Download Single versus double blade technique for skin incision and deep

Journal of Orthopaedic Surgery 2016;24(1):67-71
Single versus double blade technique for skin
incision and deep dissection in surgery for
closed fracture: a prospective randomised
control study
Vivek Trikha,1 Pramod Saini,2 Purva Mathur,3 Abhinav Agarwal,1 Senthil V Kumar,1 Budhhadev Choudhary1
Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
Department of Spine Surgery, PD Hinduja Hospital & MRC, Mahim, Mumbai, India
3
Department of Microbiology, JPNATC, AIIMS, New Delhi, India
1
2
ABSTRACT
Purpose. To compare blade cultures in surgery
for closed fracture using a single or double blade
technique to determine whether the current practice
of double blade technique is justified.
Methods. 155 men and 29 women aged 20 to 60 (mean,
35) years who underwent surgery for closed fracture
with healthy skin at the incision site were included.
Patients were block randomised to the single (n=92)
or double (n=92) blade technique. Blades were sent
for bacteriological analysis. Outcome measures were
early surgical site infection (SSI) within 30 days and
cultures from the blades.
Results. The 2 groups were comparable in baseline
characteristics. In the single blade group, 6 surgical
blades and 2 control blades showed positive cultures;
4 patients developed SSI, but only one had a positive
culture from the surgical blade (with different
organism isolated from the wound culture). In the
double blade group, 6 skin blades, 7 deep blades,
and 0 control blade showed positive culture; only
2 patients had the same bacteria grown from both
skin and deep blade. Five patients developed SSI,
but only one patient had a positive culture from the
deep blade (with different organism isolated from
the wound culture). The difference in incidence of
culture-positive blade or SSI between the 2 groups
was not significant. The relative risk of SSI in the
single blade group was 0.8. Positive blade culture
was not associated with SSI in the single or double
blade group.
Conclusion. The practice of changing blade following
skin incision has no effect on reducing early SSI in
surgery for closed fracture in healthy patients with
healthy skin.
Key words: orthopedic procedures; surgical wound
infection
INTRODUCTION
It is a traditional practice to change a surgical blade
after skin incision and use a new blade for deeper
dissection to prevent surgical site infection (SSI).1 SSI
Address correspondence and reprint requests to: Pramod Saini, Department of Spine Surgery, PD Hinduja Hospital & MRC,
Mahim, Mumbai, India. Email: [email protected]
68
Journal of Orthopaedic Surgery
V Trikha et al.
is defined as infection at or near the surgical incision
occurring within 30 days (extended to 1 year in the
presence of an implant) of surgery, and is the most
common category of nosocomial infection among
surgical patients.2–5 Most early SSIs are caused by skin
commensals.6
Some studies have suggested abandoning
this ‘double blade’ technique,7–13 based on blade
cultures and few incidence of infection. Others
recommend continuing the practice because of
blade contamination.14–16 This study compared
blade cultures in surgery for closed fractures using
the single or double blade technique to determine
whether the current practice of double blade
technique is justified.
MATERIALS AND METHODS
This prospective randomised controlled blinded
study was approved by the institutional ethical
board and registered with the Clinical Trials Registry
of India. Informed consent was obtained from each
patient.
According to the Consolidated Standards of
Reporting Trials guidelines,17 155 men and 29 women
aged 20 to 60 (mean, 35) years who underwent
surgery for closed fracture with healthy skin at the
incision site between January and July 2013 were
included. Patients with open fracture, skin disease,
compromised skin and soft tissue around the incision
site, reoperation, chronic immunosuppressive
conditions, diabetes or other systemic diseases, or
who were unable to give informed consent or refused
to participate were excluded.
Patients were block randomised to the single
(n=92) or double (n=92) blade technique. Surgery
was carried out in an operating theatre with laminar
airflow ventilation. First-generation cephalosporin
was given half an hour before skin incision; a repeat
dose was given if the operating time exceeded 2
half-lives of the drug. Antibiotics were discontinued
24 hours after surgery. Skin was prepared with 4%
chlorhexidine gluconate and then 10% povidone
iodine. An antibacterial-impregnated barrier (Ioban,
3M, USA) was used.
