n Feature Article
Comparison of Bulb Syringe, Pressurized
Pulsatile, and Hydrosurgery Debridement
Methods for Removing Bacteria From
Fracture Implants
Michael S. Hughes, MD; Eric S. Moghadamian, MD; Li-Yan Yin, MD;
Gregory J. Della Rocca, MD, PhD; Brett D. Crist, MD
abstract
Full article available online at Healio.com/Orthopedics. Search: 20120621-19
Surgical-site infection is a common form of noscomial infection that can occur in
fractures following internal fixation. Treatment of these infections has traditionally included preserving stable implants via debridement and antibiotic administration while
the fracture is healing. Recent evidence indicated that this algorithm results in lessthan-optimal rates of fracture union and infection eradication.
The premise for this study is that bacterial removal from fracture implants using the Versajet
Hydrosurgery System (Smith & Nephew, Memphis, Tennessee) method is better compared
with the bulb syringe and pressurized pulsatile lavage methods. Thirty-two stainless steel,
4-hole, nonlocking, 3.5-mm fracture plates were incubated with Staphylococus aureus
and divided into 4 groups. Eight plates in each group underwent irrigation with 1 L of saline using a bulb syringe lavage, pressurized pulsatile lavage, or the Versajet Hydrosurgery
System method. Eight plates underwent no irrigation method and served as a control group.
The residual bacterial loads following irrigation were quantitatively cultured. Each of the
experimental groups had significantly reduced levels of bacteria adherent to the plate following irrigation compared with the control group (P5.0002). Furthermore, the Versajet
Hydrosurgery System was most the effective at bacterial removal, followed by the pressurized pulsatile and bulb syringe lavage techniques (P5.0002 to P5.0012, respectively).
A
B
Figure: Photographs prior to (A) and during (B)
use of the Versajet Hydrosurgery System (Smith
& Nephew, Memphis, Tennessee) on the infected
ankle fracture with a sterile radiograph cassette
cover placed over the wound to prevent splatter.
Novel approaches to eradicate bacteria from implants, such as hydrosurgery technology,
while maintaining rigid stability of healing fracture, may improve clinical outcomes.
Dr Hughes is from Washington University, St Louis, Drs Della Rocca and Crist are from the Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri; Dr Moghadamian is from
the Department of Orthopaedics, University of Kentucky, Lexington, Kentucky; and Dr Yin is from the
Department of Orthopaedics, Ohio State University, Columbus, Ohio.
Dr Hughes received a Multi-Purpose Resident Grant from the Mid-America Orthopaedic Association. Drs Moghadamian, Yin, Della Rocca, and Crist have no relevant financial relationships to disclose.
Smith & Nephew and Stryker donated equipment necessary for the completion of the study.
This investigation was performed at the University of Missouri School of Medicine, Columbia, Missouri.
Correspondence should be addressed to: Brett D. Crist, MD, Department of Orthopaedic Surgery,
University of Missouri, Columbia, 1 Hospital Dr, Columbia, MO 65212 (cristb@health.missouri.edu).
doi: 10.3928/01477447-20120621-19
e1046
ORTHOPEDICS | Healio.com/Orthopedics
Debridement Methods for Implants | Hughes et al
I
n 2006, approximately 43,000 fractures
were treated with open reduction and
internal fixation (ORIF) in the United
States.1 Surgical-site infection occurs at
a rate of ,5% after ORIF of closed fractures.2 Acute ORIF of open fractures has
decreased infection rates compared with
historical methods of delayed stabilization.3 However, the incidence of infection
after open fractures is still reported to be as
high as 50%.4 The progression of bacterial
contamination to the infection of fracture
fixation implants is a well documented and
and difficult to treat phenomenon.5
The treatment of infected fractures
typically includes retaining stable fracture
fixation implants, irrigation and debridement procedures, and the administration
of culture-directed antibiotics (locally,
systemically, or both) to suppress the infection until fracture union occurs.6 This
treatment method places priority on the
maintenance of fracture stability over the
complete eradication of the bacterial load.
