Vết thương trong chấn thương cơ xương pps

High-pressure flow has been shown to remove more bacteria and debris and to lower the rate of wound infection compared with low-pressure irrigation, although recent in vitro and animal s

According to hospital discharge

data, there are approximately 6

mil-lion fractures in the United States

annually and 7.5 million open

wounds.1 On the basis of statistics

from European studies, it has been

estimated that 4% of fractures are

open, suggesting that there are

nearly 250,000 open fractures

annu-ally in this country.2 Compared

with closed fractures, open fractures

have a higher incidence of infection,

nonunion, and other adverse

out-comes that lead to increased cost of

treatment and result in less

satisfac-tory recovery for the patient

Many of the factors that increase

the risk of infection in open

frac-tures are beyond the control of the

surgeon, such as the severity of the

injury, delay in initiation of medical

care, and the health status of the

patient However, some treatment decisions are strongly believed to make a difference in the incidence

of infection These include timing of surgical treatment, use of systemic and local antibiotics, adequacy of surgical wound care, fracture stabil-ity, and early wound closure or flap coverage

The adequacy of initial surgical wound care may be the most impor-tant single factor under the surgeon’s control This element consists of adequate sharp debridement, with removal of all debris and devitalized tissue, and thorough irrigation De-velopment of a wound infection is a multistage process that occurs over time It requires contamination with sufficient numbers of viable bacteria, adhesion of the bacteria to wound surfaces, proliferation of bacterial

colonies on the surface, and exten-sion of the colonies beyond the origi-nal locations The goal of initial wound care is to decrease the bacter-ial load, eliminate the devitalized tis-sue that serves as a medium for bac-terial growth, and prevent further contamination, thereby facilitating the action of host defense systems Wound irrigation is universally recommended as an essential part

of open fracture treatment, although there is relatively little information available defining the details of variables such as volume, delivery method, and optimal irrigation solution additives (Table 1) How-ever, on the basis of the current knowledge about this topic, there are some widely accepted guide-lines

Volume

Most texts recommend “copious,”

“ample,” or “adequate” amounts of irrigation, without giving specific

Dr Anglen is Associate Professor of Orthopae-dic Surgery, University of Missouri-Columbia, Columbia.

Reprint requests: Dr Anglen, University of Missouri-Columbia, One Hospital Drive, MC213, Columbia, MO 65212.

Copyright 2001 by the American Academy of Orthopaedic Surgeons.

Abstract

Wound irrigation to remove debris and lessen bacterial contamination is an

essen-tial component of open fracture care However, considerable practice variation

exists in the details of technique Volume is an important factor; increased volume

improves wound cleansing to a point, but the optimal volume is unknown

High-pressure flow has been shown to remove more bacteria and debris and to lower the

rate of wound infection compared with low-pressure irrigation, although recent in

vitro and animal studies suggest that it may also damage bone Pulsatile flow has

not been demonstrated to increase efficacy Antiseptic additives can kill bacteria in

the wound, but host-tissue toxicities limit their use Animal and clinical studies of

the use of antiseptics in contaminated wounds have yielded conflicting outcomes.

Antibiotic irrigation has been effective in experimental studies in some types of

animal wounds, but human clinical data are unconvincing due to poor study

design There are few animal or clinical studies of musculoskeletal wounds.

Detergent irrigation aims to remove, rather than kill, bacteria and has shown

promise in animal models of the complex contaminated musculoskeletal wound.

J Am Acad Orthop Surg 2001;9:219-226

Wound Irrigation in Musculoskeletal Injury

Jeffrey O Anglen, MD

volume recommendations Some

authors have suggested amounts

ranging from 7 to 15 L per wound

without reference to any data

Others have described the figure as

“arbitrary.”3

In a study examining the removal

of clay particles from guinea pig

wounds by irrigation, Rodeheaver et

al4found that volume was not

im-portant over a range from 100 to 400

mL In a study of removal of

bacte-ria adherent to bovine muscle by

irrigation with benzalkonium

chlo-ride or saline, Gainor et al5found

that increasing volume from 0.1 L to

1.0 L increased bacterial removal

with both solutions Increasing to 10

L had no effect on removal with

saline but dramatically improved

bacterial removal by benzalkonium

Using a model of contaminated

dorsal soft-tissue wounds in dogs,

Peterson6 found that increasing

saline irrigation volume from 0 to

1,000 mL in 250-mL increments

re-sulted in a steady decrease in the

clinical wound infection score (with

ratings for erythema, induration,

exudate, healing rate, and abscess

formation)

