Latex-free gloves: safer for whom?

Does exposure to polymethyl methacrylate bone cement increase the risk of surgical glove failure?

INTRODUCTION

Surgical glove perforation has been linked to a double-fold increased risk of surgical site infection. Infection in the context of arthroplasty can have devastating consequences. In orthopaedics, use of polymethyl methacrylate (PMMA) bone cement is commonplace, and the impact on glove strength and perforation risk is not fully understood. This study aimed to examine the resistance to perforation and thickness of gloves following PMMA exposure, in accordance with the International Organization for Standardization (ISO) standard for glove integrity.

METHODS

Pairs of gloves were separated and randomly sorted into exposure and control groups. Twenty pairs of latex and 40 pairs of polyisoprene gloves were used. Exposure group glove cuffs were in contact with cement from a single surface of the glove for 13 min as cement cured. Force to perforation and glove thickness were tested in accordance with ISO guidelines.

RESULTS

Latex gloves were found to have a significantly increased force to perforation following PMMA exposure (10.26 Newtons (N) vs. 9.81 N, P = 0.048). Both polyisoprene under- and over-gloves were shown to have no significant change in strength to perforation post exposure (9.69 N vs. 9.83 N, P = 0.561, and 10.26 N vs. 10.65 N, P = 0.168, respectively). All groups were over the ISO standard minimum strength of 5 N.

CONCLUSIONS

Exposure of latex and polyisoprene surgical gloves to PMMA bone cement does not appear to increase glove perforation risk and rather may improve natural rubber latex glove strength. This study supports the use of latex and polyisoprene surgical gloves in procedures that involve the handling of PMMA bone cement.

Latex Allergy as an Independent Risk Factor for Prosthetic Joint Infection

In response to increasing rates of self-reported latex allergies, changes have been made to prevent anaphylaxis in the operating room, including the use of latex-free gloves. However, the impact of these changes on the risk of prosthetic joint infection (PJI) after arthroplasty is unclear. This study evaluated whether documented latex allergy is an independent risk factor for PJI and aseptic revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective matched cohort study was conducted with an administrative claims database. A total of 17,501 patients who underwent TKA and had documented latex allergy were matched 1:4 with 70,004 control subjects, and 8221 patients who underwent THA and had documented latex allergy were matched 1:4 with 32,884 control subjects. Multivariable logistic regression showed that patients who had TKA and had a latex allergy showed significantly higher risk of PJI at both 90 days (odds ratio [OR], 1.26) and 1 year (OR, 1.22) and significantly higher risk of aseptic revision TKA at 1 year (OR, 1.21) after surgery compared with control subjects. Patients who had THA and had a latex allergy had significantly higher risk of PJI at 1 year (OR, 1.19) compared with control subjects. Rates of aseptic revision THA were higher in the latex allergy cohort but statistically comparable (P>.05). Latex allergy was associated with significantly increased risk of PJI and aseptic revision after TKA and significantly increased risk of PJI after THA. More work is needed to determine whether these risks can be mitigated or if latex allergy is an inherent, nonmodifiable risk factor requiring modification to typical arthroplasty pathways. [Orthopedics. 2022;45(4):244-250.].

Perforations of tri-layer nitrile-latex and natural rubber latex gloves during ex-vivo equine intestinal anastomoses

OBJECTIVE

To compare perforation rates between tri-layer nitrile-latex and natural rubber latex surgical gloves after single-layer end-to-end jejunojejunal anastomoses in equine cadavers.

STUDY DESIGN

Prospective randomized ex-vivo study.

SAMPLE POPULATION

Pairs of surgical gloves (n = 46) worn during jejunojejunal anastomoses.

METHODS

Tri-layer nitrile-latex and rubber latex pairs of gloves were equally but randomly allocated to a right-handed surgeon performing 46 single-layer end-to-end jejunojejunal anastomoses on cadaveric material. Number and location of perforations were determined with the water leak test after each procedure. Ten unused pairs of both glove types were tested as controls.

