Effectiveness of surgical skin preparation solutions in orthopaedic surgery: A systematic review of the current comparative literature

Abstract

BACKGROUND

Surgical site infection (SSI) is a major concern in orthopaedic surgery procedures as they can have devastating consequences for patients and their outcomes. Many infection prevention measures are routinely taken in order to prevent infection during surgery, the main one being surgical skin preparation prior to any incision.

AIM

To investigate the efficacy of different perioperative surgical skin preparation products commonly used in orthopaedic surgery.

METHODS

Seven databases were searched from inception to January 25, 2025, using a combination of keywords and medical subject headings terms, specifically for studies comparing any two surgical skin preparation products used at any point prior to skin incision for orthopaedic procedures. Titles and abstracts were screened and full texts reviewed based on inclusion criteria. Data was extracted on study design, interventions, and outcomes from studies that met inclusion criteria. Meta-analysis was not completed due to heterogeneity.

RESULTS

Thirty-two studies met the inclusion criteria in this systematic review. In extremity fracture surgery, evidence was mixed on whether iodine or chlorhexidine-based solutions are more effective at preventing SSI. No significant difference was found between iodine and chlorhexidine-based solutions in total joint arthroplasty, spine surgery, foot and ankle surgery, or upper extremity surgery. No tested preparation method was superior in reducing positive Cutibacterium acnes culture rates in upper extremity (shoulder) surgery. Adding adjuncts to iodine and chlorhexidine methods, such as isopropyl alcohol, hydrogen peroxide, or benzoyl peroxide showed no significant changes to SSI or bacterial cultures.

CONCLUSION

Current literature shows no significant difference between chlorhexidine-based and iodine-based skin preparation solutions in orthopaedic extremity or spine surgery regarding SSI prevention or culture results. Likewise, adding other antiseptic agents provided no clear benefit. While skin antisepsis is important, many different factors contribute to SSI risk outside of the skin preparation solution.

Keywords: Surgical skin prep; Orthopaedics; Iodine; Chlorhexidine; Infection

Core Tip: Perioperative surgical skin preparation techniques were found to be equivalent between iodine and chlorhexidine-based solutions in multiple orthopaedic surgery settings. Perioperative surgical skin preparation still remains critical for infection prevention in orthopaedic surgery. Surgeons may use their preference and surgical expertise for choosing the appropriate surgical skin preparation solution, as the current literature does not support a superior skin preparation solution.