There have been no reported

human clinical studies related to

the volume of irrigation

Nonethe-less, it appears clear that increasing

volume improves removal of dirt and bacteria to a point, subject to some variability between solutions

Given the availability of 3-L irriga-tion bags, a reasonable protocol is 3

L for grade 1 fractures, 6 L for grade 2 fractures, and 9 L for grade

3 fractures However, there are no outcome data to support these rec-ommendations

Delivery Method

Many irrigation systems can pro-vide a pulsatile flow of fluid, al-though there is little evidence that pulsatile flow per se, separate from the issue of the benefit of increased pressure, provides any advantage

In one study involving quantitative culture of rabbit wounds

contami-nated with Staphylococcus aureus,7 pulsatile flow was found to be less effective than continuous flow in bacterial removal at a variety of pressures (0.5, 10, and 25 psi) The authors used a device that delivered

300 mL of saline at varying pres-sures It could also be adjusted to provide pulsatile flow at 8 cycles per second, with delivery of fluid through a 1.5-mm-diameter outlet for 1/16 of a second in each cycle In another study using guinea pig

dor-sal wounds contaminated with soil,4 pulsatile flow of saline was com-pared with continuous flow at pres-sures of both 1 and 10 psi There was no difference in the amount of soil removal between the two types

of flow at the same pressure

High-pressure irrigation (jet lavage) has been shown to be more effective in removing particulate matter, necrotic tissue, and bacteria than low-pressure irrigation meth-ods, such as use of a bulb syringe, in both in vitro8,9 and in vivo4,7,10,11 studies This seems to be particularly true when there has been a delay in treatment and when the wound has been contaminated with foreign material Madden et al7created dor-sal soft-tissue wounds in rabbits and

contaminated them with S aureus or Escherichia coli The wounds were

then irrigated with 300 mL of saline after a delay of 5 minutes, 2 hours,

or 4 hours at pressures of 0.5, 10, or

25 psi Increasing pressure in-creased bacterial removal at all times, but with the 2- and 4-hour delays, only irrigation at 25 psi

sig-nificantly (P<0.01) decreased the

incidence of gross infection Brown

et al11 studied rat wounds

contam-inated with E coli both with and

without the addition of sterile gar-den soil and crushed tissue Jet

Table 1

Irrigation Variables

Variable Effect Recommendation

Volume In animal studies, increasing volume removes more Grade 1 fractures, 3 L; grade 2 fractures, 6 L;

particulate matter and bacteria, but the effect plateaus grade 3 fractures, 9 L

at a level dependent on the system

Pressure Increased pressure removes more debris and bacteria; Use a power irrigation system that

however, the highest pressure settings damage bone, provides a variety of settings; select a delay fracture healing, and may increase risk of low or middle-range setting

infection by damaging soft tissue

Pulsation In theory, improves removal of surface debris by means Not established

of tissue elasticity; limited studies have not confirmed

the effect or have suggested decreased efficacy

in removing bacteria than gravity or

bulb-syringe lavage with the same

saline volume in both types of

wound, and only the jet lavage

sig-nificantly (P<0.05) lowered

contami-nation in devitalized wounds with

foreign material present

There is some evidence that

high-pressure irrigation may have

delete-rious effects as well One animal

study involved irrigating a wound

and then inoculating it with a

nor-mally subinfective dose of

staphylo-cocci Those wounds that had

un-dergone both high-pressure (70-psi)

and low-pressure (8-psi) irrigation

showed a higher infection rate than

nonirrigated control wounds,

sug-gesting impairment of

infection-fighting ability.12 The same study

demonstrated that irrigation fluid

(but not bacteria) was driven into

the tissues around the wound by

the high-pressure irrigation An in

vitro study showed more gross

damage and microscopic fissures in

cortical bone that had undergone

high-pressure (70-psi) irrigation

compared with bone subjected to

lower-pressure (14-psi) irrigation.8

In a rabbit articular fracture model,

Dirschl et al13showed a decrease in

new bone formation around

articu-lar osteotomies in the first week

after high-pressure (70-psi)

