|

Wound Irrigation for Open Fractures

Nathanael Heckmann, MD
Trevor Simcox, MD
Daniel Kelley, MD
Geoffrey S. Marecek, MD
Investigation performed at the
Department of Orthopedics, Keck
Medical Center of USC, Los Angeles,
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKbH4TTImqenVOcRVANVs8XMqdQAm4pIwiRVwtiZMcDk4rmxFgG9MKKt79+ouVJgyik= on 01/11/2020
Abstract
» The optimal regimen for wound irrigation in the setting of an open
fracture has been a subject of debate. Basic science evidence as well as
results from a recent prospective clinical trial have shed new light on
this controversial topic.
» While normal saline solution appears to be the optimal irrigation
agent, the optimal timing and volume often are determined by the
surgeon. Future clinical trials are needed to determine the optimal timing
for debridement and irrigation, as well as the ideal volume of irrigant.

California » Irrigation pressure and the use of pulsatile lavage do not appear to
have an effect on outcomes.

T
he treatment of open fractures
has evolved over the past
century. Giant strides have
been made since the era of the
American Civil War, when the standard of
care was amputation and the overall mor-
tality rate was 26%1. Modern protocols
involving expedient delivery of antibiotics,
thorough surgical debridement, and con-
temporary skeletal stabilization strategies
have decreased the morbidity and mortality
associated with these injuries. Until the
1990s, limited evidence existed regarding
the optimal irrigation strategy for the
management of open fractures. This topic
remains a subject of debate.
An effective irrigation strategy for
open fractures should emphasize reduction
of bacterial load and removal of debris and
devitalized tissue while minimizing damage
to surrounding soft tissues and osseous struc-
tures. Optimization of surgical parameters
such as irrigation volume, delivery pressure,
use of pulsatile lavage, use of irrigating agents,
and time to debridement and irrigation may
result in substantial improvement in open
fracture outcomes. The quantity of bacteria in
a wound is correlated with risk of infection,
which underscores the importance of thor-
ough debridement and irrigation to achieve a
successful outcome2. However, the benefits of
aggressive irrigation procedures must be
weighed against potential harm, including
damage to healthy soft tissues and impairment
of bone-healing from either mechanical or
chemical insult3-5. Basic science and clinical
research have sought to optimize irrigation
parameters, but a lack of consensus remains6.
In 2008, a survey of 984 orthopaedic
surgeons revealed a lack of consensus
regarding irrigation volume, delivery
pressure, and type of irrigating agent6.
Although a majority of surgeons (70.5%)
responded in favor of using normal saline
solution and low irrigation pressure
(63.3%), the survey results highlight the
need for the development of evidence-
based guidelines for the irrigation of open
fractures. We aim to provide an overview
of the current orthopaedic literature as it
pertains to the irrigation of open fractures.
This review also will provide recommen-
dations for an optimal irrigation strategy
that is based on the current body of
literature.
Volume
Orthopaedic surgeons have loosely fol-
lowed the old adage, “The solution to pol-
lution is dilution.” This concept has been

COPYRIGHT © 2020 BY THE
JOURNAL OF BONE AND JOINT
SURGERY, INCORPORATED
Disclosure: The authors indicated that no external funding was received for any aspect of this work.
On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version
of the article, one or more of the authors checked “yes” to indicate that the author had a relevant
financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/
JBJSREV/A530).

