I believe our published paper is valid on three counts.
We did use Hydrex alcohol hand rub which contains 70% alcohol and 0.5% chlorhexidine against chlorhexidine hand wash. They both contain chlorhexidine and the recommended alcohol concentration.
We did not want to use a neutralising agent because we wanted to demonstrate the latency effect of chlorhexidine which continues to have an effect even during the procedure on any possible remaining finger tip contamination. This is an extremely important fact especially in some very long orthopaedic procedures and multiple trauma. Unlike any other surgical speciality, orthopaedic cases require a clean air flow system and, as glove perforation is quite common due to contact with exposed bone, finger tip contamination can lead to infection around the prosthesis. This is considered a total failure by any orthopaedic surgeon.
Four of the 5 papers quoted in your letter were published after our paper had been submitted and accepted for publication. These papers are all based on the laboratory setting and a selected group carry out the experiments. They do, however, confirm the superior efficacy of chlorhexidine. Unfortunately, in real life, all individuals are different and they carry out the same pattern of recommended hand washing differently from each other. The aim of this study was to demonstrate that laboratory results in a controlled setting are very difficult to achieve in a realistic work environment – there is no such thing as a control group in the operating theatre.
I am disappointed with your response as I am certain no orthopaedic surgeon will only rely on alcohol to perform major surgery along with insertion of prosthesis. Alcohol should be used to disinfect an already clean hand and not the reverse.
At the end of the day, safety of the patient needs to guide us: as a surgeon, I would not recommend alcohol hand rub alone as a means of disinfection especially for orthopaedic surgeons. It may be sufficient for general surgery, ENT or other specialities where the contamination from body flora is inevitable but not in orthopaedic surgery where a clean operative site and clean hands are vital.