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The latest Journal of Bone and Joint Surgery has two papers on pre-operative skin preparation for foot and ankle surgery. Good to see such mundane and taken for granted topics getting attention:
Previous studies have demonstrated higher infection rates following orthopaedic procedures on the foot and ankle as compared with procedures involving other areas of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to evaluate the efficacy of three different surgical skin-preparation solutions in eliminating potential bacterial pathogens from the foot. Methods: A prospective study was undertaken to evaluate 125 consecutive patients undergoing surgery of the foot and ankle. Each lower extremity was prepared with one of three randomly selected solutions: DuraPrep (0.7% iodine and 74% isopropyl alcohol), Techni-Care (3.0% chloroxylenol), or ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). After preparation, quantitative culture specimens were obtained from three locations: the hallux nailfold (the hallux site), the web spaces between the second and third and between the fourth and fifth digits (the toe site), and the anterior part of the tibia (the control site). Results: In the Techni-Care group, bacteria grew on culture of specimens obtained from 95% of the hallux sites, 98% of the toe sites, and 35% of the control sites. In the DuraPrep group, bacteria grew on culture of specimens obtained from 65% of the hallux sites, 45% of the toe sites, and 23% of the control sites. In the ChloraPrep group, bacteria grew on culture of specimens from 30% of the hallux sites, 23% of the toe sites, and 10% of the control sites. ChloraPrep was the most effective agent for eliminating bacteria from the halluces and the toes (p < 0.0001). Conclusions: The use of effective preoperative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in foot and ankle surgery. Of the three solutions tested in the present study, the combination of chlorhexidine and alcohol (ChloraPrep) was most effective for eliminating bacteria from the forefoot prior to surgery.
The most efficient way to prepare the skin for foot and ankle surgery is unknown. In recent studies, >70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidone-iodine were positive. The goal of the current study was to determine the effect of isopropyl alcohol on the eradication of bacteria from the nails and skin of the normal foot and ankle. In addition, the effect of using a bristled brush rather than sponges to scrub the foot was investigated. Methods: Four skin-preparation techniques were studied in two sets of twenty-five volunteers. In phase I of the study, the right foot and ankle of each member of the first set of volunteers was prepared with method 1, which consisted of a two-stage povidone-iodine scrub and paint with use of soft sponges. The left foot and ankle was prepared with method 2, which consisted of method 1 as well as an additional prewash with 70% isopropyl alcohol. In phase II, the right foot and ankle of each member of the second set of volunteers was prepared with method 3, which consisted of a povidone-iodine scrub and paint with use of a bristled brush to scrub the foot. The left side was prepared with method 4, which consisted of an alcohol scrub and paint with use of a bristled brush to scrub the foot. At the end of the preparation process, specimens for aerobic bacterial cultures were obtained from the hallucal nail fold, interdigital web spaces, and anterior aspect of the ankle. Cultures were interpreted as positive or negative, and the results were also assessed quantitatively. Results: The rates of positive cultures of the nail-fold specimens were 76% and 80% after methods 1 and 2 (soft sponges) and 76% and 12% after methods 3 and 4 (bristled brush). The reduction in the percentage of positive cultures with method 4 was highly significant (p < 0.001). Cultures of the specimens from the web spaces showed a significant difference in the rates of positive results between methods 1 and 2 (36% and 8%, p < 0.05) but no significant difference between methods 3 and 4 (12% and 0%, p = 0.25). The rates of positive cultures of specimens from the anterior aspect of the ankle were consistently low (4% for all methods). Quantitative analysis of positive cultures demonstrated significant reductions (p < 0.01) in heavy growth when bristled brushes had been used, both with povidone-iodine and isopropyl alcohol. Conclusions: The use of isopropyl alcohol and the use of a bristled brush both have beneficial effects on the skin-preparation process before foot and ankle surgery. In the current investigation, the most effective technique was the use of isopropyl alcohol in conjunction with scrubbing with a bristled brush. Merely washing the foot with alcohol-soaked sponges provided limited benefit to the web spaces only.
