These authors point out that Cutibacterium is one of the major pathogens responsible for infection after shoulder surgery and that surgical dissection of the dermis may expose Cutibacterium from sebum producing hair follicles. Because of contact with the surgeon’s gloves and instruments, further spread occurs throughout the surgical field.
Their goal was to determine whether subcutaneous tissue application of povidone-iodine could reduce the Cutibacterium culture rate in primary open shoulder surgery through a deltopectoral approach.
108 patients were prospectively enrolled in a 2-arm, randomized, single-blinded clinical trial:treatment (n = 70) and control (n = 38). The 2 groups did not show any significant difference in terms of sex, age, body mass index, or occurrence of diabetes.
In all patients, a skin swab of the operative field was taken prior to standard surgical skin preparation. After application of sterile drapes, the remaining skin was covered with an iodine-impregnated adhesive drape. A standardized deltopectoral approach was used. The skin and subcutaneous tissue were incised in 1 layer down to the deltopectoral muscle fascia using the ‘‘outside scalpel blade.’’ At this point, the intervention (disinfection) group exclusively received an additional preparation of the whole subcutaneous layer with povidone-iodine solution (Betadine). Only thereafter were retractors placed, and the dissection of the deltopectoral interval was carried out with the ‘‘inside scalpel blade.’ Once the proximal humerus was completely exposed, 5 swabs from different sites were taken for microbiological examination. All cultures were incubated in aerobic and anaerobic conditions for 14 days.
The subcutaneous application of Betadine significantly reduced the positive culture rate of the operating field for all germs combined (P .036) and specifically for C acnes (P .013). The reduction of positive swabs for C acnes was significant for the surgeon’s gloves (P .041), as well as the retractors (P .007).
Comment: This is an interesting study suggesting the effectiveness of Betadine applied to the subcutaneous tissue in reducing the levels of Cutibacterium in open shoulder surgical wounds. It would be of interest to know the amount and concentration of Betadine that was used in the application and how it was applied.
Surgeons often use Betadine lavage before prosthetic implantation, especially in patients deemed to be at high risk for periprosthetic infection. It that application, the wound is often lavaged with saline to prevent potential adverse reaction to the Betadine. These surgeons did not note adverse effects of their application.
It is clear that no approach has been shown to be completely effective in eliminating Cutibacterium from the surgical field. It is possible that multiple steps may reduce the size of the innoculum, including preoperative antibiotics, skin and subcutaneous preparation, Betadine lavage, avoiding contact of the prosthesis and sutures with the subcutaneous tissue, changing gloves before implantation, topical antibiotics and postoperative antibiotics. Determining the effectiveness of each of these steps in preventing periprosthetic infections is a difficult clinical research challenge indeed.
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