Where Are We Now? For ideal surgical skin preparation and draping, plastic adhesive incisional drapes are placed on the skin directly over the incision site, and surgeons then make their incisions through the adhesive drape [7]. In orthopaedic surgery, these drapes are widely used in total joint arthroplasty because of their potential to reduce the risk of surgical site infections [4]. But despite improved infection prevention protocols, little progress has been made in decreasing the incidence of periprosthetic joint infection (PJI). In one population-based study, no improvement in infection rates was observed over a 15-year period [5]. The fact that the incidence of PJI remains unchanged over time means we have more work to do. Things seem no more promising on the treatment side; the survivorship of arthroplasties after irrigation and debridement, and after two-stage revisions, has not improved over the last two decades or so [8]. In the current study, Mundi et al. [6] performed a meta-analysis of MEDLINE and Embase databases and gathered evidence from randomized controlled trials that compared drapes with controls from 2000 to 2021. They had relatively little to work with; appropriately, they restricted the study to randomized trials, but only four were available in this massive database review that employed a 20-year data pull. Based on data from pooled wound swab cultures, Mundi et al. [6] found that four studies showed a reduction in wound contamination with the use of adhesive drapes. The findings of this meta-analysis suggest that adhesive drapes, including those with antimicrobial properties, decrease the risk of wound contamination during orthopaedic procedures. In circumstances where drape adhesion is compromised and peel back occurs at the wound edge, there is an increased risk of wound contamination with the use of adhesive drapes. In light of these findings, it’s fair to conclude that the best-available evidence is indeterminate as to the effect of adhesive drapes on the risk of surgical site infections; however, if used, care should be taken to avoid or minimize drape peel back. Where Do We Need To Go? Meta-analyses are most helpful when the source studies disagree. In my large, busy group practice, we generally use adhesive drapes in trauma, total joint arthroplasty, and sports medicine procedures. Do we have the data to justify this practice in these areas? The current study [6] found that two of the studies supported routine use of adherent drapes, while two randomized clinical trials showed no difference. The authors could not definitively prove that peeling back the drapes for closure or inadvertent peel back during the procedure was adverse. How might postoperative dressings protect against inadvertent skin contamination that occurs during surgery or dressing peel back? We don’t have a lot of experience to go on, despite this extensive meta-analysis. Personally, I have concerns that we are missing something, because in my practice, I am seeing an increase in unusual skin flora infections. Future studies need to further examine these gaps in our knowledge. Surgeons should look at all the ways to reduce infection. We need to be vigilant about antibiotic stewardship and draping. How Do We Get There? Randomized draping studies are realistically difficult to do because it would take a second study of more than 4000 patients to demonstrate a reduction from 2% PJI to 1% PJI by changing drapes. In our practice, we utilize barrier draping for trauma, adult reconstruction, and sports medicine procedures to try and isolate the skin flora from the deep wound. However, there is a paucity of data to support this practice. Other studies should focus on antibiotic stewardship, other barrier drapes, wound vacs, or antibiotic impregnated barriers to reduce contamination at the time of surgery [3]. There are few surgical draping studies available, but future studies should focus on decreasing the skin contamination, reducing risk of peel back, and combating the higher more insidious skin flora infections that seem to be on the rise.
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