ACADEMIA Letters Double occlusive adhesive draping technique for shoulder arthroplasty Mustafa Javed Introduction Surgical site infections (SSI) are a common problem encountered in orthopaedic surgery. Therefore prevention of bacterial contamination in the region of the surgical incision is of prime importance. Following application of pre-operative skin antiseptics, resident skin flora remains with Staphylococcus Epidermidis in the foreground. It is the remaining skin flora that can enter the surgical wound intra-operatively and cause SSI. A large proportion of the bacteria are localized in the hair follicles (1) and the alcoholic skin antiseptic may not completely reach these areas. Iodine has good penetration abilities and can be assumed that bacteria located in the hair follicles can be reached. Eyeberg et al. (2)compared iodine impregnated drape to other control drapes showed that after direct inoculation of test organisms (MRSA, S. epidermidis, E. faecalis (VRE), E. faecium (MDR), S. pyogenes, E. cloacae, E. coli, K. pneumoniae, P. aeruginosa, S. marcescens, C. albicans, C. parapsilosis) onto the iodine impregnated incision drape which were then washed off in neutralization solution to determine the reduction factor (RF). The results had shown a clinically relevant reduction of microbial count. We present a double draping technique using iodophor impregnated occlusive adhesive dressing for shoulder arthroplasty. Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Mustafa Javed, mustafajavedbhalli@gmail.com Citation: Javed, M. (2021). Double occlusive adhesive draping technique for shoulder arthroplasty. Academia Letters, Article 3957. https://doi.org/10.20935/AL3957. 1 Technique Once in the operating room, the skin of the affected upper extremity and shoulder girdle is cleaned with 4% chlorhexidine gluconate. The area included in the surgical preparation extends medially to the midline, distally to the level of the nipple and proximally to the level of the base of the neck and encompass the entire upper extremity excluding the hand. Draping is initiated by the assistant’s hand with an impermeable stockinet which is rolled passed the elbow and is covered and secured with a disposable elastic wrap. A reinforced disposable fenestrated drape is passed over the hand and extended over to the head, torso and lower extremities to prevent contamination of the surgical field. The remaining exposed skin in the surgical field is allowed to dry. Two occlusive adhesive drapes are used in our technique to effectively barrier the axilla from the surgical filed and allow ranges of movement of the shoulder during surgery. Our preference for the occlusive drape to be impregnated with Betadine unless there is specific Betadine allergy or hypersensitivity, we use a non-Betadine-impregnated version of the same drape. Two occlusive drapes sized (****) are used. Initially the smaller drape is folded into half with the adhesive surface up and held by the surgeon and the first assistant. The scrub nurse or the second assistant peels off the backing off the adhesive surface. The arm is then abducted and the occlusive drape is passed under the arm and stuck to the axilla, medial arm and the pre-draped chest wall. The larger of the two occlusive adhesive drapes is cut to the size corresponding to the size of the arm. The arm is kept abducted and externally rotated as the occlusive drape is placed anteriorly and then around the arm to meet the smaller drape placed initially. The “dog ears” are cut close to the arm. The arm is then taken through all the ranges of movement required during surgery. Discussion Studies have shown that preoperative skin preparations cannot completely eradicate bacteria, especially on patients with high preoperative bacterial counts (3-8). Given the evidence, we feel that an infection prevention program during surgery is incomplete without an incision drape system that creates a sterile surface, which is unachievable by using a patient prep alone. Iodophor impregnated adhesive occlusive dressings reduce the likelihood of skin recolonisation after prepping (9) and reduce the risk of wound contamination by skin flora which is a common cause of SSI (10). The National Institute of Clinical Excellence (NICE) guidelines Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Mustafa Javed, mustafajavedbhalli@gmail.com Citation: Javed, M. (2021). Double occlusive adhesive draping technique for shoulder arthroplasty. Academia Letters, Article 3957. https://doi.org/10.20935/AL3957. 2 for prevention of SSI also recommend that if an incise drape is required, to use an iodophor impregnated drape (11). We present a technique of double draping using two adhesive occlusive dressings for shoulder arthroplasty to isolate the surgical field effectively and allow ease of movement of the upper limb without compromise. Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Mustafa Javed, mustafajavedbhalli@gmail.com Citation: Javed, M. (2021). Double occlusive adhesive draping technique for shoulder arthroplasty. 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Welsh A, National Collaborating Centre for Women’s and Children’s Health. Surgical site infection: prevention and treatment of surgical site infection. : RCOG Press; 2008. Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Mustafa Javed, mustafajavedbhalli@gmail.com Citation: Javed, M. (2021). Double occlusive adhesive draping technique for shoulder arthroplasty. Academia Letters, Article 3957. https://doi.org/10.20935/AL3957. 4