Preoperative skin and nail preparation of the foot: Comparison of the efficacy of 4 different methods in reducing bacterial load.
de Bengoa Vallejo RB, Losa Iglesias ME, Cervera LA, Fernández Bpharm DS, Prieto JP.
J Am Acad Dermatol. 2009 Aug 6
Quote:
BACKGROUND: Orthopedic surgical procedures involving the foot and ankle are associated with high rates of infection. The optimal method of preparing the skin and nails for foot and ankle surgery remains unknown.
OBJECTIVE: This study was conducted to compare the efficacy of 4 different methods of skin and nail preparation of the foot using various antiseptic solutions.
METHODS: In this prospective, randomized study, 4 methods of skin and nail preparation were compared in terms of their efficacy in eliminating bacteria from the hallux nailfold and first web space of the normal foot in 28 healthy adult volunteers. Efficacy was determined by evaluating the difference in the total bacterial load before and after skin preparation. The foot-preparation solutions evaluated were 4% chlorhexidine gluconate, 70% isopropyl alcohol, and 7.5% to 10% povidone-iodine.
RESULTS: The addition of alcohol to povidone-iodine was found to increase the efficacy of the preparation method. The nailfold remained contaminated after any of the preoperative skin- and nail-preparation methods studied.
LIMITATIONS: This study did not measure clinically relevant infections, and the results may not correlate with decreased rates of infection after surgery.
CONCLUSION: Incorporation of alcohol and povidone-iodine into the preoperative skin- and nail-preparation process may help reduce the bacterial load. Every effort should be made to lower the risk of contamination from the nail.
Quantitative analysis of bacteria in forefoot surgery: a comparison of skin preparation techniques.
Cheng K, Robertson H, St Mart JP, Leanord A, McLeod I. Foot Ankle Int. 2009 Oct;30(10):992-7.
Quote:
BACKGROUND: Currently a lack of consensus exists on the optimum solution and preparation methods needed to decrease bacteria present during forefoot surgery. We therefore compared the effect of povidine-iodine and chlorhexidine gluconate on lowering bacterial load and to study any additional benefits gained by pre-treatment with the use of a bristled brush.
MATERIALS AND METHODS: Fifty consecutive patients undergoing forefoot surgery were recruited into the study and randomized to receive one of two surgical skin preparations (Povidine-iodine 1% with isopropyl alcohol 23% or Chlorhexidine gluconate 0.5% with isopropyl alcohol 70%). In addition to the skin preparation of the foot with the randomized solution, the subjects other foot was also scrubbed with a sterile surgical bristled brush for three minutes and then painted with the same solution. Swabs were taken from three sites and analyzed via qualitative and quantitative analysis before and after prepping.
RESULTS: All four preparation methods significantly decreased (p < 0.001), in all three sites, the number of colony forming units. Using two-way analysis of variance, no significant interaction was observed between preparation method and number of colony-forming units, suggesting that no difference in bacterial inhibition between preparation methods.
CONCLUSION: We suggest that either povidone-iodine with no more that 23% isopropyl alcohol or chlorhexidine gluconate with 70% isopropyl alcohol be used for surgical preparation in forefoot surgery. No additional benefit in reduction in bacterial load was gained by scrubbing the foot with bristles prior to painting.
Efficacy of preoperative and intraoperative skin and nail surgical preparation of the foot in reducing bacterial load
Efficacy of preoperative and intraoperative skin and nail surgical preparation of the foot in reducing bacterial load.
Becerro DE Bengoa Vallejo R, Losa Iglesias ME, Alou Cervera L, Fernández DS, Prieto JP. Dermatol Surg. 2010 Aug;36(8):1258-65.