JBJS REVIEWS 2020;8(1):e0061 · http://dx.doi.org/10.2106/JBJS.RVW.19.00061 1

 | Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s
supported in multiple animal models
that have shown a positive correlation
between increasing irrigation volume
and the amount of debris and bacteria
that are removed from a wound, with
decreasing marginal utility with irrigation
volumes above 1 to 10 L7-9. Although
there have been no clinical studies in
humans examining the optimal volume,
irrigation volume should be commensu-
rate with the wound size, the extent of soft-
tissue damage, and the presence of gross
contamination.
The Gustilo-Anderson classifica-
tion has been referenced extensively to
help determine irrigant volume because
it provides surgeons with a simple
treatment algorithm based on tissue
damage and wound complexity. Most
clinical studies employ irrigation strate-
gies of 3, 6, and 9 L for the increasing
Gustilo-Anderson fracture types10,11.
These volumes commonly are selected
based on the availability of 3-L normal
saline solution bags and are not based on
rigorous basic science or clinical data2.
Although future outcomes-based evi-
dence is needed, initiation of a clinical
trial on this subject is ethically precarious
because the possibility for under-
irrigation has dire consequences and
may result in great morbidity. Surgeons
should use their clinical judgment
regarding volume, erring on the side
of more copious irrigation volumes.
Delivery Pressure and
Pulsatile Lavage
Prior to the Fluid Lavage of Open
Wounds (FLOW) trial11, the available
literature suggested that higher irriga-
tion pressures have greater efficacy in the
removal of bacteria and gross debris, at
the cost of potentially damaging bone
and adjacent soft tissues. While several
studies have shown that high-pressure
pulsatile lavage (HPPL) is superior to
gravity lavage or bulb-syringe lavage
(BSL) at removing bacteria and partic-
ulate matter12,13, other studies have
suggested that HPPL may have a dele-
terious effect on outcomes by damaging
tissues within the wound bed (Table I).
In experimental wound models, HPPL
2 JANUARY 2020
has been shown to cause gross soft-tissue
damage14, macroscopic damage to tra-
becular and cortical bone4,13, and
impairment of bone-healing3,5,15-17.
This occurs because the higher forces
associated with HPPL may cause
mechanical disruption of trabecular
structure4,13, strip bone of cellular and
proteinaceous material3,17, and promote
the differentiation of mesenchymal stem
cells into adipocyte lineages rather than
osteoblastic lineages15. Small mamma-
lian animal studies also have found de-
layed bone-healing3,5 and reduced
biomechanical strength of fracture callus
following the use of HPPL16. In addi-
tion to tissue damage, HPPL has been
shown to drive contaminants and bac-
teria deeper into bone and adjacent
tissues, which previously was thought
to increase the risk of infection4,18.
One study by Bhandari et al.13
used a human cadaveric cut tibia model
and compared the efficacy of HPPL and
low-pressure pulsatile lavage (LPPL) at
various bacterial incubation times. The
authors found LPPL to be effective in a
time-dependent manner, demonstrat-
ing efficacy at 3 hours of incubation but
not at 6 hours, while HPPL was effective
at all time points. This suggests that
longer bacterial incubation periods
allow the bacteria to adhere to bone,
thus decreasing the ability of pulsatile
irrigation at lower pressures to remove
bacteria that have been present for lon-
ger periods13. However, the authors
noted greater macroscopic and micro-
scopic osseous damage with HPPL.
From a mechanical standpoint, the force
of irrigation must exceed the adhesion
force of the bacterium, which increases
over time. This suggests that if a role
for higher pressure lavage exists in the
management of open fractures, patients
who are treated in a delayed fashion may
stand to benefit the most.
In a Pseudomonas-contaminated
open fracture model in goats, Owens
et al. demonstrated that both HPPL and
BSL initially were effective at removing
approximately 75% of the bacterial load,
but after 48 hours, the bacterial load
in the HPPL group was significantly
greater than that in the BSL group, re-
bounding to 94% and 48% of the
inoculated bacterial count, respectively
(p 5 0.048)19. This may be caused by
the potential for HPPL to increase the
depth of bacterial penetration into
muscle, thereby increasing the amount
of retention of bacteria in the adjacent
soft tissues18. A study of musculoskele-
tal wounds in a rat hindlimb blast-
amputation model found that pulsatile
lavage at 20 psi (137.9 kPa) led to
increased rates of myonecrosis and dys-
trophic calcification, resulting in an
increased risk of wound complications
compared with BSL20. These findings
suggest that the tissue damage and bac-
terial load rebound seen following
HPPL may be more clinically relevant in
patients with high-energy trauma.
The theoretical harm from HPPL
has not been shown in clinical studies.
The FLOW trial randomized patients
with open fractures to irrigation at very
low (1 to 2 psi [6.9 to 13.8 kPa]), low
(5 to 10 psi [34.5 to 68.9 kPa]), and high
(.20 psi)-pressure pulsatile irrigation,
and no significant differences in non-
union, wound complications, or reop-
eration were identified among the 3
groups (p 5 0.80)11,21. While experi-
mental animal models have been useful
in studying the potential benefits and
risks of high-pressure irrigation, the
results from the FLOW trial suggest that
factors other than irrigation pressure
may have a larger effect on wound
complications and reoperation11,21.
Pulsatile devices and high-pressure deliv-
ery may be considered at the surgeon’s
discretion in the event of gross contami-
nation or surgical delay. However, this
should be balanced with the knowledge
that HPPL may have increasingly delete-
rious effects in high-energy injury mecha-
nisms such as blast injuries. Currently, the
results from the FLOW trial suggest that
nonpulsatile flow irrigation may be the
most cost-effective form of irrigation for
most open fractures.
Irrigating Agent
When selecting an irrigating agent, the
orthopaedic surgeon must be cognizant
· VOLUME 8, ISSUE 1 · e0061
 Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s |

