Povidone-iodine irrigation in shoulder surgery - is it safe? is it effective in reducing the load of Cutibacterium?

Subcutaneous tissue disinfection significantly reduces C. acnes burden in primary open shoulder surgery

These authors used a 2-arm randomized, single blinded clinical trial to investigate the effectiveness of treating the subcutaneous tissue with povisdone-iodine (Betadine) in reducing the Cutibacterium culture rate in primary open shoulder surgery performed through a deltopectoral approach. 108 patients were enrolled in two groups (70 treatment vs 38 control).

The procedures included 32 open reductions and internal fixations, 67 total shoulder prostheses, and 9 shoulder stabilizations using an open Latarjet procedure.

A skin swab was taken for culture prior to standard surgical skin preparation. 

After exposure of the deltoid fascia, the treatment group received preparation of the subcutaneous layer with povidone-iodine solution. 

Once the proximal humerus was completely exposed, 5 swabs from different sites were taken for culture. 

The subcutaneous Betadine treatment significantly reduced the positive culture rate of the operating field for all bacteria combined (p = 0.036) and specifically for Cutibacterium (p = 0.013). 

The reduction of positive swabs for Cutibacterium was significant for the surgeon's gloves (p = 0.041) as well as for the retractors (p = 0.007).

37% of the control group and 19% of the treatment group showed at least 1 positive culture (any bacteria) for the deep cultures (RR=0.50, p = 0.036).

26% of the control group and 9% in the intervention group were deep culture positive for Cutibacterium (RR=0.33, p = 0.013)

The percentages of the different bacteria in the cultures in the control group

showed a greater prevalence of Cutibacterium (acnes and avidum) than in the treatment group

The percentage of Cutibacterium positive swabs was lower for the treatment group for all cultures except the "outside scalpel blade, which was used prior to the treatment with Betadine. 

Comment: While this study appears to provide some support for the use of povidone-iodine in shoulder surgery, further clinical research is needed to define the benefit and the risks of this treatment. See, for example, these two articles from the hip and knee arthroplasty literature.

Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty An Analysis of 11,738 Cases

These authors identified 5,534 primary THA and 6,204 primary TKA procedures. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% Betadine prior to closure. Betadine irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases.

The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score.

Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty An Analysis of 2,884 Cases 

These authors assessed the effectiveness of Betadine irrigation in reducing infection following revision total hips (THA) and and total knees (TKA).  Betadine lavage was employed in 27% of the revision THA cases and 34% of the revision TKA cases

After adjusting for baseline differences between the groups using the propensity-score weighted models, they found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received Betadine lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. 

They noted a trend toward higher rates for reoperation for infection among patients who received PI irrigation.

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