Wound Irrigation in Orthopedic Open Fractures: A Review

Abstract

Background:

Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions.

Methods:

To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable.

Results:

Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics.

Conclusions:

Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

Despite advances in aseptic technique and prophylactic antibiotic administration, infection persists as a major cause of morbidity and death among orthopedic trauma patients. Infection rates for closed fractures treated with implants in the United States are reported between 0.5%–2.5%. Open fractures are associated with much higher infection rates, ranging from 18%–30% [1,2].

Irrigation with debridement is the most critical operation in the treatment of open fractures and, along with the early administration of broad-spectrum antibiotics, is considered to be a significant factor in preventing infection [3]. Debridement with irrigation aims to minimize bacterial load while promoting optimal bone and wound healing. Current irrigation methods struggle with balancing these goals. Soaps and antiseptics that target the bacterial load more aggressively may slow wound healing by damaging healthy cells. Similarly, high-pressure irrigation may damage the wound bed and traumatize bone as well as disperse infectious material deeper into tissues [4 –8].

In general, the administration of saline solutions under various pressures represents the current standard of care. Saline is inexpensive, non-toxic, and isotonic to the human body. Irrigation with saline may remove contaminants without significantly disrupting the normal healing processes. Considering the persistently high infections rates, though, consideration should be given to alternative solution additives depending on the nature of the wound. This review discusses the benefits and limitations of current irrigation concoctions and techniques.

First, the various modes of delivering an irrigation solution will be reviewed. Next, the physical characteristics of irrigation solutions, including volume, pressure, temperature, and timing, will be discussed. All these factors are under-studied, and the optimal irrigation temperature or timing of the irrigation procedure have yet to be agreed on.

Modes of Delivery

The delivery of irrigation fluid has been achieved through a variety of methods ranging from squeezing punctured bags of saline to utilizing pulsed jet lavage. A few factors should be considered when looking at different modes of delivery. Most importantly, delivery at an adequate pressure that can wash away debris and adherent bacteria is required. Irrigation should be easy to administer and should be adaptable to fit the specific needs of each patient encounter. The amount of material needed and the ease of setup also should be considered. Lastly, user-friendly tools that have a favorable learning curve are desired.

Gravity flow

In gravity flow (52–103 mm Hg), an elevated bag of irrigation solution releases fluid through an intravenous or larger-bore tube [9]. The equipment required for gravity flow is easy to set up and relatively inexpensive. Throughout treatment, pressure and flow are inconsistent and limited to low pressures achievable by forces of gravity or by hand squeezing of the bag. Hand squeezing can be demanding for longer cases [10].

Simple systems: Needles, syringes, bulb syringes

Higher pressures can be achieved by simple systems, specifically needles, syringes, and bulb syringes. Fluid must be taken up and released repeatedly in order to irrigate the wound fully. These systems require physical effort on the administrator's part that may lead to hand strain and increased time required to irrigate a wound fully.

Pressurized canisters and jet lavages

Administration of irrigation solution at a consistent pressure at the wound site may be hard to achieve with simple methods. Automated delivery systems utilizing pressurized canisters achieve greater consistency, but these systems may be limited by lack of adjustability of pressure settings. Furthermore, irrigation solution in pressurized canisters cannot be warmed easily. In 1992, a study by Chrisholm et al. demonstrated that pressurized canister irrigation times were twice as fast as syringes with no significant difference in wound infection rates [11]. Jet lavage, or pulsatile jet lavage, is another automated tool that allows for adjustment of pressure and reduced hand strain. This often is paired with suction to reduce flooding at the operative site and facilitates removal of necrotic debris. Pulsatile flow has not been shown to be more efficacious than continuous flow [12,13]. Indeed, one study found continuous flow to be better at removing bacteria [14].

