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The Journal of Bone and Joint Surgery 83:412 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.

The Efficacy of Low-Pressure Lavage with Different Irrigating Solutions to Remove Adherent Bacteria from Bone

Mohit Bhandari, MD, MSc, Anthony Adili, MD and Emil H. Schemitsch, MD

Investigation performed at McMaster University, Hamilton, Ontario, Canada
Mohit Bhandari, MD, MSc
Department of Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, 1200 Main Street West, Room 2C12, Hamilton, ON L8N 3Z5, Canada. E-mail address: bhandari{at}netinc.ca
Anthony Adili, MD
Department of Orthopaedic Surgery, Hamilton Health Sciences Corporation, 711 Concession Street, Hamilton, ON L8V 1C3, Canada
Emil H. Schemitsch, MD
Musculoskeletal Research Laboratory, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital, University of Toronto, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address: schemitsche@the-wire.com
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Salary support for M. Bhandari was provided, in part, by the R.K. Fraser Foundation Research Scholarship. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was the Canadian Orthopaedic Foundation—Hip Hip Hooray.
Read in part at the Annual Meeting of the Canadian Orthopaedic Research Society, St. John’s, Newfoundland, Canada, July 3, 1999, and at the Annual Meeting of the Orthopaedic Trauma Association, Charlotte, North Carolina, October 22-24, 1999.

Background: Recent studies have suggested that high-pressure irrigation may have adverse effects on bone. However, the use of low-pressure irrigation may not remove all adherent bacteria from bone. The type of irrigating solution may be an important factor in the removal of adherent bacteria with pulsatile lavage. In this study, we compared the effects of various irrigating solutions on the number and function of osteoblasts and osteoclasts and we examined the effectiveness of these solutions in removing adherent bacteria from bone.

Methods: To examine the effect of irrigating solutions on the number and activity of osteoblasts, we isolated calvarial cells from newborn C57BI/6 mice and exposed the cells to equivalent concentrations of ethanol, povidone-iodine, liquid soap, antimicrobial wash (50 U/L of bacitracin), or chlorhexidine gluconate, for two, ten, or twenty minutes. The cells were then cultured in the presence of bone-nodule-enhancing medium (b-glycerophosphate and ascorbic acid) for twenty-one days. The medium was changed every three or four days. Mineralized nodules were stained with alizarin red S, and osteoblasts were stained with a histochemical stain for alkaline phosphatase. Osteoclasts were identified with tartrate-resistant acid-phosphatase staining. In a second experiment, canine cortical tibiae were contaminated with Staphylococcus aureus for six hours and subjected to different irrigating solutions with or without low-pressure lavage. Bacterial colony-forming units were quantitated under each set of conditions.

Results: Each solution resulted in a time-dependent decrease in the number of calvarial osteoblasts and osteoclasts compared with that in the controls. The 1% soap solution resulted in greater preservation of both alkaline-phosphatase activity and bone-nodule formation than did the other solutions. Moreover, the soap solution preserved the number of osteoclasts to the greatest extent. The povidone-iodine and chlorhexidine-gluconate solutions resulted in the largest decline in bone-nodule formation, alkaline-phosphatase activity, and number of osteoclasts. Low-pressure pulsatile lavage with the soap solution removed the most bacteria from the contaminated tibia when compared with either the soap solution alone or low-pressure irrigation with saline solution.

Conclusions: Our findings suggest that certain solutions may be more effective in removing bacteria from bone than mechanical irrigation with saline solution alone. Among the various solutions examined, the soap solution preserved the number and activity of osteoblasts the most. Low-pressure lavage with the soap solution resulted in the greatest removal of adherent bacteria from bone.

Clinical Relevance: Meticulous débridement is regarded as the most important initial step in the management of open tibial fractures. The optimal technique for bone débridement should maximize the removal of adherent bacteria while preserving the structure and function of bone. It has been shown that low-pressure irrigation results in significantly less macroscopic and microscopic damage to bone and is as effective as high-pressure lavage in removing bacteria within three hours after contamination. However, irrigation is often delayed beyond three hours. In the current study, we report that débridement with low-pressure irrigation and detergent solutions can be effective for up to six hours after contamination.


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