title: Can applied external fixators be sterilized for surgery? A prospective cohort study of orthopaedic trauma patients.
abstract: BACKGROUND
  Temporary external fixators are often used to stabilize fractures when definitive fracture surgery must be delayed. Sometimes, external fixators are left in place during repeat operations, including definitive internal fixation of tibial pilon and tibial plateau fractures. It is unknown how well current surgical preparation sterilizes these devices, which become part of the surgical field. Our hypothesis was that our institution's standard surgical preparation creates a low rate of culture-positive environments on external fixators at the time of surgical skin incision.
  
  
  METHODS
  We prospectively consented and enrolled patients to obtain cultures (48 patients, 55 external fixators, 165 sets of culture data). After standard preparation and immediately before incision, cultures were obtained from three sites on each external fixator: 1) most distal pin 1cm from pin-skin interface, 2) most distal bar at midpoint between pin and clamp connectors, and 3) most distal clamp at bar-clamp interface. Our standard preparation for patients with external fixation in place is to don sterile gloves and wipe down all components of the external fixator with 70% alcohol-soaked sterile 4×4in gauze sponges before skin preparation. The skin and external fixator are then prepped in the usual fashion with ChloraPrep for closed wounds or with povidone iodine scrub and paint for open wounds. Swabs were processed and organisms from cultures identified. Clinicians were blinded to study results until study completion.
  
  
  RESULTS
  Two of 165 cultures (1.2%; 95% confidence interval [CI]: 0-2.9%) were positive for common pathogens sometimes observed in surgical site infection. Four cultures (2.4%; 95% CI: 0-4.8%) had pathogens that are rarely associated with surgical site infection, and four (2.4%; 95% CI: 0-4.8%) had nonpathogenic organisms.
  
  
  CONCLUSIONS
  Using 70% alcohol on external fixators plus either ChloraPrep for closed wounds or povidone iodine for open wounds seems to result in a low rate of positive cultures. Most species that were isolated are infrequently identified as sources of surgical site infections. This preparation protocol might be effective at producing a relatively clean environment at the time of surgery for patients with external fixators already in place.
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
authors.forename: David
authors.initials: D
authors.lastname: Hardeski
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
authors.forename: Greg
authors.initials: G
authors.lastname: Gaski
authors.affiliation: R Adams Cowley Shock Trauma Center, Division of Infectious Disease, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States.
authors.forename: Manjari
authors.initials: M
authors.lastname: Joshi
authors.affiliation: Laboratories of Pathology, University of Maryland Medical System, Baltimore, MD, United States.
authors.forename: Richard
authors.initials: R
authors.lastname: Venezia
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Nascone
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
authors.forename: Marcus F
authors.initials: MF
authors.lastname: Sciadini
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States. Electronic address: rvo3@yahoo.com.
authors.forename: Robert V
authors.initials: RV
authors.lastname: O'Toole
mesh_terms: D019840:2-Propanol / Q000494:pharmacology*; D000328:Adult; D000368:Aged; D000891:Anti-Infective Agents, Local / Q000494:pharmacology*; D016267:External Fixators / Q000382:microbiology*; D005260:Female; D005593:Fracture Fixation, Internal; D005597:Fractures, Open / Q000150:complications / Q000382:microbiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009985:Orthopedics; D011206:Povidone-Iodine / Q000494:pharmacology*; D011446:Prospective Studies; D012867:Skin / Q000382:microbiology; D013242:Sterilization / Q000379:methods*; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology / Q000517:prevention & control; D013978:Tibial Fractures / Q000150:complications / Q000382:microbiology / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States; D014945:Wound Healing; D055815:Young Adult
chemical_list: D000891:Anti-Infective Agents, Local; D011206:Povidone-Iodine; D019840:2-Propanol
keywords: External fixator; Infection; Staphylococcus epidermis; Sterilize