Arch Orthop Trauma Surg DOI 10.1007/s00402-014-1974-z
Knee Arthroplasty
No need to change the skin knife in modern arthroplasty surgery C. Ottesen · A. Skovby · A. Troelsen · C. Specht · A. Friis‑Møller · H. Husted
Received: 24 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Earlier studies have found varying contamination rates using separate skin and deep knives in total hip (THA) and total knee (TKA) arthroplasty surgery. Previous studies were primarily conducted in the setting of concomitant use of laminar airflow and/or plastic adhesive draping. This has lead to conflicting conclusions regarding discarding the skin knife or not. This study evaluates the prevalence of contamination of a separate skin knife using modern antiseptic technique in primary THA and TKA without laminar airflow. Three knives from each primary THA and TKA surgery in non-laminar airflow operating rooms were collected: one used for the skin, one used for deeper tissues and one control knife. A total of 831 knife blades from 277 patients were cultured 12 days. Contamination of the skin knife was found in eight patients (2.8 %), contamination of the “deep” knife in five patients (1.8 %) and contamination of the control knife in five patients (1.8 %). No patient developed an infection with 1-year follow-up. Our findings suggest a very low rate of contamination of the skin knife using modern antiseptic technique without laminar airflow and/or plastic adhesive draping and do not support the use of a separate skin knife in arthroplasty surgery. Keywords Arthroplasty · Infection · Skin knife · Outcome · Bacteria
C. Ottesen (*) · A. Troelsen · C. Specht · H. Husted Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark e-mail: [email protected] A. Skovby · A. Friis‑Møller Department Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
Introduction Postoperative infection following elective total hip (THA) and knee (TKA) arthroplasty surgery is a serious complication with major socioeconomic and personal consequences. Chronic diseases as well as the patient’s lifestyle may, together with intra- and perioperative conditions, influence the risk of postoperative infection [1]. Different intra-operative strategies have been introduced to prevent postoperative peri-prosthetic joint infection, among them are the use of separate knives for skin and deeper layers [2, 3], body exhaust systems (space suits) [4], antiseptic adhesive drapes [5], standardized antibiotic administration [6], and clean air (laminar airflow) operating rooms [7]. The tradition of discarding the skin knife and using a clean blade for incision of the deeper tissues has been widely practiced for many years. The underlying reason is the potential avoidance of contamination of the deeper tissues with skin bacteria contaminating the skin knife—and hence leading to peri-prosthetic infection [3, 8]. Based upon the finding of very low levels of skin contamination following modern antiseptic preparation of the skin, a number of earlier studies have questioned this practice and have suggested that it is not necessary to change the skin knife [2, 8–11]. However, more recent studies have found a higher rate of skin contamination and have suggested that contemporary microbiological methods might explain these findings—and have thus recommended sustaining the practice of changing blades after skin incision [12, 13]. All recent previous studies have been performed in the setting of laminar airflow—and as recent studies have found an increase in deep peri-prosthetic infection associated
13
with this use (potentially combined with forced airwarming) [4]—we aimed at evaluating the need to change the skin knife applying modern antiseptic conditions without the use of laminar airflow.
