Glove perforation in orthopaedic and trauma surgery. A comparison between single, double indicator gloving and double gloving with two regular gloves

The spread of viral diseases such as HIV has highlighted the importance of protecting medical personnel against contamination from blood. We have assessed the frequency of the perforation of surgical gloves during orthopaedic and trauma surgery and compared the efficiency of single and double gloving. We examined all the gloves used by surgeons for a period of two months. There were 1769 gloves from 349 operations. Perforations occurred in 18.5% of conventional and 5.8% of arthroscopic procedures. The risk of contamination from blood was 13 times higher when using single compared with double gloves. Surprisingly, the combination of two regular gloves was much less efficient than double indicator gloves when comparing the rate of perforation of the inner glove when the outer had been damaged (24% vs 4.9%; p = 0.02). We recommend double gloving in orthopaedic surgery in general and also in long arthroscopic procedures.     

Double gloving. Protecting surgeons from blood contamination in the operating room.

Health care workers, particularly surgeons, understand the importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.     

Double gloving in reducing the interoperative risk of blood borne pathogens]

The potential for blood contact with skin puts operating room personnel at increased risk of exposure to hepatitis or HIV virus. One of the most common areas of contamination with infectious biological material is the hands and fingers due to failure of glove protection. There are varying opinions regarding the frequency of glove failure during orthopaedic procedures and the necessity of wearing two gloves for added protection. The authors performed a trial of 94 procedures involving 10 surgeons from Orthopaedic Department of Pomeranian Medical University from Szczecin, Poland to answer these questions. Outer-glove perforations occurred in 15% of the cases while inner-glove--in only 3.1% (p < 0.0001). In 5 cases there was an inner-glove defect without a corresponding outer-glove perforation. Both the duration of the operation longer than 2 hours and the type of the procedure (minor versus major) were associated with increased rates of perforation (p < 0.002 and p < 0.0007 respectively). From total amount of perforated outer-gloves, only 13 (28%) were changed by the surgeon during the operation. There was no statistically significant difference between latex and neoprene used as inner-gloves (p > 0.17) in failure rates. The authors conclude double gloving during orthopaedic procedures and changing the gloves every 2 hours may significantly reduce the operating room personnel's risk of exposure to blood borne pathogens.     

Can double gloves improve surgeon-patient barrier efficiency?

The aim of this study was to compare double gloves (DGs) with single gloves (SGs) during orthopedic and trauma surgery in prevention of blood contact between patients and surgeons. DGs and SGs were collected after orthopedic operations, tested for size, site, and number of perforations. Medical records were reviewed for age, sex, type of operation, duration, and postoperative wound infection. Data were compared using t-test with level of statistical significance at P < 0.05. Five hundred seven operations yielded 1204 DGs and 830 pairs SGs. In DGs, perforations were detected in 220 outer glove and 39 inner glove (10.7%). In SGs, 226 perforations were detected (13.3%). The incidence of perforations in inner gloves of the double indicator glove was 1.6% (P < 0.001). During surgery, perforations were recognized in DGs in 67% compared with 12% in SGs (P < 0.005). This study confirms that DGs form an efficient barrier between patients and surgeons.     

Glove Perforation in Outpatient Dermatologic Surgery

BACKGROUND: Intact surgical gloves ensure protection of health-care employees and health-care recipients. Nevertheless, glove perforation is very common and puncture rates above 50% have been published in the literature. OBJECTIVE: It was our aim to evaluate the perforation rate of surgical gloves in outpatient dermatologic surgery. METHODS: Six-hundred and sixty latex surgical gloves used in outpatient dermatologic surgery were evaluated for perforations using the approved water-leak method. Perforations were analyzed microscopically. RESULTS: Twenty of the 660 gloves were found to have perforations, which corresponds to a perforation rate of 3.0%. Only 5 of these perforations (25%) were noticed by the wearer. Perforations were more numerous in nondominant-handed gloves. Microscopically, all perforations could be identified as needle stick injuries. CONCLUSION: The risk of glove perforation in outpatient dermatologic surgery is lower than in many other medical specialties. The relatively high number of surgical procedures performed successively in outpatient dermatologic surgery, however, emphasizes the decisive relevance of an intact barrier between surgeon and patient. In view of the major fact that most perforations go unnoticed by the wearer, dermatologic surgeons must balance the improved safety of double gloving with costs and the loss of sensitivity and dexterity.     

