Preoperative Sterilization Preparation of the Shoulder: A Comparative Study Evaluating Gauze Sponge and Commercially Available Applicator Prep Stick

Document Type : RESEARCH PAPER


1 Shoulder and Elbow Division, The Rothman Institute, Philadelphia, PA, USA

2 Department of Orthopedics, University of Colorado, USA

3 Medical Student, Drexel University College of Medicine, Philadelphia, PA

4 Department of Biomedical Engineering, Drexel University, Philadelphia, PA, USA

5 Division of Hand Surgery Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA


Background: Surgical site infection (SSI) remains a concern in shoulder surgery, especially during arthroplasty. While
many studies have explored the characteristics and efficacy of different sterilizing solutions, no study has evaluated the
method of application. The purpose of this study was to compare two popular pre-surgical preparatory applications (two
4 x 4 cm gauze sponges and applicator stick) in their ability to cover the skin of the shoulder.
Methods: Two orthopedic surgeons simulated the standard pre-surgical skin preparation on 22 shoulders of volunteer
subjects. Each surgeon alternated between an applicator stick and two sterile 4x4 cm gauze sponges. Skin preparation
was performed with a commercially available solution that can be illuminated under UV-A light. Advanced imageanalysis
software was utilized to determine un-prepped areas. A two-tailed paired t-test was performed to compare
percentage of un-prepped skin.
Results: The applicator stick method resulted in a significantly higher percentage of un-prepped skin (27.25%, Range
10-49.3) than the gauze sponge method (15.37%, Range 5-32.8, P=0.002). Based on image evaluation, most unprepped
areas were present around the axilla.
Conclusion: Based on our findings, the use of simple gauze sponges for pre-surgical preparatory application of
sterilization solution may result in a lower percent of un-prepped skin than commercially available applicator stick.
Orthopaedic surgeons and operating room staff should be careful during the pre-surgical sterile preparation of the
shoulder, especially the region around the axilla, in order to reduce the potential risk of surgical site infection.


Main Subjects

1. Boekel P, Blackshaw R, Van Bavel D, Riazi A, Hau
R. Sterile stockinette in orthopaedic surgery: a
possible pathway for infection. ANZ J Surg. 2012;
2. Lee MJ, Pottinger PS, Butler-Wu S, Bumgarner RE,
Russ SM, Matsen FA 3rd. Propionibacterium persists
in the skin despite standard surgical preparation. J
Bone Joint Surg Am. 2014; 96(17):1447-50.
3. Savage JW, Weatherford BM, Sugrue PA, Nolden MT,
Liu JC, Song JK, et al. Efficacy of surgical preparation
solutions in lumbar spine surgery. J Bone Joint Surg
Am. 2012; 94(6):490-4.
4. Sperling JW, Kozak TK, Hanssen AD, Cofield RH.
Infection after shoulder arthroplasty. Clin Orthop.
2001; 382(1):206-16.
5. Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau
P. The management of infection in arthroplasty of the
shoulder. J Bone Joint Surg Br. 2004; 86(1):65-9.
6. Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines
JS, Dicarlo E, et al. Propionibacterium acnes infection
after shoulder arthroplasty: a diagnostic challenge. J
Shoulder Elbow Surg. 2010; 19(2):303-7.
7. Padegimas EM, Maltenfort M, Ramsey ML, Williams
GR, Parvizi J, Namdari S. Periprosthetic shoulder
infection in the United States: incidence and economic
burden. J Shoulder Elbow Surg. 2015; 24(5):741-6.
8. Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield
RH. Periprosthetic infections after total shoulder
arthroplasty: a 33-year perspective. J Shoulder Elbow
Surg. 2012; 21(11):1534-41.
9. Verhelst L, Stuyck J, Bellemans J, Debeer P. Resection
arthroplasty of the shoulder as a salvage procedure
for deep shoulder infection: does the use of a cement
spacer improve outcome? J Shoulder Elbow Surg.
2011; 20(8):1224-33.
10. Wirth MA, Rockwood Jr CA. Complications of
shoulder arthroplasty. Clin Orthop Relat Res. 1994;
11. Ambrose CG, Clyburn TA, Mika J, Gogola GR, Kaplan
HB, Wanger A, et al. Evaluation of antibioticimpregnated
microspheres for the prevention of
implant-associated orthopaedic infections. J Bone Joint Surg Am. 2014; 96(2):128-34.
12. Glen L, Scammell B, Ashraf W, Bayston R. How sterile
is patient’s skin after preparation with alcoholic
povidone iodine? Orthop Proc. 2012; 94(Suppl 18):34.
13. Ricciardi BF, Bostrom MP, Lidgren L, Ranstam J,
Merollini KM, W-Dahl A. Prevention of surgical site
infection in total joint arthroplasty: an international
tertiary care center survey. HSS J. 2014; 10(1):45-51.
14. Phadnis J, Gordon D, Krishnan J, Bain GI. Frequent
isolation of Propionibacterium acnes from the
shoulder dermis despite skin preparation and
prophylactic antibiotics. J Shoulder Elbow Surg. 2016;
15. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS,
Koh JL. Efficacy of surgical preparation solutions
in shoulder surgery. J Bone Joint Surg Am. 2009;
16. Szpinda M, Daroszewski M, Szpinda A, Woźniak A,
Wiśniewski M, Mila-Kierzenkowska C, et al. New
quantitative patterns of the growing trachea in human
fetuses. Med Sci Monit. 2012; 18(6):PH63-70.