Patients and methods Using a standard operating setup, three knives were collected during surgery from primary hip and knee arthroplasty at our institution from 10.05.2011 to 24.04.2012. All operations were performed by 4 experienced surgeons doing both THA and TKA. Preoperatively, the surgical site was disinfected twice with 83 % ethyl-alcohol with 0.5 % chlorhexidine-digluconate colored with curcumine allowing drying up in between applications. Standard routines did not include shaving the operating site [14] or the use of plastic adhesive drapes [5]. Surgery was performed without the use of laminar airflow— instead positive pressure ventilation with shifting of the air 20 times/hour was used. All patients received antibiotic prophylaxis in the form of cephalosporine (Cefuroxime 1.5 g) 15–30 min prior to incision; a tourniquet was used in TKA. All operations were performed by experienced senior consultants using standard approaches. The knife blade used for incision of the skin was discarded immediately after this and placed directly in a liquid broth Brain Heart Infusion (BHI). Another blade was used for the remaining surgery, following which it was discarded and placed in another BHI media. At the beginning of every operation, a “control” knife blade was placed on the operating table and after the surgery placed in a third BHI media. All blades were removed from the knife or operating table by a scrubbed assistant nurse with sterile individual instruments. If the patient’s samples were incorrectly handled, the samples were discarded and the patient not included in the study, because incorrectly handled samples constituted potential contamination from touching the vials on top and dropping blades on the potentially contaminated dressings/ floor during handling. All inoculated BHI media were incubated at the department of clinical microbiology in 35 °C for 5 days. The samples were inspected daily and, if positive, subcultured. All the negative samples on day five were subcultured on 5 % horse blood agar, incubated in CO2 for an extra 7 days and inspected again for growth. All patients were seen routinely at 3-month followup postoperatively and all patients were followed for 12 months with an endpoint of revision (soft tissue and/ or prosthetic exchange)—no attempt was made to identify superficial infections as these are difficult to assess.
13
Arch Orthop Trauma Surg
Results A total of 831 knife blades were collected from 277 patients undergoing primary unilateral THA and TKA surgery. From these 115 patients underwent THA surgery while 162 patients had TKA surgery done. In eight patients (2.8 %), contamination was found on the skin-blade. In five patients (1.8 %), the deep blade showed contamination. The un-used control knife blade showed contamination in five patients (1.8 %). Only from one patient both the skinblade and the deep blade showed growth with the same bacteria, Staphylococcus epidermidis. In eight out of the seventeen patients (47 %), the bacteria were detected only after further subculturing. In four out of the five contaminated skin knives, bacteria were detected only after further subculturing. Bacteria found in this study were all part of the normal skinflora, with Staphylococcus aureus found on one skin knife as the only exception. The results including microbiology are shown in Table 1.
Discussion The aim of this study was to evaluate the contamination of the skin knife following modern antiseptic technique (no skin shaving, use of alcohol skin preparation, no plastic adhesive drapes) without laminar airflow in lower limb arthroplasty surgery. Using contemporary microbiological methods, we found a very low contamination rate of the skin knife of 2.8 %. The skin knife was removed from the operating environment immediately following skin incision—thus not exposing it to the potential contamination during the entire procedure. This was done intentionally and although one can argue that the contamination rate would have been higher for this specific blade if placed on a table for the reminder of the operation, we wanted to isolate the contamination from contact with the skin for this knife. Leaving it exposed longer would have caused bias as to the true contamination from the skin only. Only the 3 blades cultured in each case were used for the procedure, and thus the deep knife was used for almost the entire operation (apart from the skin incision). The control knife was left on the table for the entire procedure which was around 45 min. No attempt was made to characterize the skin of the patients as all patients had intact skin without any wounds—also, no hair removal was performed. Even though more extensive and sensible culturing was performed in our study, the low contamination rate compares favorably with other studies. Fairclough et al. [8] in 1983 found 4.2 % contaminated skin knives and the same percentage of contaminated deep knives in 187 patients
