Wednesday, December 17, 2014

Is it a good idea to remove axillary hair before shoulder surgery?

The effect of axillary hair on surgical antisepsis around the shoulder

These authors studied the effect of clipping axillary hair (with commercially available surgical clippers) on the aerobic and anaerobic cultures taken from the axillae of 85 healthy male volunteers. 

All subjects with clipped axillae and most of those with unclipped axillae had positive cultures.

Coagulase negative staph was found in 73%, Propionibacterirum in 72%, and Corynebacterium in 17%. 

The overall bacterial burden was higher in the clipped axilla, but removal of axillary hair had no effect on the burden of P. acnes in the axilla.

Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae apparently immediately after the preparation.There was a significant reduction in total bacterial load and P. acnes load for both axillae immediately after surgical preparation (P < .001 for all).

Comment: This work does not support the practice of clipping axillary hair prior to shoulder surgery.

The conclusion that a "2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla" is not that comforting in that it has been shown that Propionibacterium live in and not on the skin. Furthermore it has been previously shown that skin preparation does not eliminate Propionibacterium from the shoulder region, especially if the cultures are obtained a while after the skin preparation is applied.

So our current practice is to avoid clipping the axillary hair, to use a standard skin preparation after intravenous administration of Ceftriaxone and Vancomycin, to irrigate the wound with three liters of antibiotic saline and to avoid as much as possible contact of the prosthesis with the wound edge - all of this is based on the assumption that every shoulder incision is likely to be contaminated with Propionibacterium because the skin incision transects the dermal organs in which they reside.


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