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C OPYRIGHT Ó 2014 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Surgical Attire and the Operating Room:
Role in Infection Prevention
Tiare E. Salassa, MD, and Marc F. Swiontkowski, MD
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Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota

ä Although there is some evidence that scrubs, masks, and head coverings reduce bacterial counts in the operating
room, there is no evidence that these measures reduce the prevalence of surgical site infection.

ä The use of gloves and impervious surgical gowns in the operating room reduces the prevalence of surgical site
infection.

ä Operating-room ventilation plays an unclear role in the prevention of surgical site infection.

ä Exposure of fluids and surgical instruments to the operating-room environment can lead to contamination. Room
traffic increases levels of bacteria in the operating room, although the role of this contamination in surgical site
infection is unclear.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.

Surgical site infection continues to be one of the most common
and costly postoperative complications. It is estimated that nearly
300,000 surgical site infections occur each year, accounting for
$10 billion in direct costs annually1.
Over the past fifty years, surgical attire has remained
relatively unchanged. This uniform has traditionally been
thought to play two roles: to protect scrubbed personnel from
exposure to body fluids and to maintain the sterile surgical
field. Likewise, the operating-room environment has remained
stable with green or blue drapes marking the sterile field and
instruments on the back table.
Multiple organizations, including The Joint Commis-
sion, Centers for Disease Control and Prevention (CDC),
Association of periOperative Registered Nurses (AORN),
and Occupational Safety and Health Administration (OSHA),
publish guidelines that govern operating-room practices2-5.
Despite the numerous policies relating to the subject of in-
fection prevention, many of our practices have limited liter-
ature support.
The scope of this article is to synthesize the current ev-
idence regarding the role of surgical attire and the operating-
room environment in infection prevention. The influence of
perioperative antibiotics, patient and surgeon preoperative
skin preparation, wound closure, drains, and dressings were
recently addressed by Fletcher et al.6.
Definition
The CDC’s National Nosocomial Infections Surveillance
system describes three levels of surgical site infections: su-
perficial incisional, deep incisional, and organ or space in-
fection (Table I). In most instances, infection must be
apparent within thirty days after the index procedure to be
considered a surgical site infection, or within the first year if
implants are used3,7.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author
has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in
this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2014;96:1485-92 d http://dx.doi.org/10.2106/JBJS.M.01133

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TABLE I Criteria for Defining a Surgical Site Infection (SSI)*†

Superficial incisional SSI

Infection occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one
of the following:
1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.
3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial
incision is deliberately opened by surgeon, unless incision is culture-negative.
4. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
2. Infection of an episiotomy or newborn circumcision site.
3. Infected burn wound.
4. Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).
Deep incisional SSI
Infection occurs within 30 days after the operation if no implant‡ is left in place or within 1 year if implant is in place and the infection
appears to be related to the operation and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least
one of the following:
1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site.
2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following
signs or symptoms: fever (>38°C), localized pain, or tenderness, unless site is culture-negative.
3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by
histopathologic or radiographic examination.
4. Diagnosis of a deep incisional SSI by a surgeon or attending physician.
Notes:
1. Report infection that involves both superficial and deep incision sites as deep incisional SSI.
2. Report an organ/space SSI that drains through the incision as a deep incisional SSI.
Organ/space SSI
Infection occurs within 30 days after the operation if no implant‡ is left in place or within 1 year if implant is in place and the infection
appears to be related to the operation and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision,
which was opened or manipulated during an operation and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab wound§ into the organ/space.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by
histopathologic or radiographic examination.
4. Diagnosis of an organ/space SSI by a surgeon or attending physician.

*Reproduced, with modification, from: Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; Centers for Disease Control and Prevention
(CDC) Hospital Infection Control Practices Advisory Committee. Guideline for Prevention of Surgical Site Infections, 1999. Am J Infect Control.
7
1999 Apr;27(2):97-132; quiz 133-4; discussion 96. †Horan et al. . ‡National Nosocomial Infection Surveillance definition: a nonhuman-derived
implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or hip prosthesis) that is permanently placed in
a patient during surgery. §If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft-tissue infection,
depending on its depth.