Arch Orthop Trauma Surg Table 1 Results including microbiology Patient
Sex
Surgery
Skin knife
Deep knife
Control knife
1-year follow-up
5
F
Hip
S. epidermidis
None
No sign of deep infection
16
M
Knee
S. epidermidis None
No sign of deep infection
F
Knee
None
+Microbacterium testaceum
None
72
None
No sign of deep infection
77
F
Knee
None
S. epidermidis None
No sign of deep infection
96
M
Knee
129
F
Hip
+S. species None
Coagulase neg. staphylococcus None None
No sign of deep infection
143
M
Knee
+S. hominis
+S. warneri None
None
No sign of deep infection
144
F
Hip
None
No sign of deep infection
F
Knee
+S. capitis None
None
177
None
Enterococcus cecorum
No sign of deep infection
178
M
Hip
None
No sign of deep infection
M
Hip
None
S. species None
None
179
No sign of deep infection
188
M
Hip
None
194
F
Knee
+S. hominis
S. capitis None
S. aureus
None
None
No sign of deep infection
205
F
Knee
S. epidermidis
None
None
No sign of deep infection
217
M
Knee
None
No sign of deep infection
M
Hip
+S. epidermidis None
None
253
None
No sign of deep infection
275
M
Knee
None
None
+S. warneri
None
S. epidermidis
No sign of deep infection
No sign of deep infection
No sign of deep infection
Bacteria marked + only grew after further subculturing day 5
undergoing surgery for closed fractures. The authors did not note whether or not laminar airflow was used. Grabe et al. [2] compared skin contamination with and without the use of laminar airflow in 358 patients undergoing elective orthopedic surgeries. The study did not find evidence to support changing blades after skin incision. These findings were supported by Ramon et al. [9] in a study, which found a higher incidence of contamination of the deep blade (11.3 %) compared to the skin knife (5.3 %). As opposed to these older studies, newer studies have recommended discarding the skin knife. Davis et al. [13] in 1999 presented a study including 100 patients undergoing primary THA and TKA. Skin and deep blades were grown and resulted in an incidence of contamination of skin blades of 9.4 % and of deep blades of 3.2 %. In 2006, Schindler et al. found a 15.3 % contamination rate in skin knives collected from 203 patients in vertical laminar airflow during elective orthopedic surgery [12]. Comparing this incidence to the level of contamination of the deep blade (10.8 %) and that of the control knife (6.4 %)—together with the finding of predominantly coagulase-negative staphylococci and Proprioni bacterium species—lead to the recommendation of changing the blade after skin incision in elective orthopedic surgery. The contamination rates found in previous studies may reflect various nonevidence-based suboptimal settings. The low contamination rate found in our study using contemporary evidence-based antiseptic techniques does not support changing the blade after skin incision.
Antibiotics given 15–30 min prior to surgery, no skin shaving, the use of an alcohol-based skin antiseptic and not using plastic adhesive drapes all constitute best current evidence [4–6, 14–16] and may explain the lower incidence of contamination. We found no infections at 1-year follow-up in any of the patients with contaminated surgical knives. It may be argued that this is too short a period of follow-up to exclude infection, but as our study focuses on intra-operative contamination potentially leading to infection, potential secondary hematogenous spread of infection should be excluded. One-year followup seems a sufficient compromise, although with the rather common finding of contamination with coagulasenegative staphylococci—a major culprit in “slow” infections—very late manifestation of deep infection cannot be completely ruled out, however, unlikely in the absence of clinical symptoms. This study is the biggest cohort study published regarding contamination of knives with the intention to document the amount of contamination present under the contemporary conditions described. No power analysis was used nor was any randomization performed. The main outcome of this study is the finding of very low contamination rates and bacterial findings on the corresponding blades not supporting discarding the skin knife. The result is changing an old tradition which no longer is supported when using contemporary techniques in skin preparation and surgical environment; also minor savings are achieved by not needing so many blades.