Another tool at the surgeon's hand is a waterjet debridement device, such as Versajet (Smith & Nephew, London, UK) or a direct-contact ultrasound device, such as SonicVac (Misonix, Farmingdale, NY). Instruments such as these remove damaged tissue and adherent bacteria through physical force or rapid pressure sound waves, respectively. These devices are used widely and impact surgical debridement beneficially but may spread bacteria as they are removed from the wound [15].

Volume

Factors such as performance and cost should be considered when deciding on the volume of solution to be used for irrigation. Greater volume leads to a higher cost but may be necessary for larger wounds or those with a greater burden of contamination. Too little volume may not cleanse the wound. An optimal volume of irrigation solution has yet to be determined, and although the volume used in irrigation generally shows a positive correlation with increased wound size and complexity, surgeons differ in how much irrigation solution they use. According to the 2008 FLOW survey, given to surgeons regarding open fracture wounds, the majority of surgeons endorsed 3 L or less of irrigation solution for Gustilo Type I wounds, 3–6 L for Type II wounds, and >6 L for Type III wounds [16]. When treating Gustilo Type II wounds, nearly 20% used >6 L, and another 30% used <3 L. These differences illustrate the variance between irrigation volumes utilized by surgeons. It is understood that wounds with more debris require greater volumes. However, more research needs to be done to determine the optimal volumes for effective wound irrigation.

Pressure

Pressure is an important consideration for wound irrigation. High-pressure irrigation is effective in reducing bacterial presence, foreign material, and necrotic tissue but can cause pain to the patient. High-pressure irrigation also runs the risk of damaging bone and soft tissue, thus impeding bone growth after the procedure [17]. High pressures may retard bone growth by driving more mesenchymal stem cells down the adipocyte lineage than the osteoblast lineage compared with low-pressure irrigation [18]. Additionally, high-pressure irrigation can push bacteria deeper into the wound, such as into the intramedullary canal of the bone, causing higher post-operative infection rates [19]. As high-pressure irrigation may damage host cells, the bacterial burden may increase because of an ineffective immune response, such as humoral migration, in the compromised area [19]. This damaged bone provides an opportunistic space for bacterial proliferation and survival [20].

Although earlier studies questioned the efficacy of low-pressure wound irrigation for removal of debris and bacteria from the wound site, pressures of 8–12 psi are sufficient to overcome bacterial adhesion [21]. Additionally, re-operation rates are similar for patients who undergo procedures with very low-, low-, or high-pressure irrigation [22,23]. This finding supports the use of very low pressure (12 psi) as a standard of care for wound irrigation, as it has equal performance with low cost in comparison with higher-pressure irrigation systems.

Temperature

Temperature is an under-studied factor in wound irrigation. In order to minimize the risk of a post-operative complication, namely hypothermia, warm irrigation fluid may be preferred. However, the evidence linking hypothermia incidence and irrigation temperature is conflicting [24]. In a comparison study of warm and room-temperature irrigation fluid, patients who received room-temperature fluids had larger changes in body temperature, resulting in a cold feeling, shivering, and longer hospital stays [25]. However, deployment of solutions at colder temperatures may reduce inflammatory cytokines, enzymatic function, and bleeding [26], although it may slow the wound healing process also [27]. Cold irrigation in total knee arthroplasty (TKA) decreases post-operative pain scores and reduces blood loss [26]. More focused research needs to be done to determine the efficacy of warm, room-temperature, and cold irrigation on clearing bacteria and debris and promoting wound healing long term.

Timing of Irrigation

Irrigation after open fractures has long been considered to be an urgent procedure. A six-hour rule originated from a 19^th Century animal study that found that early irrigation reduced the risk of infection [28]. Timely irrigation may remove bacteria sooner, mitigating bacterial replication on the site and decreasing the chance of infection. Some studies highlight the importance of urgent irrigation in reducing infection in open fractures [29,30]. However, several studies have contradicted this notion of a six-hour rule, even finding that 24-hour delays in irrigation are not associated with significant increases in the rate of infection [31 –38]. There is little evidence supporting the six-hour rule, but more research is needed to determine appropriate delays in irrigation that do not increase the risk of infection.

