SLR - December 2020 - Elliott N. Wityk

Preoperative Skin Antisepsis Using Chlorhexidine May Reduce Surgical Wound Infections in Lower Limb Trauma Surgery when Compared to Povidone-Iodine – A Prospective Randomized Trial

Reference: Ritter B, Herlyn PKE, Mittlmeier T, Herlyn A. Preoperative skin antisepsis using chlorhexidine may reduce surgical wound infections in lower limb trauma surgery when compared to povidone-iodine - a prospective randomized trial. Am J Infect Control. 2020 Feb;48(2):167-172. doi: 10.1016/j.ajic.2019.08.008. Epub 2019 Oct 8. PMID: 31604621.

Level of Evidence: 2 - Prospective Randomized Trial

Scientific Literature Review 

Reviewed By: Elliott N. Wityk, DPM
Residency Program: John Peter Smith Hospital – Fort Worth, TX

Podiatric Relevance: Lower limb foot and ankle trauma surgery is an area of interest for many podiatrists and podiatric medicine resident physicians. Preparation of the surgical site in foot and ankle trauma usually consists of preoperative skin antisepsis using Povidone-Iodine (PVP-I) or Chlorhexidine (CHX), but which antiseptic is most effective? The aim of this study is to evaluate which of these two aseptic skin preparations led to fewer postoperative wound healing complications in closed foot and ankle trauma surgery. 

Methods: A prospective randomized trial was performed on 279 consecutive participants undergoing elective or emergency trauma surgery including the lower leg, ankle or foot. The study was performed from June 1, 2014 to March 20, 2015 at a single institution. Exclusion criteria included: personal history of systemic disease, allergy to CHX or PVP-I or any of their components, underage participants (<18 years), polytrauma, open fractures or manifest infections. Of the 279 participants, 167 were treated with PVP-I, and 112 were treated with CHX. Randomization was performed by chronologically enlisting each subject in a randomization list and randomly assigning them to be aseptically prepared using CHX or PVP-I. The primary aim was to compare the occurrence of surgical site infections (SSIs) and wound healing disorders (WHDs) within six months of surgery. 

Results: Two hundred seventy-nine total participants (112 treated with CHX and 167 treated with PVP-I) completed the study and were evaluated 6 months postoperatively. The present study found a difference in the incidence of SSI to be significantly higher with the PVP-I group (9/167) compared to the CHX group (2/112). WHDs were also significantly different with the PVP-I group (12.6 percent) compared to CHX group (4.5 percent). After regression analysis, complications of wound healing were 3.5 times greater in the PVP-I group when compared to the CHX group. 

Conclusions: Trauma surgery of the lower limb, ankle and foot poses inherent challenges to the surgeons treating these complex situations, among these challenges is surgical site infection. The present study concludes that the use of CHX in preoperative skin antisepsis leads to significantly lower wound healing complications at 6 months postoperatively when compared to the use of PVP-I in closed foot and ankle trauma surgery. A possible confounding variable is that PVP-I is more likely to be used in traumatic injuries that feature even mildly compromised skin integrity, which could skew the results. The large discrepancy in the size of the two groups despite randomization is also a concern. Overall, it would be helpful to see these results confirmed by additional studies that explicitly mention the skin integrity.

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