Self protection in surgery: the use of double gloves

This study assesses the perforation rate of single and double gloves and thus the extent to which double gloving protects the surgeon from diseases transmissible from the patient. We have also investigated whether double gloving offers the patient extra protection by reducing wound sepsis. Two hundred adult hernia repairs were performed, the first 100 single gloved and the second 100 double gloved. Glove perforation rates were not significantly different between single gloves and the outer of the double gloves. Although 46 of 400 outer gloves were perforated there were only 15 inner glove perforations and only eight of these matched the outer perforations. The percentage of operations in which the latex protective barrier was breached was reduced from 31 per cent when the surgeon wore single gloves to 8 per cent with double gloves. Wound sepsis was not increased by glove perforation nor reduced by double gloving. While careful technique remains mandatory we conclude that double gloving offers increased protection to the surgeon operating on high risk infectious cases.     

Anticipated Detection of Imminent Surgeon–Patient Barrier Breaches. A Prospective Randomized Controlled Trial Using an Indicator Underglove System

The double gloving indicator underglove system (IUS) is based on a colored detection of the outer glove perforation. Our objective was to determine the IUS efficiency to detect outer glove perforations and to reduce the risks of blood and body fluids exposure, warning the surgeon before the breach of the surgeon–patient barrier (SPB). A series of 100 visceral surgical procedures were randomly assigned to either double (IUS) or single gloving. The noticed glove perforations (using the water test method) and the IUS efficiency were analyzed in 99 procedures. In 49 single-gloving procedures, 19 perforations were noticed: one was immediately perceived (perceived accidental exposure, PAE); 3 were discovered as the gloves were being removed, and 15 were undetected before the water test (unperceived prolonged contact, UPC). In 50 double-gloving procedures (IUS), 16 perforations were noticed, all of them involving only the outer glove: the IUS allowed immediate detection of 3 perforations without any blood exposure; 13 other perforations went undetected but without any UPC. In conjunction with the protective quality of double gloving, the IUS allows detection of significant breaches of the outer glove before the breach of the SPB.     

Efficacy of double versus single gloving in protecting the operating team

Double-glove perforation rates and perforation rates in standard single-gloved operating teams were compared, in order to determine whether double gloving provides additional protection for the operating team. Patients were randomized to undergo surgery with a double-gloved or single-gloved operating team. All gloves worn during the operation were tested for perforations by water-filling and individual digital distension; 115 single-gloved operations and 103 double-gloved operations were performed. There were 841 individual operating team members 'at risk'. In the single-glove group, 20.8% of individuals had perforations, but only 2.5% had perforations in both inner and outer gloves (dual perforation) in the double-glove group (P less than 0.0001). The surgeon was most at risk of glove perforation (34.7% of cases in the single-glove group, 3.8% dual perforation in the double-glove group). Longer operations were associated with increased risk of glove perforation. Double-gloving significantly reduces the risk of skin contamination by blood and body fluids and is recommended for all high risk cases.     

Surgical glove perforation

In a study to investigate the incidence and significance of surgical glove perforation, bacterial contamination of surgeons' hands and gloves before and after operation was measured and the gloves tested for damage. Perforations were found in 74 of 582 gloves (12.7 per cent) and occurred in 34.5 per cent of operations. Glove perforation did not influence bacterial counts on the surgeons' hands or on the outside of their gloves. A separate clinical study of 100 adult hernia repairs gave no evidence that perforation increased wound sepsis. After standard pre-operative hand preparation, glove perforations are of no clinical significance to the patient, but their high incidence should alert surgeons to the need for protection against pathogens transmissible during surgery, such as hepatitis B and the human immunodeficiency virus. Protection of the surgeon is the main indication for preoperative change of damaged gloves.     