RESULTS

At least one perforation occurred in 41% (19/46) of the pairs of gloves. Glove perforations were present in 22% (5/23; 95% CI: 9-42) of tri-layer glove pairs and 61% (14/23; 95% CI: 41-78) of the rubber glove pairs. The odds of glove perforation were 5.6 times (p = .009, 95% CI: 1.5-20.5) lower when tri-layer rather than rubber gloves were used. The duration of procedure did not affect the risk of glove perforation (p = .679). No perforations were observed in the unused gloves.

CONCLUSION

Perforations were less common when the surgeon wore tri-layer nitrile-latex gloves rather than to the natural rubber latex gloves tested in this study.

CLINICAL RELEVANCE

Tri-layer nitrile-latex gloves were more resistant to perforations in experimental settings; further studies may confirm that they are also superior in a clinical setting.

Comparison of surgical gloves: perforation, satisfaction and manual dexterity

The purpose of this study was to assess the effectiveness of two different surgical gloves (powdered latex and powder and latex free) for glove perforation frequency, problems and satisfaction with glove usage and manual dexterity levels during surgical operations that include scrub nurses. Scrub nurses wore antiallergenic gloves (powder and latex free) gloves during three operations, double latex and powdered gloves during three operations and single latex and powdered gloves during three operations. The gloves were checked for punctures after each surgery with a water-inflation test. In our study, 19% of single gloves and 18.1 % of double gloves and 4.8% of powder and latex free worn by scrub nurses were punctured during surgery. None of the inner gloves in double gloves were punctured. Although wearing double gloves restricts manual dexterity, results in discomfort problems such as perspiration and fetor and results in a low satisfaction rate among scrub nurses, double gloves are protective against injuries and punctures.

The Medical Gloves Assessment Tool (MGAT): Developing and validating a quantitative tool for assessing the safety and ergonomic features related to medical gloves

BACKGROUND

Medical gloves play a very important role in protecting health care workers and patients. It is very important to pay attention to the safety and ergonomic properties of medical gloves in their protective function.

AIM

To develop a quantitative tool for evaluating the safety and ergonomic properties of the medical gloves.

METHODS

Five hospitals with a total of 185 health care workers participated in the research. The domains and items of the tool were developed based on an expert's panel, interviews with health care workers and a literature review. Face, content and construct validity was used for validation. Reliability was also evaluated using internal consistency.

RESULTS

The final tool included 26 items in six domains, including tactile sensation, dexterity, grip strength, fitting, reliability and hand hygiene. The Cronbach's alpha was 0.82 for the total scale.

CONCLUSION

The final tool had good validity and reliability. The findings of this study led to the development of a comprehensive standard tool that can be used to assess the ergonomic and safety status of medical gloves.

IMPLICATIONS FOR NURSING MANAGEMENT

With this tool, problems related to medical gloves can be identified among nurses, and the necessary interventions can be predicted.

Management of Periprosthetic Joint Infection in Total Elbow Arthroplasty

Periprosthetic joint infection (PJI) is a potentially devastating complication after total elbow arthroplasty (TEA) that can lead to significant morbidity for the patient as well as increased health care-related costs. Despite the potential morbidity associated with TEA PJI, evidence is limited regarding an optimal treatment algorithm. Initial management typically consists of either irrigation and debridement or 2-stage revision. A stable implant, a functioning triceps, and an intact soft tissue envelope are necessary to perform irrigation and debridement. Irrigation and debridement is associated with a relatively high risk of infection recurrence especially in chronic infections. Two-stage revision offers a lower recurrence risk, although there is a 25% chance of not completing the second stage. Resection arthroplasty, arthrodesis, and amputation are salvage options, whereas medical treatment, in the form of antibiotics alone, is reserved for poor surgical candidates. Further multicenter prospective study and retrospective review of registry data focusing on different treatment algorithms, prevention strategies, and functional outcomes would be helpful to elucidate the ideal management of elbow PJI.

