Deterioration of theatre discipline during total joint replacement--have theatre protocols been abandoned?

The results of the Medical Research Council trial by Lidwell et al. in 1982 [Lidwell OM, Lowbury EJ, Whyte W et al. Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. BMJ 1982; 285: 10-4] showed a decrease in infection rates following joint replacements carried out in ultraclean air theatres. Since then, the orthopaedic community in the UK has relied to a large extent on laminar airflow theatres to control infection following arthroplasty. At the same time, there has been a decline in the emphasis on basic principles and practices of antisepsis based on scientific evidence. We undertook this audit to establish whether published recommendations on theatre discipline were being followed in operating theatres where joint replacements are carried out, in England, Scotland and Wales. Our results show that with improvement in technology involved in clean air theatres, and availability in practice, slackness has crept into theatre protocol. In view of the fact that infection following arthroplasty has not been eliminated or indeed in some cases, maintained at the levels of the Medical Research Council study, we feel that traditional practices should be reintroduced. This study shows that there is pressing need for a set of recommendations on theatre practice for all staff in operating theatres that carry out joint replacements.