September
Wound irrigation is used to decrease the number of viable bacteria in a wound and remove debris.
Volume of irrigation
The normal volume of irrigation is 6-10L in an open fracture. Increased volume improves wound cleansing to a point but the optimum volume is unknown. Anglen in his JAAOS article recommends 3L for Grade I fractures, 6L for Grade II fractures and 9L for Grade III fractures.
There is clinical data to show that in a dog contaminated soft tissue wound increasing the volume of irrigation from 0 to 1000mL in 250mL increments leads to progressively less contamination.
Pressure of irrigation
Data shows that higher pressures result in the removal of more bacteria than lower pressures. However, once pressures of 50-70psi are reached damage may be caused to the bone and soft tissues and bacteria may be disseminated.
Pulsatile lavage
There is no benefit in the use of pulsatile as opposed to continuous flow lavage.
Addition of antiseptics
The use of chlorhexidine, Betadine or hydrogen peroxide all results in increased soft tissue damage, and these agents should not be used. 0.2% chlorhexidine inadvertently used in an ACL reconstruction caused marked chondrolysis.
When hydrogen peroxide is diluted to the point where it is no longer harming the host cells it will have lost its effectiveness against bacteria.
Addition of antibiotics
These are often used. There is no strong evidence to support or discredit their use.
The possible deleterious effects are threefold:
- Financial
- Possible anaphylactic reaction
- Possible resistance
Use of soaps
Surfactants act to disrupt the hydrophobic or electrostatic adhesion of bacteria to host tissues, and allow removal rather than destruction of bacteria.
They are more effective at removing bacteria than antibiotic solutions or normal saline.
They should be used in heavily contaminated wounds.
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