The benefits of latex-free gloves in the operating room environment

Sterile protective gloves are used to reduce the risk of infection for patients and clinicians in all healthcare settings. This is particularly important in operating theatres, where surgical site infection is a common and serious complication for perioperative patients. These gloves have traditionally been made from natural rubber latex and dusted with cornstarch powder. However, frequent use of latex gloves can lead to a hypersensitivity or allergy to latex. A latex allergy causes discomfort and inconvenience, and it may reduce productivity, impose significant financial burdens and even be life threatening. There has not been sufficient evidence to ban the clinical use of latex; however, in cases of suspected latex allergy, guidelines recommend the use of either latex-free gloves or powder-free, low-protein latex gloves. The use of these alternative gloves has typically been limited to cases of allergy, because they have previously been associated with reduced dexterity and durability compared with latex gloves. This article presents four case studies, in which health professionals in a perioperative setting compare the advantages and disadvantages of using traditional latex surgical gloves with those of latex-free gloves manufactured by Cardinal Health. The findings of these case studies suggest that these latex-free gloves are equal to latex gloves in terms of establishing asepsis and providing comfort and dexterity to the wearer, without presenting the risk of developing latex sensitivity and/or allergy.

BIO-CACO3 FROM RAW EGGSHELL AS ADDITIVE IN NATURAL RUBBER LATEX GLOVE FILMS

Raw hen eggshell powder, a calcium carbonate source, was used as a biofiller in the natural rubber latex compound and latex glove film formation via dipping process. The powder was anticipated to improve the physical (smoothness and thickness of film) and mechanical properties (tensile strength and elongation at break) of latex film and to reduce the extractable protein content on film surface. Eggshell powder ground by a rapid mill was fine particles of approximately 37.48 μm in diameter, suitable for homogeneous and compatible addition into the natural rubber latex compound. Dipping hand mold into the natural rubber latex compound with 50 wt% eggshell added was the best formula to obtain a smooth, clear, thin film surface, with the tensile strength of 23.24 ± 0.745 MPa and the highest elongation at break of 723.99 ± 14.60%, along with a low protein content, a dense film without water leakage, and with a good contact angle. The natural rubber latex glove film possessed good physical-mechanical properties and a low protein content as the results of the raw eggshell powder added as a biofiller.

Preparation Polyisoprene (NR) and Polyacrylonitrile Rubber Latex Glove Films by Dipping Ceramic Hand Molds Process and their Properties

Both synthetic and natural rubber latex can be used to form rubber latex glove films for medical and dental applications. The objective in this research is to study the natural and synthetic rubber latex glove films formation by dipping process with the bone china ceramic hand molds for 5, 10, and 15 min. From the experimental, the obtained natural rubber latex glove films are good appearance and good physical-mechanical properties i.e. smooth film surface, light pale yellow color, soft, translucent, high tensile strength, high elongation at break, and high flexibility better than those of synthetic rubber latex glove films. When the dipping time of bone china hand mold into natural rubber latex compound increases effect to tensile strength, thickness, and elongation at break increase. Tensile strength, elongation at break, and tensile stress of natural rubber latex films dipped for 15 min are equal to 12.82 ± 1.19 MPa, 1090.91 ± 4.92%, and 39.23 ± 3.63 N, respectively.

Visible glove perforation in total knee arthroplasty

PURPOSE

The risk of superficial surgical site infection (SSI) and periprosthetic joint infection (PJI) after glove perforation is not evident. This study was to identify risk factors for glove perforation in primary TKR (total knee replacement) and the risk of subsequent superficial SSI and PJI.

METHODS AND MATERIALS

Results of visible glove perforation of both inner and outer gloves during TKR were reviewed. A case-control analysis was performed on the preoperative and operative variables to identify predictive risk factors for glove perforation. Rate of SSI and PJI was compared between perforation and non-perforation groups, including 1226 series and 183 case-control subset.

