Annotation
ANNOTATION
Irrigation of the wounds in open fractures
D. J. Crowley,
N. K. Kanakaris,
P. V. Giannoudis
From Leeds General
Infirmary, Leeds,
England
D. J. Crowley, MRCS,
Research Fellow
N. K. Kanakaris, MD, Clinical
Fellow in Trauma
P. V. Giannoudis, BSc, MB,
MD, EEC(Ortho), Professor
Academic Department of
Trauma & Orthopaedics
Leeds General Infirmary,
Clarendon Wing, Great George
Street, Leeds, LS1 3EX, UK.
Correspondence should be sent
to Professor P. V. Giannoudis;
e-mail: pgiannoudi@aol.com
©2007 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.89B5.
19286 $2.00
J Bone Joint Surg [Br]
2007;89-B:580-5.
580
Modern principles for the treatment of open fractures include stabilisation of the bone and
management of the soft tissues. Wound debridement and irrigation is thought to be the
mainstay in reducing the incidence of infection. Although numerous studies on animals and
humans have focused on the type of irrigation performed, little is known of the factors
which influence irrigation. This paper evaluates the evidence, particularly with regard to
additives and the mode of delivery of irrigation fluid.
Normal saline should be used and although many antiseptics and antibiotics have been
employed, no consensus has been reached as to the ideal additive. Despite the advocates of
high-pressure methods highlighting the improved dilutional ability of such techniques, the
results are inconclusive and these irrigation systems are not without complications.
New systems for debridement are currently being investigated, and an ideal method has
yet to be determined.
The principles of the management of open
fractures include meticulous wound debridement, tetanus prophylaxis, administration of
intravenous antibiotics and stabilisation of the
fracture.1-4
The debridement of wounds was first
described in the 18th century by Desault5 and has
since evolved to include the thorough irrigation
of the fracture site by a number of different
means. Various specialised devices have been
used for irrigation with the aim of removing devitalised tissue, foreign material and contaminating
bacteria in order to facilitate the prevention of
infection by the immune system of the host.6-15
Irrigation and debridement is believed to be
the most important factor in reducing the prevalence of infection following an open fracture.16 Despite this, there is little scientific
research concerning the factors that influence
irrigation.16-18 No clear guidelines exist for the
optimal additive to be used, the volume of
fluid and its mode of delivery.
We have attempted to evaluate the current
evidence concerning irrigation in order to provide some guidance as to the ideal method to
be used in the clinical setting.
Additives
Most surgeons use sterile saline for the irrigation of wounds.18 Other solutions have been
added to a saline medium with the aim of
improving wound healing and preventing
infection. The most popular additives are antiseptics, antibiotics, and soap (Table I).16,19-27
Antiseptics. A number of studies have been
carried out on animals and humans into the
use of antiseptics.19-23,25 The most commonly
used are povidone-iodine (Betadine; Seton
Scholl Healthcare Pty Ltd, Terrey Hills, United
Kingdom) and chlorhexidine gluconate (Hibitane; (Bioglan) Bradley Phamaceuticals Inc.,
West Fairfield, New Jersey).21-23,25 These antiseptics are active against a broad spectrum of
bacteria, fungi and viruses, and they help eliminate wound pathogens. Advocates of antiseptics believe that by reducing the bacterial
load, their use will lead to less pressure on the
host defence system.19,20,23 The disadvantages
are their toxicity towards host cells and to cell
function, which may cause delayed wound
healing.19
In high concentrations povidone-iodine,
sodium hypochloride and hydrogen peroxide
killed 100% of human fibroblasts tested in
vitro.21 A level of dilution that caused no damage to fibroblasts while maintaining bactericidal activity was also determined in this
investigation (1/1000 for povidone iodine and
1/100 for sodium hydrochloride). Kaysinger et
al25 had similar findings in their study on chick
tibiae in vitro, even at high levels of dilution.
