Prevention of infection in fracture care is paramount to successful outcomes. Unfortunately, surgical site infections (SSIs) are a disheartening and inevitable complication in an orthopaedic surgeon’s practice. However, recent resources and literature aim to improve outcomes and reduce the prevalence of SSIs. From proper draping and gown-donning techniques to airflow and operative theater environment, reducing contamination before incision has been a critical facet of this literature theme. A recent study by the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma (PREP-IT), investigators sought to add to the body of knowledge in infection prevention by critically evaluating commonly available surgical skin-preparation antisepsis agents.

As described in the New England Journal of Medicine in February of 2024, the PREP-IT investigators performed a cluster-randomized crossover trial comparing 0.7 percent iodine povacrylex in 74 percent isopropyl alcohol (3M DuraPrep) to 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol (BD ChloraPrep; 3M SoluPrep S Sterile Antiseptic Solution). Twenty-five hospitals in both the United States and Canada served as study sites, and each hospital alternated intervention type every 2 months. The study looked primarily at the difference in infection rates between the two skin antisepsis agents in extremity-fracture surgery in either open or closed fractures. Of note, the open cohort included both upper- and lower-extremity fractures (excluding hand), whereas the closed cohort included lower-extremity and pelvis fractures only.

The investigators found a statistically significant reduction in SSI rates in the closed-fracture arm of 6,785 patients, with 77 patients (2.4 percent) in the iodine/DuraPrep group experiencing infection, compared with 108 patients (3.3 percent) in the chlorhexidine/ChloraPrep group (P = 0.049). In the separate arm of 1,700 patients with open fractures, no significant difference was observed, with infections occurring in 54 patients (6.5 percent) and 60 patients (7.3 percent) in the iodine and chlorhexidine groups, respectively. Unplanned reoperation rates within 1 year were not significantly different in either group, regardless of surgery type.

What does all of this mean? First, credit to the authors for publishing a high-quality study aiming to help reduce the incidence of postoperative infections, which can be devastating for both the patient and surgeon. The data show that overall infection rates were lower than historic average, but improvement was still seen in closed fractures with 3M DuraPrep. With the high number of confounding variables in open fractures, it is not surprising to see a lack of significance within that arm. Thus, assuming institutional cost equivalency and lack of contraindications, iodine-based skin antiseptics, such as 3M DuraPrep, seem to be the narrow winner with regard to infection prevention based on these recent data.

Additionally, as the study investigators pointed out, 3M DuraPrep comes with the added benefit of theoretically improved adherence to surgical drapes, which can be anecdotally obvious when switching between the two, in this author’s opinion. Of course, none of this is a substitute for strict adherence to antiseptic technique and appropriate antibiotic prophylaxis, which remain important pillars in the prevention of infection. Rather, this study does a great job building on the aseptic protocols and principles and answering a question that is long overdue in the orthopaedic realm, considering it has been looked at in numerous other specialties previously.

Thomas L. Hand, MD, FAAOS, is an orthopaedic trauma surgeon and an assistant professor of orthopaedics at UT Health San Antonio.