13
An American study published in 2008 [17] found that 56 % of orthopedic surgeons change the blade after skin incision. This shows that there is still a controversy on this subject and although our results may not be extrapolated to all other settings, they demonstrate that by applying similar evidence-based features, very low incidences of skin knife contamination can be achieved not necessitating changing the knife. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References 1. Pulido Luis, Ghanem Elie, Joshi Ashish, Purtill James J, Parvizi Javad (2008) FRCS, periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 466:1710–1715 2. Grabe N, Falstie-Jensen S, Fredberg U, Schrøder H, Sørensen I (1985) The contaminated skin-knife: fact or fiction. J Hosp Infect 6:252–256 3. Jacobs HB (1974) Skin knife-deep knife: the ritual and practice of skin incisions. An Surg 179(1):102–104 4. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC (2011) Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? The ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br 93(1):85–90 5. Webster J, Alghamdi A (2007) Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 4:CD006353. doi:10.1002/14651858.CD006353. pub2
13
Arch Orthop Trauma Surg 6. AlBuhairan B, Hind D, Hutchinson A (2008) Antibiotic prophylaxis for wound infections in total joint arthroplasty: a systematic review. J Bone Joint Surg Br 90(7):915–919 7. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D (1982) Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J 285:10–14 (Clin Res Ed) 8. Fairclough JA, Mackie IG, Mintowt-czyz W, Phillips GE (1983) The contaminated skin-knife: a surgical myth. J Bone Joint Surg Br 65(2):210 9. Ramón R, García S, Combalia A, Puig de la Bellacasa J, Segur JM (1994) Bacteriological study of surgical knives: is the use of two blades necessary? Arch Orthop Trauma Surg 113:157–158 10. Ritter MA, French ML, Eitzen HE (1975) Bacterial contamination of the surgical knife. Clin Orth 108:158–160 11. Hill R, Blair S, Neely J, Ramanathan M (1985) Changing knives a wasteful and unnecessary ritual. Ann R Coll Surg Engl 67(3):149–151 12. Schindler OS, Spencer RF, Smith MD (2006) Should we use a separate knife for the skin? J Bone Joint Surg Br 88(3):382–385 13. Davis N, Curry A, Gambhir AK et al (1999) Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br 81(5):886–889 14. Tanner J, Norrie P, Melen K (2011) Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 11:CD004122. doi:10.1002/14651858.CD004122.pub4 15. Van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC (2007) Antibiotic prophylaxis and the risk of surgical site infections following total hip artroplasty timely administration is the most important factor. Clin Infect Dis 44(7):921–927 16. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A (2013) Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 3:CD003949. doi:10.1002/14651858.CD003949.pub3 17. Tejwani NC, Immerman Igor (2008) Myths and legends in orthopaedic practice—are we all guilty? Clin Orthop Relat Res 466(11):2861–2872
Knee Arthroplasty
No need to change the skin knife in modern arthroplasty surgery C. Ottesen · A. Skovby · A. Troelsen · C. Specht · A. Friis‑Møller · H. Husted
Received: 24 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Earlier studies have found varying contamination rates using separate skin and deep knives in total hip (THA) and total knee (TKA) arthroplasty surgery. Previous studies were primarily conducted in the setting of concomitant use of laminar airflow and/or plastic adhesive draping. This has lead to conflicting conclusions regarding discarding the skin knife or not. This study evaluates the prevalence of contamination of a separate skin knife using modern antiseptic technique in primary THA and TKA without laminar airflow. Three knives from each primary THA and TKA surgery in non-laminar airflow operating rooms were collected: one used for the skin, one used for deeper tissues and one control knife. A total of 831 knife blades from 277 patients were cultured 12 days. Contamination of the skin knife was found in eight patients (2.8 %), contamination of the “deep” knife in five patients (1.8 %) and contamination of the control knife in five patients (1.8 %). No patient developed an infection with 1-year follow-up. Our findings suggest a very low rate of contamination of the skin knife using modern antiseptic technique without laminar airflow and/or plastic adhesive draping and do not support the use of a separate skin knife in arthroplasty surgery. Keywords Arthroplasty · Infection · Skin knife · Outcome · Bacteria
C. Ottesen (*) · A. Troelsen · C. Specht · H. Husted Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark e-mail: [email protected] A. Skovby · A. Friis‑Møller Department Clinical Microbiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
Introduction Postoperative infection following elective total hip (THA) and knee (TKA) arthroplasty surgery is a serious complication with major socioeconomic and personal consequences. Chronic diseases as well as the patient’s lifestyle may, together with intra- and perioperative conditions, influence the risk of postoperative infection [1]. Different intra-operative strategies have been introduced to prevent postoperative peri-prosthetic joint infection, among them are the use of separate knives for skin and deeper layers [2, 3], body exhaust systems (space suits) [4], antiseptic adhesive drapes [5], standardized antibiotic administration [6], and clean air (laminar airflow) operating rooms [7]. The tradition of discarding the skin knife and using a clean blade for incision of the deeper tissues has been widely practiced for many years. The underlying reason is the potential avoidance of contamination of the deeper tissues with skin bacteria contaminating the skin knife—and hence leading to peri-prosthetic infection [3, 8]. Based upon the finding of very low levels of skin contamination following modern antiseptic preparation of the skin, a number of earlier studies have questioned this practice and have suggested that it is not necessary to change the skin knife [2, 8–11]. However, more recent studies have found a higher rate of skin contamination and have suggested that contemporary microbiological methods might explain these findings—and have thus recommended sustaining the practice of changing blades after skin incision [12, 13]. All recent previous studies have been performed in the setting of laminar airflow—and as recent studies have found an increase in deep peri-prosthetic infection associated
13
with this use (potentially combined with forced airwarming) [4]—we aimed at evaluating the need to change the skin knife applying modern antiseptic conditions without the use of laminar airflow.