Historical Background He also proposed methods to eliminate microorganisms, in-

In 1843, Oliver Wendell Holmes Sr. presented the theory that
puerperal fever was spread from patient to patient via physi-
cians8. Shortly after, Ignaz Semmelweis proposed that simple
hygiene could reduce the prevalence of puerperal fever, dem-
onstrating that hand washing reduced the maternal mortality
rate during childbirth by 90%9. At the time, doctors were
offended by the suggestion that they should wash their hands
as doctors were gentlemen, and ‘‘a gentleman’s hands are
clean.’’10
By the 1860s, Louis Pasteur presented the modern germ
theory, proving Streptococcus pyogenes caused puerperal fever11.
cluding exposure to chemical solutions. In 1865, Joseph Lister
began experimenting with such solutions to obtain an aseptic
operating-room environment, requiring surgical personnel to
wash their hands, instruments, and operating surfaces with a
5% carbolic acid solution12.
Contamination and Surgical Site Infection
Because the overall prevalence of surgical site infections is low,
large numbers of participants or procedures must be included for
a study to prove the efficacy of a particular intervention. Assuming
a 1.5% to 2.0% rate of surgical site infection, establishing a power
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TABLE II Recommendations for Surgical Attire

Grade of Recommendation* Recommendation

B Surgical masks have not been shown to reduce rates of surgical site infection in the operating room.
B Impervious surgical gowns and drapes are superior to permeable cotton gowns and drapes in the
prevention of surgical site infection.
C Space suits are effective in the prevention of surgical site infection in total joint arthroplasty.
I There is insufficient evidence to support or refute the use of long-sleeved uniforms by nonscrubbed
personnel in the operating room.
I There is insufficient evidence to support or refute the benefit of double-gloving in the prevention of
surgical site infections.

*Grade A indicates consistent, good (Level-I) evidence for or against the recommendation; Grade B, consistent, fair (Level-II or III) evidence for or
against the recommendation; Grade C, conflicting or poor-quality (Level-IV or V) evidence not allowing a recommendation for or against; and Grade
64
I, there is insufficient evidence to make a recommendation .

