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Sterility of Surgical Site Marking
Geoffrey Cronen, MD1; Vytautas Ringus, MD1; Gavin Sigle, MS IV1; Jaiyoung Ryu, MD1
1 Department of Orthopaedics, West Virginia University, P.O. Box 9196, Health Sciences Center, Morgantown, WV 26506-9196. E-mail address for G. Cronen: wvubonehead@yahoo.com
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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Investigation performed at the Department of Orthopaedics, West Virginia University, Morgantown, West Virginia

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Oct 01;87(10):2193-2195. doi: 10.2106/JBJS.E.00293
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Background: Over the past decade, wrong-site surgery has been a popular topic of discussion, not only in medical and legal journals but also in the mainstream press. Marking of the surgical site according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Universal Protocol was implemented at our institution to help reduce the number of wrong-site operations. In this study, we determined whether marking of the site affected the sterility of the surgical field.

Methods: The study included twenty volunteers. The right forearm was used as the experimental (marked) arm and the left forearm, as the control arm. The experimental forearms were marked with a surgical marker as described by the protocol. Both upper extremities were then sterilized from the antecubital fossa to the phalanges with a 7.5% povidone-iodine scrub followed by the application of a 10% povidone-iodine paint. Swabs were used to obtain samples from the experimental and control arms as well as from the marker and were sent for microbiological culture and analysis.

Results: No growth was seen in the cultures of the swabs used on the experimental or control arms or on the marking pens.

Conclusions: Preoperative marking of surgical sites in accordance with the JCAHO Universal Protocol did not affect the sterility of the surgical field, a finding that provides support for the safety of surgical site marking.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Geoffrey A. Cronen, M.D.
    Posted on April 11, 2006
    Dr. Cronen responds to Dr. Maripuri
    West Virginia University, Morgantown, WV 26506

    While we wholeheartedly agree with Dr. Maripuri that pens used to mark surgical sites should be discarded after a single use, the reality, as pointed out, is different. Our study used a single marking pen identical to those found in the surgical preoperative holding area. It had been commandeered from our musculoskeletal research laboratory where it had been used for many months prior to its use in this study. Therefore, we believe that this effectively simulates the aforementioned "real world" condition.

    Although many surgeons do not mark directly over their surgical site, there are a few instances where incisions may necessarily cross these sites. The first is commonly seen among plastic surgeons who preoperatively outline their incisions in an effort to produce a symmetric, aesthetic result. Their procedures routinely take them directly through these marks. As another example, certain procedures require prepping either the entire extremity or, during the case, it is found that the incision needs to be expanded. In either instance, the surgical site marking may find its way into the surgical field or be incised.

    Lastly, a power analysis was done evaluating the number of patients needed to obtain a significant result. The number of 20 was determined to have an appropriate Beta statistic to validate our results - especially considering that our findings were of no growth on all specimens.

    While we appreciate your well thought out critique of this study, we feel that the reasons stated above invalidate any concerns you may have.

    Subramanyam n Maripuri
    Posted on January 12, 2006
    University Hospital of Wales, Dept. Trauma & Orthopaedics, Cardiff, UK

    To The Editor:

    Surgical Site Marking is essential to avoid wrong site operations, and the idea of ensuring that the marked site is sterile is beyond dispute. However, there were certain limitations of this study.

    First, the methodology of this study did not mimic the real practice on wards, where the same marker pen may be used to mark an infected case and then a clean case by two different surgeons (unknowingly), which is not an unusual practice.

    Second, this study was conducted on only twenty volunteers. With such a small study group, the evidence is not enough to conclude that surgical site marking is safe.

    I would like to highlight a few points: first, the marker pens used to mark infected cases should be discarded immediately to prevent their inadvertent use on clean cases; second, since many surgeons prefer to avoid marking directly over the surgical site(in contradistinction to JCAHO protocol) to avoid possible contamination of the surgical site, the mark should be placed apart from the surgical site and point to it with an arrow and the mark should be draped out of surgical field.

    Surgical site marking should not be considered entirely safe until unless it has been proven by a large randomised control study.

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