Patients and methods Using a standard operating setup, three knives were collected during surgery from primary hip and knee arthroplasty at our institution from 10.05.2011 to 24.04.2012. All operations were performed by 4 experienced surgeons doing both THA and TKA. Preoperatively, the surgical site was disinfected twice with 83 % ethyl-alcohol with 0.5 % chlorhexidine-digluconate colored with curcumine allowing drying up in between applications. Standard routines did not include shaving the operating site [14] or the use of plastic adhesive drapes [5]. Surgery was performed without the use of laminar airflow— instead positive pressure ventilation with shifting of the air 20 times/hour was used. All patients received antibiotic prophylaxis in the form of cephalosporine (Cefuroxime 1.5 g) 15–30 min prior to incision; a tourniquet was used in TKA. All operations were performed by experienced senior consultants using standard approaches. The knife blade used for incision of the skin was discarded immediately after this and placed directly in a liquid broth Brain Heart Infusion (BHI). Another blade was used for the remaining surgery, following which it was discarded and placed in another BHI media. At the beginning of every operation, a “control” knife blade was placed on the operating table and after the surgery placed in a third BHI media. All blades were removed from the knife or operating table by a scrubbed assistant nurse with sterile individual instruments. If the patient’s samples were incorrectly handled, the samples were discarded and the patient not included in the study, because incorrectly handled samples constituted potential contamination from touching the vials on top and dropping blades on the potentially contaminated dressings/ floor during handling. All inoculated BHI media were incubated at the department of clinical microbiology in 35 °C for 5 days. The samples were inspected daily and, if positive, subcultured. All the negative samples on day five were subcultured on 5 % horse blood agar, incubated in CO2 for an extra 7 days and inspected again for growth. All patients were seen routinely at 3-month followup postoperatively and all patients were followed for 12 months with an endpoint of revision (soft tissue and/ or prosthetic exchange)—no attempt was made to identify superficial infections as these are difficult to assess.
13
Arch Orthop Trauma Surg
Results A total of 831 knife blades were collected from 277 patients undergoing primary unilateral THA and TKA surgery. From these 115 patients underwent THA surgery while 162 patients had TKA surgery done. In eight patients (2.8 %), contamination was found on the skin-blade. In five patients (1.8 %), the deep blade showed contamination. The un-used control knife blade showed contamination in five patients (1.8 %). Only from one patient both the skinblade and the deep blade showed growth with the same bacteria, Staphylococcus epidermidis. In eight out of the seventeen patients (47 %), the bacteria were detected only after further subculturing. In four out of the five contaminated skin knives, bacteria were detected only after further subculturing. Bacteria found in this study were all part of the normal skinflora, with Staphylococcus aureus found on one skin knife as the only exception. The results including microbiology are shown in Table 1.