of >80% would require the enrollment of nearly 10,000 patients
to determine the effect of one independent variable13. As a result,
many investigators use bacterial contamination (commonly
measured by airborne or settled colony-forming unit [CFU]
counts) as an adjunct measure of surgical site infection. While
many infectious disease experts agree that contamination and
CFU counts are important, there is no clear evidence that either of
these markers is directly associated with surgical site infection.
Davis et al., in a study of patients undergoing total joint
arthroplasty, showed that contamination of the surgical field is
widespread14. In their series of 100 procedures, 63% had contam-
ination of the operative field, with 76% of the organisms grown
being coagulase-negative Staphylococcus. At the two-year follow-
up, one deep surgical site infection was noted; however, the caus-
ative organism was not identified as a contaminant during surgery.
Although a direct correlation between CFUs and surgical
site infections has not been proven in the literature, the theory of
aseptic technique is founded on the premise that a reduction in
bacterial contamination will reduce the prevalence of surgical
site infection. Currently, studies demonstrating reduced con-
tamination are the only data available supporting many of our
practices because of the inherent difficulties involved with in-
vestigators reporting the rates of surgical site infection. Caution
must be used when applying CFU data, as contaminating organ-
isms are often not of the same species as infecting organisms.
Surgical Attire
Although most surgical site infections are caused by the pa-
tient’s endogenous flora, operating-room personnel are also a
source of bacterial contamination15,16. Surgical attire aims to
provide a functional barrier between the surgical team and the
patient. However, the efficacy of surgical clothing in preventing
surgical site infection is often unclear (Table II).
Scrubs
Scrubs have become standard operating-room attire since
the 1950s. Several studies have evaluated the effect of scrub
material and design on CFU counts; however, randomized
controlled clinical trials looking at surgical site infections are
lacking.
Dankert et al. showed that cotton-polyester-blend
scrubs drastically reduced airborne CFUs compared with
normal cotton clothing during open heart surgery (5.2 versus
10.1 CFU/ft3 at the wound wall; p < 0.05)17. Furthermore, they
demonstrated that female subjects wearing skirted scrubs led to
a significant increase in the number of CFUs compared with
pant-type scrubs (340 versus 191 CFU/min; p < 0.05). Overall,
however, male subjects tended to shed larger numbers of CFUs
than female subjects (755 versus 191 CFU/min; p < 0.05). The
addition of knee-high boots over scrub pants reduced the
number of CFUs shed by male subjects (1036 versus 318 CFU/
min; p < 0.05). Hubble et al. compared cotton with cotton-
polyester-blend scrubs during sham orthopaedic operations18.
They demonstrated a fivefold reduction in the number of CFUs
when cotton-polyester scrubs were worn than when cotton
scrubs were worn (21 versus 126 CFU/m2/hr; p < 0.02). In a
prospective interventional study, Tammelin et al. looked at
airborne and wound-wall bacteria levels in patients undergoing
coronary artery bypass19. In alternating weeks, operating-room
personnel wore scrubs with the shirts untucked or scrubs with
shirts tucked and tight fitting cuffs at the arm and ankle. They
showed a reduction of >50% in airborne CFUs during pro-
cedures with the use of tucked and cuffed scrubs (21.4 versus
7.7 CFU/m3; p = 0.002). The rate of wound contamination
was not different between the two groups, and surgical site
infection rates were not reported.
Although there is evidence suggesting that tucked,
cuffed, cotton-polyester-blend scrubs that cover the legs are more
effective than all-cotton scrubs in reducing operating-room
contamination, no study, to our knowledge, has shown a re-
lationship between the use of scrubs and the prevalence of
surgical site infection.
Arm Covering for Nonscrubbed Personnel
The use of long sleeves by nonscrubbed personnel has become
controversial in recent years. In 2007, the United Kingdom
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introduced their ‘‘bare below the elbows’’ policy, banning long
sleeves, watches, and jewelry in all medical settings, citing
clothing and accessories at the wrist as a source of infection
spread20. Conversely, in their 2004 guidelines, the AORN began
recommending that long sleeves be worn by all nonscrubbed
personnel in operating rooms, suggesting that long sleeves
capture skin squames, thus reducing bacterial contamination21.
Unfortunately, there are limited data in the literature supporting
either policy.
Hill et al. showed that 27% of >600 health-care workers
were nasal carriers of Staphylococcus aureus; however, only 1%
of women and 13% of men actually shed S. aureus22. This
shedding was almost exclusively from the perineum and was
essentially abolished by donning bacteria-proof underwear
made of Ventile. Benediktsdóttir and Hambraeus reported
similar findings when looking at rates of bacteria shed from
different parts of the body23. They showed that although bac-
terial densities were highest on the face and upper trunk, dis-
persal rates were highest from the lower trunk and perineal
areas. Additionally, when bacterial dispersal rates from naked
and dressed subjects were compared, the addition of scrubs
actually increased the dispersal of aerobic and anaerobic CFUs.
They hypothesized that friction caused by clothing on the skin
triggers shedding of skin squames.