Quote:
BACKGROUND A common problem associated with toenail removal surgery is the accompanying bacterial infection that often ensues. The foot has a particularly difficult anatomy to prepare antiseptically for surgery, which contributes to this wide-spread problem.
OBJECTIVE To compare the antiseptic efficacy of two skin pretreatment methods before toenail avulsion surgery.
METHODS Two presurgical methods were performed on 24 patients each (48 patients total). Swab samples were taken from each patient at five distinct stages (pretreatment, post-treatment, after surgery, after saline solution irrigation of the nail bed, and after phenol application) throughout the surgical procedure, and bacterial culture analysis was performed (total inocula count and identification of specific microorganisms).
RESULTS We found both methods to be effective at reducing the initial bacterial load when used at pretreatment, but the reduction in bacterial load was lost after the nail avulsion surgery, achieving values similar to the initial bacterial load before the presurgical scrub, from 5.17 and 5.04 log(10) colony-forming units (CFU)/cm(2) to 4.86 and 5.07 log(10) CFU/cm(2), respectively. An interoperative irrigation step was effective in reducing the bacterial load by 95.2% and 95.3%, respectively.
STUDY LIMITATIONS Our patients underwent phenol-based nail avulsion, resulting in no bacterial load after complete nail removal because of the intrinsic antiseptic nature of the phenol. CONCLUSIONS Incorporation of intraoperative irrigation of sterile saline solution after nail avulsion surgery reduces potential bacterial load. Every effort should be made to lower the risk of contamination after nail plate avulsion. The authors have indicated no significant interest with commercial supporters.
Does anybody know of an alternative to iodine as a pre-operative swab for nail avulsion available in Australia? I have a patient with an iodine allergy who requires partial nail avulsion? Thanks
Bethy, if you don't get a reply from anyone on this site, try contacting the theatre at a hospital. The theatre staff should be able to help you. Wouldn't mind knowing the answer me self....Good luck!!
Comparison of the effectiveness in bacterial decontamination between chlorhexidine gluconate and povidone-iodine solution in foot and ankle: a pilot study.
Rugpolmuang L, Thanabodeethada R, Riansuwan K. J Med Assoc Thai. 2012 Sep;95 Suppl 9:S95-8.
Quote:
BACKGROUND:
The decontamination for foot and ankle surgery should be considered as a special preparation due to higher rate of bacterial contamination. The footwear and humidity is also the issue of interest especially in tropical country. The contamination before surgery should be reduced to avoid the infection. The effectiveness of antiseptics and special condition for the foot and ankle surgery should be elucidated for better medical care.
MATERIAL AND METHOD:
The twenty volunteers were included in the present study. In group 1, the foot was scrubbed with 7.5% Povidone-lodine and painted with 10% Povidone-lodine solution. In group II, the foot was scrubbed with Chlorhexidine gluconate scrub and painted with 2% Chlorhexidine gluconate in 70% alcohol. At the beginning and end of the preparation, specimens were taking from all toes, nailfold, interdigital web spaces. These samples were sent for aerobic bacterial cultures. The results were interpreted as positive or negative cultivation and the number of bacterial colonies.
RESULTS:
All of the samples from 40 feet were collected; In Group I, positive culture was 5 samples (25%). In Group II, positive culture was 2 samples (10%) (p = 0.2).
CONCLUSION:
The Chlorhexidine gluconate and Povidone-lodine are effective in reduction the number of bacterial colonization. The steps of preparation before surgery also play an important role in eliminating the pathogenic bacteria. Both antiseptics were found no significant different in efficacy of pathogenic bacteria reduction.
Efficacy of preparation solutions and cleansing techniques on contamination of the skin in foot and ankle surgery: A systematic review and meta-analysis.
Yammine K, Harvey A. Bone Joint J. 2013 Apr;95(4):498-503.
Quote:
We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001). Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S&P) followed by alcohol showed significantly better efficacy over PI (S&P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S&P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.
Evidence base of pre-op skin preparation
Linear Mode