Blades were transferred to sterile containers by
the scrub nurse immediately after use. To control for
false-positive results secondary to environmental
contamination, an unused blade kept on the
instrument table was also sent for bacteriological
analysis. The blades were pressed onto culture
plates, which was then transferred to Robertson
cooked meat broth for enrichment. Post incubation
in the enrichment media both aerobic and anaerobic
subculture was taken. Blood and MacConkey agar
was used for aerobic bacteria. Anaerobic blood agar
plates were supplemented with brain heart infusion,
vitamin K, and haemin.
Postoperatively, surgical wounds were examined
after 48 hours and then daily until discharge and at
days 14 and 30. Wounds were considered infected
if 2 of the following were present: (1) seropurulent
discharge, (2) positive culture of exudates, and
(3) local signs and symptoms of infection such as
redness, swelling, increased local temperature.2–4 All
patients were instructed to report to the hospital for
any symptoms of infection. Any discharge from the
wounds was swabbed and sent for bacteriological
analysis.
Outcome measures were early SSI within 30
days and cultures of the blades. The 2 groups were
compared using the Mann-Whitney U test for
continuous variables and the Chi-squared test or
Fisher exact test for categorical variables. The upper
boundary of the 95% confidence interval (CI) for
difference in the incidence of SSI between 2 groups
was not >1%. An intent-to-treat-analysis was used.
The latest follow-up data were used for any missing
data.
RESULTS
Of the 184 patients, one patient in the single blade
group died in the early postoperative period, and
2 patients in the single blade group and one in the
double blade group were lost to follow-up. The
remaining 89 patients in the single blade group and
91 patients in the double blade group completed the
entire follow-up.
The 2 groups were comparable in terms of
baseline characteristics (Table 1). In the single blade
group, 6 surgical blades and 2 control blades showed
positive cultures; 4 patients developed SSI, but only
one had a positive culture from the surgical blade
(with different organism isolated from the wound
culture). In the double blade group, 6 skin blades,
7 deep blades, and 0 control blade showed positive
cultures; only 2 patients had the same bacteria
grown from both skin and deep blades. Five patients
developed SSI, but only one patient had a positive
culture from the deep blade (with different organism
isolated from the wound culture). The difference in
incidence of culture-positive blade between the 2
groups was not significant (p=0.220).
Respectively in the single and double blade
groups, the incidence of SSI was 4.35% (95% CI=0.18–
Vol. 24 No. 1, April 2016
Single versus double blade technique in surgery for closed fractures
69
Table 1
Baseline characteristics of patients in the single and double blade groups*
Single blade group (n=92)
Age (years)
No. of males: females
Delay in surgery (days)
Length of hospital stay (days)
American Society of Anesthesiologists
Grade 1
Grade 2
Duration of surgery (minutes)
Bone involved
Femur
Tibia
Foot
Patella
Humerus
Radius & ulna
Hand
Pelvis & acetabulum
Spine
Clavicle
Type of implant used
Intramedullary nail
Plate
Screw
Prosthesis
Double blade group (n=92)
35.1 (20–60)
78:14
2.9 (1-10)
9.5 (2-21)
34.1 (20–60)
77:15
3.2 (1-9)
9.2 (3-21)
74
18
110.4 (35–200)
70
22
106.7 (45–200)
47
17
1
2
8
1
1
12
2
1
36
15
1
0
9
11
0
15
4
1
24
54
11
3
63
22
6
1
p Value
0.530
0.728
0.132
0.754
0.409
0.331
0.112
0.341
* Data are presented as mean (range) or no. of patients
Table 2
Patients with positive culture in any of the surgical or control blade or surgical site in the single blade group
Patient no.
3
17
26
28
29
38
46
50
74
79
Surgical blade
Control blade
Diptheroids
Sterile
S epidermidis
Sterile
S epidermidis
S epidermidis
Sterile
Acinetobacter baumenii
Sterile
S aureus
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Pseudomonas
S hominis
Sterile
Sterile
Surgical site infection
Escherichia coli
Klebsiella
Enterococcus faecalis
E coli
Table 3
Patients with positive culture in any of the skin, deep, or control blade or surgucial site in the double blade group
Patient no.