Currently, there is limited information supporting the
use of long sleeves for nonscrubbed operating-room personnel
as the addition of sleeves may increase bacterial fallout due to
frictional forces. To date, no study, as far as we know, has shown
that either option reduces rates of surgical site infection.
Masks
Surgical masks were first developed in the early 20th century24.
Since that time, they have become standard operating apparel,
although few studies have supported their efficacy in the op-
erating room.
McLure et al. looked at bacterial dispersal rates directly in
front of the mouth with and without the use of surgical masks25.
They showed that 90% of plates grew at least 1 CFU when in
front of a nonmasked subject, while only 9% of plates in front
of masked subjects grew bacteria (p < 0.002). Ritter et al.
showed that wearing face masks had no effect on overall bac-
terial counts in the operating room as measured by settled
CFUs on trays at various locales in the room (447.3 versus
449.7 CFU/ft2/hr)26. They proposed that wearing masks in the
operating room simply redirected the projectile effects of
talking and breathing and that, although CFU counts directly
in front of the mouth may be reduced, overall room CFU
counts are not affected by the use of surgical masks.
In a prospective randomized controlled trial of 3088 pa-
tients undergoing general surgery procedures, Tunevall showed
no significant difference in the rates of surgical site infection
between masked and unmasked groups (4.7% versus 3.5%; p >
0.5) in which all operating-room personnel had either worn or
not worn a mask27. Additionally, there were no differences in
types of bacterial species isolated from the surgical wounds of
either group. In a prospective randomized controlled trial of
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nonscrubbed personnel, including those in orthopaedic proce-
dures, Webster et al. demonstrated similar findings28. In their
cohort of 811 patients with complete data available, surgical site
infections were recorded for forty-six (11%) of 401 patients in
the masked group and for thirty-seven (9%) of 410 patients in
the nonmasked group (p = 0.151). A meta-analysis of three trials
and 2113 patients by the Cochrane group also supported these
findings as there was no significant difference in surgical site
infection rates when surgical teams were masked or unmasked in
any trial or within the pooled data29.
In conclusion, current literature has been unable to
support the use of surgical masks in reducing rates of surgical
site infection in the operating room, although the evidence is
somewhat limited. However, current OSHA regulations and
universal precautions require face masks as part of personal
protective equipment for scrubbed personnel5.
Head Coverings
Multiple types of head coverings, including skullcap, bouffant,
and hood styles, are available to the surgeon (see Appendix).
Several studies have demonstrated that hair and ears can harbor
S. aureus and have recognized that hair, ears, and scalp are
potential sources of contamination in the operating room30-34.
Ritter et al. examined six combinations of head coverings:
no head cover, cloth cap (ears exposed), and cloth hood (ears
covered), each with and without hairspray, in volunteers with and
without facial hair35. In a mock surgical setting, they showed no
significant differences in environmental contamination among
any of the types of head covering. However, the addition of
hairspray decreased bacterial shedding for all groups (186 versus
337 CFU/ft2/hr; p < 0.02). Humphreys et al., in a comparison of
disposable hoods (ears covered) and no head covering, reported
similar findings36. They showed no significant reduction in air-
borne CFUs when the head, ears, and hair were covered. Hubble
et al. demonstrated a fourfold increase in CFUs at waist level
when head coverings were omitted in a laminar flow operating
room (21 versus 84 CFU/m2/hr; p < 0.05)18. However, when
evaluated in conventional rooms, bacterial counts were consis-
tently high regardless of whether head coverings were worn.
Overall, there is mixed evidence regarding the efficacy of
head coverings in containing bacterial fallout from the hair,
scalp, and ears. To date, as far as we know, no study has clearly
noted whether the use of head coverings influences surgical site
infection.
Space Suits
Since their development by John Charnley in the 1960s, total
body-exhaust systems (space suits) have been developed as
a method to reduce infection in total joint arthroplasty37.
Charnley and Eftekhar reported a substantial reduction in the
incidence of infection at the site of total joint replacements
after the implementation of space suits, among other improve-
ments including laminar flow ventilation and double gloves, at
their facility from 1960 to 196738.
Early studies seemed to support the results reported by
Charnley and Eftekhar. In a quasi-randomized controlled trial,
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Lidwell et al. looked at the incidence of infection in 8055 pa-
tients undergoing total hip or knee arthroplasty, performed
with and without space suits, in conventional and laminar flow
operating rooms39. They reported a lower incidence of infec-
tion after total joint arthroplasties in both conventional and
laminar flow operating rooms with the addition of spacesuits
(1.3% versus 2% in conventional rooms and 0.3% versus 1% in
laminar flow rooms). Of note, the use of perioperative anti-
biotics was not controlled for in the analysis.
In some series, the use of space suits reduces the levels of
CFUs in the operating room to as low as 1.0 CFU/m3 when