RESULTS

One thousand two hundred twenty-six primary TKR from 2011 to 2014 was reviewed. Fifty-five knees had visible glove perforations. The operation perforation rate was 4.5%. Risk factors identified were body mass index (BMI) > 30, bilateral surgery, operation time >120 min and non-trainee surgeons. Superficial SSI was significantly higher in glove perforation group (9.15 vs. 0.51% and 0.55%). PJI was not significantly different (1.82% vs. 0.60% and 1.1%). The adjusted odds ratio for superficial SSI after perforation was 15.2, independent of BMI and operation time.

CONCLUSION

Visible glove perforation in TKR is associated with several risk factors. The risk of superficial SSI is higher after perforation.

Influence of material properties on gloves' bacterial barrier efficacy in the presence of microperforation

BACKGROUND

Medical examination gloves and surgical gloves protect the wearer directly and the patient indirectly from the risk of contamination. Because of concerns related to latex allergy, an increasing trend toward the use of synthetic gloves made of materials other than latex is observable. However, currently it is unknown if the physical properties of different materials may influence bacterial passage in case of a glove puncture.

METHODS

We examined 9 different medical examination gloves from various manufacturers made of nitrile (n = 4), latex (n = 3), or neoprene (n = 2). Additionally, 1 latex surgical glove each with and without antibacterial chlorhexidine gluconate coating and 1 synthetic surgical glove made of thermoplastic elastomer were included in the experiments. The studied materials were perforated following a standardized procedure, and direct bacterial passage was measured under dynamic conditions. Glove elasticity at 1 cm up to 2.5 cm elongation was measured following EN 455-2.

RESULTS

Nitrile gloves demonstrated higher material stiffness compared with latex gloves. Medical examination gloves made of nitrile and neoprene showed a 10-fold higher bacterial passage through a standardized puncture compared with latex gloves. All surgical gloves showed a lower bacterial passage compared with the tested examination gloves.

CONCLUSION

Bacterial passage through punctures is correlated with the stiffness or elasticity of the glove material. Therefore, gloves made of latex may have an increased protective effect in case of a glove breach. Whenever gloves are purchased and selected, a risk-benefit assessment should be conducted, balancing the risk of allergy against the degree of required protection in case of a glove puncture.

A randomized prospective study of glove perforation in orthopaedic surgery: is a thick glove more effective?

We compared perforation rates among operative staff who were randomly assigned either thick latex surgical gloves or conventional gloves for use in performing total knee arthroplasty. A total of 1120 gloves were assessed in 70 total knee arthroplasties. Additionally, the degree of tactile sensitivity provided by the gloves was compared using a two-point discrimination (TPD) test. Perforation occurred in 27 surgeries (38.5%) and in 48 gloves (4.29%). Binary logistic regression analysis revealed that the operator was a risk factor for perforation rate (Odds ratio 14.448, P < .0.01) and that the type of glove was not (P = .896). In the TPD test, tactile sensitivity was lower for a thick outer glove than the conventional double glove (P < .001 for each site). Not only did thick surgical gloves lower tactile sensitivity, they also offered no superior protective effect over conventional gloves.

Reducing surgical site infection in arthroplasty of the lower limb: A multi-disciplinary approach

Objectives

To review the current best surgical practice and detail a multi-disciplinary approach that could further reduce joint replacement infection.

Methods

Review of relevant literature indexed in PubMed.

Results

Surgical site infection is a major complication following arthroplasty. Despite its rarity in contemporary orthopaedic practice, it remains difficult to treat and is costly in terms of both patient morbidity and long-term health care resources.

Conclusions

Emphasis on education of patients and all members of the health-care team and raising awareness in how to participate in preventative efforts is imperative.