TABLE I Summary of Select Studies Assessing Irrigation Pressure for the Treatment of Wounds and Open Fractures*
Treatment
Reference Wound Model Groups (N) Study Design Outcomes Findings

In vitro studies
Bhandari et al.4 (1998) Human tibiae from No irrigation (9), Human tibial diaphyseal Bacterial CFUs and CFUs identified up to 4 cm
above-the-knee HPPL at 70 psi (482.6 fracture model inoculated macroscopic from the fracture site in the
amputations kPa) (9) with Staphylococcus aureus or architectural bone HPPL group vs. ,1 cm in all
Escherichia coli; serial 10-mm destruction quantified controls; severe bone
sections of bone were for each section destruction observed at
assessed; NS used for all the fracture site in all HPPL
tibiae specimens
Bhandari et al.13 (1999) Human (H) and No irrigation (10 H 1 Tibiae sections inoculated Macroscopic and Macroscopic and
canine (C) tibiae 8 C), LPPL at 14 psi with S. aureus and treated microscopic bone microscopic bone damage
(96.5 kPa) (10 H 1 16 with LPPL or HPPL NS after 0, destruction, bacterial increased with HPPL;
C), HPPL at 70 psi (10 3, and 6-hr delays adherence using SEM, decreased bacterial
H 1 16 C) and number of CFUs adherence with HPPL alone
at 6 hr
Bhandari and Calvarial bone Low-pressure BSL, Postirrigation calvarial bone Osteoblast lineage cells High-pressure lavage
Schemitsch15 (2002) marrow cultures high-pressure marrow cell culture and cell and adipocyte-like cells increased adipocyte-like
lavage at 8 psi (55.2 types quantified using quantified cells and decreased
kPa) histochemical analysis and number of osteoblasts
RT-PCR
Lee et al.42 (2002) New Zealand rabbit BSL (10), HPPL at 70 Intra-articular distal femoral Maximum graphite HPPL and BSL were equally
distal femoral psi (10) osteotomy contaminated distance from osteotomy effective at removing
fracture, harvested with 4 g of particulate site and total number of particulate matter;
graphite; NS used in both graphite particles maximum graphite
groups distance was similar
between the 2 groups
Hassinger et al.18 (2005) Ovine gluteal No irrigation (10), Ovine gluteal muscle Bacterial count and HPPL had higher bacterial
muscle, harvested LPL (4), HPPL (4) fluorescently labeled with S. depth of bacterial counts at deeper depths
aureus; after lavage was propagation recorded than LPL and control
performed, tissues were fixed for each group
immediately for histological
analysis
Animal studies
Hamer et al.12 (1975) Sprague- Dawley rat No irrigation (25), S. aureus and E. coli Gross inspection and HPPL had the lowest
soft-tissue wound gravity flow (25), BSL inoculation with and without quantitative bacterial bacterial count and lowest
(25), HPPL at 50 psi gross particulate count at 3 and 10 days rate of infection at 10 days
(344.7) (25) contamination; NS used for
all groups
Dirschl et al.5 (1998) New Zealand rabbit No irrigation (10), Intra-articular distal femoral Histological evidence of Trend toward less bone
distal femoral BSL (10), HPPL at 70 osteotomy irrigated with NS bone formation at 1 and formation in HPPL group at
fracture psi (10) in the 2 treatment groups 2 wk 1 wk; trend toward higher
rate of nonunion in HPPL
group at 2 wk
Adili et al.16 (2002) Sprague-Dawley rat No irrigation (12), Sterile midshaft femoral Biomechanical testing At 3 wk, HPPL group had a
open midshaft BSL (12), HPPL at 70 fractures created, followed assessed 3-point lower peak bending force
femoral fracture psi (12) by BSL or HPPL with NS and bending parameters to and decreased stiffness
retrograde intramedullary quantify stiffness and compared with BSL and
pin; biomechanical testing peak bending force control groups; no
performed at 3 and 6 wk differences observed at 6
wk
Polzin et al.3 (2006) New Zealand rabbit 20 psi (137.9 kPa) (6), Intra-articular distal femoral Histological evidence of At 1 wk, less bone growth
distal femoral 30 psi (206.8 kPa) (8), fracture created using sterile bone growth at 1 and 2 with increasing psi; at 2 wk,
fracture 50 psi (344.7 kPa) (7), technique; NS lavage wk; removal of cellular no difference in growth;
70 psi (7) performed at 4 different elements from more cellular elements
pressures trabeculae quantified removed with higher psi
using SEM
Owens et al.19 (2009) Goat hindlimb BSL (8), HPPL (8) Wounds inoculated with Bacterial count At 48 hr, the HPPL group
complex wound light-emitting Pseudomonas measured using photon- showed higher levels of
model: muscle, aeruginosa and irrigated with counting camera bacteria than the BSL
fascia, periosteum, NS after a 6-hr incubation immediately after group
and bone injury period irrigation and at 48 hr
continued

