble iodophor-in-alcohol solution therefore may be preferred as it is equal in skin preparation and it facilitates secure drape adhesion. It is easier to use as far as storage and application are concerned, it requires less time to be deployed, and might be less expensive than the traditional scrub-and-paint method. In this study, bacterial colony counts were made by sampling the incision area with culture plates before skin preparation and just prior to surgical site closure [32].

On the other hand, draping has its own complications sometimes. Liu et al. presented two cases of degloving injuries sustained from the use of drapes during TKR. According to them, patients who suffer skin avulsion injuries should receive standard surgical site care and close follow-up until the healing of the lesions [33].