irriga-tion, compared with control sites

treated with low-pressure (bulb)

irrigation

Using highly contaminated (1×

108 bacterial suspension) sections

from human tibiae, Bhandari et al14

demonstrated that pulsatile lavage

with a nozzle pressure of 70 psi

resulted in more positive cultures at

1 to 4 cm from the contaminated

sur-face than were found in nonirrigated

control specimens The irrigation

procedure removed more than 99%

of the bacteria from the

contam-inated surface, but did result in

some propagation of bacteria down

the medullary canal However, the

number of colony-forming units

re-nated with S aureus was quite low

(range, 1 to 11), which is probably below the infection-causing

thresh-old The use of E coli appeared to

result in higher counts, but the differ-ence was not statistically significant

The authors also quantitated macro-scopic structural damage to the bone and found it to be maximal at the irri-gated surface The clinical signifi-cance of these findings is unclear

A new delivery strategy being investigated involves the use of an irrigation tip that provides fluid flow parallel to the surface rather than perpendicular to it.15 The goal

is to generate high rates of fluid flow, which may be less damaging

to the bone surface and yet will maintain effectiveness in removal of debris, but this has yet to be verified

The nozzle pressure of the irriga-tion system has generally been reported in studies of irrigation pressure and its effects on bone

However, the actual impact pressure

at the bone surface may be signifi-cantly less Impact pressure varies with nozzle-tip design, as well as the distance from the surface of the bone and the degree of inclination For example, surface-impact pressures measured with an electronic pres-sure transducer and oscilloscope for the Pulsavac system (Zimmer, Warsaw, Ind) at a distance of 1.5 inches vary from 0.12 to 8.8 psi depending on setting and tip design (Timothy Donaldson, written com-munication, December 2000) These are markedly lower than the nozzle and tubing pressure values that are typically reported It is important for future studies to standardize the measurement variables and to at-tempt to develop a “dose-response”

curve relating pressure to bacterial removal and bone damage while controlling for time of fluid expo-sure Similarly, the clinical signifi-cance of both macroscopic and microscopic changes needs to be clarified

operator to adjust the pressure and flow rate of the irrigator For now,

it seems prudent to utilize higher pressure settings in severely contam-inated wounds and delayed treat-ment situations when bacterial removal is the most important issue, and lower pressure settings or bulb-syringe irrigation when the level of contamination is less and treatment

is prompt

Irrigation Additives

Since prehistoric times, wounds have been washed with a variety of fluids, including water, wine, milk, vinegar, turpentine, oils, and even urine In the biblical story of the Good Samar-itan, wounds were treated by pour-ing in wine and oil (Luke 10:33-34)

In modern times, wounds are usually irrigated with sterile saline, either alone or with additives For conve-nience, the various additives can be divided into three categories: anti-septics, antibiotics, and surfactants (Table 2) Chelating agents were also used in irrigation in one animal study, but were shown to be of no benefit or possibly even to have been detrimental.4

Antiseptics

It is well known that decreasing the bacterial load of the inoculum will lessen the rate of clinical infec-tion The purpose of antiseptic ad-ditives is to kill bacteria in the wound and thus lessen the patho-gen load that must be handled by the host immune system A partial list of antiseptics that have been used either clinically or experimen-tally includes hydrogen peroxide, povidone-iodine (Betadine) solu-tion, povidone-iodine scrub, chlor-hexidine gluconate (Hibitane), hexa-chlorophene (pHisoHex), sodium hypochlorite (Dakin’s solution), benz-alkonium chloride (Zephiran), and various alcohol-containing solutions