Brennen and Leaper,22 in rabbit studies,
showed that all antiseptics have a negative
effect on microvascular flow and endothelial
THE JOURNAL OF BONE AND JOINT SURGERY
IRRIGATION OF THE WOUNDS IN OPEN FRACTURES
581
Table I. Studies on additives to saline irrigation
Author/s
Model
Solutions tested
Benefits
Toxic effects
Vilijanto19
Human
Povidone-iodine
Nil
Increased infection rates
Rogers et al20
Human
Povidone-iodine
Nil
Nil
Lineaweaver et al21
Human
Povidone-iodine
Killed all bacteria, fungi and viruses Killed all fibroblasts at working concentration
Sodium hypochlorite
Hydrogen peroxide
Brennan and Leaper22
Rabbit
Povidone-iodine
Sodium hypochlorite
Hydrogen peroxide
All caused microvascular flow damage
Gilmore and Sanderson23 Human
Povidone-iodine
Decreased infection in surgical
wounds
Nil
Rosenstein et al24
Canine
Bacitracin soap
Bacitracin reduced infections
Nil
Kaysinger et al25
Chicken
Povidone-iodine
Killed all bacteria
Toxic to tissue and bone
Conroy et al26
Rat
Castile soap
Bacitracin reduced infections
Bensalkonium chloride
Bacitracin
Nil
Stevenson et al27
Human
Flucloxacillin
Saline
No difference
Nil
Anglen et al16
Human
Castile soap
Bacitracin
Equal effects
Nil statistically significant
integrity. Only povidone-iodine has been studied in
humans. In 1975, Gilmore and Sanderson23 showed a statistically significant reduction in wound infection with the
prophylactic use of povidone-iodine. However, no difference was found in the infection rates between operative
wounds treated with normal saline or with povidoneiodine in the large series of Rogers et al.20
In 1980, Vilijanto19 showed that a 5% povidone-iodine
solution was too strong from the standpoint of wound
healing, and that a 1% solution was safer. It was efficient
in reducing the numbers of wound infections in children
with appendicitis.
Antibiotics. Not all antibiotics are suitable for instillation
in wounds because of their pharmacokinetic and
pharmacodynamic properties. The most commonly studied antibiotics have been neomycin, whose mode of action
is unknown, bacitracin, which interferes with cell wall synthesis, and polymyxin, which directly alters the permeability of the cell membrane.18,24,26
Conroy et al26 used a rat model to show that infections in
complex contaminated orthopaedic wounds could be reduced
with the use of bacitracin. Rosenstein et al24 compared bacitracin with saline in a canine model and demonstrated a reduction in positive wound cultures and wound infections.
Evidence is sparse as to the topical use of antibiotics in
orthopaedic surgery. However, animal models have shown
that irrigation with antibiotic reduces the rate of infection
compared with the use of saline solution.18,24,26,28
VOL. 89-B, No. 5, MAY 2007
The lack of well designed and controlled clinical studies
focused on the intra-operative local use of antibiotic irrigation has been identified.29 In a randomised controlled trial
it was found that there was no benefit in the use of flucloxacillin for the irrigation of open fractures of the distal phalanx.27 Moreover, the use of antibiotics in irrigation is not
without risk. There are two case reports of bacitracin causing an anaphylactic reaction after irrigation in surgical
procedures.30,31 The use of antibiotics is costly, and the
promotion of antibiotic resistance will always be a concern.
Surfactants. Before the widespread use of antibiotics,
Koch32 recommended the use of soap solutions to cleanse
open wounds. Surfactants work by disrupting the hydrophobic or electrostatic forces that drive the initial stages of
bacterial surface adhesion. The purpose of the soap is to
lower the bacterial load in the wound by removing the bacteria, rather than killing them.
Conroy et al26 found in an animal study that soap
appeared to be at least as effective as many antiseptics and
antibiotics. A prospective randomised clinical study16
comparing soap and antibiotic solutions for the irrigation
of wounds in open fractures of the lower limb showed that
neither method had a particular advantage.
