Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Emil H. Schemitsch, MD, FRCS(C)*,
Division of Orthopaedic Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
Posted October 12, 2006
Patients with open fractures are at risk of the development
of an infection, especially if the fracture is severe or is grossly
contaminated. The single most important steps in the initial management of open
fractures are débridement and copious irrigation of the wound1,2. Although
there is some experimental evidence available, there is currently no clinical consensus
on the optimal volume, type, or pressure of irrigation or on whether pulsatile irrigation
is preferable to nonpulsatile irrigation2. To my knowledge, there has
been only one study on irrigation additives3. Advocates of high-pressure
irrigation believe that higher pressures provide the best method of removing
all particulate matter and contamination4,5; however, advocates of
low-pressure irrigation believe that it better preserves bone architecture and causes
less extensive damage to bone than does high pressure irrigation6,7,8.
The type of irrigating solution and its efficacy with regard to wound débridement
also remains controversial, with some recent interest expressed in the effects
of soap solutions. Moreover, comparison of these studies is limited by a lack
of standardization of variables, including what constitutes "high-pressure" and
"low-pressure" irrigation and the degree of wound contamination.
In the current study, the authors used a caprine model of a
complex, contaminated musculoskeletal wound and used a bioluminescent strain
of Pseudomonas aeruginosa to quantify
their results. Luminescent activity was recorded six hours after the wound was
created and inoculated. Twelve goats were randomly assigned either to pulsed
lavage or to bulb syringe irrigation. Each wound underwent irrigation with
normal saline solution in 3-L increments for a total of 9 L and was imaged
after each 3-L increment. Quantitative culture samples were obtained from
different tissues within the wound both before and after irrigation.
Significant differences were noted with regard to luminescence between the two
groups after both 6 and 9 L of irrigation (p ≤0.04). After both 6 and 9 L of
irrigation, pulsed lavage was found to be more effective than bulb syringe
irrigation in reducing bacterial luminescence. Both device and volume effects
could be demonstrated with use of this model.
The authors state that the clinical relevance of this study
is that pulsed lavage is a more effective and efficient method of irrigation to
remove bacteria in a complex musculoskeletal wound. They reported that this
pulsed lavage irrigation with 3 L of saline solution resulted in a reduction of
approximately the same amount of bacteria as did irrigation with 9 L with use
of a bulb syringe.
This work supports the findings of previous authors who have
shown that pulsed lavage irrigation is more effective than bulb syringe
irrigation in reducing bacterial counts on various surfaces, including wounds.
The work also shows that bioluminescent bacteria can be used as a research tool
to both quantify and determine the distribution of bacteria in an entire wound.
The strength of their study lies in their novel and well-controlled model of a
contaminated orthopaedic wound. The use of bioluminescent bacteria allowed the
changes in quantity and distribution of bacteria to be visualized and
quantified noninvasively over multiple volumes of irrigant. This model does
have the potential to allow for the evaluation of numerous factors that may be
important in wound irrigation, including fluid type, fluid volume, and delivery
method; however, the limitations of the study, including lack of débridement of
the open wounds, an inability to assess gram-positive strains of bacteria with
their techniques, and the acute nature of the study, prevent the authors from
making recommendations that can be incorporated into current clinical practice.
The authors conclude that irrigation with pulsed lavage is
more effective than irrigation with a bulb syringe in this large animal model
of a complex contaminated wound. Given that they have only looked at bacterial
removal, we are still unclear if this benefit is outweighed by the detrimental
effects of pulsed lavage on bone. In addition, there is no evidence that a
smaller volume of irrigant can be used clinically for irrigation of complex
wounds. The study confirms that there is currently no clinical evidence on the
optimal volume, type, or pressure of irrigation; on whether pulsatile irrigation
is preferable to nonpulsatile irrigation; or on whether the irrigation should
have additives. Moreover, given the lack of consensus and conflicting biologic
evidence, a clinical investigation—specifically, a large, multicenter,
randomized controlled clinical trial—of irrigation pressure and solution type
is warranted.
*The author did not receive grants or outside funding in
support of his research for or preparation of this manuscript. He did not
receive payments or other benefits or a commitment or agreement to provide such
benefits from a commercial entity. No commercial entity paid or directed, or
agreed to pay or direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
author is affiliated or associated.
References
1. Anglen J, Apostoles PS, Christensen G, Gainor B, Lane J. Removal of surface bacteria by irrigation. J Orthop Res. 1996;14:251-4.
2. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9:219-26.
3. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. J Bone Joint Surg Am. 2005;87:1415-22.
4. Caprise PA Jr, Miclau T, Dahners LE, Dirschl DR. High-pressure pulsatile lavage irrigation of contaminated fractures: effects on fracture healing. J Orthop Res. 2002;20:1205-9.
5. Lee EW, Dirschl DR, Duff G, Dahners, LE, Miclau T. High-pressure pulsatile lavage irrigation of fresh intraarticular fractures: effectiveness at removing particulate matter from bone. J Orthop Trauma. 2002;16:162-5.
6. Adili A, Bhandari M, Schemitsch EH. The biomechanical effect of high-pressure irrigation on diaphyseal fracture healing in vivo. J Orthop Trauma. 2002;16:413-7.
7. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. J Orthop Trauma. 1999;13:526-33.
8. Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. High pressure pulsatile lavage irrigation of intra-articular fractures: effects on fracture healing. J Orthop Trauma. 1998;12:460-63.
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