All antiseptics function similarly,

by damaging the cell wall or cell

membrane of the pathogen, leading

to changes in permeability Each

has a broad but slightly different

spectrum of activity, and all are toxic

to some bacteria, spores, fungi, and

viruses Antiseptics are also toxic to

host cells, such as leukocytes,

eryth-rocytes, fibroblasts, keratinocytes, and

osteocytes Cell and tissue culture

studies uniformly show that

antisep-tics have concentration-dependent

detrimental effects on the viability

and function of host cells.16,17 Some

antiseptics can be diluted enough to

be nontoxic to cells in culture while

retaining some bactericidal

activ-ity (e.g., povidone-iodine solution,

Dakin’s solution) The dilutions

uti-lized in the cell culture experiments

have been below the strengths

gener-ally utilized in clinical practice.16

Other antiseptics lose their

bacteri-cidal activity before they lose their

tissue toxicity during dilution (e.g.,

hydrogen peroxide, acetic acid).16

However, the relevance of

deleteri-ous effects on cells in culture as

com-pared with cells within a functioning

organ is at best tenuous

In evaluating animal studies of antiseptic irrigation, two issues are important: interference with wound healing (toxicity to host tissues) and efficacy in preventing infection All antiseptics—and indeed, all irriga-tion fluids other than saline (includ-ing water)—have been shown to have some negative effects on micro-vascular flow and endothelial integ-rity in live animal studies.18

Benzalkonium chloride exposure has been shown to decrease the ten-sile strength of skin in dorsal rat incisions 7 days after suture repair.19 Hypochlorite solutions (such as chloramine) have been shown to be particularly injurious to microvascu-lar circulation.18 Chlorhexidine has been shown to delay early skin healing and to decrease the tensile strength of healing skin wounds in animal models.20

Povidone-iodine solution has been evaluated in various animal models Unfortunately, the results from the studies are contradictory, even when the same species and the same concentrations were used

Several studies have shown that povidone-iodine scrub and other

combinations of antiseptic and de-tergent are particularly damaging to wounds, although either alone may

be less toxic.20 The data with regard

to infection prevention are equally unconvincing; of four studies in-volving contaminated guinea pig wounds and povidone-iodine irri-gation, two showed a decreased infection rate,21and two showed no effect.21-23 Differences in type and quantity of inoculum, irrigation method, time from inoculation to irrigation, and bacterial recovery techniques prevent direct compar-isons In many of these studies, low-pressure, low-volume irrigation

or soaking methods were used

In human studies, most informa-tion is related to the use of povidone-iodine The results have been mixed Data on efficacy have been derived primarily from general surgical stud-ies evaluating the use of povidone-iodine spray in abdominal wounds Some studies have shown a de-creased infection rate24; others have shown no difference25 or an in-creased rate of infection.26 Similarly, chlorhexidine use in general surgical operations has been examined with

Table 2

Irrigation Additives

Class Examples Advantages Disadvantages Recommendation

Antiseptics Povidone-iodine, Broad spectrum of Toxic to host cells, may Findings from both animal

chlorhexidine, activity against bacteria, impair immune cell and clinical studies are con-hydrogen peroxide fungi, viruses; kills function and delay or tradictory; toxicity is more

pathogens in the wound weaken wound healing clearly established than

benefits; should not be used Antibiotics Bacitracin, Bactericidal or bacterio- Cost, rare toxicity or Clinical efficacy in

pre-polymyxin, static activity in the allergic reaction, pro- venting infection not

neomycin wound, if in adequate motion of bacterial proved; should not be

concentration and resistance used routinely duration

Surfactants Castile soap, Interfere with bacterial Mild host-cell toxicities Clinical efficacy not

green soap, adhesion to surfaces; proved; consider use

benzalkonium emulsify and remove in highly contaminated chloride debris wounds, first irrigations