used in combination with laminar flow ventilation40,41. Other
studies have shown no difference in room or wound bacterial
counts in comparisons of space suits and traditional hoods and
masks42,43. More recently, the efficacy of space suits in the
prevention of surgical site infections has been called into ques-
tion. In 2011, Hooper et al. reported the ten-year results of
the New Zealand Joint Registry on the subject44. Their retro-
spective review of more than 50,000 primary total hip and
30,000 primary total knee arthroplasties showed that the use
of space suits was actually associated with an increased rate of
surgical site infections compared with traditional head cov-
erings regardless of the type of operating-room ventilation
(0.186% versus 0.064% [p < 0.0001] for total hip arthro-
plasties and 0.243% versus 0.098% [p < 0.001] for total knee
arthroplasties).
As such, the current literature is divided on the efficacy of
space suits in the reduction of bacterial particles in the operating-
room environment. Additionally, there is some evidence that the
use of space suits may in fact be associated with higher rates of
surgical site infections after total joint arthroplasty.
Gowns
Gustav Neuber first began using surgical gowns in 1883 and
soon after reported a decrease in surgical site infections with
their use45. Due to the wide variety of gowns used, interpreta-
tion of the literature regarding their efficacy is difficult. In
general, gowns are classified as either disposable or reusable
and require a coating or membrane to render them imper-
meable to fluids.
The use of permeable cotton gowns to prevent the
transfer of bacteria was shown to be ineffective as early as
194846. In a prospective trial including 2181 general surgical
procedures, Moylan et al. compared the efficacy of imper-
meable disposable gowns and drapes with permeable cotton
gowns and drapes47. Overall, the disposable system showed a
marked reduction in the rate of surgical site infection com-
pared with reusable gowns (2.8% versus 6.5%). In a random-
ized prospective clinical trial of 494 patients, Garibaldi et al.
showed that impermeable disposable gowns and drapes were
no better barriers to intraoperative wound contamination or
surgical site infection than impermeable reusable gowns and
drapes (five of 226 patients versus six of 268)48. Similarly,
Bellchambers et al., in a randomized controlled clinical trial of
505 patients undergoing coronary artery surgery, found no
significant difference between the group in which disposable
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gowns and drapes were used and the group in which reusable
impervious gowns and drapes were used with regard to the rate
of surgical site infections in the sternum or leg (p = 0.87 and
0.62, respectively)49.
Overall, permeable cotton gowns and drapes are inferior
to impervious gown and drape materials in the prevention of
surgical site infections. To date, no study, as far as we know, has
shown a difference between impermeable disposable and re-
usable gowns in the prevention of surgical site infections.
Gloves
William Halsted is often credited with developing rubber gloves
for use in the operating room. In early reports, his rates of
surgical site infection were reduced from 9.6% (ten of 104
patients) to 1.8% (four of 226 patients) during hernia repairs
when gloves were worn by the surgical team50.
Although modern studies looking at the effect of gloves
on surgical site infections are lacking, multiple studies have
compared the efficacy of single and double layers of gloves.
Ritter et al. reported that contamination of outer gloves is
common (approximately 30%) and is similar across all scrubbed
personnel51. They showed that although double-gloving was
efficacious in reducing the number of holes on the innermost
glove, it was not efficacious in reducing contamination levels on
the outer layer. In a meta-analysis performed by the Cochrane
group, thirty-one randomized controlled trials comparing
glove penetration with single-gloving and double-gloving
were reviewed 52. All studies showed that there were fewer
perforations of the inner glove when multiple layers were
worn. Only two trials addressed the primary outcome, sur-
gical site infection. Neither trial identified a difference in the
prevalence of surgical site infections between groups; how-
ever, this finding was insufficiently powered.
In conclusion, the institution of sterile gloves resulted in
a dramatic reduction of surgical site infections over the early
part of the twentieth century. However, modern trials proving
the efficacy of single or double-gloving are lacking. Despite this,
many orthopaedic surgeons prefer double-gloving as a method
of self-protection from body fluid exposure.
Operating Room
Although it is well established that personnel are the major
cause of bacterial contamination in the operating room 16,
maintenance of the surgical field in contact with the patient
also plays a role (Table III).
Operating-Room Ventilation and Ultraviolet Lighting
Sir John Charnley developed and employed an ultraclean
(laminar flow) ventilation system to reduce airborne bacteria
in his operating rooms. The use of bactericidal ultraviolet light
has also been implemented for this purpose. Evidence regarding
both of these techniques in the prevention of surgical site in-
fections is mixed.
In a study of 8055 patients undergoing total joint ar-
throplasty, Lidwell et al. showed a reduction in the rates of
surgical site infection from 1.5% to 0.6% (p < 0.001) in a
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TABLE III Recommendations for Operating-Room Measures*

