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Letters to the Editor to:

Scientific Articles:
Geoffrey Cronen, Vytautas Ringus, Gavin Sigle, and Jaiyoung Ryu
Sterility of Surgical Site Marking
J Bone Joint Surg Am 2005; 87: 2193-2195 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Cronen responds to Dr. Maripuri
Geoffrey A. Cronen, M.D.   (11 April 2006)
[Read Letter to the Editor] IS SURGICAL SITE MARKING REALLY SAFE?
Subramanyam n Maripuri   (17 January 2006)

Dr. Cronen responds to Dr. Maripuri 11 April 2006
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Geoffrey A. Cronen, M.D.,
Orthopaedic Resident
West Virginia University, Morgantown, WV 26506

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Re: Dr. Cronen responds to Dr. Maripuri

wvubonehead{at}yahoo.com Geoffrey A. Cronen, M.D.

While we wholeheartedly agree with Dr. Maripuri that pens used to mark surgical sites should be discarded after a single use, the reality, as pointed out, is different. Our study used a single marking pen identical to those found in the surgical preoperative holding area. It had been commandeered from our musculoskeletal research laboratory where it had been used for many months prior to its use in this study. Therefore, we believe that this effectively simulates the aforementioned "real world" condition.

Although many surgeons do not mark directly over their surgical site, there are a few instances where incisions may necessarily cross these sites. The first is commonly seen among plastic surgeons who preoperatively outline their incisions in an effort to produce a symmetric, aesthetic result. Their procedures routinely take them directly through these marks. As another example, certain procedures require prepping either the entire extremity or, during the case, it is found that the incision needs to be expanded. In either instance, the surgical site marking may find its way into the surgical field or be incised.

Lastly, a power analysis was done evaluating the number of patients needed to obtain a significant result. The number of 20 was determined to have an appropriate Beta statistic to validate our results - especially considering that our findings were of no growth on all specimens.

While we appreciate your well thought out critique of this study, we feel that the reasons stated above invalidate any concerns you may have.
IS SURGICAL SITE MARKING REALLY SAFE? 17 January 2006
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Subramanyam n Maripuri,
Clinical Research Fellow
University Hospital of Wales, Dept. Trauma & Orthopaedics, Cardiff, UK

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Re: IS SURGICAL SITE MARKING REALLY SAFE?

naidumsuk{at}yahoo.co.in Subramanyam n Maripuri

To The Editor:

Surgical Site Marking is essential to avoid wrong site operations, and the idea of ensuring that the marked site is sterile is beyond dispute. However, there were certain limitations of this study.

First, the methodology of this study did not mimic the real practice on wards, where the same marker pen may be used to mark an infected case and then a clean case by two different surgeons (unknowingly), which is not an unusual practice.

Second, this study was conducted on only twenty volunteers. With such a small study group, the evidence is not enough to conclude that surgical site marking is safe.

I would like to highlight a few points: first, the marker pens used to mark infected cases should be discarded immediately to prevent their inadvertent use on clean cases; second, since many surgeons prefer to avoid marking directly over the surgical site(in contradistinction to JCAHO protocol) to avoid possible contamination of the surgical site, the mark should be placed apart from the surgical site and point to it with an arrow and the mark should be draped out of surgical field.

Surgical site marking should not be considered entirely safe until unless it has been proven by a large randomised control study.