Table 3.
Included studies on intraoperative sources of implant contamination
| Study | Source of contamination | Study size | Main results | Conclusion |
|---|---|---|---|---|
| Intraoperative sources of implant contamination | ||||
| Surgical instrument trays | ||||
| Waked et al. (2007) [15] | Surgical instrument trays | 90 sterilization wraps | Detection rates ranged from 7 to 97% | Substantial perforations in sterilization wraps may be missed |
| Mobley and Jackson 3rd. (2018) [16] | Surgical instrument trays | 20 sterilization wraps | Overall 56% accuracy | Current method for assessing sterility is inadequate |
| Surgical equipment | ||||
| Radcliff et al. (2013) [17] | Preoperative in-room time | 7991 spine surgeries including 276 SSIs | ART was significantly higher in patients with infection (68 vs. 61 min); significant increase in infection rate if ART was > 1 h | Preoperative in-room time is a risk factor for SSI |
| Blom et al. (2000) [18] | Surgical drapes | 24 agar plates covered with 7 types of surgical drapes | All of the reusable woven drapes allowed bacterial penetration; non-woven drapes were impermeable apart from one | Recommendation for non-woven disposable drapes over woven drapes |
| Lankester et al. (2002) [19] | Surgical gowns | 40 surgical gowns of 2 types | Disposable gowns showed less bacterial penetration than reusable gowns in all tested regions | Reusable gowns may be unsuitable for use in orthopaedic implant surgery |
| Ward Sr et al. (2014) [20] | Surgical gloves and gowns |
1. 102 surgical team members 2. 251 surgical team members |
1. 31 vs. 7% baseline bacterial contamination in cloth gowns vs. paper gowns 2. 23% of surgeons retaining outer gloves had positive glove contamination vs. 13% of those exchanging gloves |
Recommendation for disposable paper gowns and outer glove exchange just before handling implant materials |
| Klaber et al. (2019) [21] | Surgical gowns | 140 surgical gowns | Bacterial contamination in 12% of surgical gowns (4% in total hip arthroplasty vs. 22% in spine and knee surgery) | Higher surgical gown contamination during non-arthroplasty procedures |
| Wichmann et al. (2019) [22] | Surgical gloves | 43 pairs of knitted cotton outer gloves | 9% of gloves yielded > 100 CFU under aerobic conditions, 14% under anaerobic conditions | Low microbial contamination of knitted cotton outer gloves, but relevant proportion showing contamination above minimal thresholds |
| Amirfeyz et al. (2007) [23] | Theatre shoes | 50 outside shoes, 50 theatre shoes morning and 50 end of day | Microbial growth in 90% of outside shoes, 68% of theatre shows in the morning, and 56% of theatre shoes end-of-day | Recommendation for dedicated theatre shoe use and good floor washing protocol |
| Implant exposure to air | ||||
| Bible et al. (2013) [24] | Coverage of implants | 105 surgical trays (54 uncovered vs. 51 covered trays) | Overall 10% contamination with 2% of covered vs. 17% of uncovered implants | Coverage of implants significantly reduces their contamination |
| Dalstrom et al. (2008) [25] | Coverage of implants | 45 surgical trays (15 uncovered and no traffic, 15 uncovered and traffic, 15 covered) | Microbial growth in 4% at 30 min to 30% at 4 h of uncovered trays vs. 0% in covered trays | Coverage of implants significantly reduces their contamination; microbial growth correlated with the duration of open exposure |
| Menekse et al. (2015) [26] | Coverage of implants | 42 surgical trays (20 uncovered vs. 22 covered) | Microbial growth in 55% vs. 18% in uncovered and covered trays, respectively, after 120 min | Coverage of implants significantly reduces their contamination; microbial growth correlated with the duration of open exposure |
| Uzun et al. (2019) [27] | Coverage of implants | 60 surgical trays (30 uncovered vs. 30 covered) | Statistically significant difference in contamination at all time points | Coverage of implants significantly reduces their contamination; microbial growth correlated with the duration of open exposure |
| Agarwal et al. (2019b) [28] | Usage of an impermeable guard | 10 sterile packaged pedicle screws (5 with and 5 without an intraoperative guard) | All samples without guard showed bacterial growth; none with guard | Using an intraoperative guard provides higher asepsis |
| Smith et al. (2009) [29] | Individual packaging | 50 screw packets | Microbial growth on 48% of packet exteriors and in 14% of acts of opening | Individual packaging of screws is a potential risk factor for contamination |
| Surgical environment | ||||
| Andersson et al. (2012) [30] | Door openings, number of persons in the OR | 30 orthopaedic surgeries in 3 ORs | Positive correlation between CFU and door openings and CFU and number of persons in the OR | Negative impact of traffic flow and number of persons present in the OR |
| Perez et al. (2018) [31] | Door openings, number of persons in the OR | 48 orthopaedic and general surgeries | Positive correlation between CFU and door openings and number of persons in the OR | Negative impact of traffic flow and number of persons present in the OR |
| Knobben et al. (2006) [32] | Door openings, number of persons in the OR, airflow systems | 207 orthopaedic surgeries | Under original conditions 33% of contamination and 11% of SSI, after disciplinary measures and LAF installation 9 and 1% of SSI | Systemic and behavioral changes significantly decrease bacterial contamination and SSI |
| Andersson et al. (2014) [33] | Airflow systems | 63 orthopaedic implant surgeries (30 DV, 33 LAF) | Bacterial growth > 10 CFU/m3 in 1% of LAF ORs and 57% of DV ORs | LAF ORs offer high-quality air during surgery |
| Sadrizadeh et al. (2014) [34] | Airflow systems | Physical model | Reduction of airborne and sedimenting bacteria-carrying particles by MLAF | MLAF may be an option to reduce the level of microbial contamination |
| Sossai et al. (2011) [35] | Airflow systems | 34 total knee arthroplasties (17 with MLAF, 17 without) | Reduction of bacterial count from 24 CFU/m3 without MLAF to 4 CFU/m3 with MLAF | MLAF may be an option to reduce the level of microbial contamination |
| Noguchi et al. (2017) [36] | Airborne particles | 3 patterns of physical movements | Large number of particles when unfolding surgical gown, removing gloves, and putting arms through gown sleeves; LAF reduced particles | Unnecessary actions should be avoided and LAF potentially reduces bacterial contamination |
| Richard and Bowen (2017) [37] | OR surfaces | 13 surfaces in 6 orthopaedic ORs | Bioburden detectable on all included surfaces | Detection of environmental trouble spots in the OR possible with ATP bioluminescence |
| Supportive equipment | ||||
| Ahmad et al. (2011) [38] | Supports | 40 supports used in 20 hip arthroplasty procedures | 85% of anterior and 50% of posterior supports showed bacterial colonisation | High bacterial load on supports may contribute to higher infection rates |
| Ranawat et al. (2004) [39] | Pressure sore prevention pads | 13 pressure sore prevention pads | 85% of pads showed bacterial growth | Use of pressure sore prevention pads should be closely reviewed |
| Ahmed et al. (2009) [40] | Tourniquets | 20 tourniquets | All tourniquets were contaminate with 9 to > 385 CFU | Tourniquets should be cleaned before every surgery |
ART anesthesia ready time, CFU colony forming units, DV displacement ventilation system, LAF laminar airflow ventilation system, MLAF mobile laminar airflow ventilation system, OR operating room, SSI surgical site infection