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General: M. Al-Maiyah, A. Bajwa, P. Finn, P. Mackenney, D. Hill, A. Port, and P. J. Gregg Glove perforation and contamination in primary total hip arthroplasty J Bone Joint Surg Br 2005; 87-B: 556-559 [Abstract] [Full text] [PDF]

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Electronic letters published:

Response to Boddu Siva Rama and Apsingi

M. Al-Maiyah   (23 June 2005)

Response to Agarwal and Agarwal

M. Al-Maiyah   (20 June 2005)

Response to Professor Wroblewski

M. Al-Maiyah   (17 June 2005)

Glove contamination

B. Michael Wroblewski, Wrightington Hospital, Appley Bridge Nr Wigan WN6 9EP   (23 May 2005)

The variables in glove perforation technique

Anil Agarwal, Rachna Agarwal   (12 May 2005)

Glove contamination - what is the main cause?

K. R. Boddu Siva Rama, Sunil Apsingi   (8 April 2005)

Response to Boddu Siva Rama and Apsingi 23 June 2005
M. Al-Maiyah Send letter to journal: Re: Response to Boddu Siva Rama and Apsingi mamaiyah{at}yahoo.co.uk M. Al-Maiyah	Sir, We thank Messrs Boddu Siva Rama and Apsingi for the interest they have shown in our article. We analysed the association between glove perforation and glove contamination from the available data. We found that there was poor correlation between glove perforation and glove contamination (Pearson correlation coefficient, rp = 0.17, p =0.24). Similar results were reached by Dodds et al.1 However, it is worth mentioning that single gloves were used in their study compared with double gloves in ours. In our study only the outer gloves were analysed for perforation and contamination. We therefore cannot comment upon the rate of inner-glove perforation and contamination. M. AL-MAIYAH, FRCS James Cook University Hospital Middlesbrough, UK. 1. Dodds RD, Guy PJ, Peacock AM, et al. Surgical glove perforation. Br J Surg 1988;75:966-8.
Response to Agarwal and Agarwal 20 June 2005
M. Al-Maiyah Send letter to journal: Re: Response to Agarwal and Agarwal mamaiyah{at}yahoo.co.uk M. Al-Maiyah	Sir, The choice of 20-minute intervals in this study group was not arbitrary. It followed careful observation of our practice and the evaluation of the results of our pilot study. Surgical teams involved in the study used the same techniques and protocol. However, due to the very nature of the study, whereby a surgeon has to change gloves, there is no objective scientific method to rule out the possibility of bias completely, although it is unlikely that experienced arthroplasty surgeons would work less carefully in the control group. In the study and control groups median operating times of 70 minutes (95% confidence interval (CI) 60 to 80) and 75 minutes (95% CI 65 to 90) respectively were similar. This shows that half the total number of operations lasted longer than the median time. In the study group no glove was used for longer than 20 minutes, while in the control group the gloves were used for a longer time. Median times between each glove change were 16 minutes (95% CI 15 to 20) in the study group and 23 minutes (95% CI 21.5 to 25) in the control group. In the study group operations which lasted longer there was more than one glove change, while in the controls there was a smaller number of gloves used even if the operation lasted longer than the median time, unless a perforation was noticed. We noticed more glove perforations in this group. M. AL-MAIYAH, MRCS James Cook University Hospital Middlesbrough, UK.
Response to Professor Wroblewski 17 June 2005
M. Al-Maiyah Send letter to journal: Re: Response to Professor Wroblewski mamaiyah{at}yahoo.co.uk M. Al-Maiyah	Sir, We agree with Professor Wroblewski that surgical field contamination is a serious matter. The incidence of contamination was 4.8% and 13.9% in the study and control groups respectively. However, this study showed that there was detectable bacterial contamination in 44% (11 of 25) of operations in the study group and 76% (19 of 25) in the control group. Davis et al1 reported that 28.7% of gloves used for preparation were contaminated and 63% of the operations showed bacterial contamination in the operating field even under laminar air flow. The clinical implications of these findings are of great importance. The main sources of contamination of surgical wounds are the patients’ own skin flora and airborne bacteria from theatre personnel and the environment of the operating theatre.2,3 Various measures have been introduced to control the operating room environment, including Charnley’s ultra-clean air system, sterile hoods and a body-exhaust system. Ritter4 reported that to reduce operating theatre environmental bacteria contamination the number of personnel in the operating room and the length of surgery should be reduced. In our study we found that glove changing at regular intervals is an effective way to decrease microbial contamination during hip arthroplasty. In conclusion, we believe that every source of wound and surgical field contamination should be addressed and the appropriate measures should be adopted to reduce the level of glove and wound contamination to a minimum. M. AL-MAIYAH, MRCS James Cook University Hospital, Middlesbrough, UK. 1. Davis N, Curry A, Gambhir AK, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg [Br] 1999;81-B:886-9. 2. Ha’eri GB, Wiley AM. Total hip replacement in a laminar flow environment with special reference to deep infection. Clin Orthop 1980;148:163-8. 3. Howorth FH. Prevention of airborne infection during surgery. Lancet 1985;1:386-8. 4. Ritter MA. Operating room environment. Clin Orthop Relat Res 1999;(369):103-9.
