What Role Does a Colored Under Glove Have in Detecting Glove Perforation in Foot and Ankle Procedures?

BACKGROUND: Many orthopaedic surgical teams practice double gloving or use colored indicator gloving techniques to reduce contamination intraoperatively. Although the likelihood of glove perforation can be affected by the procedure type and surgeon habits, as well as the surgeon’s technique, these factors have not been considered to determine the glove perforation rate, and the role of a colored under glove during operations seems less investigated. QUESTIONS/PURPOSES: (1) What proportion of foot and ankle procedures result in perforation of outer gloves or under gloves? (2) What factors (such as the type or duration of operation) appear to be associated with the likelihood of glove perforation? (3) Does the use of a colored indicator under glove make it more likely that a surgeon would perceive the perforation of an outer glove intraoperatively? METHODS: Between September 2020 and August 2021, the author performed 577 surgical foot or ankle procedures. Of those, patients who underwent subsequent operations under general or spinal anesthesia were considered as potentially eligible. Further, 16% (93) were excluded because the procedures were performed with the patient under local anesthesia, and another 1% (eight patients) were not analyzed (incomplete datasets for emergency operations performed at night). Finally, 82% (476 patients) were examined. To ensure statistical independence, gloves used in right-side operations in bilateral procedures and the most proximal surgery in unilateral procedures were included. Preoperatively, the surgeon was randomly assigned to use either a combination of two regular surgical gloves or a regular outer glove worn over a colored indicator under glove. Patient diagnosis, type of procedure, tourniquet time, and gloving type were recorded. There was no difference in potentially relevant confounding variables, such as the proportion of procedures performed on bone (78% [188 of 242] versus 83% [195 of 234]; p = 0.13), nor in tourniquet time (58 ± 30 minutes versus 62 ± 31 minutes; p = 0.45) between the regular glove and indicator glove groups. At the end of each procedure, the surgeon was asked whether he believed either the outer or under glove was perforated, and whether the use of a colored under glove increased the proportion of procedures in which the surgeon correctly ascertained that a perforation had occurred. To determine the proportion of gloves that were perforated, a standardized water-leak method was used, and the proportion of gloves with perforations based on several parameters of interest, including bone versus soft tissue operation and tourniquet time, was compared. RESULTS: During 476 foot and ankle procedures, the overall glove perforation proportion was 19% (92 of 476 procedures). Under-glove perforation was observed in 4% (17 of 476 procedures) of the operations. There was no difference in glove perforation proportions between bone and soft tissue operations (76 of 383 versus 16 of 93; odds ratio [OR] = 0.84, 95% confidence interval [CI] 0.46 to 1.52; p = 0.56). As tourniquet time (operation time) increased, the glove perforation proportion also increased (Exp[B] = 1.02; 95% CI 1.01 to 1.03; p < 0.001). The use of indicator under gloves increased the surgeon’s intraoperative detection of glove perforation (in 68% of procedures [32 of 47] versus 29% [13 of 45]; OR = 5.3; 95% CI 2.2 to 12.8; p < 0.001). CONCLUSION: Surgical glove perforation occurred in approximately one of five foot and ankle procedures. Based on the results of this study, I recommend using colored indicator under gloves and replacing the under glove when replacing the outer glove after perforation is seen in order to detect contamination early and reduce any intraoperative contamination related to glove injury. LEVEL OF EVIDENCE: Level I, therapeutic study.