JANUARY 2020 · VOLUME 8, ISSUE 1 · e0061 3

 | Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s
TABLE I (continued )
Reference Wound Model
Human studies
Longmire et al.43 (1987) Traumatic soft-tissue
wounds ,24 hr after
accident
Bhandari et al. and Open extremity
FLOW Investigators11 fractures requiring
(2015) operative fixation
*HPPL 5 high-pressure pulsatile lavage, NS 5 normal saline solution, CFUs 5 colony-forming units, LPPL 5 low-pressure pulsatile lavage, SEM 5 scanning electron
microscope, BSL 5 bulb-syringe lavage, RT-PCR 5 reverse transcription-polymerase chain reaction, LPL 5 low-pressure lavage, and CS 5 castile soap.
of the theoretical advantages and disad-
vantages of each irrigation type. While
several irrigants have properties that aid
in the removal or disruption of bacteria,
many have the potential of causing
caustic tissue injury, particularly to vul-
nerable tissues at the margins of trau-
matic wound beds. During a surgical
debridement, there exists a zone of tissue
that is viable but vulnerable to a sec-
ondary insult22. It is this transition zone
that is susceptible to necrosis from sec-
ondary chemical insult at the time of
wound debridement. In general, 4 cat-
egories of irrigating agents have been
used in the treatment of open fractures:
antiseptics, surfactants, antibiotics, and
normal saline solution (Table II).
Antiseptics
The theoretical advantage of using an
antiseptic agent during wound irrigation
is the potential broad-spectrum bacte-
ricidal effect on the wound bed. In
experimental animal models, this bac-
tericidal effect often was associated with
a competing deleterious effect of host
cellular toxicity. In a contaminated
wound model in guinea pigs, 0.05%
chlorhexidine gluconate was superior to
1% povidone-iodine, 0.1% benzalko-
nium chloride, and normal saline solu-
tion at removing bacteria, with no
apparent effect on wound-healing23.
Bhandari et al. conducted a study in
contaminated canine tibial cut sections
that tested several antiseptic agents,
4 JANUARY 2020
Treatment
Groups (N) Study Design
BSL at 0.05 psi (0.35 Nonblinded, randomized
kPa) (151), needle study using NS irrigation in
syringe lavage at 13 the emergency room
psi (89.6 kPa) (116)
Gravity irrigation at Multicenter, blinded,
1 to 2 psi (16.9 to 13.8 randomized, controlled trial
kPa) (812), LPL at 5 assessing 3 pressures and 2
to10 psi [34.5 to 68.9 irrigant types: CS vs. NS
kPa] (809), HPPL at
.20 psi (826)
including 1% chlorhexidine gluconate
and 1% povidone-iodine24. While these
agents demonstrated antimicrobial
properties, at these concentrations they
caused in vitro death of osteoblasts and
osteoclasts in vitro24. Penn-Barwell et al.
used a contaminated open fracture rat
model to assess chlorhexidine gluconate
at 3 concentrations (0.5%, 0.05%, and
0.005%) and found no superiority
compared with normal saline solution
among these 3 concentrations25. How-
ever, in a group assessing 0.05% chlo-
rhexidine gluconate followed by a
normal saline solution rinse, the authors
noted a trend toward lower infection
rates that did not reach significance (p 5
0.20)25. These experimental models
indicate that antiseptics have inherent
antimicrobial properties within wounds,
but may be nonselectively caustic to
both host and foreign cells. For these
reasons, antiseptic additives such as
chlorhexidine gluconate should not be
added to irrigation solutions for routine
open fracture management.
Surfactants
Surfactants are effective in the removal
of bacteria and debris from highly con-
taminated wounds. This occurs through
the formation of lipophilic micelles that
reduce the surface tension of water and
cause bacteria to lose their grip on host
tissue. This functions to remove bacteria
and debris from the wound rather than
disrupt the bacterial membranes26.
Outcomes Findings
Infection defined by Irrigation with needle
inflammation plus syringe resulted in
tenderness, swelling, decreased infection rate
warmth, or drainage at from 6.9% to 1.3%
the 5 to 7-day follow-up
Reoperation within 12 No significant difference in
mo for infection or the rate of reoperation
wound-healing or bone- among the 3 pressure
healing problems groups
Several in vitro and in vivo studies
have found castile soap to be superior
to alternative irrigants, including
povidone-iodine24, chlorhexidine glu-
conate24, bacitracin10,26, and benzalko-
nium chloride26. In a contaminated goat
open fracture model, Owens et al. found
that castile soap removed 87% of the
initial bacterial inoculum, but counts
rebounded to 120% of the initial inoc-
ulum after 48 hours19. In contrast, goats
irrigated with normal saline solution
showed worse initial efficacy with only
71% removal of bacteria, but bacterial
counts at 48 hours were only 68% of the
initial inoculum19. In a human pro-
spective randomized trial, castile soap
resulted in similar deep infection rates,
but there was a lower rate of wound-
healing complications, when compared
with bacitracin irrigation10. However, in
the FLOW trial, open fractures that had
been irrigated with castile soap had a
higher reoperation rate compared with
those that had been irrigated with nor-
mal saline solution11. Despite promising
theoretical utility, the use of surfactants
during the irrigation of open fractures
appears to be inferior to normal saline
solution and should generally be
avoided.
Antibiotics
During irrigation of musculoskeletal
wounds and open fractures, the most
commonly used antibiotics are bacitra-
cin and neomycin6,27. Experimental
· VOLUME 8, ISSUE 1 · e0061
 Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s |

