Busting Myths in the Operating Room

Surgery is arguably as much an art as it is a science, and it could be said that there is even some superstition involved when operating. Some surgeons like the exact same setup for every case, with some of these practices rooted in evidence, while instead other practices are just what people were taught and continue to do. Let’s take a quick dive into a few examples of these practices and see what is evidence-based versus simply convention.
 
Covering the toes in rearfoot surgery. Perioperative infection control is of utmost importance for modern day surgeons. Infections can increase morbidity and mortality, and are a large burden to the health care system in The United States.¹ A tactic I’ve observed many surgeons use to combat infections when performing hindfoot and ankle surgeries is to cover the digits, usually with a self-adherent bandage (eg, Coban) or a sterile glove. It turns out that the available data shows that covering the toes has no effect on infection rates and is likely not necessary. Goucher and Coughlin in 2007 studied 40 patients randomly assigned to having their toes covered with a sterile glove or uncovered.² Both groups had 3 cultures taken in the second web space—before surgical prep, immediately after draping, and after conclusion of the operation. Each limb was prepped with chlorhexidine gluconate and isopropyl alcohol, and all patients had the same perioperative intravenous antibiotic. Reasonably, most of the patients had positive cultures before the prep. In their sample, 7/40 patients had signs of local wound infection after their operation, 3 of these patients had their toes covered, and 4 did not. All 7 of these patients had oral antibiotic therapy and went on to heal without incident or need to return to the operating room. The authors concluded, based on the data, that there is no apparent benefit to covering the toes for hindfoot surgery.²
 
This was echoed by Foot and Ankle International in a 2019 consensus statement that stated, “during total ankle replacement surgery, there is insufficient data demonstrating advantage or disadvantage to covering the toes.”³ While there isn’t much literature out there, the currently published data demonstrates that this practice is likely unnecessary and possibly a waste of time and resources.^2,3 In order to decrease infection risk, it is likely more prudent to decrease tourniquet time and prep appropriately (either with alcohol-betadine or an alcohol-chlorhexidine solution, the former being non-inferior to the latter).⁴ These techniques have demonstrated a resultant significant decreased risk of perioperative infection.⁴ So, if covering the toes doesn’t work, why do we continue to do it? There is likely no harm in doing so, but it is another semi-regular medical practice without good evidence to support its use.
 
Antibiotics in irrigation solutions. Irrigation is an important step prior to surgical closure as it can reduce microbial burden, metabolic waste from the innate immune response, and tissue exudate.⁵ Irrigants are usually neutral (eg, normal saline), antibiotic, or antiseptic. Unfortunately, this is another topic with mostly low-quality evidence. However, a Cochrane meta-analysis found that there is likely no difference in the incidence of surgical site infection (SSI) between irrigants, especially antibacterial and non-antibacterial.6 The only US Food and Drug Administration (FDA) approved products for surgical wound irrigation are saline, sterile water, and a combination of sterile water and 0.05% chlorhexidine gluconate (CHG).⁷ Zhadan and colleagues found that 30 minutes of exposure with most antiseptic and antibiotic irrigations was needed for sterility of the surgical site, which is significantly more time than surgeons use on average for irrigation.⁸
 
There is also data to suggest that antibiotics and other irrigants other than the 3 listed above may cause harm. With antibiotics, there is a risk of development of antimicrobial resistance, anaphylaxis, tissue irritation, or systemic toxicity.⁹ Bacitracin, which was fairly popular until the FDA requested withdrawal from the market in 2020, has various possible severe side effects including nephrotoxicity and anaphylaxis.¹⁰ Resistance can also develop, as antibiotics need sufficient time to bind to their target site. There also needs to be a persistent concentration above the minimum inhibitory concentration (MIC) 90—which is not met during simple irrigation.⁵ To prevent infection, there should be sufficient antibiotic activity present in the tissue at the time of surgical incision.¹¹ With povidone-iodine (Betadine), high concentrations are toxic to human fibroblasts, and this can lead to a delay in wound healing. However, a 1% solution was found to have bactericidal activity without damaging fibroblasts.^9,10 That being said, a 2017 meta-analysis revealed only low quality evidence suggesting modest benefit to wound irrigation with Betadine compared to saline in clean and clean contaminated surgical wounds.¹² The World Health Organization and United States Centers for Disease Control and Prevention have both suggested irrigation with diluted Betadine prior to surgical closure as being appropriate. However, this is only a weak recommendation due to moderate quality evidence.^13,14
 
Not only is the irrigant of choice important, but the pressure of the fluid delivered is often debated as well. The available literature favors low pressure irrigation, typically between 5–15 psi of pressure.¹⁵ This allows removal of bacteria from tissue while sparing the risk of tissue and bone injury. There also has been no demonstrated benefit of pulsed over continuous lavage.¹⁵ There are unfortunately many variables when it comes to irrigation, which makes it incredibly difficult to infer the “best” combination of irrigant, pressure, angle of jet stream, and pulsed versus continuous delivery.
 
