Discussion
THA
SKIN LAXITY, SITE INFECTION, BLIND
We hypothesized that the visualization of skin antiseptics is an important factor in orthopaedic joint surgery. Surgical skin preparation of a complete leg in THA is more challenging than for example abdominal/spinal surgery because the areas are much larger, three-dimensional and sometimes outside one’s own field of view, we were able to demonstrate the following in our study:Using colored antiseptic disinfection in THA (supine) leads more often to complete skin coverage, than colorless, as demonstrated by overall adequacy of skin preparation (overall view: 13.5% vs. 38.5%. level of significance: p = 0.007).The combination of resident orthopedic surgeons and use of colorless antiseptic agent provided the highest rate of incomplete skin preparation. It is often common practice that the resident starts with the preoperative skin preparation, before the consultant joins for the surgical part.There is no control function by the operating theatre staff when using uncolored disinfectants.Even when incomplete skin areas appeared after skin preparation, the size was significantly smaller when using the colored antiseptic agent.Most of the time uncleansed skin areas were outside the surgeon view, like dorsal lower leg. So at least one additional person in the operating room should always observe the disinfection process.One limitation of this study was our inability to blind the surgeons or the examiners of the photo documentation regarding which antiseptic agent used, as colored vs. colorless skin preparation was easy to distinguish between. Furthermore, another limitation of our study was the lack of heterogeneity in our study group. Most participants were young and healthy and as a consequence the composition of their body and skin (e.g., skin laxity) may well be different in our elderly population. We attempted to minimized the impact of this limitation through not telling study participants what the aims of the study were.The study strength is that for the first time, the actual skin coverage of colorless antiseptic agent, in supine THA protocol could be visualized, by using UV—light.Several studies have investigated different skin disinfectants with respect to the risk of subsequent SSI. PVP-iodine (in aqueous solution) alone is clearly inferior to reduce surgical site infections, which has been shown in various studies and meta-analysis (14, 18). Although there is some evidence that CHX + alcohol is superior to PVP-I + alcohol, proof in orthopedic hip surgery is still pending [