Effectiveness of surgical skin preparation solutions in orthopaedic surgery: A systematic review of the current comparative literature

Table 2 Surgical skin preparation demographics and results of studies evaluating lower extremity surgery

Ref.	Level of evidence	Surgery type	Sample size (n)	Interventions	Comparisons	Key findings
Cho et al[27], 2023, China	Randomized control trial (level 1)	Total knee arthroplasty	150 (50 per group)	10% povidone-iodine scrub-and-paint (P); 2% chlorhexidine gluconate in 72% ethanol paint after povidone-iodine scrub (P); 10% povidone-iodine paint after 2% chlorhexidine gluconate in 72% ethanol scrub (P)	Post preparation culture swabs between the groups	Povidone-iodine scrub-and-paint group had positive cultures in 12% of patients; chlorhexidine gluconate paint after povidone-iodine scrub had positive cultures in 2%; povidone-iodine paint after chlorhexidine gluconate had positive cultures in 2%; isolated povidone-iodine scrub-and-paint had a significantly higher number of positive cultures (P = 0.037)
Droll et al[28], 2022, Canada	Randomized control trial (level 1)	Total hip arthroplasty	105	2% chlorhexidine gluconate in 70% isopropyl alcohol (S); 0.7% iodophor in 74% isopropyl alcohol (S)	Comparison of cultures pre-preparation and post-preparation	The pre-preparation chlorhexidine group had positive cultures in 93% of patients, and the iodophor group had positive cultures in 94% of patients; after preparation, the iodophor had a lower relative risk of a positive culture than the chlorhexidine group (RR = 0.40, 95%CI: 0.18-0.85)
Rouquette et al[29], 2020, France	Prospective cohort study (level 2)	Thigh sampling of lower extremity volunteers	30	5% povidone-iodine in 95% ethanol with adhesive polyester draping (U); 5% povidone-iodine in 95% ethanol with adhesive iodine draping (U); 0.5% chlorhexidine in 90% ethanol with adhesive polyester draping (U); 0.5% chlorhexidine in 90% ethanol with adhesive iodine draping (U)	Culture growth at 30 minutes intervals up to 90 minutes after draping	No protocols demonstrated superiority in reducing bacterial load
Morrison et al[30], 2016, United States	Randomized control trial (level 1)	Total joint arthroplasty	600	7.5% povidone-iodine scrub, followed by 10% iodine paint, and 75% isopropyl alcohol (P); preparation of group one plus 0.7% iodine povacrylex in 74% isopropyl alcohol after draping (S)	Rate of SSI and blistering between the groups	The intervention group with the additional intervention after draping had significantly lower superficial SSI (P = 0.02); the intervention group had lower rates of blistering, but this was not statistically significant
Peel et al[31], 2019, Australia	Randomized control trial (level 1)	Total joint arthroplasty	780	0.5% chlorhexidine gluconate in 70% ethanol (S); 1% iodine in 70% ethanol (S)	Postoperative SSI and superficial wound complications	No difference in superficial wound complications between the chlorhexidine and iodine-based groups; significantly higher odds of SSI in the chlorhexidine group when compared with the iodine group (OR = 3.55; 95%CI: 1.20-10.44; P = 0.022)
Ritter et al[32], 2020, Germany	Randomized control trial (level 1)	Lower limb fractures	279	2% chlorhexidine in 70% isopropyl alcohol (S); 1% povidone-iodine in 50% 2-propanol (S)	Postoperative SSI and wound healing disorders	The povidone-iodine group had significantly higher rates of SSI and wound healing disorders than the chlorhexidine group (P = 0.022)

S: Stick application; P: Paint application; U: Unspecified application method; SSI: Surgical site infection; RR: Risk ratio; CI: Confidence interval; OR: Odds ratio.