The effectiveness of standard povidone iodine surgical preparation in decontaminating external fixator components

Are Infection Rates Increased After Sterilization of the External Fixator During Staged Internal Fixation of High-Energy Tibial Plateau Fractures?

OBJECTIVES

To compare infection rates after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not.

DESIGN

Retrospective cohort study.

SETTING

Two academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Two hundred forty-four patients met inclusion and exclusion criteria between the 2 institutions.

INTERVENTION

Prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. 162 patients were in the prepped group, and 82 patients were in the nonprepped group.

MAIN OUTCOME MEASUREMENTS

The primary outcome was the rate of deep infection after definitive fixation. Secondary outcome was operative time.

RESULTS

There were no significant differences in infection rates between prepped (11.7%) and nonprepped (18.3%) groups ( P = 0.162). Patients in the prepped groups had significantly decreased operative time (168.2 minutes vs. 221.9 minutes, P < 0.001) even after controlling for confounders in regression analysis.

CONCLUSIONS

There is no increased risk of infection associated with prepping and maintenance of the external fixator during definitive internal fixation for high-energy tibial plateau fractures. These data suggest that this practice may lead to shorter operative times as well.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Randomized Clinical Trial on the Use of Antiseptic Solutions for the Pin-Site Care of External Fixators: Chlorhexidine-Alcohol Versus Povidone-Iodine

Pin-site infections remain a common clinical complication in patients with external fixators. Pin-site care is commonly performed with either chlorhexidine-alcohol solution or povidone-iodine solution. This study aimed to investigate the superiority of chlorhexidine-alcohol solution versus povidone-iodine solution for external fixator pin-site care in pin-site infection. This prospective randomized clinical trial using an open, parallel-group design was conducted in a single Spanish hospital. Eligible consenting patients from November 2018 to May 2019 who underwent placement of an external fixator were included. Patients were randomly assigned to receive pin-site care using either a 2% chlorhexidine-alcohol solution or a 10% povidone-iodine solution. The primary endpoint was the development of a pin-site infection. In total, 568 pins were analyzed (128 patients, with a mean of 4.3 pins per patient). No significant differences were found between groups. However, statistically significant differences were found regarding time and infection variables. The longer the person had the fixator, the higher the risk of infection, t(x) = 5.49, p = .002. Both chlorhexidine-alcohol and povidone-iodine solutions are equally effective antiseptic agents for the prevention of infections in external fixators.

Staged internal plate fixation of severe lower extremity fractures that use a temporary external fixator for the initial treatment as an intraoperative retention tool: a technical note

Staged treatment for severe lower extremity fractures is coming into widespread use, and some reports have described internal fixation (IF) using a temporary external fixator for primary care as an intraoperative retention tool. However, the infection risk with this procedure has not been examined sufficiently. To our knowledge, this article is the first report focusing exclusively on this specific surgical technique. A key point of our developed protocol for internal plate fixation with this technique to avoid postoperative infection is a precisely structured sterilization procedure, which required multiple changes of sterile surgical gloves. In all 19 fractures treated with our set protocol, postoperative infection did not occur. In this regard, however, a goal of definitive IF at the time of initial treatment is essential for this specific procedure. This technique could help orthopaedic trauma surgeons to import a temporary external fixator into the operative field for definitive IF, with less concern regarding risk of infection.

Does temporary external fixation and staged protocol for closed fractures lead to bacterial contamination of the surgical site and associated complications? - A prospective trial

INTRODUCTION

Temporary external fixation is a viable option for numerous conditions and fixations in orthopaedic and trauma surgery. If the external fixator is left in place it is necessary to disinfect it prior to surgery, yet the subsequent risk for bacterial contamination of the surgical site originating from the external fixator remains unknown.

MATERIAL AND METHODS

In a prospective study, samples were taken at the time of definitive osteosynthesis to assess bacterial contamination of the surgical site and the external fixator in twenty consecutive patients treated with temporary external fixation for closed fractures from October 2016 until March 2017.

RESULTS

Twenty external fixators of twenty patients with complete sampling and a mean follow-up of seven months (range: 3-14) were available for analysis. Ten out of 120 cultures of the surgical site (8.3%) were positive for bacterial growth in a total of seven patients (35%). Pathogen's detected were Propionibacterium acnes (60%) and Staphylococcus epidermidis (30%). No contamination of the external fixator was detected.

CONCLUSION

We conclude that the presented perioperative management to decontaminate external fixators allows for a safe definitive osteosynthesis in a staged protocol without increasing bacterial contamination of the surgical site. It is safe to leave the external fixator in place for definitive osteosynthesis.

Perioperative management of external fixation in staged protocols: an international survey

INTRODUCTION

Despite the frequent use of external fixation, various regimes of antibiotic prophylaxis, surgical technique and postoperative pin care exist and underline the lack of current evidence. The aim of the study was to assess the variability or consensus in perioperative protocols to prevent implant-associated infections for temporary external fixation in closed fractures of the extremities.