The consensus of available research suggests that if one does irrigate, there is no recommended volume of fluid and lower pressures with sterile saline seems to be appropriate and well-tolerated. The Fluid Lavage of Open Wounds (FLOW) group has done several studies on open fractures and irrigation, and found that castile soap increased reoperation risk compared to plain saline irrigation, and high or low pressure did not differ from gravity pressure.¹⁶
 
Wearing lead in all cases. Radiation exposure is a hazard in many podiatric surgeries, due to using fluoroscopy for most, if not all, osseous procedures. That being said, if one uses a miniature C-arm, how important is wearing a lead apron, and what are the associated risks?
 
During training it was heavily emphasized to me by professors, senior residents, hospital staff, and attendings to always wear lead during every case if any fluoroscopy was planned. There is a large fear of radiation and its increased risk of malignancy, dermatitis, and cataracts; however, some of the risks may be slightly exaggerated.¹⁷ Fuller et al in 2016 demonstrated that in hand surgery, if a surgeon uses 413 seconds (6.8 minutes) of mini C-arm per case, they are subject to approximately 2.7 millirems (mrem). With this level of exposure, one could perform over 18,000 procedures before exceeding the annual allowable exposure limit.¹⁸ It is important to note that this is just the recommended safety limit and it would take 20 times that amount in one year for “excessive risk” and a 5.5–6.0% increase in cancer risk.¹⁹
 
Wearable lead aprons are unfortunately a risk for lead exposure and possible toxicity. Burns et al found that 63% of wearable lead they tested had significant lead dust on the surface, with a higher proportion of these being older/more worn lead, lead that was not hanging, and full-body and thyroid shields. These had the highest chance of containing lead dust.²⁰ The authors concluded that they are “unable to assess the clinical impact, however chronic low-level lead exposure, often asymptomatic, is toxic to both adults and children.” Side effects of lead poisoning/exposure in adults include memory loss, difficulty concentrating, headache, mood disorders, joint and muscle pain, and it can be fatal as well.²¹ Katsari and colleagues demonstrated similar findings in European centers, with 23% of samples tested failing their quality control with levels of lead being too high.²² While these studies cannot draw clear conclusions about clinical relevance, it is important to understand and minimize workplace toxic exposures while inspiring an interesting discussion.
 
Now this isn’t to suggest that one should never wear lead, but it’s important to clean and refresh the lead that you use and store it properly, to ensure both protection from radiation as well as prevention of wear and tear. This may allow the best of both worlds, protection from radiation as well as limiting lead dust exposure to the best of one’s ability.
 
These topics above are debatable and ripe with dogma. However, I think it is important to understand both sides of the proverbial coin and to continue to practice the best possible medicine, rooted in evidence and not solely opinion.

Dr. Ehlers is in private practice in Arvada, CO, and is an attending at the Highlands-Presbyterian/St. Luke’s Podiatric Residency Program. He finds interest in debunking medical myths and dogma.