Solution Type

A 2019 international survey of 1,197 orthopedic trauma physicians showed a lack of consensus about the solution type to be used for wound irrigation: Physiologic saline was the most frequently used fluid, followed by povidone–iodine, hydrogen peroxide, chlorhexidine, and antibiotic solutions [39].

First and foremost, the solution should be isotonic, non-hemolytic and non-toxic to avoid damage to tissue. Irrigation solutions containing active ingredients that damage pathogens or prevent adherence to the wound bed would be preferable to inactive solutions. The following factors are important but should not change the efficacy of the solution. Transparent solutions make it easier for healthcare workers to observe the wound bed during irrigation. Solutions that can be sterilized easily are preferred to minimize the risk of infection. Inexpensive ingredients make the solution financially feasible, because a single irrigation procedure can use many liters of fluid. Thus far, no irrigation fluid on the market satisfies all these considerations.

Chemically inert fluids

In this section, we explore the following chemically inert fluids: Physiologic saline, sterile water, and tap water. Because they are chemically inert, none of these kills pathogens. Instead, they work simply by washing away pathogens and debris from the wound bed.

Physiologic saline

Physiologic saline, a mixture of sodium chloride and water, remains the standard of care in wound irrigation. Because of its isotonicity and non-toxicity to the normal healing process, saline provides a relatively inexpensive solution for irrigation [40,41]. Saline bags may be punctured to irrigate wounds with gravity as the driver of irrigation pressure. Unused saline bags are either disposed of or are used to completion, regardless of whether the wound truly needs the remaining volume. Saline may become contaminated with bacteria rapidly and should be used within 24 hours after opening.

Sterile water and tap water

Sterile water is water that is free of all microorganisms, but not free of minerals or chemicals. Tap water is a form of potable water that is not free of contaminants. Both of these fluids are hypotonic, which has the potential to cause cellular damage, impair cellular functioning, and delay wound healing, potentially resulting in higher infection rates [40,41]. If using large volumes, water toxicity is possible as a result of hemolysis and the rate at which tissues take in the water [42]. Furthermore, in a study comparing irrigation with tap water and physiologic saline, there was no reported difference in infection rates, with the conclusion that tap water is just as effective in wound irrigation and a useful and safe alternative when saline is not available [43]. With regard to relative expense, potable water is the least expensive, followed by sterile water and physiologic saline [41].

Antibiotics

Antibiotics treat and prevent bacterial infections through bactericidal and bacteriostatic mechanisms. Some in vitro and animal studies have suggested antibiotic solutions are more effective at preventing infections, where others have reported no significant advantages for the use of antibiotic irrigation [44 –46]. Clinical data largely have been lacking because of limitations in study design, but some report no significant differences in infection rate or wound healing using antibiotic irrigation [2,47]. It is important to keep in mind that administration of antibiotics does not come without risks. Anaphylactic shock has been reported with bacitracin administration [48,49]. Antibiotic administration may have higher rates of wound healing issues [2]. Administration of antibiotics may promote antibiotic resistance and is costly compared with saline. More specific targeting of bacteria requires debridement and subsequent culturing, which may be time consuming and prone to contamination [44]. This leads to further delays of the irrigation procedure. It is recommended that the wound be irrigated as early as possible, as antibiotics and irrigation are less effective once bacterial biofilms have formed [50].

Castile soap

Castile soap is made from coconut oil with potassium salts and is non-sterilizable. It has neither bactericidal nor bacteriostatic activity. Instead, it disrupts bonds at the bacteria–tissue interface, causing the bacteria to loosen [17]. The bacteria are surrounded by micelles that will be rinsed from the wound [17]. This mechanism is effective for some bacteria, such as Pseudomonas aeruginosa, but not others, such as Staphylococcus aureus [51]. This may be because S. aureus forms covalent bonds, which may be harder to break than those formed by bacteria that utilize weaker bonds [51]. Interestingly, sequential surfactant irrigation, defined as irrigation by castile soap, followed by benzalkonium chloride, eradicates both P. aeruginosa and S. aureus [52].