MATERIALS AND METHODS

A 26-question survey was sent to 170 members of the Traumaplatform. The survey included questions concerning demographics, level of training, type of training and perioperative protocols as: antibiotic prophylaxis, intraoperative management, disinfection and postoperative pin site care. All responses were statistically analysed, and intraoperative measures rated on a 5-point Likert scale.

RESULTS

The responses of fifty orthopaedic trauma and general surgeons (response rate, 29.4%) were analysed. The level of experience was more than 5 years in 92% (n = 46) with up to 50 closed fractures of the extremities annually treated with external fixation in 80% (n = 40). Highest consensus could be identified in the following perioperative measures: preoperative antibiotic prophylaxis with a second-generation cephalosporin (86%, n = 43), changing gloves if manipulation of the external fixator is necessary during surgery (86%, n = 43; 4.12 points on the Likert scale), avoid overlapping of the pin sites with the definitive implant site (94%, n = 47; 4.12 points on the Likert scale) and soft tissue protection with a drill sleeve (83.6%, n = 41).

CONCLUSION

Our survey could identify some general principles, which were rated as important by a majority of the respondents. Futures studies' focus should elucidate the role of perioperative antibiotics and different disinfection protocols on implant-associated infections after temporary external fixation in staged protocols.

LEVEL OF EVIDENCE

This study provides Level IV evidence according to Oxford centre for evidence-based medicine.

Can applied external fixators be sterilized for surgery? A prospective cohort study of orthopaedic trauma patients

BACKGROUND

Temporary external fixators are often used to stabilize fractures when definitive fracture surgery must be delayed. Sometimes, external fixators are left in place during repeat operations, including definitive internal fixation of tibial pilon and tibial plateau fractures. It is unknown how well current surgical preparation sterilizes these devices, which become part of the surgical field. Our hypothesis was that our institution's standard surgical preparation creates a low rate of culture-positive environments on external fixators at the time of surgical skin incision.

METHODS

We prospectively consented and enrolled patients to obtain cultures (48 patients, 55 external fixators, 165 sets of culture data). After standard preparation and immediately before incision, cultures were obtained from three sites on each external fixator: 1) most distal pin 1cm from pin-skin interface, 2) most distal bar at midpoint between pin and clamp connectors, and 3) most distal clamp at bar-clamp interface. Our standard preparation for patients with external fixation in place is to don sterile gloves and wipe down all components of the external fixator with 70% alcohol-soaked sterile 4×4in gauze sponges before skin preparation. The skin and external fixator are then prepped in the usual fashion with ChloraPrep for closed wounds or with povidone iodine scrub and paint for open wounds. Swabs were processed and organisms from cultures identified. Clinicians were blinded to study results until study completion.

RESULTS

Two of 165 cultures (1.2%; 95% confidence interval [CI]: 0-2.9%) were positive for common pathogens sometimes observed in surgical site infection. Four cultures (2.4%; 95% CI: 0-4.8%) had pathogens that are rarely associated with surgical site infection, and four (2.4%; 95% CI: 0-4.8%) had nonpathogenic organisms.

CONCLUSION

Using 70% alcohol on external fixators plus either ChloraPrep for closed wounds or povidone iodine for open wounds seems to result in a low rate of positive cultures. Most species that were isolated are infrequently identified as sources of surgical site infections. This preparation protocol might be effective at producing a relatively clean environment at the time of surgery for patients with external fixators already in place.

Optimization and validation of an ion-pair RP-HPLC-UV method for the determination of total free iodine in rabbit plasma: application to a pharmacokinetic study

An ion-pair reverse-phase high performance liquid chromatographic method with UV-vis detection has been developed for the determination of total free iodine in rabbit plasma after vaginal administration of povidone-iodine (PVP-I). Sample preparation was done by protein precipitation with acetonitrile in 96-well format and aspirin was used as the internal standard. The 100 microL sodium thiosulfate solution (5 g L(-1)) was added to 100 microL plasma sample before protein precipitation, to convert the total free iodine in plasma to iodide (I(-)). Separation was performed on a C(18) column (200 x 4.6 mm i.d., 5 microm). The mobile phase consisting of a mixture of water phase (containing 10 mmol L(-1) 18-crown-6 ether, 5 mmol L(-1) octylamine and 5 mmol L(-1) sodium dihydrogen phosphate, pH adjusted to 6.0 with phosphoric acid) and acetonitrile in the ratio 70:30 (v/v) was delivered isocraticly at a flow rate of 1.0 mL min(-1). The method was sensitive with a lower limit of quantification of 0.005 microg mL(-1), with good linearity (r(2) > 0.9990) over the linear range of 0.005-2 microg mL(-1). All the validation data, such as linearity, accuracy and precision, were within the required limits. The method was successfully applied to study the pharmacokinetic of PVP-I in rabbits after vaginal administration.