Comparison of open and closed staff‐assisted glove donning on the nature of surgical glove cuff contamination

Background: We have observed that surgical glove cuffs commonly fold over during an operation, exposing the inside of the glove cuff to the sterile field and wound, a potential source of contamination if the inside of the glove cuff has been in contact with the fingers during glove donning. We hypothesize that open staff‐assisted gloving results in more inside‐glove cuff contamination than a closed staff‐assisted technique. Method: We performed a blinded, randomized study comparing open and closed staff‐assisted glove donning. Two surgeons were gloved 20 times after covering their fingers and hands with GlitterBug(TM) powder. The gloves were turned inside out and the distance of GlitterBug(TM) powder from the free edge of the cuff was measured. Results: Staff‐assisted open glove donning was associated with significantly more glove cuff contamination than closed staff‐assisted glove donning (P= 0.001). Conclusion: Given glove cuff ‘turn down’ intra‐operatively, we strongly recommend closed staff‐assisted gloving.     

Double or single gloves: which is safer in pediatric orthopedic surgery

BACKGROUND AND AIM: Surgical gloves should form an efficient barrier between surgeons and patients to prevent cross infection. Single gloves (SGs) have long been reported unsafe, and usage of double gloves (DGs) is still not universal. No study has reported the usage of DGs in pediatric orthopedic operations. The aim of this study was to assess the efficacy of DGs versus SGs in prevention of body fluid contact between patients and surgeons during pediatric orthopedic surgery. METHODOLOGY: After 150 pediatric orthopedic operations, DGs and SGs were collected and tested for perforations. Gloves were tested for size, site, and number of perforations among principal surgeons, assistant surgeons, and scrub nurses. Gloves were not changed during long surgical procedures and were changed only if perforations were identified and recorded. The DGs used were Maxitex Duplex, powder-free indicator gloves and the SGs were of Gammex-Ansell. One hundred unused gloves of each group were tested as controls. Medical records of the patients were reviewed for age, sex, type of operation, duration of operation, and any postoperative wound infection. The data were entered in database and analyzed using SPSS package. The data were compared between double and SGs using t test with a level of statistical significance at P less than 0.05. RESULTS: Five hundred twenty-six DGs and 316 SGs were tested. Forty-three perforations were detected in DGs (8.1%). Outer gloves were breached in 7.8% and inner in 0.3% as compared with SGs in which 28 (8.7%) were perforated. In DGs, 4% had multiple perforations compared with 11.9% in SGs. There was a statistical significance (P<0.001) when the perforations of inner gloves were compared with the SGs. None of the inner perforations were recognized during surgery, but the outer gloves of the DGs were recognized in 71% as compared with 9% in SGs (P<0.001). The majority of perforations were seen in the nondominant hand in surgeons and assistants hands, whereas scrub nurses had 85% of perforations in the dominant hand. The index finger was the site of perforations in DGs (53.4%; SGs, 43%). The inner gloves were breached only when the outer glove was found to be perforated. The duration of surgery had a direct impact on the number of perforations. There were no perforations in DGs in less than 60 minutes as compared with 3 (10.7%) in SGs. Between 60 and 120 minutes, the perforations in the DGs were 11, and in SGs, 21. During the study period, 4 patients had surgical site infection. Three were superficial and one deep-seated infection. In 3 patients with infection, the gloves were found to be perforated, and 1 patient with infection had no perforations in the gloves. CONCLUSION: Our study confirms that DGs are safer than SGs during pediatric orthopedic operations. In the event of nonavailability of DGs, SGs should be changed on an hourly basis during long procedures. Lastly, there exists a relationship between surgical site infection and glove perforations.     

