Basic Science
The effect of axillary hair on surgical antisepsis around the shoulder

https://doi.org/10.1016/j.jse.2014.10.007Get rights and content

Background

Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking.

Methods

We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test.

Results

There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all).

Conclusions

Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.

Section snippets

Materials and methods

Eighty-five healthy male volunteers were enrolled in the study. Eligible volunteers were men aged 18 to 80 years; only men were enrolled as P. acnes infection is more common in men than in women.14, 15 Enrollment was precluded if volunteers had active infections or antibiotic use in the previous 2 weeks or a history of dermatologic conditions in the axillae. The median age of participants was 27 years (range, 21-53 years).

We clipped one randomly selected axilla in each volunteer with

Results

The right axilla was clipped in 42 participants; the left was clipped in 43. Only 3 subjects had no axillary hair before clipping; 14 had perspiration, and 4 had acne. Only 1 subject reported tobacco use. A summary of baseline characteristics is found in Table II.

All subjects had positive cultures from the clipped axilla, whereas 7 subjects had negative cultures from the unclipped axilla. The most commonly isolated organism was coagulase-negative staphylococcus (124 of 170; 72.9%), followed by

Discussion

The role of P. acnes in the pathogenesis of postoperative shoulder infection and specifically in periprosthetic glenohumeral arthroplasty infection is increasingly recognized in the literature.2, 5, 7, 9, 16, 20, 26 This awareness has prompted surgeons to pursue various methods of risk reduction and infection prevention. Some of the proposed methods include excluding the axilla from the surgical field, preoperative antibiotics targeted to P. acnes, preoperative axillary cleansing, and axillary

Conclusions

Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation was effective at removal of all bacteria and specifically P. acnes from the axilla, whether or not axillary hair had been removed.

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Acknowledgments

The authors would like to acknowledge Mary Kwasny, ScD, for her assistance with statistical analysis and Eric Pang, MD, for his assistance with data collection.

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  • Cited by (0)

    Investigation performed at Northwestern Memorial Hospital, Chicago, IL, USA.

    The Northwestern University Institutional Review Board approved this study: No. CR3_STU00030047.

    Funding: This project was supported by Orthopaedic Research and Education Foundation (OREF) Resident Research Grant #11-251 and by CareFusion unrestricted research Grant #7211-002. CareFusion provided surgical preparation solution (ChloraPrep) and surgical clippers.

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