Grade of Recommendation Recommendation

C Laminar flow ventilation is effective in the prevention of surgical site infection in total joint arthroplasty.
I There is insufficient evidence to support or refute the notion that contamination of fluids and instruments
on the back table increases rates of surgical site infection.
I There is insufficient evidence to support or refute the benefits of limiting door openings or room traffic in
the operating room.

*Grade C indicates conflicting or poor-quality (Level-IV or V) evidence not allowing a recommendation for or against, and Grade I indicates there is
64
insufficient evidence to make a recommendation .

comparison of laminar flow with conventional ventilation, al-
though perioperative antibiotics use was not controlled in that
study39. Conversely, a retrospective analysis of the German
Krankenhaus Infektions Surveillance System (KISS), including
99,230 general and orthopaedic operations, showed no protec-
tive benefit of laminar flow ventilation and even demonstrated
a higher risk of surgical site infections after hip replacements
(adjusted odds ratio, 1.63; 95% confidence interval [CI], 1.06 to
2.52)53.
Ritter et al. looked at rates of surgical site infections after
5980 total joint arthroplasties performed before and after the
installation of ultraviolet lighting in their operating rooms54. All
procedures performed prior to the installation of ultraviolet
lighting utilized laminar flow, while those after ultraviolet
lighting installation used conventional ventilation. The rate of
surgical site infections was 1.77% without ultraviolet lighting
and decreased to 0.57% with ultraviolet lighting (p < 0.0001).
However, in a report on the safety of ultraviolet lighting in the
operating room at one institution, Sylvain and Tapp noted
exposures of six to twenty-eight times greater than the rec-
ommended limits55. Of fourteen orthopaedic operating-room
personnel exposed, five reported having symptoms possibly
related to excessive ultraviolet exposure including eye and skin
changes.
Evans, in a review of the literature, advocated that both
laminar flow and ultraviolet light reduce the rates of surgical
site infection after total joint arthroplasty and that the absence
of high-level evidence was not proof of ineffectiveness because
of the inherent difficulties of performing such studies13. The
CDC recommended further study of laminar flow ventilation
but recommended against the use of ultraviolet lights sec-
ondary to potential health risks to operating-room personnel56.
Adhesive Drapes
The use of adhesive incise drapes, which cover the entire surgical
field, is a common practice in orthopaedic operating rooms. The
Cochrane group performed a meta-analysis of randomized
controlled studies including five trials (3082 patients) comparing
adhesive incise drapes with standard draping (no adhesive incise
drapes) and two studies (1113 patients) comparing iodine-
impregnated adhesive incise drapes with no incise drapes57.
The rate of surgical site infection was significantly higher in
the adhesive incise drape group than in the group in which no
incise drapes were used (risk ratio, 1.23; p = 0.03), while
iodine-impregnated adhesive incise drapes had no effect on
the rate of surgical site infection (risk ratio, 1.03; p = 0.89).
In the current literature, there is no clear evidence that
iodine-impregnated adhesive drapes reduce the prevalence of
surgical site infection. Plastic adhesive drapes may, in fact, in-
crease the rates of surgical site infection.
The Back Table (Fluids and Instruments)
Instruments and fluids used during surgery can also harbor
bacteria in the operating room. Although improper sterilization
can happen, frequently these surfaces become contaminated via
contact with people or airborne particles.
Splash basins used to rinse instruments have been fre-
quently cited as a potential source of infection. Splash basin
contamination has been reported in the literature to range
from 2% to 74%58-60. Irrigation fluid on the back table may also
become contaminated over time. In a study of twenty-one
consecutive operations lasting longer than one hour, Andersson
et al. noted that irrigation fluid samples from 62% (thirteen
operations) had positive cultures61.
Surgical instruments have also been implicated as a po-
tential carrier of bacteria. Dalstrom et al. demonstrated that
uncovered trays quickly become contaminated once opened in
the operating room, even in rooms without people62. In their
study, 15% (four) of twenty-seven trays were contaminated at
one hour, while 30% (eight) of twenty-seven trays were con-
taminated at four hours. Open trays that were covered by a
sterile towel after opening did not become contaminated.
Although it appears that fluids and instruments left open
to the operating-room environment have fairly high levels of
contamination, we know of no study to date that has made a
definitive correlation between back table bacterial contamina-
tion and surgical site infection.
Room Traffic
As it has been well established that people are the major source
of bacteria in the operating room, it calls into question whether
limiting operating-room traffic has an effect on reducing the
rate of surgical site infections. Certainly, ending the days of the
‘‘operating theater’’ has reduced the number of observers in
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the operating room, yet it remains unclear what role in infec-
tion prevention this has played.
In a prospective cross-sectional study, Young and O’Regan
recorded the number of door openings in forty-six consecutive
cardiac operations63. They showed a trend toward an increased
frequency of door openings for patients who developed a surgical
site infection (mean, ninety-four door openings) than for those
who had not (mean, 76.4 door openings); however, the difference
was not significant.
Although a correlation between the number of operating-
room door openings and increased CFU counts in the operating
room has been demonstrated16, there is no evidence in the
current literature that has identified a correlation between
room traffic and rates of surgical site infection.
Overview
Although there have been drastic improvements in the arena of
surgical site infection prevention over the last century, evidence
supporting many of our current wardrobe and aseptic envi-
ronment practices in the operating room continues to be lim-
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A figure showing three types of head coverings is available
with the online version of this article as a data supplement
at jbjs.org. n
Tiare E. Salassa, MD
Marc F. Swiontkowski, MD
Department of Orthopaedic Surgery,
University of Minnesota,
2450 Riverside Avenue, Suite R200,
Minneapolis, MN 55454.
E-mail address for T.E. Salassa: sala0114@umn.edu
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