An Overview of Skin Antiseptics Used in Orthopaedic Surgery Procedures

Joseph Letzelter, MD; J. Bradford Hill, MD; Jacques Hacquebord, MD


J Am Acad Orthop Surg. 2019;27(16):599-606. 

In This Article

Abstract and Introduction


Surgical site infections (SSIs) in orthopaedics are a common complication, with more than half a million SSIs occurring in the United States each year. SSIs can carry a notable burden for patients and physicians alike. Skin antiseptic solution plays an important role in preventing SSI. Many studies have looked at different skin antiseptic solution in preventing SSIs. Different surgical preps can decrease bacterial loads at surgical sites in varying degrees. Yet, the amount of bacterial load does not always correlate with a lower risk of infection. Chlorhexidine, for example, has been shown to cause markedly less SSIs compared with povidone-iodine prep in general surgery cases. Whereas chlorhexidine with alcohol may best work in the forefoot, iodine povacrylex with alcohol is equivalent in the spine. Conversely, joint arthroplasty SSIs were markedly decreased with a combination of preps. Because of all these differences, understanding which prep solution to use and when can be invaluable to the orthopaedic surgeons.


More than half a million surgical site infections (SSIs) occur in the United States each year. SSIs have been reported to occur in 2.8% of surgical procedures.[1] Some risk factors that may help predict SSIs include age, diabetes, obesity, urinary incontinence, and prolonged surgical time.[2] Not only are SSIs costly surgical complications, they also carry a notable burden for patient well-being and quality of life. SSIs are associated with revision surgeries, delayed wound healing, increased or prolonged antibiotic use, and increased length of hospital stay.[3] One of the most common nosocomial infections is the SSI, which leads to mortality in thousands of patients each year.

SSIs not only cause morbidity to the patients but also drive health-care costs up. Hospital-acquired complications receive limited reimbursement, and SSIs account for 38% of nosocomial infections. In an effort to stave this trend, perioperative skin preparation has become an important quality performance measure in the Centers for Disease Control and Prevention and Centers for Medicare and Medicaid-initiated Surgical Care Improvement Project.[4]

Skin antiseptic solution (SAS) plays an important role in preventing SSIs. The three main antiseptics most commonly used in the operating room (OR) for skin prepping include chlorhexidine, iodine, and alcohol. This review covers the most commonly used SASs and their cost. It then summarizes the use and efficacy of these antiseptic agents in the various subspecialties of orthopaedic surgery.