TABLE II Summary of Select Studies Assessing Antiseptic, Surfactant, and Antibiotic Irrigation Solutions for the Treatment
of Wounds and Open Fractures*
Treatment
Reference Wound Model Groups (N) Study Design Outcomes Findings

In vitro studies
Anglen et al.27 In vitro stainless steel No irrigation, NS (16), Screws seeded with Quantity of post-irrigation CS with power irrigation
(1994) cortical bone screw BAC (12), CS (8), NEO Staphylococcus epidermidis CFUs showed the lowest number
(12), P-NEO (8) and irrigated with various of CFUs; bulb syringe with
solutions using a bulb syringe antibiotics showed elevated
or power irrigator values of CFUs similar to no
irrigation
Bhandari et al.24 In vitro calvarial cells NS (15 CC 1 8 T), 1% Cultured calvarial cells Cultured cells assessed for NS and soap were least toxic
(2001) (CC) and canine and 10% EtOH (15 exposed to various treatment cell viability, bone nodule to cells and had the highest
tibiae (T) CC 1 8 T), 1% and solutions; canine tibiae cut formation, and osteoblast number of bone nodules,
10% PI (15 CC 1 8 T) sections inoculated with and osteoclast counts; while PI, CHG, EtOH, and BAC
1% and 4% CHG (15 S. aureus and irrigated at low CFUs quantified for canine were most toxic and had the
CC 1 8 T), 1% and pressure or bathed with tibial sections lowest number of nodules;
10% Soap (15 CC 1 8 treatment agents 1% PI and 1% CHG effective in
T), 1% and 10% BAC reducing CFUs in tibial
(15 CC 1 8 T) sections, however, soap with
LPL showed no CFUs
Animal studies
Rosenstein et al.28 Dog femoral shaft No irrigation (3), NS Bone window created in Systemic signs of infection BAC group had fewer local
(1989) contaminated (9), BAC (8) femoral shaft and inoculated and wound-healing and systemic signs of
fracture with S. aureus; wounds were complications; cultures infection as well as decreased
irrigated and closed from bone defect taken at 7 rate of positive cultures at 7
or 28 days and 28 days
Conroy et al.26 Sprague- Dawley rat NS (50,) BzC (50), CS Spinous process inoculated Positive wound cultures at CS decreased rate of P.
(1999) contaminated (50), BAC (40), with Pseudomonas postoperative day 14 aeruginosa compared with
spinous process Sequential aeruginosa or S. aureus; NS; BzC increased rate of P.
model BzC/CS/NS (10) wounds irrigated after 15 min aeruginosa; BzC decreased
and tissue cultures taken at S. aureus compared with NS;
postoperative day 14 CS did not decrease S. aureus;
BzC associated with wound
complications
Owens et al.19 Goat hindlimb NS (8), HPPL (8), BzC Wounds inoculated with Bacterial count measured At 48 hr the NS group had the
(2009) complex wound (8), CS (8) light-emitting P. aeruginosa using photon-counting lowest number of bacteria
model: muscle, and irrigated after a 6-hr camera immediately after remaining in the wound; the
fascia, periosteum, incubation period irrigation and at 48 hr CS group had the highest
and bone injury number of bacteria
Penn-Barwell Sprague- Dawley rat NS (10), 0.5% CHG Open femoral fractures in rats Number of bacterial CFUs No significant difference was
et al.25 (2012) open femoral (10), 0.05% CHG (10), were inoculated with at 14 days post- found among any of the
fracture 0.005% CHG (10), S. aureus and closed for 6 hr, debridement and irrigation treatment groups and
0.05% CHG and NS followed by debridement control
rinse (10) and irrigation
Human studies
Anglen10 (2005) Open lower- BAC (171), CS (180) Randomized controlled trial Wound infection, Wound-healing problems
extremity fractures stratified by Gustilo- nonunion, delayed union, were higher in BAC group
Anderson type; patients were and failure of soft-tissue (9.5%) compared with CS
followed until fracture and healing group (4%); no differences in
soft-tissue healing was infection and bone-healing
observed rates
Bhandari et al. and Open extremity NS (1,218), CS (1,229) Multicenter, blinded, Reoperation within NS group had a lower
FLOW fractures requiring randomized, controlled trial 12 months for infection or reoperation rate (11.6%)
Investigators11 operative fixation assessing 3 pressures and 2 wound-healing, or bone- compared with the CS group
(2015) irrigant types: CS vs. NS healing problems (14.8%)

