The postoperative infection rate in procedures where no ring is worn, and those where a plain metal wedding band is worn under the glove was studied retrospectively. From January 1998 through June 2002, 2127 surgeries were performed by the lead author (D.T.S.), the first 2 years without a wedding band and the next 2 years with a simple platinum wedding band worn under the glove. Attention was paid to sliding the ring proximal and distal on the finger, ensuring scrub solution was under the ring and that the area of skin below the ring was cleansed. Twenty-two postoperative infections were recorded in 2127 surgeries. This is a postoperative infection rate of 1.0%, and <1 (0.449) postoperative infection per month. The no ring group totaled 987 cases with an infection rate 1.6%; the ring group revealed an infection rate of 0.53% in 1140 cases. Previous studies of jewelry in the operating room do not discuss the type of wedding ring worn, nor do they demonstrate an increased infection rate with wearing jewelry. This study suggests that there is no correlation between wearing a plain wedding band under the surgical glove and an increase in postoperative infections. The crevices and cuticle of the fingers and nails may provide more significant infection risk than a plain metal wedding band. This is a level III retrospective cohort study.
A surgeon wears a wedding band to pronounce his vows to another. After marriage many remove the ring during surgical procedures in an effort to reduce infection or follow protocol. This can be disheartening to some who for many reasons feel compelled to wear a band at all times. In this study, the author tested postoperative infection rates before and after marriage and without and with wearing a wedding band.
In many cultures the wearing of a wedding band is a symbol of marital commitment and fidelity; removal of the ring may be interpreted as an intent to break marital vows. These beliefs stem from traditions based in folklore and religion. The Egyptians are credited with the wedding bands origin. Around 3000 BC, they began twisting plant material such as hemp into rings to be worn on the fourth finger of the left hand. The Egyptians believed the vena amoris (love vein) directly connected the left fourth finger to the heart, thus linking a couples destiny. The Egyptians also coined the phrase without beginning, without end.1
In the Christian tradition, wedding bands are placed on the fourth finger because the priest arrives at this finger after counting off In the name of the Father, the Son, and The Holy Ghost. In the Eastern Orthodox Church the Best Man exchanges the rings three times from the bride to the groom, then from the groom to the bride. This symbolizes that the weaknesses and imperfections of one spouse are compensated by the strength of the other.1,2 Jewish law requires the groom to present the bride with a physical gift. The Jewish wedding band is traditionally a simple ring of 1 metal without breaks in the circle. A verbal declaration of marriage is inadequate, and a wedding band must be accepted before the marriage is legally binding. This band signifies the wholeness an individual may achieve once married, and the hope for an unbroken union.3
The goal of this study was to evaluate the risk of postoperative infection in procedures where no ring is worn, and those where a plain metal wedding band is worn.
No articles could be found relating wearing wedding bands and surgical infection rates. A study by Bernthal4 and Salisbury et al,5 revealed an increased bioload (including bacteria) under rings and watches. In these studies, cultures were taken without proper scrubbing under or around the jewelry. Additionally, these studies failed to establish an increased infection rate in patients when the surgeon wore a ring.
A study Nicolai et al6 demonstrated a higher incidence of glove perforation of staff wearing rings. This study showed that a particular brand of gloves increased awareness of perforation. This report did not differentiate the type of ring worn (prongs or engraving), nor did it report an increased infection rate. Also, this study was subsidized, in part, by a glove manufacturer selling gloves that indicate perforation.6
A study by Field et al7 concluded bacterial flora cultured from beneath (unwashed) rings and watches was significantly higher than the control sites; however, the organisms cultured did not commonly cause oral infections. The study also concluded the organisms cultured from beneath the (unwashed) rings and watches only posed a threat in a immunocompromised patient if the glove were torn during surgery.7
Materials and Methods
Patients of the author (D.T.S.) who underwent orthopedic surgical procedures beginning January 1998 through June 2002, were compiled for this study totaling 2127 surgeries. Procedures between June 1998 and May 2000 were performed without a ring under the glove and totaled 987 surgeries. The author was married in June 2000 and the procedures beginning June 2000 to June 2002 were performed with a wedding band worn under the glove. These totaled 1140 procedures. The same ring was worn during all 1140 cases. The ring was a plain platinum band without design, grooves, holes, stones, prongs, nor engraving. The ring was always worn on the fourth finger of the left hand. A standard 5-minute surgical scrub was performed preoperatively before every procedure. Attention was paid to sliding the ring proximal and distal on the finger, ensuring scrub solution was under the ring and that the area of skin below the ring was cleansed. This was followed by sterile procedure per operating room protocol.