2
11
15
17
18
32
35
39
42
51
55
59
86
90
91
Skin blade
Deep blade
Control blade
Sterile
Micrococcus
Sterile
Diptheroids
Sterile
Sterile
Sterile
Sterile
Sterile
S epidermidis
S haemolyticus
S epidermidis
Sterile
S hominis
Sterile
S xylosus
Sterile
Sterile
Sterile
S aureus
S epidermidis
S hominis
Sterile
Sterile
S epidermidis
Sterile
Sterile
S xylosus
S hominis
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Sterile
Surgical site infection
Proteus
Klebsiella
Acinetobacter baumenii
Enterococcus faecalis
Enterococcus faecalis
70
Journal of Orthopaedic Surgery
V Trikha et al.
8.5%) and 5.43% (95% CI=0.8–10.06%) based on
intention-to-treat analysis, and was 4.49% (95%
CI=0.19–8.79%) and 5.49% (95% CI=0.81–10.17%)
based on per protocol analysis, with the difference in
incidence being -1.09% (95% CI= -0.0899 to 0.0681); the
negative value indicated in favour of the single blade
group. The difference in incidence of SSI between the
2 groups was not significant (p=0.500 in intention-totreat analysis, p=0.514 in per protocol analysis, onesided test). The relative risk of SSI in the single blade
group was 0.8 (95% CI=0.221–2.884) in the intentionto-treat analysis and 0.81 (95% CI=0.226–2.947) in the
per protocol analysis. Positive blade culture was not
associated with SSI in the single blade group (p=0.126)
or the double blade group (skin blade: p=0.577, deep
blade: p=0.283).
DISCUSSION
The practice of changing surgical blade after skin
incision to prevent SSI can be traced back to the
pre-antibiotic era in which microorganisms were
isolated from sweat and surgically prepared skin.18,19
Changing blades became a routine practice following
introduction of the ‘no touch technique’.20
Skin harbours microorganisms, mostly bacteria,
which can be broadly divided into resident flora
that permanently reside on skin in superficial layers
of the epidermis and the appendages, and transient
flora that is transferred from the environment to the
skin for a short period.21 These microbes are usually
non-pathogenic and act as commensals, but can be
pathogenic in patients with local or systemic immunity
problems. Preoperative preparation of skin with
antiseptics reduces the number of microorganisms on
skin but cannot completely eradicate them, especially
the resident flora.22 Hypothetically, whenever the skin
is incised, microorganisms that colonise the deeper
layers of skin can contaminate the exposed tissues
and lead to SSI.
The most common blade culture isolated is
coagulase negative staphylococcus, which is a
skin commensal.14,15 Some studies reported higher
bacterial isolation rate from skin than deep blades;
this theoretically can lead to an increase in SSI if the
blade is not changed, but the actual infection rate was
not measured.14,15
In our study, using a separate blade for skin
and deep incision did not result in reduced SSI. The
deep blade could be equally contaminated with
skin flora, and patients with positive blade cultures
did not necessarily develop SSI. Moreover, positive
culture from control blades indicated non-operative
contamination. Nonetheless, the cost of treating SSI is
much higher than that of a new blade.14 If the double
blade technique is logically sound, why suture
needles that pass through the skin many times have
never been reported to increase the risk of SSI.23–25
There were a few limitations to this study. A
power analysis should have been performed. A larger
sample may have been needed to show a significant
difference between groups, because the incidence of
SSI is low after clean operations for healthy patients
with closed fracture and healthy skin. Nonetheless,
there is no study with strong methodological basis
that can determine the effect of changing surgical
blade on the incidence of SSI in this population. In
addition, although the surgeon was blinded as to
whether the blade was the same or changed by the
scrub nurse, he may have guessed by the presence
or absence of blood on the blade. In addition, the
follow-up was short and potential cases of SSI could
have been missed, because patients with an implant
remain susceptible for SSI up to a year.2 Nonetheless,
only early SSI that occurs within 30 days is related to
skin commensals. The findings of this study can only
be generalised to healthy patients with closed fracture
with clean and healthy skin, rather than those with
open fracture, systemic disease, or unhealthy skin.
