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

Table 3 Surgical skin preparation demographics and results of studies in foot and ankle surgery

Ref.	Level of evidence	Surgery type	Sample size (n)	Interventions	Comparisons	Key findings
Becerro de Bengoa Vallejo et al[33], 2009, Spain	Prospective randomized comparative study (level 2)	Foot	28	4% chlorhexidine gluconate scrub for 5 minutes + 70% isopropyl alcohol paint (P); 7.5% povidone-iodine scrub for 5 minutes + 10% povidone-iodine paint (P); prewash with 70% isopropyl alcohol for 3 minutes + 7.5% povidone-iodine scrub for 5 minutes + 10% povidone-iodine paint (P); 4% chlorhexidine gluconate immersion + prewash with 70% isopropyl alcohol for 3 minutes + 7.5% povidone-iodine scrub for 5 minutes + 10% povidone-iodine paint (P)	Culture growth of nail fold and first web space	The nailfold remained contaminated regardless of preparation type; the addition of alcohol may reduce the bacterial load in foot surgery, however, study results are limited due to lack of measurement of clinical infections
Cheng et al[34], 2009, United Kingdom	Randomized control trial (level 1)	Forefoot surgery	50	0.5% chlorhexidine gluconate in 70% isopropyl alcohol (S); 1% povidone-iodine in 23% isopropyl alcohol (S)	Culture growth before and after skin preparation	No significant difference in colony growth between skin preparation methods
Hunter et al[35], 2016, United States	Randomized control trial (level 1)	Foot and ankle surgeries	95	4% chlorhexidine application followed by 70% isopropyl alcohol rinse (P); 70% isopropyl alcohol followed by 4% chlorhexidine (P)	Cultures and postoperative SSI between the cohorts	The alcohol followed by chlorhexidine group showed a significant difference in positive cultures after draping (P = 0.02) and postoperatively (P = 0.05); there was no difference in SSI between the two cohorts
Keblish et al[36], 2005, United States	Randomized control trial (level 1)	Foot and ankle of volunteers	50	10% povidone-iodine alone (P); 10% povidone-iodine alone and 70% isopropyl alcohol pre-wash (P); 10% povidone-iodine and scrubbing with bristled brush (P); 70% isopropyl alcohol and scrubbing with bristled brush (N/A)	Cultures of hallux nailfold, interdigital web spaces, and anterior ankle	1.70% isopropyl alcohol and scrubbing with bristled brush showed a significant reduction in positive cultures from the nail-fold when compared with other preparation methods (P < 0.001); quantitative analysis found that bristled brushes had a significant decrease in heavy growth when compared to no bristles (P < 0.01)
Mehraban et al[37], 2021, United States	Randomized control trial (level 1)	Foot and ankle surgery	242	70% isopropyl alcohol followed by 2% chlorhexidine in 70% isopropyl alcohol (S); 7.5% povidone-iodine followed by 70% isopropyl alcohol followed by 2% chlorhexidine in 70% isopropyl alcohol (P + S)	Culture taken from the hallux nailfold	There was no significant difference in culture rate between cohorts
Ostrander et al[38], 2005, United States	Randomized control trial (level 1)	Foot and ankle surgery	125	2% chlorhexidine gluconate in 70% isopropyl alcohol (S); 0.7% iodine in 74% isopropyl alcohol (S); 3% chloroxylenol (S)	Culture at the toe and hallux sites	The chlorhexidine culture was significantly lower at both hallux (P = 0.01) and small toe site (P = 0.05) than the iodine group, and the iodine group was significantly lower than chloroxylenol (P = 0.001)
Rugpolmuang et al[39], 2012, Thailand	Randomized control trial (level 1)	Foot of volunteers	20	4% chlorhexidine gluconate scrub then painted with 2% chlorhexidine in 70% alcohol (P + S); 7.5% povidone-iodine scrub then painted with 10% povidone-iodine (P)	Cultures taken from toes, nail fold, interdigital spaces	There was no significant difference in culture rate between cohorts
Shadid et al[40], 2019, Netherlands	Randomized control trial (level 1)	Foot surgery	49	0.5% chlorhexidine with 70% isopropyl alcohol (S); 1% iodine with 70% isopropyl alcohol (S)	Cultures, complications and postoperative SSI between cohorts	There was no significant difference in SSI, complications or cultures between cohorts
Talhaoğlu and Çürük[41], 2023, Türkiye	Randomized trial (level 1)	Diabetic foot debridement	60	0.05% chlorhexidine gluconate before and after debridement, 10% povidone iodine (P + S); 10% povidone iodine (P)	Cultures taken after debridement	Microbial growth was 46.7% in the chlorhexidine group after debridement and 83.3% in the iodine alone group (P = 0.05); the mean number of species per foot was reduced in the chlorhexidine group (P = 0.05)

S: Stick application; P: Paint application; P + S: Paint and stick; N/A: Not applicable; SSI: Surgical site infection.