However, recent studies reported that this
treatment method resulted in a 29% to
32% nonunion rate and a 30% to 50% recurrence rate of infection in the fractures
that ultimately achieved union.6,7
It is possible that commonly used
methods of debridement and irrigation
of infected fracture beds with retained
implants are not sufficiently effective at
reducing bacterial loads. A novel surgical debridement tool, such as the Versajet
Hydrosurgery System (Smith & Nephew,
Memphis, Tennessee), may be a more effective tool for debridement compared
with traditional methods. The Versajet
Hydrosurgery System uses the Venturi
effect of fluid dynamics, where a highpressure stream of saline is used tangentially to cut tissue while simultaneously
creating a local vacuum that facilitates the
removal of tissue or foreign debris.
The purpose of this ex vivo study was
to evaluate the efficacy of the Versajet
Hydrosurgery System in removing adherent bacteria from stainless steel fracture
plates compared with the traditional meth-
JULY 2012 | Volume 35 • Number 7
ods of bulb syringe and pressurized pulsatile lavage. The null hypothesis is that
no difference will exist in the amount of
residual bacterial loads on incubated fracture plates after irrigation between these 3
techniques.
Materials and Methods
Staphylococcus aureus, a common
pathogen found in approximately 65% of
infected orthopedic wounds, was selected for this experiment. Staphylococcus
aureus (29213; American Type Culture
Collection, Rockville, Maryland) was
incubated in 15 mL of tryptic soy broth
for 24 hours at 37°C. The broth was then
centrifuged for 10 minutes, and the supernatant was discarded. The bacterial
pellet was resuspended in 5 mL of 0.9%
sodium chloride solution. A 20-µL sample
was removed, and the bacterial count was
quantified. Multiple flasks of 7.5 mL of
tryptic soy broth were then incubated with
1,000,000 bacteria. Thirty-two sterile,
stainless-steel, 4-hole, conventional fracture plates (Smith & Nephew) were used
in this protocol. One plate was placed
into each container of bacterial broth and
mixed for 10 seconds on a vortex (Analog
Mixer 02-215-365; Fisher Scientific,
Waltham, Massachusetts). Plates were
then incubated for 24 hours at 37°C.
At the conclusion of incubation, all
plates were removed from the bacterial
broth. Irrigation of the plates was performed in a laminar flow biological safety
cabinet (A2; Thermo Scientific, Waltham,
Massachusetts). The 32 plates were divided equally into 4 groups. Plates from each
of the 3 experimental groups were irrigated with 1 L of sterile 0.9% saline solution: group 1 with a standard bulb syringe
(Kendall, Mansfield, Massachusetts),
group 2 with a low-pressure pulsatile
lavage (InterPulse Irrigation System;
Stryker, Kalamazoo, Michigan) operated
at its highest setting using a high-flow
tip attachment (model 210-14; maximum
pressure, 19 psi; maximum flow rate, 1025
mL/min), and group 3 with the Versajet
Hydrosurgery System (at power setting
5). A fourth control group of 8 plates was
not exposed to irrigation. Bulb syringe
and pressurized pulsatile lavage irrigation
devices were held 3 cm from the plates
during testing. The Versajet Hydrosurgery
System requires plate contact for debridement. At the completion of irrigation,
each plate was placed in 5.0 mL of sterile
saline and sonicated with an intermediate
size probe (Artek Sonic Dismembrator,
Model 301; Dynatech Laboratories,
Chantilly, Virginia) for 30 seconds at 0.6
power. For each group, 10-µL samples of
undiluted sonicate, 1:100 sonicate dilution, and 1:1000 sonicate dilution were
cultured in triplicate on sheep blood agar
plates (Fisher Scientific). In the control
group, the 1:100 dilution was replaced
with a 1:100,000 dilution on the agar plate
because further dilution was required to
count the individual colonies (due to the
large amount of bacterial growth). The
culture plates were incubated for 24 hours
at 37°C, and the colonies were counted
manually.