CONCLUSION
The practice of changing blade following skin incision
has no effect on reducing early SSI in surgery for
closed fracture in healthy patients with healthy skin.
DISCLOSURE
No conflicts of interest were declared by the authors.
REFERENCES
1. Tejwani NC, Immerman I. Myths, and legends in orthopaedic practice: are we all guilty? Clin Orthop Relat Res
2008;466:2861–72.
2. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a
Vol. 24 No. 1, April 2016
Single versus double blade technique in surgery for closed fractures
71
modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–8.
3. Peel AL. Definition of infection. In: Taylor EW, editor. Infection in surgical practice. Oxford: Oxford University Press;
1992:82–7.
4. Ward HR, Jennings OG, Potgieter P, Lombard CJ. Do plastic adhesive drapes prevent post caesarean wound infection? J
Hosp Infect 2001;47:230–4.
5. Watanabe A, Kohnoe S, Shimabukuro R, Yamanaka T, Iso Y, Baba H, et al. Risk factors associated with surgical site infection
in upper and lower gastrointestinal surgery. Surg Today 2008;38:404–12.
6. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med 2004;351:1645–54.
7. Jacobs HB. Skin knife-deep knife: the ritual and practice of skin incisions. Ann Surg 1974;179:102–4.
8. Ritter MA, French ML, Eitzen HE. Bacterial contamination of the surgical knife. Clin Orthop Relat Res 1975;108:158–60.
9. Fairclough JA, Mackie IG, Mintowt-Czyz W, Phillips GE. The contaminated skin-knife. A surgical myth. J Bone Joint Surg Br
1983;65:210.
10. Hasselgren PO, Hagberg E, Malmer H, Saljo A, Seeman T. One instead of two knives for surgical incision. Does it increase
the risk of postoperative wound infection? Arch Surg 1984;119:917–20.
11. Grabe N, Falstie-Jensen S, Fredberg U, Schröder H, Sörensen I. The contaminated skin-knife: fact or fiction. J Hosp Infect
1985;6:252–6.
12. Hill R, Blair S, Neely J, Ramanathan M. Changing knives a wasteful and unnecessary ritual. Ann R Coll Surg Engl
1985;67:149–51.
13. Ramon R, Garcia S, Combalia A, Puig de la Bellacasa J, Segur JM. Bacteriological study of surgical knives: is the use of two
blades necessary? Arch Orthop Trauma Surg 1994;113:157–8.
14. Schindler OS, Spencer RF, Smith MD. Should we use a separate knife for the skin? J Bone Joint Surg Br 2006;88:382–5.
15. Davis N, Curry A, Gambhir AK, Panigrahi H, Walker CR, Wilkins EG, et al. Intraoperative bacterial contamination in
operations for joint replacement. J Bone Joint Surg Br 1999;81:886–9.
16. Matar WY, Jafari SM, Restrepo C, Austin M, Purtill JJ, Parvizi J. Preventing infection in total joint arthroplasty. J Bone Joint
Surg Am 2010;92(Suppl 2):36–46.
17. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel
group randomized trials. Ann Intern Med 2010;152:726–32.
18. Welch WH. Conditions underlying the infections of wounds. Am J Med Sci 1891;102:438–41.
19. Welch WH. General bacteriology of surgical infections. In: Dennis FS, editor. System of surgery. Philadelphia: Lea Bros;
1895:25.
20. Fu LK. History of orthopaedics. Great names in the history of orthopaedics XIII: William Arbuthnot Lane. Hong Kong J
Orthop Surg 2010;14:52–62.
21. Lilly HA, Lowbury EJ. Transient skin flora: their removal by cleansing or disinfection in relation to their mode of deposition.
J Clin Pathol 1978;31:919–22.
22. Selwyn S. Skin preparation, the surgical ‘scrub’ and related rituals. In: Karran S, editor. Controversies in surgical sepsis. New
York: Praeger; 1980:23–32.
23. Figueroa D, Jauk VC, Szychowski JM, Garner R, Biggio JR, Andrews WW, et al. Surgical staples compared with subcuticular
suture for skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol 2013;121:33–8.
24. Shuster M. Comparing skin staples to sutures. Can Fam Physician 1989;35:505–9.
25. Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ
2010;340:c1199.