lized.21 The use of 0.2%

chlorhexi-dine during arthroscopic

reconstruc-tion of the anterior cruciate ligament

has been shown to cause marked

chondrolysis in articular cartilage.27

Taken together, the evidence that

the use of antiseptics in surgical

wounds lowers the infection rate is

not convincing, and there is little

information regarding their use in

musculoskeletal wounds On the

contrary, substantial evidence

sug-gests that wounds can be damaged

by antiseptic use Therefore,

anti-septic irrigation should not be used,

as it offers risks without

demon-strated benefit

Antibiotics

Antibiotics differ from antiseptics

in their mechanism of action as well

as in their origin Many antibiotics

function through interference with

some aspect of bacterial cell

physiol-ogy; these agents affect only cells in

the actively growing phase of the

cell cycle Other antibiotics are

di-rectly damaging to cell membranes

on contact However, overall, the

spectrum of activity of antibiotics is

usually narrower and more specific

than that of antiseptics

Historically, the use of

sulfanil-amide powder in open wounds

resulted in increased wound

prob-lems due to local toxicity Penicillins,

cephalosporins, and

aminoglyco-sides have been added to irrigation

fluid in the past, but currently the

most widely used additives are

baci-tracin (which interferes with cell

wall synthesis), polymyxin (which

directly alters cell-membrane

per-meability), and neomycin (which,

although an aminoglycoside, acts

topically through a mechanism that

is unknown) Combinations of these

agents in varying concentrations are

also used

The effectiveness of topical

anti-biotics has been suggested by the

results of in vitro studies of bacterial

growth in suspension or on agar

combination of bacitracin and neo-mycin applied with a plastic spray bottle would kill bacterial colonies growing on sheep’s blood agar

The results of these studies are not surprising, but may not be relevant

to the clinical situation

Animal studies have been per-formed on several different species, including guinea pigs, dogs, goats, pigs, rabbits, and rats, using a vari-ety of antibiotic agents.29-31 Wound

contaminants have included S au-reus, Staphylococcus epidermidis, E coli,

P aeruginosa, Proteus mirabilis, and

human feces In most animal stud-ies, antibiotic irrigation has been more effective than saline irrigation

in reducing the infection rate, and has caused little or no tissue toxicity

Two studies involved a skeletal injury Rosenstein et al31 showed that instillation of 50 mL of bacitracin solution into the intramedullary canal of canine femora inoculated with staphylococci decreased the number of positive cultures 7 days later Conroy et al29found that baci-tracin irrigation was no better than saline irrigation at reducing positive cultures in a complex musculoskel-etal wound in the rat contaminated

with either S aureus or P aeruginosa.

The human studies are primarily from the general surgery, obstetrics, and urology literature They involve wound sprays, powders, and low-volume drug solutions introduced or instilled into body cavities or surgi-cal wounds either during a surgisurgi-cal procedure or at closure The agent was left in place or aspirated from the wound after a specific period In

a review of the literature, Roth et al32 found that most studies had major design defects, and those that had only minor defects were, in their opinion, inconclusive and uncon-vincing Golightly and Branigan33 reviewed eight recent randomized, controlled, prospective trials and found that antibiotic irrigation did not seem to add anything to systemic

were not established; and that sys-temic absorption and toxicity do occur, especially with neomycin Evaluating the literature from an orthopaedic perspective, Dirschl and Wilson30found a paucity of informa-tion defining either the efficacy in musculoskeletal wounds or the dif-ferences between its use in soft-tissue incisional wounds and in skeletal injuries They nonetheless recom-mended “strong consideration” of the practice of antibiotic irrigation for such wounds, on the basis of infor-mation extrapolated from the general surgery literature

There are two studies in the orthopaedic literature regarding the use of topical antibiotics in elec-tive orthopaedic surgery cases Maguire34 reported on a series of 1,200 patients who underwent clean elective procedures and were randomized to receive systemic antibiotics (penicillin or tetracy-cline), topical antibiotics (bacitracin

or neomycin wound spray at clo-sure), or neither Only the topical antibiotic wound spray decreased the infection rate Nachamie et al35 evaluated the data on 216 cases in which 100 mL of 1% neomycin was instilled into the wound at the con-clusion of an elective procedure and 247 cases in which it was not They found no difference in infec-tion rate There are no studies on antibiotic irrigation in human open fracture wounds

Many surgeons who use

antibiot-ic irrigation are aware of the lack of proven efficacy but believe that at least it does no harm However, there are three important drawbacks

to the use of topical antibiotic for irrigation The first issue is patient safety There are reported cases of anaphylaxis following bacitracin irrigation,36as well as major compli-cations due to other antibiotics The second concern in this era of cost containment is the expense of un-necessary antibiotics The cost of