Statistical analysis was performed using SAS Institute, Inc, version 9 software
(Cary, Northo Carolina). The Wilcoxon
rank sum test was used to assess equality
of group means. A natural log transformation was also used because the bacterial
counts exhibited a wide range of variability. A sample size of 8 plates per group
was large enough to detect an effect size
of 2.0 when using a 2-tailed paired t test
with a power of 0.80 and a significance
level as small as .01.
Results
Residual bacterial loads for each
treatment group are shown in Table 1.
Decreased residual bacterial counts were
noted in each group as compared with the
control group (P5.0002). Statistically
significant differences existed between
the means of each of the treatment groups
(Table 2). The pressurized pulsatile lavage
and Versajet Hydrosurgery System groups
had significantly fewer residual bacteria
e1047
n Feature Article
than the bulb syringe group (P5.0002).
The Versajet Hydrosurgery System group
had significantly lower bacterial counts
than the pulsatile lavage group (P5.0012).
Although the irrigation systems
with higher pressure removed significantly more bacteria, aerosolization of
irrigant (presumably containing bacteria) was noted with use of the higherpressure systems, especially the Versajet
Hydrosurgery System. An example of the
pattern of contaminated fluid dispersion
with the Versajet Hydrosurgery System is
shown in Figure 1.
Debridement Methods for Implants | Hughes et al
Table 1
Residual Bacterial Load on Plate Following Irrigation
in Colony-forming Units
Group
Mean
Control
1.58310
Bulb syringe lavage
a
e1048
SE of Mean
6.66310 to 2.63 x 10
7
8
2.333107
2.483105
5.53104 to 8.53105
9.373104
b
573
67 to 1.283103
149
c
50
0 to 166
22
Low-pressure pulsatile lavage
Versajet Hydrosurgery System
a
Kendall, Mansfield, Massachusetts.
b
Interpulse Irrigation System; Stryker, Kalamazoo, Michigan.
c
Smith & Nephew, Memphis, Tennessee.
Discussion
Surgical wound infection prevention
is a high priority for surgeons, patients,
and hospital systems. Once infection has
occurred, optimizing its treatment is imperative. The purpose of this study was to
evaluate the effectiveness of different irrigation and debridement methods on bacterial removal from fracture fixation plates
in an ex vivo fashion. This study does not
recreate the complex in vivo setting of a
fracture stabilized with fracture fixation
implants that are colonized with bacteria,
such as eradicating bacteria from crevices
under the implant or the interface of the
screw head with the plate.
A paucity of data exists in the literature regarding the effectiveness of current
infection management strategies in the
setting of healing fractures stabilized with
metallic implants. Current management
strategies often include the retention of
stable fracture implants, debridement of
the wound, and adjunctive antibiotic administration. Recent studies have reported
suboptimal fracture union rates (range,
68% to 71%) and high rates of recurrent
infection (range, 30% to 50%) in fractures
that achieved union.6,7
In the arthroplasty literature, debridement and systemic antibiotic administration with the preservation of infected
implants has been associated with poor
outcomes, with success rates of approximately 31%.8 Instead, staged manage-
Range
8
Table 2
Mean Residual Bacterial Loads Statistical Comparison
in Colony-forming Units
Group
Bulb Syringe
Lavage
Low Pressure
Pulsatile Lavage
Versajet Hydrosurgery
System
P
1.58310
2.48310
-
-
.0002
1.58310
-
573
-
.0002
1.58310
-
-
50
.0002
-
2.483105
573
-
.0002
-
2.483105
-
50
.0002
-
-
573
50
.0012
Control
8
8
8
5
a
Kendall, Mansfield, Massachusetts.
b
Interpulse Irrigation System; Stryker, Kalamazoo, Michigan.
c
Smith & Nephew, Memphis, Tennessee.
ment of the infected arthroplasty, consisting of hardware explantation and the administration of locally and systemically
delivered antibiotics followed by delayed
reimplantation when signs of infection
are absent, has resulted in successful outcomes in up to 90% of patients.9
A bacterial wound infection begins
with the adhesion of bacteria to a surface, which occurs in 4 distinct stages:
nonspecific attachment, specific attachment, in situ multiplication, and release
and dissemination.10 Irrigation methods
that are used for the treatment of infected wounds must balance the effective
removal of bacteria with tissue damage
associated with the debridement proce-
1
Figure 1: Photograph of the laboratory setting that
was used to aerosolize saline during irrigation of
bacteria-contaminated plates with the Versajet Hydrosurgery System (Smith & Nephew, Memphis,
Tennessee).