*NS 5 normal saline solution, BAC 5 bacitracin, CS 5 castile soap, NEO 5 neomycin, P-NEO 5 polymyxin and neomycin, CFUs 5 colony-forming units, EtOH 5 ethanol, PI 5
povidone-iodine, CHG 5 chlorhexidine gluconate, LPL 5 low-pressure lavage, BzC 5 benzalkonium chloride, and HPPL 5 high-pressure pulsatile lavage.

studies have demonstrated variable effi- tion to be inferior to castile soap10,26 and extremity fractures showed that they
cacy of antibiotic irrigation to remove normal saline solution19,24. A random- were equivalent with regard to infection
bacterial contamination19,27,28, with ized controlled trial comparing castile and fracture union rates, but bacitracin
most studies showing antibiotic irriga- soap and bacitracin in open lower- was associated with increased rates of

JANUARY 2020 · VOLUME 8, ISSUE 1 · e0061 5

 | Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s
wound-healing complications (9.5% in
the bacitracin group versus 4% in the
castile soap group)10. Currently, there
are limited data supporting the use of
antibiotic irrigation in the management
of open fractures.
Normal Saline Solution
Normal saline solution is the most
commonly used irrigation agent for
open fracture management6 and has the
benefit of being less cytotoxic to host
tissues than commonly used antiseptic
and antibiotic irrigants7,19,26,27,29,30.
Several experimental studies have shown
greater efficacy of surfactants24,26,27 and
antiseptics24,30 at removing bacteria in
various contamination models. How-
ever, more recent data utilizing a large
mammalian open fracture model sug-
gest that normal saline solution may be
superior to castile soap (surfactant),
bacitracin (antibiotic), and benzalko-
nium chloride (antiseptic) irrigants by
minimizing the amount of rebound
bacterial growth following initial frac-
ture irrigation19. In the FLOW trial,
2,447 patients with open fractures from
41 centers were randomized to receive
either normal saline solution or castile
soap11. The patients who received nor-
mal saline solution had a lower rate of
reoperation at 1 year (11.6%) compared
with those who received castile soap
(14.8%) (p 5 0.01). These findings
suggest that normal saline solution is the
optimal irrigation agent despite other
agents demonstrating improved ability
to remove bacteria from wounds in
experimental models24,26,27.
Irrigation Timing
A long-standing tenet of open fracture
management has been to expeditiously
perform debridement and irrigation of
the traumatic wound within a 6-hour
time frame despite little evidence sup-
porting this practice. However, several
studies have shown no association
between a reasonable delay in operative
debridement and increased rates of
infection31-34. Rather, the rapid delivery
of antibiotics35,36, the timing of defini-
tive soft-tissue coverage36, and the
6 JANUARY 2020
Gustilo-Anderson type37,38 may be
more strongly associated with the risk of
infection than the timing of surgical
debridement and delivery of the irrigant.
Experimental models have dem-
onstrated that the efficacy of irrigation
has an inverse relationship with the
timing of irrigation treatment. In an in
vitro model of human tibial sections,
Bhandari et al. found that irrigation with
either HPPL (70 psi [482.6 kPa]) or
LPPL (14 psi [96.5 kPa]) was effective
with up to a 3-hour delay, but only
HPPL at 70 psi successfully removed
adherent bacteria after 6 hours of
delay13. Using a musculoskeletal goat
wound model, Owens and Wenke