100,000 U of bacitracin (the dose

commonly used per liter of

irriga-tion fluid) is over $50; if 10 L is used,

the cost is more than $500 per

wound per irrigation procedure

The third concern is that the

indis-criminate or inadequate use of

anti-biotics may contribute to the

develop-ment of resistant strains of bacteria,

or at least a selection pressure

to-ward more resistant strains in the

wound In summary, antibiotic

irri-gation is of no proven value in the

care of open fracture wounds and

does entail some risk, albeit small

Surfactants

Before the antibiotic era, the use

of soap to cleanse open wounds was

recommended frequently Koch

wrote in 1941 that “In our

judge-ment there is no method so effective

and none which carries so little risk

of injury as the use of plain white

soap applied with soft cotton and

gloved hands.”37 However, with the

advent of antibiotics, that practice

seems to have fallen by the wayside

and is not widely used today

Soaps belong to that category of

substances called surfactants The

surface-active molecules of

surfac-tants consist of two domains: a

hy-drophilic portion and a

hydropho-bic (or lipophilic) portion, which

are usually on opposite ends of the

molecule The hydrophilic portion

may be charged: in amphoteric

sur-factants, both charges are present; in

cationic surfactants (invert soaps),

there is only a positive charge; and

in anionic surfactants (e.g., soaps),

there is only a negative charge

Neither charge is present in nonionic

surfactants

Surfactants function by

disrupt-ing the hydrophobic or electrostatic

forces that drive the initial stages of

bacterial surface adhesion They

lower the surface tensions that

cause bacteria to clump together on

a surface, and they surround the

organisms in micelles, allowing

them to be rinsed from the wound

The purpose of detergent irrigation

is to lower the bacterial load in the wound by removing the bacteria, rather than by killing them Some surfactants are also antiseptics

In vitro studies have revealed detrimental effects of surfactants on living cells Above a certain concen-tration, they are toxic to white and red blood cells Anionic surfactants can denature proteins and damage cell membranes Cationic surfac-tants inhibit clotting and hemolyze red blood cells Both anionic and cationic surfactants inhibit phagocy-tosis Nonionic detergents have been described as being gentler on tissues, but also have some tissue toxicity, which varies with the size

of the hydrophilic portion Both anionic and cationic surfactants are skin irritants; the intensity of the irritation potential varies with indi-vidual compounds.38 In one rat study, cationic surfactants de-creased the tensile strength of skin strips from healing wounds in a concentration-dependent manner.19

In another study, rat spinal wounds treated with benzalkonium chloride (a cationic surfactant with antiseptic properties) showed no histologic differences from those treated with normal saline.39 In vivo studies have shown some wound irritation with soaps and detergents, primarily when they have been injected into tissues or have been allowed to soak into a wound without rinsing, which

is a different manner of usage than clinically intended

In vitro studies of efficacy have shown surfactants to be better at removing surface-adherent bacteria than other types of irrigation solu-tions Castile soap (made with a potassium salt of coconut oil) was compared with saline and antibiotic solutions with regard to the ability

to remove glycocalyx-producing adherent bacteria from stainless steel screws The soap solution was more effective by several orders of magnitude, and that effect was

increased by the use of jet lavage.40 This greater efficacy of soap solu-tion has been confirmed in studies involving various bacterial species and surfaces.39 The castile soap solution was as good as or better than antibiotic in removing two species of staphylococci from steel, titanium, and bone and in removing

Pseudomonas organisms from both

metallic surfaces

A systematic evaluation of differ-ent types of surfactants using a vari-ety of microbiologic assays in vitro showed oleic acid (the primary con-stituent of castile soap), sodium dodecyl sulfate, and benzalkonium chloride to be better than saline in removing various bacterial species from steel surfaces.9 Of the three, only benzalkonium chloride was active against a preformed bacterial film When the effectiveness of ben-zalkonium chloride in removing bacteria from contaminated bovine muscle was tested, it was found to

perform significantly better (P≤0.001)

than saline irrigation.5 With ade-quate volume (10 L) delivered via jet lavage, the recoverable residual bacterial count could be driven to 0, while irrigation with saline never resulted in counts less than 1×105