In general, castile soap irrigation had higher re-operation rates than those associated with physiologic saline [41]. Castile soap can be a skin irritant but usually is considered non-irritating in mild concentrations [52]. Because of this and its potential to damage vascular endothelium, castile soap is recommended only for certain wounds, such as those contaminated with grease [53,54].

Benzalkonium chloride

Benzalkonium chloride is an organic salt classified as a quaternary ammonium compound. As it is a cationic surfactant, dissociation of positively charged salts will bind to the negatively charged cell walls of bacteria, causing membrane disorganization, leakage, and cell lysis [55]. This is effective at removing some types of bacteria, such as S. aureus, but causes skin breakdown in others [51]. Skin breakdown is hypothesized to be caused by lysis of certain bacteria, such as P. aeruginosa, with the release of bacterial enzymes [51]. Skin breakdown can be minimized by using sequential irrigation [51].

Chlorhexidine

Chlorhexidine is another cationic agent and similarly dissociates into positively charged chlorhexidine that will bind to negatively charged bacterial cell walls. At low concentrations, it has bacteriostatic effects, but at higher concentrations, membrane disruption and cell death may result. Chlorhexidine is effective against gram-positive bacteria and, to a lesser extent, gram-negative bacteria. It works synergistically with other agents when used in oral irrigation [56]. Despite this, comparisons with saline show no advantage in chlorhexidine irrigation [57]. Further, chlorhexidine may cause host cell toxicity [57].

Hydrogen Peroxide

The chemical H₂O₂, widely known as hydrogen peroxide, is cheap and widely available and decomposes into non-toxic by-products [58]. Hydrogen peroxide acts as an oxidant and produces hydroxyl free radicals. It is thought that this reaction dislodges debris and bacteria from tissue. Interestingly, synergistic effects have been seen when it is combined with dilute povidone–iodine [59]. However, catalases present in both bacteria and human tissue may compromise the efficacy of hydrogen peroxide [56]. Furthermore, in vitro studies show toxicity to human cells, whereas in vivo animal and human experiments show no deleterious effects on wound healing. Hydrogen peroxide also may break down to form oxygen gas, which can cause gas embolisms [56].

Povidone–iodine

Povidone–iodine and related iodine-releasing agents that break down into free iodine can penetrate microorganisms and cause cell death [60]. Povidone–iodine is effective against both gram-positive and gram-negative bacteria as well as fungi and viruses. It has efficacy somewhat comparable to that of saline and hydrogen peroxide [61]. However, there are mixed results on its effectiveness as a treatment. As with hydrogen peroxide, host cytotoxicity may result, but some studies demonstrate that this may be attributable to the detergent used in povidone–iodine scrubs, not to the compound itself [62 –64]. Scrubs are not recommended for open wounds but can be useful cleansers for intact skin. It was found that when povidone–iodine solution is administered at low concentrations, it can be applied without toxicity while maintaining its bactericidal activity [65]. Povidone–iodine may induce or aggravate hyperthyroidism/hypothyroidism and may cause allergic responses, although this is rare even in iodine-allergic patients [61,66,67].

Ultimately, lack of standardization of irrigation methods has resulted in a wide array of outcomes for patients. Although no physical method has been identified to be superior to others (Table 1) and may carry the disadvantage of tissue damage, the utilization of antimicrobial solutions (Table 2) offers hope for the improvement of such a crucial intervention in infection prevention and wound care.

Table 1.

