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

Table 4 Surgical skin preparation demographics and results of studies evaluating upper extremity surgery

Ref.	Level of evidence	Surgery type	Sample size (n)	Interventions	Comparisons	Key findings
Blonna et al[42], 2018, Italy	Prospective comparative study (level 2)	Proximal humerus fracture	40	1% povidone iodine in 50% isopropyl alcohol (P); 4% chlorhexidine followed by 1% povidone iodine in 50% isopropyl alcohol (P)	Comparison of positive culture rates	The 4% chlorhexidine followed by 1% povidone iodine in 50% isopropyl alcohol produced a significant decrease in positive coagulase-negative Staphylococci cultures when compared to the single preparation (P < 0.001)
Crutcher et al[43], 2024, United States	Randomized control trial (level 1)	Shoulders of volunteers	72	2% chlorhexidine in 70% isopropyl alcohol alone (S); 3% hydrogen peroxide followed by 2% chlorhexidine in 70% isopropyl alcohol (S)	Comparison of culture growth for C. acnes	No statistically significant difference in culture rate between the two interventions
Dörfel et al[44], 2021, Germany	Prospective crossover (level 2)	Shoulders of volunteers	16	2% chlorhexidine in 70% isopropyl alcohol (S); 3.24% povidone-iodine in 38.9% isopropyl alcohol and 37.3% ethanol (P)	Comparison of culture growth for aerobic and anaerobic bacteria	Aerobic skin flora was significantly reduced by povidone-iodine at 2.5 minutes of application than chlorhexidine (P = 0.04), but not at thirty minutes or three hours; anaerobic skin flora was significantly reduced by povidone-iodine at 2.5 minutes (P < 0.01) and 30 minutes (P < 0.01) of application than chlorhexidine, but not at three hours
Hancock et al[45], 2018, New Zealand	Randomized control trial (level 1)	Shoulder of volunteers	22	Two applications of 2% chlorhexidine in alcohol (S); 5% benzoyl peroxidase wash + 2% chlorhexidine in alcohol (S)	Comparison of culture growth for C. acnes of the anterior deltoid and axilla	No statistically significant difference in culture growth between the two groups
Mizels et al[46], 2024, United States	Prospective comparative study (level 3)	Total shoulder arthroplasty	61	70% ethyl alcohol followed by two applications of 2% chlorhexidine in 70% isopropyl alcohol (S); 70% ethyl alcohol followed by hydrogen peroxide followed by two applications of 2% chlorhexidine in 70% isopropyl alcohol (S)	Comparison of patient reported outcomes, infection rate, and revision surgeries	No statistical difference was found in patient reported outcomes between groups; no statistical difference was found in revision or infection rate between groups
Saltzman et al[47], 2009, United States	Randomized control trial (level 1)	All shoulder surgeries	150	2% chlorhexidine gluconate in 70% isopropyl alcohol (S); 0.7% iodophor 74% isopropyl alcohol (S); 0.75% iodine scrub and 1.0% iodine paint (P)	Comparing positive culture rate of the different preparation methods	The positive culture rate was significantly lower in the chlorhexidine group than the iodophor (P = 0.01) or iodine paint (P < 0.001) groups; chlorhexidine and iodophor significantly reduced positive coagulase-negative Staphylococcus cultures (P < 0.001 for both groups); no significant difference noted for positive C. acnes cultures between the groups
Wade et al[51], 2021, United Kingdom	Prospective cohort (level 2)	Upper limb surgeries	2454	Aqueous or alcoholic chlorhexidine (P) (concentration unspecified); aqueous or alcoholic povidone-iodine (P) (concentration unspecified)	Comparison of 90 days SSI between the two groups	Alcoholic povidone iodine produced a decreased risk of SSI in emergency upper extremity surgery (HR = 0.15; 95%CI: 0.02-0.94); alcoholic chlorhexidine produced a decreased risk of SSI in elective upper extremity surgery (HR = 0.30; 95%CI: 0.11-0.83)
Xu et al[49], 2017, United States	Randomized control trial (level 1)	Hand surgery	240	10% povidone-iodine (P); 2% chlorhexidine gluconate in 70% isopropyl alcohol (S); 0.7% iodine in 74% isopropyl alcohol (S)	Comparison of positive cultures	1.2% chlorhexidine gluconate and 70% isopropyl alcohol had higher rates of positive cultures than the 10% povidone-iodine and 0.7% iodine and 74% isopropyl alcohol groups (P < 0.001)
Yamakado[50], 2021, Japan	Randomized control trial (level 1)	Arthroscopic rotator cuff repair	151	1% chlorhexidine gluconate in 70% isopropyl alcohol (S); chlorhexidine alcohol with 3% hydrogen peroxide (S)	Comparison of the cultures of cut arthroscopic sutures and SSI	There was no statistically significant difference in the positive culture rate for C. acnes or number of SSI between the two groups

S: Stick application; P: Paint application; SSI: Surgical site infection; C. acnes: Cutibacterium acnes; HR: Hazard ratio; CI: Confidence interval.