Letter to the Editor: Regarding “Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center”

Dear editor:

We read with interest the article “Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center” by Singer et al. ¹ and published in Surg Infect (Larchmt). In this retrospective clinical study of 524 patients undergoing primary Total knee arthroplasty (TKA) at an Ambulatory Surgery Center (ASC), the efficacy of a novel surgical irrigant called XPERIENCE was clearly found to be efficacious in decreasing Surgical site infection (SSI)/Periprosthetic joint infection (PJI) after TKA. We acknowledge the work of the authors and appreciate the objective discussion of their findings, including some of the inherent limitations noted. However, after extensive discussion with our professional peer group, we have several salient and pertinent questions that we hope you will address:

First of all, it has been shown that the effect of surgical irrigant on infection prevention in arthroplasty is influenced by the duration of irrigation, the strength of the water flow, and the volume of the rinse fluid. ² In this study, the new surgical irrigant XPERIENCE was used by pouring it into the surgical area, then mechanically agitating it in the surgical area, suctioning it, and then carefully drying the surface of the cancellous bone afterward. Although the new flushing agent does not require a post-application rinse, the effects of irrigation duration and intensity of the irrigation stream also need to be taken into account when using a constant 500 mL of flushing agent. However, this was not mentioned by the authors in the article, so we suggest that the authors could standardize the use of the new flushing agent in subsequent studies, for example, by using a specific pulsatile irrigator or by standardizing the duration, frequency, and rate of agitation.

Secondly, this study was designed to investigate the effect of novel irrigants on the incidence of SSIs after TKA, and a number of other potential factors that may contribute to the development of SSIs, such as duration of surgery, type of anesthesia, type of prophylactic antibiotic, and the use of tranexamic acid were excluded from the analyses. ³ We believe that these circumstances warrant adjustment in the analyses to reduce potential bias.

In addition, as this study was conducted in an outpatient surgery center, unlike routine inpatient surgery, all patients were discharged home on the day of surgery. This resulted in the administration of postoperative antibiotics and postoperative rehabilitation after the patients were discharged from the hospital not being guaranteed, which again may have affected the accuracy of the results.

Finally, we again thank Singer and his colleagues for an important study. We hope that our reflections will help readers interpret the results of the article, help researchers improve the design of subsequent studies, and inspire future scientific research.