The effect of pressure
Low-pressure methods. Traditionally, irrigation fluid has
been delivered either via a bulb syringe or with an elevated
582
D. J. CROWLEY, N. K. KANAKARIS, P. V. GIANNOUDIS
Table II. Studies on bone damage by pulsed lavage
Bone damage/fracture
healing
Author/s
Model
Systems
Bacterial studies
Debris studies
Dirschl et al37
Rabbit
Pulsed lavage vs bulb syringe
N/A*
N/A
Macroscopic damage and
decreased new bone formation
Bhandari et al42
Human
tibiae
Pulsed lavage vs no irrigation
Intramedullary bacterial
seeding
observed
N/A
Macroscopic damage
Bhandari et al36
Human tibiae 70 psi pulsed lavage vs 14 psi
pulsed lavage
Equal reduction up to 6
hours
N/A
High pressure caused significant microscopic damage
Lee et al38
Rabbit
Pulsed lavage vs bulb syringe
N/A
Equal reduction of
debris with no
intramuscular seeding
Microscopic damage
Draegar and
Dahners33
Rabbit
High-pressure pulse lavage vs
low-pressure lavage
N/A
N/A
New bone inhibited at 50
psi and above
* N/A, not applicable
Table III. Studies on soft-tissue effects of pulsed lavage
Author/s
Model
Specimens Irrigation system
Bacterial clearance*
Debris removal Tissue damage
Bhhaskar et al35
Rats
1095
Pulsed lavage vs bulb syringe
N/A
PL > BS
N/A
72
Pulsed lavage vs bulb syringe
N/A
PL > BS
N/A
Rodeheaver et al44 Guinea pigs
Madden et al43
Rats
100
Pulsed lavage vs gravity flow
vs bulb syringe
PL 7 x more effective
than BS
N/A
N/A
Wheeler et al40
Pigs
15
Pulsed lavage vs bulb syringe
Greater infection rate
in PL group
N/A
PL: deeper damage
Brown et al34
Rats
234
50 psi pulsed lavage vs bulb
syringe
PL SS p < 0.5
N/A
N/A
Tabor et al45
Canines
20
Pulsed lavage vs bulb syringe
26% better with PL
N/A
N/A
Boyd and
Wongworowat41
Ovine muscle
65
Pulsed lavage vs gravity flow
N/A
N/A
PL > GF†
Hassinger et al46
Ovine muscle
50
Pulsed lavage vs gravity flow
Gravity > PL
N/A
Bacterial penetration
with PL
Draegar and
Dahners33
Beef steaks
8
Pulsed lavage vs bulb syringe
N/A
BS > PL
PL > BS
* N/A, not available; PL, pulsed lavage; BS, bulb syringe; SS, statistically significant
† GF, gravity flow
fluid bag and a giving set, aided by the use of a scrubbing
brush and suction. The benefit of using non-pulsatile
methods is that more debris may be removed from a wound
than when using pulsed devices.33 There is no evidence to
suggest that bulb syringe and suction cause soft-tissue damage or inhibit fracture healing if used at the fracture site.
Draegar and Dahners33 used beef steaks to show that
high-pressure pulsed lavage removed significantly less
inorganic material than suction irrigation and bulb syringe,
and caused more tissue damage.
Brown et al34 compared the use of pulsed lavage with a
bulb syringe in vivo and found that the former was more
effective in bacterial clearance. Bhhaskar et al35 also found
that pulsed lavage was three times more effective than a
bulb syringe in wound irrigation.
High-pressure methods. Many pulsed lavage systems exist,
such as the Interpulse (Stryker Orthopaedics, Mahwah,
New Jersey),6 Powerpulse (Smith & Nephew Orthopaedics
Ltd, Warwick, United Kingdom)8 and the MicroAire
(MicroAire Europe, Meerbush, Germany).7 These systems
work optimally at pressures of 50 psi to 80 psi.6-8 Advocates of the pulsed lavage system claim that it works more
effectively to remove contaminants from wounds than the
bulb syringe.18,34,35 However, it has been noted to cause
damage to the structure of bone, interfere with fracture
healing and to damage soft tissue.11,36-41
THE JOURNAL OF BONE AND JOINT SURGERY
IRRIGATION OF THE WOUNDS IN OPEN FRACTURES
Concerns over bone damage with the use of pulsed lavage were first noted by Dirschl et al in 1998.37 An in vivo
osteotomy model was used to prove detrimental effects on
early new bone formation after pulsed lavage. An in vitro
study of contaminated fractures of the human tibia confirmed that pulsed lavage causes macroscopic damage to
the architecture of the bone and allows seeding of bacteria
into the medullary canal.42 In a follow-up study, Bhandari
et al36 demonstrated the microscopic damage to bony
architecture caused by pulsed lavage. More animal studies
followed38,39 to show that pulsed lavage caused damage to
bone and was no better than a bulb syringe for removing
debris from a wound. A pressure threshold of 50 psi was
identified, beyond which new bone formation was inhibited.39 The studies focusing on bone damage33,36-38,42 are
summarised in Table II.
An earlier study on pigs40 investigated irrigating a
wound and then inoculating it with a normally sub-infective dose of staphylococci. This investigation raised concerns about increased fluid penetration within tissues,
reduced wound resistance to infection, and probable transient bacteraemia, although this has never been shown to
be clinically significant.40
A recent study on fresh ovine muscle showed that high
pressure pulsed lavage penetrates and disrupts soft tissue
to a deeper level than low-pressure lavage, causing considerable gross and microscopic tissue disruption.41 Table III
summarises the available studies focusing on soft tissue
damage.33-35,40,41,43-46
Bacterial clearance
The best method of irrigation to promote better bacterial
clearance has not been established.
