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• W2808668457 abstract "Whether for treatment of an infection or management of a contaminated open injury, irrigation and débridement is among the most-common procedures orthopaedic surgeons perform. While its name seems backwards—I commonly remind our trainees that débridement should precede irrigation—this does not diminish the prominence of this procedure in our practices. For the last 100 years or so, the irrigation ingredient of choice has been sterile saline solution. At the end of it all, we’re just delivering clean water with a bit of added salt to an infected or open wound. Prior attempts at adding ingredients to improve the disruption of bacterial adherence or biofilm (generally, surfactants or pressure) or to increase the solution’s toxicity to bacteria (using antiseptics or antimicrobials) have added little, or even were harmful, in animal studies or clinical trials [1, 4, 5, 6, 8]. Why can’t we do better than salt water? Perhaps we can. Enter saline ethylenediaminetetraacetic acid (EDTA) as a potential, and potentially better, alternative to salt water. Widely used in both medicine and industry, EDTA functions as a chelating agent for heavy metal poisoning in humans [3], and also to prevent blood from clotting in laboratory tubes. By chelating metal ions (notably calcium, zinc and magnesium), EDTA can prevent bacterial adhesin formation, and thus prevent bacteria from adhering to host tissues [2]. In both an in vitro and in an in vivo rodent model, Zhu and colleagues [9] demonstrated no difference in endothelial and fibroblast toxicity versus saline, fewer positive cultures and infections versus both saline or soap for both Staphylococcus aureus and Escherichia coli, and fewer débridements to achieve negative wound cultures in both the contaminated and infected models. The orthopaedic rule of thumb is to irrigate with 3 L, 6 L, or 9 L of fluid for small, medium, and large/severe wounds [1], a process that is necessary … and boring. Indeed, irrigation, both as a surgical activity and a topic of scientific study sometimes seems dull. But it is also the best means we have for removing contaminants following appropriate débridement. Despite the limitations of expert opinion, there are other problems with this routine, volume-based approach. First, many of the contaminants associated with open wounds may not necessarily be soluble in normal saline, hence the repeated past attempts to use soaps and detergents, and so washing away the foreign material or “drowning” the bacteria through a “more is more” approach doesn’t necessarily work. Next, clearing or killing wound bacteria with irrigation additives either in vitro and in vivo is not necessarily hard; concentrated bleach, or any number of medical or commercial antiseptics, delivered with an industrial-grade pressure washer, would do that job quite nicely. But doing so without harming local host tissues has proven difficult. Indeed, antiseptics, antibiotics, soaps, and high(er)-pressure irrigation techniques have all shown promise in theory, in vitro, or in early studies, and have all essentially failed in larger in vivo animal and human trials, in most cases presumably due to local tissue toxicity or injury [1, 6, 8]. One of these studies, the FLOW trial [6], prospectively randomized 2551 patients with open fractures treated at 41 centers. The FLOW investigators did not detect meaningful differences in reoperation rates following débridement and irrigation using high pressure, low pressure, or very low pressure, but higher reoperation rates were found in patients irrigated with castile soap (14.8%) compared to normal saline (11.6%; hazard ratio, 1.32; 95% CI, 1.06 to 1.66; p = 0.01). Thus, at present, nothing works better than saline to prevent surgical site infection for both contaminated [4] and uncontaminated [5] wounds, which makes the findings by Zhu and colleagues [9] both promising and exciting. What if we could substantially reduce the infection (or increase infection clearance) rates simply by changing what we use to irrigate? Our collective boredom at this often lengthy and tedious portion of the procedure would be justly rewarded, and the benefits to patients and healthcare costs savings could be enormous. Given the prior failures in this area, we must (as is seemingly always the case in this column) temper our enthusiasm for want of further evidence of both safety and efficacy. That is, we’ve been down this road before, and it has been a dead end. But perhaps by asking different questions, we can fill the gaps in our knowledge. Will saline EDTA irrigation result in concerning side effects, such as hypocalcemia, when used repeatedly or in large wounds [7]? Will it work as well in actual human wounds and infections as in rodent models of same? Will these decreased bacterial counts translate into more reliable and consistent clearance or prevention of clinical infections? Will it work in the presence of retained orthopaedic implants? What about cost effectiveness, particularly in “low risk” wounds? Irrigation isn’t the sexiest topic, but the fact remains that we have not improved upon clean salt water in over a century. But the work now being done makes me wonder—and hope—that perhaps we can finally do better." @default.
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• W2808668457 date "2018-06-19" @default.
• W2808668457 modified "2023-09-26" @default.
• W2808668457 title "From Bench to Bedside: Irrigation—Time For Something Better Than Salt Water?" @default.
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• W2808668457 doi "https://doi.org/10.1097/corr.0000000000000383" @default.
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