整形手术中手套穿孔情况调查及其与医源性感染相关性的探讨

目的:外科手术中手套穿孔和皮肤的损伤成为病原体血源性传播的重要途径之一,然而在外科手术中,特别是在整形外科手术过程中,手套穿孔发生情况的调查鲜有报道。方法:2005年5月～2006年3月我院整形外科手术室采用超量注水挤压试验(Mafulli检测法)检查了A(短时手术,手术时间在30min以内)、B(长时手术,手术时间在1h以上)两组620例整形美容手术使用的3420个手套穿孔部位及发生率,了解整形美容外科手术过程中手套穿孔发生情况。结果:结果显示A组手套穿孔率较低(2.61%)。B组手套穿孔率较高(13.65%);手套穿孔率与手术时间成正比;左手食指掌侧面为穿孔高发部位。结论:手套穿孔是整形外科手术过程中经常发生的问题,随手术时间和次数的增加,手术人员可能接触患者血液和其它体液的几率增加。     

Electronic detection of breaks in the surgeon-patient barrier. Evaluation of protective clothing in visceral surgery

STUDY AIM: Breakdown of the aseptic surgeon-patient barrier causing abnormal contact between skin and body fluids represents a risk for transmission of infectious disease. Such breakdowns are frequently not perceived by the surgical team over prolonged periods. The aim of this prospective randomized study was to evaluate the protection afforded by double gloving and reinforced gowns in visceral surgery. METHODS: An electronic device detected breakdowns of the surgeon-patient barrier in a series of 80 surgical procedures, randomly assigned to double or single gloves, and normal or reinforced gowns. Fluid contacts due to glove perforation, glove porosity or gown wetting were recorded during 151 individual participations covering 238 hours. Surgical procedures were called deep for incisions of more than 10 cm. RESULTS: Deep surgical procedures carried a sevenfold-increased risk of barrier breakdown, compared with superficial ones. Skin contacts through wet gowns were not prevented by the use of double thickness materials, but double gloving reduced the number of perforation and porosity alarms twofold in both superficial and deep surgery. CONCLUSION: Without electronic detection, 96% of barrier breakdowns would remain undetected by the surgical team and lead to prolonged contact with potentially contaminating-fluids. The use of double gloving provides a real protection against contamination risk.     

Glove perforation rate in open lung surgery.

OBJECTIVE: In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities. METHODS: Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations. RESULTS: One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation. CONCLUSIONS: The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.     

Surgical glove use in France

Since the end of the 19th century, surgeons have used gloves to prevent infectious complications to the patient. The AIDS epidemic of the 1980's sparked the use of universal precautions to protect the surgeon from infection and vice-versa. The interface between surgeon and patient is in effect a two-way street. Surgical techniques must be modified and barrier protection optimized to minimize these risks. A single layer glove is a fragile barrier to blood exposure; unrecognized glove perforations may lead to unrecognized and prolonged exposure. Double gloving, though far from being a widespread practice in France, seems to be the best protection from pathogen exposure. Glove powder and latex allergies have their own inherent risks to both surgeon and patient in the form of latex allergies and adhesive peritonitis. New institutional protocols will be necesssary in order to make powder-free non-latex gloves available to French surgeons.     

Evaluation of microbial contamination of surgical gloves during actual use.

The contamination rate of gloves is about the same for all scrubbed personnel, be they single or double gloves (33%). More holes are noted in the gloves of personnel who use their hands more strenuously. A double pair of gloves does not reduce the amount of contamination but does reduce the number of holes. The contamination could not be associated with the hole in the glove in our study. The amount of contamination beneath the glove does not influence its exterior contamination. Contamination generally comes from somewhere else in the operative field environment.     