In 1945, Peterson6studied the use

of soaps in a canine soft-tissue wound model and found that while soaking a wound with soap made little difference in wound healing or inflammation, it did increase the in-fection rate in contaminated wounds Scrubbing with soap decreased the infection rate over soaking alone However, in this very early study, none of the data were subjected to statistical analysis In a guinea-pig study, Singleton et al41 found that use of soaps decreased the infection rate in soft-tissue wounds contami-nated with human fecal material, and that scrubbing augmented that effect Falconer et al42 found that guinea pig wounds contaminated with staphylococci had a lower infec-tion rate when irrigated with soap

saline in experiments with a 2- to

4-hour delay between inoculation and

irrigation The effect did not hold

true for groups with a 0.5- to 1-hour

delay or a 10- to 12-hour delay

In a rat model of a complex

mus-culoskeletal wound with bone and

soft-tissue injury, the presence of

hardware, and staphylococcal

inocu-lation, benzalkonium chloride was

significantly (P<0.001) better than

normal saline at reducing the

num-ber of positive wound cultures.39

When the authors attempted to

extend those findings to other

bacte-rial species, they found that

al-though benzalkonium chloride was

better than saline or castile soap at

decreasing positive cultures in

wounds inoculated with

staphylo-cocci, it was significantly worse

(P<0.05) when tested against

Pseu-domonas organisms.29 In fact, wounds

inoculated with Pseudomonas

organ-isms and irrigated with

benzalko-nium chloride had a 75% incidence

of wound breakdown This finding

suggests that there are interactions

between host tissue, pathogen, and

treating agent that are specific and

vary with each factor There may be

specific wound-cleansing agents that

are more effective in certain types of

wounds or with certain types of

pathogen contamination—similar to

the situation with antibiotics, in

which sensitivity testing of bacterial

cultures guides therapy

Based on the premise that

break-down of Gram-negative bacteria by

benzalkonium chloride causes the

resulting in wound inflammation and dehiscence, a sequential irriga-tion strategy using different irrigants was tried.30 Sequential irrigation with benzalkonium chloride, castile soap, and normal saline reduced the rate of infection compared with saline alone in wounds

contami-nated with P aeruginosa, without the

wound breakdown observed with benzalkonium chloride alone.29 Subsequent studies involving this complex wound model showed that sequential irrigation strategies can reduce the rate of infection com-pared with saline alone in wounds inoculated with combinations of Gram-negative and Gram-positive organisms.43

Although there are no studies of the use of soap or surfactant irri-gation for human open fracture wounds, the animal data suggest that surfactant irrigation may prove

to be a useful adjunct to wound cleansing It carries a low risk and should be considered in the heavily contaminated or very dirty wound

Summary

Irrigation of open fractures has been and remains an important compo-nent of wound treatment, with the goal of reducing the amount of for-eign material and necrotic debris and the bacterial load on the host immune system, thereby reducing the incidence of infection It is an adjunct to surgical debridement but

quate surgical procedure Despite the near unanimous consensus on the importance of irrigation, specific practices concerning volume, deliv-ery method, and fluid additives vary considerably

Animal studies have convincingly shown that volume, high-pressure irrigation is more effective

at removing bacteria and particulate debris than low-volume, low-pressure (e.g., bulb-syringe) irrigation Al-though the threshold volume is un-known, most would agree that 6 to

10 L of fluid is a reasonable range for irrigation of grade 2 or 3 open fractures Several types of power-irrigator and jet-lavage systems are available and have made it much simpler to deliver high volumes of fluid to a wound Concerns about damage to bone and other tissues dictate avoiding the highest pres-sure settings and selecting a middle range setting on the irrigator Although a variety of irrigation additives have been advocated, the scientific literature offers no conclu-sive evidence of their efficacy Antiseptic irrigation is potentially damaging and without proven bene-fit and should, therefore, be avoided Antibiotic usage in irrigation fluid for open fractures, although wide-spread and of generally low risk, is likewise unproved and expensive Soap irrigation improves removal of dirt and interferes with bacterial adhesion at a low cost with low risk, but its clinical efficacy has yet to be established

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