Summary of Advantages and Disadvantages of Current Physical and Environmental Irrigation Delivery Methods

Physical property	Specific characteristics	Procedure/technique	Advantages	Disadvantages
Modes of delivery	Gravity Flow	Elevated bag of irrigation solution that releases fluid through an IV or large-bore tube	Easy to set up; inexpensive	Pressure and flow inconsistent; limited to low pressures; hand strain
	Needles/syringes/bulb syringes	Simple systems to take up and release irrigation solution	Can achieve higher pressures	Increased physical effort
	Pressurized cannisters/jet lavage	Automated delivery systems to administer irrigation solution	Greater consistency; paired with suction to remove dead tissue	Lack of adjustability; no significant difference in infection rate; can spread bacteria removed from wound
Volume	Less than 3L	Using less fluid to irrigate smaller wounds	Economical	Too little volume to fully clean large wounds
Volume	Greater than 6L	Using larger amounts of fluid to irrigate significantly sized wounds	Enough volume to successful clean wounds	Increased cost
Pressure	Ultra-low/low	Using pressures of 1–12 psi to irrigate wounds	Less pain and damage to tissue	More difficult to remove bacteria/necrotic tissue/foreign material^a
Pressure	High	Using pressures >12 psi to irrigate wounds	Effective in reducing bacterial presence/necrotic tissue/foreign material	Can damage tissue and bone, leading to decreased growth after injury; can push bacteria deeper into wound; pain
Temperature	Cold	Using fluid below body temperature to irrigate wounds	Reduce inflammatory cytokines, enzymatic function, bleeding	Hypothermia; can slow healing process
Temperature	Warm	Using fluid closer to body temperature to irrigate wounds	Reduce risk of hypothermia	Data linking hypothermia incidence to irrigation temperature are conflicting
Timing	Within 6 h	Near immediate wound irrigation	Timely removal of bacteria to mitigate risk of infection	Recent studies show no significant difference from 24 h irrigation^b
	Over 6 h	Delayed wound irrigation	24-h delays in irrigation not associated with significant increases in the rate of infection^b	Increased time for bacterial adhesion and proliferation; debris in wound longer

Newer studies have shown that re-operation rate is the same with very low-, low-, and high-pressure irrigation. Also, pressures of 8–12 psi overcome bacterial adhesion. Longmire et al. 1987, Polzin et al. 2014, FLOW Investigators et al. 2015.

Mener et al. 2020; Pollak et al. 2010; Prodromis et al. 2016; Schenker et al. 2012; Weber et al. 2014; Fehring et al. 2013; Hull et al 2014; Konbaz et al. 2019.

Table 2.

Advantages and Disadvantages of Various Irrigation Solutions

Solution type	Procedure/characteristics	Advantages	Disadvantages
Sterile saline	Sterile water with 0.9% NaCl	Isotonic and non-toxic; relatively inexpensive	Easily contaminated; most expensive of chemically inert fluids
Sterile water	Sterile water, free of all microorganisms, but not free of minerals or chemicals	Lower cost than sterile saline, no microorganisms	Hypotonic; can lead to water toxicity
Tap water	Potable water that is not free of contaminants	Least expensive, no increased risk of infection compared to saline^a	Hypotonic; can contain microorganisms
Antibiotic additives	Using added antibiotics to irrigation solution	Treat and prevent bacterial infection	Inconsistent data, anaphylactic shock, wound issues, antibiotic resistance, delay in irrigation until species identification
Castile soap	Soap made with potassium salts from coconut oil	Loosens bacteria from tissue, removes Pseudomonas aeruginosa	Non-sterilizable; not effective against bacteria that make covalent bonds to tissue; higher re-operation rate
Benzalkonium chloride	Quaternary ammonium organic salt	Bacterial membrane disorganization, leakage, and cell lysis	Skin breakdown can release bacterial toxins into wound
Chlorhexidine	Cationic agent that binds to negatively charged bacterial cell walls	Bacteriostatic/bactericidal, effective with gram + and gram - bacteria	Some studies show no advantage over saline
Hydrogen peroxide	Produces hydroxide free radicals to remove debris	Cheap, widely available; decomposes into non-toxic products	Human/bacterial catalase reduces efficacy; toxicity; can lead to gas embolisms
Povidone–iodine	Releases iodine which penetrates cell walls to cause death	Effective against gram+/gram-/fungi/viruses	Mixed results on effectiveness; induce or aggravate hyperthyroidism or hypothyroidism, can cause allergic reaction

Weiss et al. 2013.

