Does Extent of Skin Preparation Influence Contamination During Direct Anterior Total Hip Arthroplasty? A Fluorescent Tracer Proof-of-Concept Study

Abstract

There is currently no evidence-based consensus regarding the optimal extent of skin preparation when performing total hip arthroplasty (THA) through the direct anterior approach using dedicated anterior-approach draping systems (DAA Drapes). The purpose of this study was to evaluate the contamination risk associated with different disinfection and draping strategies for anterior-approach THA using a proof-of-concept contamination model. Six commonly used skin preparation protocols were evaluated using a standardized fluorescent contamination model. Protocols ranged from extensive bilateral lower-limb preparation to limited ipsilateral preparation excluding the foot or distal leg. After draping, the operative field was assessed under ultraviolet light for contamination. Contamination rates and distances from the surgical field were recorded and analyzed using non-parametric statistics. No contamination was observed in the four most extensive preparation strategies. Contamination occurred in 28.6% of trials when the ipsilateral foot and ankle were excluded from preparation and in 57.1% of cases when preparation was limited to above the knee. Lifting the leg to disinfect the posterior aspect and disinfecting the contralateral limb did not reduce contamination risk. In this proof-of-concept study, limited skin preparation of the ipsilateral lower limb—particularly omission of the foot and distal leg was associated with a substantially increased risk of surgical field contamination. More extensive measures, such as lifting the leg or disinfecting the contralateral limb, did not confer additional benefit. These findings should be considered hypothesis-generating and require validation through microbiological and clinical outcome studies.