found that earlier wound irrigation re-
sulted in superior bacterial removal,
with a significant stepwise decline in
bacteria removal of 70%, 52%, and 37%
of inoculum with delays of 3, 6, and 12
hours, respectively (p , 0.004)39. These
findings are consistent with basic science
literature that suggests that bacterial
adhesion begins within 3 hours and is
followed by aggregation and biofilm
maturation by 10 hours40,41.
Despite experimental data, a recent
meta-analysis pooled 16 studies that
included 3,539 open fractures and was
unable to identify a difference in infec-
tion rates between patients who were
treated early and those who were treated
after a delay31. However, these findings
are not intended to justify an unneces-
sary delay in operative debridement.
Rather, the orthopaedic surgeon should
recognize that strict adherence to a
6-hour rule has not been shown to
improve clinical outcomes. Instead,
urgent administration of antibiotics and
provisional skeletal stabilization should
be performed as early as possible, and
formal debridement and irrigation
should be performed once the patient
is resuscitated and stabilized.
Overview
Surgical debridement and irrigation of
open fractures remains the cornerstone
for the successful management of
open fractures. At the time of surgery,
debridement of nonviable tissue is par-
amount in order to remove any nidus for
infection. The role of subsequent irri-
gation is to aid in the removal of non-
viable tissue, gross debris, and bacteria
while minimizing additional tissue
damage. An effective irrigation strategy
helps remove gross contamination and
devitalized tissues from the wound bed,
thereby decreasing the bacterial load in
order to minimize subsequent wound
problems, decrease infection rates, and
establish a biological environment that
promotes bone-healing.
While recent literature has shed
light on this topic, several questions
remain unanswered regarding an opti-
mal irrigation strategy, including the
utility of pulsatile lavage, the ideal irri-
gation volume, and the ideal timing of
surgical intervention. Intuitively, the
volume of irrigation and the amount of
wound contaminant that are removed
are positively correlated, with decreasing
marginal utility at higher volumes. With
the available data, we suggest that sur-
geons err on using more, not less, irri-
gation when considering irrigation
volume. Recent clinical data have shown
pulsatile lavage to be equivalent to low-
pressure delivery and gravity flow alone,
calling into question the clinical relevance
of prior animal studies that have shown
negative effects of HPPL. Lastly, prompt
surgery should be sought in the setting of
an open fracture, but other factors such as
the timely administration of antibiotics
may be more critical in minimizing
infections and optimizing outcomes.
Recent studies suggest that normal
saline solution is the optimal irrigation
solution regardless of the pressure that is
used during surgery11,21. It is our belief
that timely low-pressure nonpulsatile
irrigation with copious normal saline
solution should be used for most open
fractures. The use of HPPL may still
have a place in a modern treatment
paradigm, particularly when gross con-
tamination is noted in the wound bed.
The use of additives in irrigation is
largely discouraged, but may have a role
in select cases at the discretion of the
operating surgeon, such as in the pres-
ence of infection.
· VOLUME 8, ISSUE 1 · e0061