Future Directions

Although developments in irrigation have given surgeons additional options for wound management, further study is necessary to combat the growing challenge of microbial wound infection. In addition to optimizing temperature, volume, and method of delivery, future development of irrigation solutions that can target specific components of bacterial contamination such as adherence and biofilm formation will aid in the treatment of orthopedic wounds.

Possible components of these solutions include ethylenediaminetetraacetic acid (EDTA) and phenol, which are hypothesized to remove adherent bacterial more effectively than saline. Its mechanism of action is as a calcium chelator, used in chelation therapy, that can disrupt the outer membrane of bacteria with its divalent cations such as Mg²⁺ [68]. It also can remove bacterial cell wall lipopolysaccharide, exposing the internal phospholipids, and potentiate the effect of other anti-microbial agents [69].

Phenol is another candidate agent for irrigation solutions. Phenol is commonly utilized in sore throat sprays because of its demulcent properties [70]. It is hypothesized to be a good candidate for the removal of adherent protein.

Key chemicals such as these may be able to reduce bacterial colonization of wounds without damaging host tissue. Other selected compounds being investigated include maleic acid and dilute Betadine, with more investigation being done on povidone–iodine [71 –74]. The use of compounds that are not traditional antibiotics is important in this age of growing antibiotic resistance.

Further experimentations should involve testing against common biofilm-producing orthopedic pathogens such as S. aureus, S. epidermidis, and P. aeruginosa, which may resist standard irrigation treatment. Identification and testing of potential irrigation cocktail components should continue.

Conclusion

Irrigation is a critical procedure for wound care; bacterial colonization may cause life-threatening infections and can be mitigated with irrigation soon after trauma. Debris and necrotic tissue may delay wound healing. Optimal pressure, volume, and temperature are yet to be established and may need to be adjusted for specific clinical needs. The current recommendation includes saline-type solutions administered at 8–12 psi consistently over the wound bed. Specific recommendations on volume and temperature have yet to be determined, but it is agreed that larger wounds require more volume. Historically, surgeons have performed irrigation within six hours of fracture, but the new evidence suggests that delaying irrigation past six hours may not be associated with more infection. Different modes of delivery have become available over time that are more consistent and easier to use but may be more costly and harder to set up and can generate pressures high enough to damage tissues. Simpler modes of delivery may not be able to achieve the minimum pressure or consistency desired.

Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, and affordable. No current irrigant achieves all these characteristics. Saline is the current standard of care, as it is not harmful to the body and has been shown to be as effective as most agents, even though it has no active ingredients. Sterile water and tap water are reasonable alternatives when saline is not available (such as in a disaster situation), but water toxicity at high volumes should be remembered. Soaps should be considered for wounds contaminated with grease but otherwise should be avoided because of the higher re-operation rates and effectiveness only equal to saline. Cationic compounds, hydrogen peroxide, and iodine-releasing agents have variable effectiveness and may cause host toxicity.

Despite irrigation being a crucial part of most emergency rooms and surgical suites, research has not yet determined the most effective techniques. Although there is some movement on the innovation of new delivery methods, there is a lack of attention to finding new, safer, and more effective irrigation solutions that will reduce infection and promote wound healing.

Footnotes

Acknowledgments

We thank Diane N. Weiss and the Sipprelle Family Foundation for their continued support.

Funding Information

No external funding was received for this study.

Author Disclosure Statement

Mursal Gardezi, Daniel Roque, Douglas Barber, Carole S.L. Spake, Jillian Glasser, and Ellis Berns have no disclosures. Valentin Antoci has no relevant disclosures. Christopher T. Born holds equity in BI Medical, LLC. and is a stockholder in BioIntraface, Inc, and Illuminoss, LLC. Dioscaris R. Garcia holds equity in BI Medical, LLC.

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