A total of 22 postoperative infections were recorded in 2127 surgeries. This is a postoperative infection rate of 1.0%, and <1 (0.449) postoperative infection per month.
No ring was worn during the preoperative scrub nor under the sterile gloves in procedures beginning June 1998 to May 2000. This no ring group totaled 987 cases with an outcome of 16 postoperative infections. This is an infection rate 1.6% for the 24 months, and a mean of 0.667 postoperative infection per month.
The ring was worn during the preoperative scrub and under the sterile gloves during all procedures beginning June 2000 to June 2002. This ring group totaled 1140 cases with an outcome of 6 postoperative infections. This is an infection rate of 0.53% during the 25-month period, and a mean of 0.240 postoperative infection per month.
A total of 22 infections were found in 2127 surgeries over a 4-year period from May 1998 to June 2002 performed solely by the author. The ring group bore 6 infections in 1140 surgeries, compared with 16 infections in 987 surgeries in the no ring group (P=.0163). The postoperative infection rate is significantly lower in the ring group. Furthermore the data suggests there is no correlation (r=0) of increasing infection rates between the no ring group and the ring group (Figure).
Identified pathogens included Staphylococcus aureus, Streptococcus, and Serratia marcescens. Staphylococcus aureus was found in 66.6% of these cases; Streptococcus in 16.6 % and Serratia marcescens in 16.6% of cases. Antibiotic treatment included intravenous vancomycin, cefazolin, levofloxacin, clindamycin, and oxacillin for S aureus infections, Penicillin for Streptococcus, and Gentamicin for Serratia marcescens. All patients were treated for at least 2 weeks with home intravenous therapy.
Figure: Number of cases and infections and percentage of infections for the groups with rings and no rings.
A previous study demonstrated an increase in bacteria, fungi, and virus cultured beneath the rings and watches of improperly cleaned hands. Another study showed increased glove perforations at the base of the ring finger of surgeons wearing wedding rings. These studies do not discuss the type of wedding ring worn, nor do they demonstrate an increased infection rate with wearing jewelry. A third study showed that dental postoperative infections were produced by a different bacteria than that cultured from beneath the jewelry. The authors of that study reported that jewelry should be removed for immunocompromised patients, but did not present data to support this recommendation. These previous studies and current operating room protocol suggest that there would be a lower postoperative infection rate in a cohort where no wedding band is worn during surgery, compared to a group where a wedding band is worn.
In this study, there is no correlation between wearing a plain wedding band and an increase of postoperative infections. Our incidence of postoperative infections significantly decreased when the surgeon wore a wedding band. The crevices and cuticle of the fingers and nails may provide more significant infection risk than a plain metal wedding band.
- Kunz GF. Rings for the Finger. New York, NY: Dover; 1973.
- Spangenberd LM. Timeless Traditions: a Couples Guide to Wedding Customs Around the World. New York, NY: Universe Publishing; 2001.
- Diamant A. The New Jewish Wedding. New York, NY: A Fireside Book, Simon & Schuster; 1985.
- Bernthal E. Wedding rings and hospital-acquired infection. Nurs Stand. 1997; 11(43):44-46.
- Salisbury DM, Hutfilz P, Treen LM, Bollin GE, Gautam S. The effect of rings on microbial load of health care workers hands. Am J Infect Control. 1997; 25(1):24-27.
- Nicolai P, Aldam CH, Allen PW. Increased awareness of glove perforation in major joint replacement. A prospective, randomized study of Regent Biogel Reveal gloves. J Bone Joint Surg Br. 1997; 79(3):371-373.
- Field E, McGowan P, Pearce PK, Martin MV. Rings and watches: should they be removed prior to operative dental procedures? J Dent. 1996; 24(1-2):65-69.
Dr Stein is from Coastline Orthopaedic Associates, Fountain Valley, and Dr Pankovich-Wargula is from Sonoma, California.
Drs Stein and Pankovich-Wargula have no relevant financial relationships to disclose.
Correspondence should be addressed to: Daniel T. Stein, MD, Coastline Orthopaedic Associates, 11160 Warner Ave, Ste 311, Fountain Valley, CA 92708.