Wearing ambidextrous vinyl gloves does not impair manual dexterity

Universal precautions mandate that health care workers wear gloves to prevent the unintended spread of bloodborne pathogens. Gloves may affect manual dexterity, generally delaying task completion. Our previous study showed that wearing the wrong size latex surgical glove degraded manual dexterity. The use of non-sterile and non-latex gloves may limit certain risks and be more cost-effective. However, such gloves may produce different results. We hypothesized that ambidextrous vinyl examination gloves would degrade manual dexterity compared with bare hands. We studied 20 random subjects from a medical environment. Subjects performed a standard battery of Grooved Pegboard tasks while bare-handed, wearing ambidextrous non-sterile vinyl gloves that were their preferred size, a size too small, and a size too large. The order was randomized with a Latin Square design to minimize the effects of time, boredom, and fatigue on the subjects. Subjects were also invited to comment on the fit of different size gloves. Wearing vinyl gloves of both the preferred size and a size up or down failed to affect manual dexterity vs. bare hands on time to insert pegs, and pegs dropped during insertion or removal. In contrast, the time to remove pegs was reduced by wearing preferred size vinyl gloves compared with performing the task with bare hands (P<0.05). Subjects reported a generally poor fit in all sizes. Vinyl gloves that were too small caused significant hand discomfort. Vinyl gloves surprisingly do not degrade manual dexterity even when worn in ill-fitting sizes. Wearing a preferred size vinyl glove vs. bare hands may improve dexterity in selected tasks. Choosing a comfortable, large size seems the best strategy when the preferred size is unavailable. Thinner vinyl gloves may improve grip and may not degrade touch as much as latex surgical gloves and may thus represent a reasonable choice for selected tasks.

Latex medical gloves: time for a reappraisal

Many hospitals have implemented policies to restrict or ban the use of devices made of natural rubber latex (NRL) in healthcare as precautionary measures against the perceived risk of NRL allergy. Changes in glove technology, progress in measuring the specific allergenic potential of gloves and a dramatic decrease in the prevalence of NRL allergies after interventions and education prompted us to revisit the basis for justifiable glove selection policies. The published Anglophone literature from 1990 to 2010 was reviewed for original articles and reviews dealing with the barrier and performance properties of NRL and synthetic gloves and the role of glove powder. The review shows that NRL medical gloves, when compared with synthetic gloves, tend to be stronger, more flexible and better accepted by clinicians. The introduction of powder-free gloves has been associated with reductions in protein content and associated allergies. Recently, new methods to quantify clinically relevant NRL allergens have enabled the identification of gloves with low allergenic potential. The use of low-protein, low-allergenic, powder-free gloves is associated with a significant decrease in the prevalence of type I allergic reactions to NRL among healthcare workers. Given the excellent barrier properties and operating characteristics, dramatically reduced incidences of allergic reactions, availability of specific tests for selection of low-allergen gloves, competitive costs and low environmental impact, the use of NRL gloves within the hospital environment warrants reappraisal.

Unsuitability and high perforation rate of latex-free gloves in arthroplasty: a cause for concern

INTRODUCTION

Any increase in perforations in surgical gloves is a concern. We conducted a prospective study to find a clinically acceptable brand of latex-free gloves suitable for orthopaedic surgery.

METHOD

Five different brands of gloves approved for use were selected. Two of the latex-free gloves were rejected as their clinical usability in arthroplasty was poor. The Cardinal Esteem latex-free glove has a smooth surface and was slippery, especially in total knee arthroplasty. The Biogel Skin Sense under glove was found to be unacceptably thick, affecting both surgical dexterity and tactility.

RESULTS

The three remaining gloves were Biogel latex (control), Synthesis Polyco (latex-free) and Cardinal Esteem SMT (latex-free). Gloves were then collected for testing from 241 arthroplasties. Gloves used for primary knee/hip replacements were tested using a validated water distension test. Latex-free gloves were found to have higher perforation rates compared to latex.

CONCLUSION

Our study demonstrates that currently available latex-free gloves have inferior clinical performance and are not recommended for use in arthroplasty surgery.