Enturia

24. Efficacy of Surgical Preparation Solutions in Foot and Ankle Surgery

Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980–985.

Rationale
Previous studies have shown higher infection rates associated with orthopedic procedures involving the foot and ankle than with those involving other parts of the body. Studies have also documented the difficulty of eliminating bacteria from the forefoot before surgery. Although many factors affect postoperative infection, the unique anatomy of the foot and its resident organisms might play a role in the high infection rates seen following foot and ankle surgery. Use of an effective patient preoperative skin preparation solution is an important step in helping to limit surgical wound contamination and preventing infection in foot and ankle surgery.

Objectives
To assess the efficacy of three different surgical patient preoperative skin preparation solutions in eliminating potential bacterial pathogens from the foot by evaluating residual bacterial skin contamination following surgical skin preparation:

• ChloraPrep (2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA])
• Techni-Care® (3% chloroxylenol)
• DuraPrep™ (0.7% iodine and 70% IPA)

Design
A prospective, randomized study including 125 consecutive patients undergoing surgery of the foot and ankle between October 2002 and May 2003.

Methods

• Each lower extremity was prepared with one of three randomly selected solutions, according to manufacturer’s instructions
• Treatment allocation was maintained by using the solutions in a consistent order throughout the study period
• No home cleansing or disinfection protocols were used before surgery
• Overall, the patient population (N=125) was healthy
• Immediately before surgical preparation, culture specimens were obtained in an identical fashion from five additional patients (the pre-prep group) to quantify the normal amount of skin bacteria present before treatment with an antibacterial surgical scrub
• All patients received a preoperative dose of an antibiotic within one hour before the surgical start time
• After preparation and draping were completed, quantitative culture specimens were obtained from three locations on the foot and ankle
  • The first specimen was taken from the anterior part of the tibia, 12 cm proximal to the ankle joint; this was used as the control site because there was no documented problem with regard to the elimination of skin bacteria or with regard to high rates of postoperative infection in this region
  • The second specimen was taken along the hallucal nail fold, which is referred hereafter as the hallux site
  • The third specimen was taken from the web spaces between the second and third and between the fourth and fifth toes and are referred to hereafter as the toe site
• If any growth was detected in the specimens taken, the sample was considered positive

Results

• The positive culture rate associated with the hallux site in the ChloraPrep group was significantly lower than that in the DuraPrep^™ group, which was significantly lower than that in the Techni-Care^® group
• The positive culture rate associated with the toe site in the ChloraPrep group was significantly lower than that in the DuraPrep group, which was significantly lower than that in the Techni-Care group
• On average, 4544 CFUs were identified per culture in the pre-prep group, compared with 177 in the ChloraPrep group, 682 in the DuraPrep group, and 2833 in the Techni-Care group
• All three treatment preparations were significantly different from one another with regard to the mean number of CFUs

Conclusion
Of the three patient preoperative skin preparations tested in this study, the combination of chlorhexidine and alcohol (ChloraPrep) was the most effective in reducing bacteria from the foot and ankle prior to surgery.

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