The mechanical and microbiological integrity of surgical gloves

Background: Several manufacturers supply surgical gloves that have been individually tested (IT) for leaks. Other manufacturers supply gloves in which sample gloves from each batch are tested for leaks (batch tested: BT). The latter brands may be rejected by surgeons because of presumed increased risk of wound infection and staff exposure to patient pathogens. The influence of differences between glove brands on performance in surgery has not been extensively studied. The aims of the present study were to test the mechanical and microbiological integrity of IT compared to BT gloves. Methods: A total of 110 unused gloves from each of an IT and a BT brand were tested for leaks, first, by observation of water‐jets from water‐filled gloves and second, by measuring electrical resistance between inside and outside the glove surfaces, to give a baseline measure. A total of 304 IT and 280 BT gloves were then similarly leak‐tested after 98 clean surgical procedures. The hands and gloves of scrub team members were cultured postsurgery. Results: A total of 1/110 BT and 0/110 IT unused gloves contained leaks (NS, Fisher's exact test). Operative perforation rates were lower for BT compared with IT (8/280 cf. 22/304; P < 0.05 Fisher's exact test). There was no bias in types of operations or scrub team members to account for the difference. Growth of normal skin flora was found on virtually every wearer's hands post­operatively. Similar bacteria were frequently cultured from the outside of gloves at the conclusion of surgery (111/152 pairs IT cf. 122/140 pairs BT; P < 0.01, Fisher's exact test). Conclusion: This study provides evidence that the clinical performance of BT gloves is no different to IT gloves. There was no significant difference in mechanical leak rates for unused gloves. Paradoxically, although IT gloves were more likely to show macro­perforations after surgery, the incidence of contamination on the surface of BT gloves was greater, possibly reflecting a qualitative difference in glove material. This study suggests that both types of gloves develop microporosity during use, which may allow transfer of bacteria from the surgeon's skin to the surface of the glove.     

Risk of Glove Perforation in Minor and Major Plastic Surgery Procedures

Background Incidental needlestick injury with exposure of blood pathogens has a high incidence among health care workers. Because plastic surgeons make up an important risk group for this type of accident, this study sought to evaluate the incidence of glove perforation during minor and major plastic surgery procedures.Methods Evidence of glove perforation was evaluated for 390 gloves after 100 consecutive minor surgical procedures and for 710 gloves after 100 consecutive major surgeries using Maffulis test. An index based on the number of first assistants glove perforation and the surgical time was created to compare these accidents associated with both types of procedures.Results Glove perforations were found in four gloves (1.02%) after minor surgery and 76 gloves (21.40%) after major surgery. During minor surgeries, the assistant was more likely to have exposure than the surgeon. During major surgery, the surgeon experienced more glove perforations (59.21%) than the assistant (40.79%). The most common location of perforations was the palmar face of the left hand in both groups. The surgeons did not notice these perforations at any time. The duration of the minor procedures varied from 10 to 30 min (average, 17.55 min), whereas the time of major procedures ranged from 1 to 6 h (average, 186 min). There was no statistical significant difference in the perforations index between minor and major procedures.Conclusions The risk of perforation to the surgeons glove during minor surgery is minimal. The frequency of perforation to the first assistants glove is similar between minor and major plastic surgery procedures.     

Glove punctures in major and minor orthopaedic surgery with double gloving

We assessed the frequency of glove perforation during major and minor orthopaedic surgeries, in order to determine the efficacy of double gloving. A total number of 1528 gloves (622 inner and 906 outer) used in 200 procedures (100 major-100 minor), and 100 pairs of unused gloves were examined. Glove perforation rate, incidence among surgical team, location of perforation and duration of surgery were compared. The overall perforation rate was 15.8% (242/1528). Perforation rates for major versus minor surgical procedures were 21.6% and 3.6%, respectively. The perforation rate for the unused control group was 1% (2/200). Inner-outer gloves perforation rates were 3.7% (23/622) and 22.7% (206/906), respectively. Surgeons had a higher perforation rate compared with the other staff. The right thumb and left index finger had more punctures than other fingers. Routine use of double gloving during orthopaedic procedures is recommended, because this significantly reduces the perforation of inner gloves.     

Needlestick injuries at operations for trauma. Are surgical gloves an effective barrier?

Surgeons are at risk from both hepatitis B and human immunodeficiency viruses. While vaccines have been developed against the former, barrier methods remain the mainstay of protection. Puncture wounds of the hand are a potential source of contamination; the protection afforded by surgical gloves has been investigated. Gloves from 280 orthopaedic operations for trauma were tested for perforations; one or more was found after 30% of the operations in gloves worn by the surgeon or scrub nurse. About 60% of the perforations were noticed at the time of penetration and most affected the dominant thumb and index finger. Puncture was more common during operations lasting more than one hour. The incidence of perforation was 19% for the outer of double gloves, 14% for a single glove and 6% for the inner of double gloves. These results indicate that surgical gloves function poorly as a protective barrier, especially in difficult, lengthy, fracture surgery. The practice of double-gloving confers increased but not absolute protection.