References
1.    Goucher NR, Coughlin MJ. Covering of the toes during hindfoot and ankle surgery: a randomized, controlled, clinical study. Foot Ankle Int. 2007 Apr;28(4):413-5. doi: 10.3113/FAI.2007.0413. PMID: 17475133.
2.    Piednoir E, Robert-Yap J, Baillet P, Lermite E, Christou N. The socioeconomic impact of surgical site infections. Front Public Health. 2021 Aug 4;9:712461. doi: 10.3389/fpubh.2021.712461. PMID: 34422751; PMCID: PMC8371390.
3.    Kaplan J, Embil JM. During draping for total ankle arthroplasty (TAA), should the foot be prepped into the surgical field or be covered? Foot Ankle Int. 2019 Jul;40(1_suppl):10S-11S. doi: 10.1177/1071100719859327. PMID: 31322942.
4.    Smith SR, Gani J, Carroll R, et al. Antiseptic skin agents to prevent surgical site infection after incisional surgery: a randomized, three-armed combined non-inferiority and superiority clinical trial (NEWSkin Prep Study). Ann Surg. 2022 May 1;275(5):842-848. doi: 10.1097/SLA.0000000000005244. Epub 2021 Oct 8. PMID: 35129525.
5.    Papadakis M. Wound irrigation for preventing surgical site infections. World J Methodol. 2021 Jul 20;11(4):222-227. doi: 10.5662/wjm.v11.i4.222. PMID: 34322371; PMCID: PMC8299912.
6.    Norman G, Atkinson RA, Smith TA, et al. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev. 2017 Oct 30;10(10):CD012234. doi: 10.1002/14651858.CD012234.pub2. PMID: 29083473; PMCID: PMC5686649.
7.    Abboud K, Blee J, Shah PJ. Antibiotic irrigation solutions for prevention of surgical site infections: A call to action. Am J Health Syst Pharm. 2020 Dec 4;77(24):2040-2041. doi: 10.1093/ajhp/zxaa316. PMID: 33079184.
8.    Zhadan O, Becker H. Surgical site irrigation in plastic surgery. Aesthet Surg J. 2018 Feb 15;38(3):265-273. doi: 10.1093/asj/sjx171. PMID: 29087441.
9.    Edmiston CE Jr, Leaper D, Spencer M, et al. Considering a new domain for antimicrobial stewardship: Topical antibiotics in the open surgical wound. Am J Infect Control. 2017 Nov 1;45(11):1259-1266. doi: 10.1016/j.ajic.2017.04.012. Epub 2017 Jun 5. PMID: 28596018.
10. Barnes S, Spencer M, Graham D, Johnson HB. Surgical wound irrigation: a call for evidence-based standardization of practice. Am J Infect Control. 2014 May;42(5):525-9. doi: 10.1016/j.ajic.2014.01.012. PMID: 24773788.
11. Fry DE. Fifty ways to cause surgical site infections. Surg Infect (Larchmt). 2011 Dec;12(6):497-500. doi: 10.1089/sur.2011.091. Epub 2011 Dec 5. PMID: 22142318.
12. de Jonge SW, Boldingh QJJ, Solomkin JS, et al. Systematic review and meta-analysis of randomized controlled trials evaluating prophylactic intra-operative wound irrigation for the prevention of surgical site infections. Surg Infect (Larchmt). 2017 May/Jun;18(4):508-519. doi: 10.1089/sur.2016.272. Epub 2017 Apr 27. PMID: 28448203.
13. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS; WHO Guidelines Development Group. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016 Dec;16(12):e288-e303. doi: 10.1016/S1473-3099(16)30402-9. Epub 2016 Nov 2. PMID: 27816414.
14. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791. doi: 10.1001/jamasurg.2017.0904. Erratum in: JAMA Surg. 2017 Aug 1;152(8):803. PMID: 28467526.
15.  Fry DE. Pressure irrigation of surgical incisions and traumatic wounds. Surg Infect (Larchmt). 2017 May/Jun;18(4):424-430. doi: 10.1089/sur.2016.252. Epub 2017 Mar 1. PMID: 28437197.
16. FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373:2629–2641
17. Giordano BD, Ryder S, Baumhauer JF, DiGiovanni BF. Exposure to direct and scatter radiation with use of mini-c-arm fluoroscopy. J Bone Joint Surg Am. 2007 May;89(5):948-52. doi: 10.2106/JBJS.F.00733. PMID: 17473130.
18. Fuller CB, Wongworawat MD, Riedel BB. Radiation exposure and hand dominance using mini C-arm fluoroscopy in hand surgery. Hand (N Y). 2016 Jun;11(2):188-91. doi: 10.1177/1558944715627224. Epub 2016 Feb 2. PMID: 27390561; PMCID: PMC4920527.
19. Yu C. Don't be caught half-dressed when working with radiation. Cardiovasc Intervent Radiol. 2020 Mar;43(3):369-375. doi: 10.1007/s00270-019-02391-7. Epub 2019 Dec 16. PMID: 31844952.
20. Burns KM, Shoag JM, Kahlon SS, et al. Lead aprons are a lead exposure hazard. J Am Coll Radiol. 2017 May;14(5):641-647. doi: 10.1016/j.jacr.2016.10.024. Epub 2017 Jan 9. PMID: 28082154.
21. Mayo Clinic. Lead poisoning. https://www.mayoclinic.org/diseases-conditions/lead-poisoning/symptoms-causes/syc-20354717
22. Katsari K, Paraskevopoulou C, Barati M, et al. Lead exposure in clinical imaging - The elephant in the room. Eur J Radiol. 2020 Oct;131:109210. doi: 10.1016/j.ejrad.2020.109210. Epub 2020 Aug 7. PMID: 32858494.

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