Pre-operative Skin preparation for Hip and Knee Arthroplasty

T. Ankers, N. Donnachie

Background: Periprosthetic joint infection (PJI) is a devastating complication of hip and knee arthroplasty. I have encountered a variety of strategies for skin preparation during my training. In this abstract a review of current literature regarding pre-operative skin preparation is summarised. A protocol based on the evidence is proposed.

Methods: A literature search was performed using Medline and EMBASE. It focussed on five aspects of skin preparation: MSSA & MRSA screening, pre-operative washing, hair removal, skin disinfection and incise drapes.

Findings: Evidence suggests that screening for MSSA and subsequent eradication reduces the rate of PJI. This intervention has been shown to be cost effective. There is recent evidence to support pre-operative washing with chlorhexidine gluconate (CHG) impregnated cloths. There is limited evidence to support the routine removal of hair from the operative site. If hair must be removed, clippers or depilatory cream are preferable to a razor. Regarding skin disinfection, a CHG and alcohol mixture may be more effective than iodophors. A second application of disinfectant, prior to placing the incise drape, has been shown to reduce infection rate. Lastly incise drapes themselves have not been shown to reduce the rate of infection. Those incise drapes not impregnated with iodine may increase infection rates.

Conclusion: Based on the findings of this literature review I propose the following skin preparation regime for patients undergoing hip and knee arthroplasty:

1. MSSA and MRSA screening in all patients and eradication in carriers.
2. Pre-operative washing with CHG cloths the night before and morning of surgery.
3. Hair removal with clippers if required.
4. Skin disinfection with a CHG-alcohol scrub before draping and again before applying the incise drape.
5. Iodine impregnated incision drapes.