Discussion The aim of this study was to evaluate the contamination of the skin knife following modern antiseptic technique (no skin shaving, use of alcohol skin preparation, no plastic adhesive drapes) without laminar airflow in lower limb arthroplasty surgery. Using contemporary microbiological methods, we found a very low contamination rate of the skin knife of 2.8 %. The skin knife was removed from the operating environment immediately following skin incision—thus not exposing it to the potential contamination during the entire procedure. This was done intentionally and although one can argue that the contamination rate would have been higher for this specific blade if placed on a table for the reminder of the operation, we wanted to isolate the contamination from contact with the skin for this knife. Leaving it exposed longer would have caused bias as to the true contamination from the skin only. Only the 3 blades cultured in each case were used for the procedure, and thus the deep knife was used for almost the entire operation (apart from the skin incision). The control knife was left on the table for the entire procedure which was around 45 min. No attempt was made to characterize the skin of the patients as all patients had intact skin without any wounds—also, no hair removal was performed. Even though more extensive and sensible culturing was performed in our study, the low contamination rate compares favorably with other studies. Fairclough et al. [8] in 1983 found 4.2 % contaminated skin knives and the same percentage of contaminated deep knives in 187 patients
Arch Orthop Trauma Surg Table 1 Results including microbiology Patient
Sex
Surgery
Skin knife
Deep knife
Control knife
1-year follow-up
5
F
Hip
S. epidermidis
None
No sign of deep infection
16
M
Knee
S. epidermidis None
No sign of deep infection
F
Knee
None
+Microbacterium testaceum
None
72
None
No sign of deep infection
77
F
Knee
None
S. epidermidis None
No sign of deep infection
96
M
Knee
129
F
Hip
+S. species None
Coagulase neg. staphylococcus None None
No sign of deep infection
143
M
Knee
+S. hominis
+S. warneri None
None
No sign of deep infection
144
F
Hip
None
No sign of deep infection
F
Knee
+S. capitis None
None
177
None
Enterococcus cecorum
No sign of deep infection
178
M
Hip
None
No sign of deep infection
M
Hip
None
S. species None
None
179
No sign of deep infection
188
M
Hip
None
194
F
Knee
+S. hominis
S. capitis None
S. aureus
None
None
No sign of deep infection
205
F
Knee
S. epidermidis
None
None
No sign of deep infection
217
M
Knee
None
No sign of deep infection
M
Hip
+S. epidermidis None
None
253
None
No sign of deep infection
275
M
Knee
None
None
+S. warneri
None
S. epidermidis
No sign of deep infection
No sign of deep infection
No sign of deep infection
Bacteria marked + only grew after further subculturing day 5
undergoing surgery for closed fractures. The authors did not note whether or not laminar airflow was used. Grabe et al. [2] compared skin contamination with and without the use of laminar airflow in 358 patients undergoing elective orthopedic surgeries. The study did not find evidence to support changing blades after skin incision. These findings were supported by Ramon et al. [9] in a study, which found a higher incidence of contamination of the deep blade (11.3 %) compared to the skin knife (5.3 %). As opposed to these older studies, newer studies have recommended discarding the skin knife. Davis et al. [13] in 1999 presented a study including 100 patients undergoing primary THA and TKA. Skin and deep blades were grown and resulted in an incidence of contamination of skin blades of 9.4 % and of deep blades of 3.2 %. In 2006, Schindler et al. found a 15.3 % contamination rate in skin knives collected from 203 patients in vertical laminar airflow during elective orthopedic surgery [12]. Comparing this incidence to the level of contamination of the deep blade (10.8 %) and that of the control knife (6.4 %)—together with the finding of predominantly coagulase-negative staphylococci and Proprioni bacterium species—lead to the recommendation of changing the blade after skin incision in elective orthopedic surgery. The contamination rates found in previous studies may reflect various nonevidence-based suboptimal settings. The low contamination rate found in our study using contemporary evidence-based antiseptic techniques does not support changing the blade after skin incision.
