Letter to the Editor: Does an Antimicrobial Incision Drape Prevent Intraoperative Contamination? A Randomized Controlled Trial of 1187 Patients

To the Editor,

We read the article, “Does an Antimicrobial Incision Drape Prevent Intraoperative Contamination? A Randomized Controlled Trial of 1187 Patients” by Hesselvig and colleagues [3] with great interest.

Antimicrobial incision drapes are commonly used, particularly in orthopaedics, to prevent surgical site infections. We propose repurposing these incision drapes to protect the orthopaedic surgical team when operating on a patient with coronavirus disease 2019 (COVID-19).

There is growing concern that COVID-19 can be transmitted through airborne particles [6] and these COVID particles can be potentially aerosolized during orthopaedic procedures, particularly with the use of power tools like drills and reamers [1, 2, 4, 5, 7]. But steps can be taken intraoperatively to mitigate against inadvertent COVID-19 exposure.

When drilling, an additional incision drape can be used to both cover open surgical wounds and minimize blood splash and potential aerosolization. We suggest prepping and draping the patient as normal. But after the surgical site is exposed, we propose adding and securing a transparent incisional drape directly over the open surgical wound. The surgeon can then make a small hole in the middle of the drape for the passage of a drill guide. The drill can then be passed through the drill guide into the surgical site before subsequent drilling is performed (Fig. 1).

Fig. 1.

An example of how orthopaedic surgeons can drill through a drape to minimize blood spatter and potential aerosolization is shown.

We recognize that incisional drapes may not be readily available in all institutions, but transparent/translucent materials like urine bags can be used with similar effect. Surgeons should ensure these urine bags are sterile before using them to avoid introducing inadvertent infection. A rectangular hole can be made on one surface of the urine bag before it is secured over the surgical site using adhesive tape. We propose making another smaller hole on the superior surface of the urine bag, through which a drill guide and drill can be passed for drilling (Fig. 2A-B). This serves to contain any blood spatter and potential COVID-19 aerosolization.

Fig 2 A-B.

(A) A sterile urine bag prepared for use during (B) intraoperative drilling to prevent blood spatter and aerosolization is shown.

Urine bags can also be modified to prevent blood spatter during reaming. Both the top and bottom ends of the urine bag can be cut; with one end secured around the incision site to act as a plastic sleeve when the reamer is being passed. Again, before attempting any modification, surgeons must ensure that the urine bags are sterile.

Although we have not done a formal study on these approaches, our experiences suggest that they are easy to perform and implement. All the same, surgeons need to take the appropriate precautions when using the approaches that we have suggested, especially when they limit visualization of parts of the surgical field. Caution must be taken to ensure that critical structures e.g. vessels and nerves are well protected, and that drill and reamer angles are maintained as intended when working behind plastics barriers like we have proposed. We have not experienced difficulties or complications related to these approaches, but nonetheless we urge care and caution in their implementation.

Orthopaedic surgeons can easily perform this simple surgical technique. Given the nature of this COVID-19 pandemic, it is imperative that we take steps to protect ourselves and our surgical teams against any inadvertent occupational exposure. The use of power tools is a potential source of aerosolization and so they should be used with great caution to minimize unnecessary blood and fluid spatter [1, 5].