Advocates of the high pressure pulsed lavage system
believe that it allows quicker and more efficient delivery of
irrigant to the wound and has superior dilutional effects
which promote greater bacterial clearance. This opinion
has been supported in studies using rat, canine and human
models.34,44,45,47 An early study also demonstrated that
pulsatile flow was less effective than continuous flow in
bacterial clearance.43 It was suggested that 15 psi is the
minimum level required to achieve sufficient tissue
debridement.44 Tabor et al45 showed that bacterial levels
were reduced by a mean of 70% (SD 10%) by high pressure
pulsed lavage and 44% (SD 50%) by bulb irrigation.
Nevertheless, a number of concerns exist over the use of
pulsed lavage in open fractures, and its use is by no means
universal. In addition to the ample evidence suggesting
that bone healing and soft tissue are damaged,33-38,40-46
Hassinger et al46 have shown that high pressure pulsed lavage causes deeper penetration of bacteria and results in
greater bacterial retention in soft tissue than low-pressure
lavage.
As noted, Bhandari et al42 identified increased bacterial
seeding into the medullary canal in the human tibia, and
they also showed that pulsed lavage was more effective in
VOL. 89-B, No. 5, MAY 2007
583
reducing bacterial counts only when irrigation was delayed
for six hours after contamination.36
Latest developments
The surgical knife remains the standard of care to which all
other forms of tool for debridement have to be compared.
Other alternatives have been designed, such as enzymatic11
and laser12 debridement, with the potential advantages of
haemostasis, surgical precision and control of the depth of
excision.
Klasen11 described a study dating back to the Second
World War using enzymes of plant origin, such as the proteolytic enzymes derived from filtrates of Clostridium histolyticum and Bacillus subtilis, for debridement. Although
this is an interesting idea, the results have been far too variable for this method to be recommended.11
Levine et al12 compared the use of a carbon dioxide laser
with the standard technique for debridement of burns
using a scalpel, and found that there was considerably less
blood loss. However, the results were of little clinical consequence. Despite the efficacy of laser treatment in reducing the amount of bleeding from the wound bed, it has
failed to gain general acceptance.
The Versajet system (Smith & Nephew Orthopaedics
Ltd) has recently been specifically designed and introduced
for controlled surgical debridement.9 Initially this instrument became popular in neurosurgery and was developed
to aid debridement of the nucleus pulposus during laminectomy.10 This system used the Venturi48 effect and fluidjet technology. The Venturi effect creates a local vacuum
on the surface of the debridement area directly facing the
operating window. Recent studies have suggested that it
produces a lower bacterial load in burns.13,14
The Versajet has been shown to be more selective and
less aggressive than the scalpel, and allows superior sparing of healthy tissue. It also prevents the diffusion of
microbial contamination deeper into the wound. The system is gaining favour in the debridement of vascular ulcers,
and patients have found that the system is more comfortable than high-pressure pulsed lavage when used at the
bedside without anaesthetic.15
Discussion
Irrigation has always been, and will remain, a key step in
the initial management of open fractures. The object is to
reduce necrotic debris and foreign material, and minimise
the bacterial load. No study has doubted the need for irrigation, but many have differed as to the ideal method.1-4,16
The first issue we have examined is which additive, if
any, should be used for irrigation. Many studies in animals
using antiseptics such as betadine and hydrogen peroxide
have shown that in the undiluted form both solutions have
toxic effects on tissues.21,25 Human studies have shown a
reduction in wound infections when using betadine.23
The use of antibiotics as additives has also been investigated, but the results are inconclusive. Human studies
584
D. J. CROWLEY, N. K. KANAKARIS, P. V. GIANNOUDIS
using antibiotics are sparse and tend to be confined to general surgery. The use of antibiotics is not without risk, with
instances of anaphylaxis following irrigation with bacitracin.29-31 Soap has been shown to be as effective as antibiotics in the irrigation of open wounds, and at least as
effective as bacitracin in the irrigation of open fractures.16
When pulsed lavage was introduced in the early 1970s,
the studies were then supportive of the high-pressure system. Several in vivo studies34,35,44,45 found that the bacterial burden could be reduced following irrigation with
high-pressure lavage. More recently, however, concerns
have been raised as to the macroscopic and microscopic
damage to the bone and surrounding soft tissues caused by
pulsed lavage.33,37-39,41,46 These studies also identified concerns over a delay in fracture healing, but there is no clinical evidence to support this.
The Versajet system is one of the latest advancements
but has yet to be tested in the debridement of open fractures.
Based on current evidence we can make the following
recommendations:
1. Normal saline should be used routinely for the irrigation of fractures.
2. The use of antibiotics and antiseptics as additives
should be limited because of inconclusive evidence and
potential risks.
3. Low-pressure irrigation methods should be used routinely.
4. Surgeons who continue to use high-pressure pulsed
lavage systems should limit the pressure to 50 psi.
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