ORTHOPEDICS | Healio.com/Orthopedics
Debridement Methods for Implants | Hughes et al
2A
2B
Figure 2: Photographs prior to (A) and during (B) use of the Versajet Hydrosurgery System (Smith &
Nephew, Memphis, Tennessee) the infected ankle fracture with a sterile radiograph cassette cover placed
over the wound to prevent splatter.
dure. Pressurized pulsatile lavage has
been more effective in vitro at removing particulate matter, necrotic tissue,
and bacteria from tissue compared with
low-pressure irrigation methods, such as
the use of a bulb syringe.11,12 However, it
may also alter osteoblast differentiation,
damage cortical bone and soft tissue, and
increase bacterial penetration into tissues, potentially leading to higher infection rates.13-17 Other studies have shown
that pressurized pulsatile lavage may not
have an adverse effect on fracture callus
and the soft tissue that envelopes the surrounding bone.18-20 Pressurized pulsatile
lavage has also been reported to propagate bacterial contamination into deeper
tissues and distant sites, such as in the
medullary canal.21 However, other data
indicate that it does not differ from bulb
syringe.22 Despite numerous animal and
in vitro studies, no human clinical data
exist that demonstrate superiority of one
method of irrigation over another with
regard to eradicating or decreasing the
occurrence of infections.
The Versajet Hydrosurgery System has
the ability to cut and aspirate tissue simultaneously in a plane reportedly as thin as
50 µm. It has reduced operative time without adversely affecting wound healing
times when compared with knife debridement and pulsatile lavage.23 Evidence also
exists that it decreases bacterial loads in
burn wounds.24
Debridement is often quoted as being
the key component of the irrigation and
debridement procedure, and the Versajet
JULY 2012 | Volume 35 • Number 7
Hydrosurgery System may be considered a method of accomplishing both.
The use of a hydrosurgery debridement
tool on metal implants may represent a
novel approach to infected fracture and
nonunion management. It allows for the
simultaneous removal of local necrotic
tissue and bacteria from implants and
tissue. This study demonstrates that use
of the Versajet Hydrosurgery System is
more effective than other tested irrigation
methods of bacteria removal from stainless steel implants. It deserves further research investigating its applicability as a
debridement tool in the clinical setting.
Limitations of this study include its in
vitro design, which does not effectively
recreate the clinical scenario of infection
following fracture fixation. Only onebacteria species (S aureus) was studied,
but many surgical wound infections occur from different organisms and may be
polymicrobial. Only one power setting
was used on the Versajet Hydrosurgery
System and the pressurized pulsatile
lavage system, and this experiment included no other methods of debridement,
such as suction-brush instruments that
have been successful in removing contaminants in similarly designed ex vivo
studies.25
During this study, the authors noted
that splatter and aerosolization of the irrigation fluids with use of the Versajet
Hydrosurgery System was substantial. It
is possible that redirection of the fluid outside of the vacuum circuit of the Versajet
Hydrosurgery System (ie, splatter) occurs
when the water stream cannot cut into the
surface against which it is apposed (in the
current case, the metallic plate). Surgeons
are encouraged to consider the use of inexpensive shielding devices, such as sterile radiograph cassette covers, during debridement with the Versajet Hydrosurgery
System to reduce hazard to the operative
team (Figure 2).26
Conclusion
Irrigation and debridement are key
components in managing infected fractures with retained implants. Multiple
methods of irrigation exist. Of the 3 modalities (ie, bulb syringe lavage, pressurized pulsatile lavage, and Versajet
Hydrosurgery System) that were tested in
this ex vivo study, the Versajet
Hydrosurgery System was the most effective in reducing the residual bacterial colonization of a stainless steel fracture fixation plate.
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