Antibiotics given 15–30 min prior to surgery, no skin shaving, the use of an alcohol-based skin antiseptic and not using plastic adhesive drapes all constitute best current evidence [4–6, 14–16] and may explain the lower incidence of contamination. We found no infections at 1-year follow-up in any of the patients with contaminated surgical knives. It may be argued that this is too short a period of follow-up to exclude infection, but as our study focuses on intra-operative contamination potentially leading to infection, potential secondary hematogenous spread of infection should be excluded. One-year followup seems a sufficient compromise, although with the rather common finding of contamination with coagulasenegative staphylococci—a major culprit in “slow” infections—very late manifestation of deep infection cannot be completely ruled out, however, unlikely in the absence of clinical symptoms. This study is the biggest cohort study published regarding contamination of knives with the intention to document the amount of contamination present under the contemporary conditions described. No power analysis was used nor was any randomization performed. The main outcome of this study is the finding of very low contamination rates and bacterial findings on the corresponding blades not supporting discarding the skin knife. The result is changing an old tradition which no longer is supported when using contemporary techniques in skin preparation and surgical environment; also minor savings are achieved by not needing so many blades.
13
An American study published in 2008 [17] found that 56 % of orthopedic surgeons change the blade after skin incision. This shows that there is still a controversy on this subject and although our results may not be extrapolated to all other settings, they demonstrate that by applying similar evidence-based features, very low incidences of skin knife contamination can be achieved not necessitating changing the knife. Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References 1. Pulido Luis, Ghanem Elie, Joshi Ashish, Purtill James J, Parvizi Javad (2008) FRCS, periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 466:1710–1715 2. Grabe N, Falstie-Jensen S, Fredberg U, Schrøder H, Sørensen I (1985) The contaminated skin-knife: fact or fiction. J Hosp Infect 6:252–256 3. Jacobs HB (1974) Skin knife-deep knife: the ritual and practice of skin incisions. An Surg 179(1):102–104 4. Hooper GJ, Rothwell AG, Frampton C, Wyatt MC (2011) Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement? The ten-year results of the New Zealand Joint Registry. J Bone Joint Surg Br 93(1):85–90 5. Webster J, Alghamdi A (2007) Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 4:CD006353. doi:10.1002/14651858.CD006353. pub2
13
Arch Orthop Trauma Surg 6. AlBuhairan B, Hind D, Hutchinson A (2008) Antibiotic prophylaxis for wound infections in total joint arthroplasty: a systematic review. J Bone Joint Surg Br 90(7):915–919 7. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D (1982) Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J 285:10–14 (Clin Res Ed) 8. Fairclough JA, Mackie IG, Mintowt-czyz W, Phillips GE (1983) The contaminated skin-knife: a surgical myth. J Bone Joint Surg Br 65(2):210 9. Ramón R, García S, Combalia A, Puig de la Bellacasa J, Segur JM (1994) Bacteriological study of surgical knives: is the use of two blades necessary? Arch Orthop Trauma Surg 113:157–158 10. Ritter MA, French ML, Eitzen HE (1975) Bacterial contamination of the surgical knife. Clin Orth 108:158–160 11. Hill R, Blair S, Neely J, Ramanathan M (1985) Changing knives a wasteful and unnecessary ritual. Ann R Coll Surg Engl 67(3):149–151 12. Schindler OS, Spencer RF, Smith MD (2006) Should we use a separate knife for the skin? J Bone Joint Surg Br 88(3):382–385 13. Davis N, Curry A, Gambhir AK et al (1999) Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg Br 81(5):886–889 14. Tanner J, Norrie P, Melen K (2011) Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 11:CD004122. doi:10.1002/14651858.CD004122.pub4 15. Van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC (2007) Antibiotic prophylaxis and the risk of surgical site infections following total hip artroplasty timely administration is the most important factor. Clin Infect Dis 44(7):921–927 16. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A (2013) Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 3:CD003949. doi:10.1002/14651858.CD003949.pub3 17. Tejwani NC, Immerman Igor (2008) Myths and legends in orthopaedic practice—are we all guilty? Clin Orthop Relat Res 466(11):2861–2872