Glove contamination 23 May 2005
B. Michael Wroblewski, Professor John Charnley Research Institute, Wrightington Hospital, Appley Bridge Nr Wigan WN6 9EP Send letter to journal: Re: Glove contamination bmwhipdr{at}hotmail.com B. Michael Wroblewski, et al.	Sir, I wish to comment on the subject of glove perforation and contamination in primary total hip arthroplasty. The fact that the incidence of glove perforation during surgery increases with time is clear from the principle of the extremes. The reverse would be true when frequency of glove changes is increased. There is, however, a more serious aspect of this study. If we assume that gloves are initially sterile and the wound in primary total hip arthroplasty free from bacteria, then the authors have clearly shown that contamination of the gloves, and thus presumably also the wound, occurs during surgery. Would not a single change in theatre environment, the operative technique, or both, be more effective in reducing glove contamination than frequent glove changes? B. M. WROBLEWSKI, FRCS Wrightington Hospital Wigan, UK.
The variables in glove perforation technique 12 May 2005
Anil Agarwal, Consultant Orthopaediciam, Delhi, India , Rachna Agarwal Send letter to journal: Re: The variables in glove perforation technique rachna_anila{at}yahoo.co.in Anil Agarwal, et al.	Sir, We read this article with interest. There are many variables in this study which we believe, if eliminated, will provide more conclusive evidence of the effectiveness of the technique. The criteria for a 20 minute glove change in this study for surgery of average duration of 70 minutes seems arbitrary and with no justification. As the surgeon and his team were unblinded they may have become biased, working more attentively and carefully in the study group, resulting in lesser glove perforations and contaminations. Furthermore, upon analysing the results of Table I we gather that the surgeon for each operation in the study group changed gloves only once on average compared with the control group [(120 - 94 pairs)/ 25 operations = 1.04]. That this change of one extra pair of gloves per member of the surgical team in a single operation produces so much difference in the incidence of glove perforations and contaminations somehow appears unlikely. A. AGARWAL R. AGARWAL Delhi, India.
Glove contamination - what is the main cause? 8 April 2005
K. R. Boddu Siva Rama, Research Fellow Imperial College, London., Sunil Apsingi Send letter to journal: Re: Glove contamination - what is the main cause? r.rama{at}imperial.ac.uk K. R. Boddu Siva Rama, et al.	Sir, We thoroughly enjoyed reading this article by Al-Maiyah et al. It is very interesting to find that changing gloves at regular intervals decreases the incidence of glove perforation and glove contamination independently during total hip arthroplasty. However, the authors did not mention the association between glove perforation and glove contamination in their study, an important issue to consider, with the data available to them. Perforation of the gloves can spread the bacterial flora from the skin to the surface of the gloves. But with 63% of the operations showing bacterial contamination in the operating field even under laminar air flow,1 contamination of the gloves can arise from anywhere in the field including being air-borne. McCue et al2 found draping to be an important factor in causing the contamination of outer gloves. Interestingly, Dodds et al3 showed that glove perforation did not influence the bacterial counts on the outer surface of the gloves in general surgical operations. On the other hand, if we find that perforation of the outer glove is associated with its contamination, it may indicate a causal relationship, suggesting that the inner gloves are one of the sources of contamination. In such circumstances, changing both the outer and the inner gloves at regular intervals may be necessary to further reduce the incidence of the contamination. The association between glove perforation and glove contamination needs to be analysed from the data included in the authors' study. Finding the incidence of the perforation of inner gloves and their contamination as well could have further enhanced the outcome of their study. K. R. BODDU SIVA RAMA, S. APSINGI, Imperial College, London, UK. 1.Davis N, Curry A, Gambhir AK, et al. Intraoperative bacterial contamination in operations for joint replacement. J Bone Joint Surg [Br] 1999;81-B:886-9. 2. McCue SF, Berg EW, Saunders EAJ. Efficacy of double-gloving as a barrier to microbial contamination during total joint arthroplasty. J Bone Joint Surg [Am] 1981;63-A:811-13. 3. Dodds RD, Guy PJ, Peacock AM, et al. Surgical glove perforation. Br J Surg 1988;75(10):966-8.