Nathanael Heckmann, MD1,
Trevor Simcox, MD1,
Daniel Kelley, MD1,
Geoffrey S. Marecek, MD1
1Department of Orthopedics, Keck
Medical Center of USC, Los Angeles,
California
Email address for N. Heckmann:
athanael.heckmann@med.usc.edu
ORCID iD for N. Heckmann:
0000-0003-1293-1702
ORCID iD for T. Simcox:
0000-0001-6435-5407
ORCID iD for D. Kelley:
0000-0003-2622-0899
ORCID iD for G.S. Marecek:
0000-0001-5147-3332
References
1. Pape HC, Webb LX. History of open wound
and fracture treatment. J Orthop Trauma. 2008
Nov-Dec;22(10)(Suppl):S133-4.
2. Anglen JO. Wound irrigation in
musculoskeletal injury. J Am Acad Orthop Surg.
2001 Jul-Aug;9(4):219-26.
3. Polzin B, Ellis T, Dirschl DR. Effects of varying
pulsatile lavage pressure on cancellous bone
structure and fracture healing. J Orthop
Trauma. 2006 Apr;20(4):261-6.
4. Bhandari M, Adili A, Lachowski RJ. High
pressure pulsatile lavage of contaminated
human tibiae: an in vitro study. J Orthop
Trauma. 1998 Sep-Oct;12(7):479-84.
5. Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn
BA, Miclau T. High pressure pulsatile lavage
irrigation of intraarticular fractures: effects on
fracture healing. J Orthop Trauma. 1998 Sep-
Oct;12(7):460-3.
6. Petrisor B, Jeray K, Schemitsch E, Hanson B,
Sprague S, Sanders D, Bhandari M. FLOW
Investigators. Fluid lavage in patients with open
fracture wounds (FLOW): an international
survey of 984 surgeons. BMC Musculoskelet
Disord. 2008 Jan 23;9:7.
7. Gainor BJ, Hockman DE, Anglen JO, Christensen
G, Simpson WA. Benzalkonium chloride: a potential
disinfecting irrigation solution. J Orthop Trauma.
1997 Feb-Mar;11(2):121-5.
8. Peterson LW. Prophylaxis of wound infection.
Studies with particular reference to soaps and
irrigation. Arch Surg. 1945;50(4):177-83.
9. Rodeheaver GT, Pettry D, Thacker JG,
Edgerton MT, Edlich RF. Wound cleansing by
high pressure irrigation. Surg Gynecol Obstet.
1975 Sep;141(3):357-62.
10. Anglen JO. Comparison of soap and
antibiotic solutions for irrigation of lower-limb
open fracture wounds. A prospective, ran-
domized study. J Bone Joint Surg Am. 2005 Jul;
87(7):1415-22.
11. Bhandari M, Jeray KJ, Petrisor BA,
Devereaux PJ, Heels-Ansdell D, Schemitsch EH,
Anglen J, Della Rocca GJ, Jones C, Kreder H, Liew
S, McKay P, Papp S, Sancheti P, Sprague S, Stone
TB, Sun X, Tanner SL, Tornetta P 3rd, Tufescu T,
Walter S, Guyatt GH. FLOW Investigators. A trial
of wound irrigation in the initial management
JANUARY 2020 · VOLUME 8, ISSUE 1 · e0061
Wo u n d I r r i g a t i o n f o r O p e n F r a c t u r e s
of open fracture wounds. N Engl J Med. 2015
Dec 31;373(27):2629-41. Epub 2015 Oct 8.
12. Hamer ML, Robson MC, Krizek TJ,
Southwick WO. Quantitative bacterial
analysis of comparative wound irrigations.
Ann Surg. 1975 Jun;181(6):819-22.
13. Bhandari M, Schemitsch EH, Adili A,
Lachowski RJ, Shaughnessy SG. High and low
pressure pulsatile lavage of contaminated
tibial fractures: an in vitro study of bacterial
adherence and bone damage. J Orthop Trauma.
1999 Nov;13(8):526-33.
14. Boyd JI 3rd, Wongworawat MD. High-pressure
pulsatile lavage causes soft tissue damage. Clin
Orthop Relat Res. 2004 Oct;(427):13-7.
15. Bhandari M, Schemitsch EH. High-pressure
irrigation increases adipocyte-like cells at the
expense of osteoblasts in vitro. J Bone Joint
Surg Br. 2002 Sep;84(7):1054-61.
16. Adili A, Bhandari M, Schemitsch EH. The
biomechanical effect of high-pressure irriga-
tion on diaphyseal fracture healing in vivo. J
Orthop Trauma. 2002 Jul;16(6):413-7.
17. West BR, Nichter LS, Halpern DE, Nimni ME,
Cheung DT, Zhou ZY. Ultrasound debridement
of trabeculated bone: effective and atraumatic.
Plast Reconstr Surg. 1994 Mar;93(3):561-6.
18. Hassinger SM, Harding G, Wongworawat
MD. High-pressure pulsatile lavage propagates
bacteria into soft tissue. Clin Orthop Relat Res.
2005 Oct;(439):27-31.
19. Owens BD, White DW, Wenke JC. Comparison
ofirrigationsolutions anddevices inacontaminated
musculoskeletal wound survival model. J Bone Joint
Surg Am. 2009 Jan;91(1):92-8.
20. Chiaramonti AM, Robertson AD, Nguyen TP,
Jaffe DE, Hanna EL, Holmes R, Barfield WR,
Fourney WL, Stains JP, Pellegrini VD Jr. pulsatile
lavage of musculoskeletal wounds causes
muscle necrosis and dystrophic calcification in
a rat model. J Bone Joint Surg Am. 2017 Nov 1;
99(21):1851-8.
21. FLOW Investigators. Fluid Lavage of Open
Wounds (FLOW): a multicenter, blinded,
factorial pilot trial comparing alternative
irrigating solutions and pressures in patients
with open fractures. J Trauma Acute Care Surg.
2011 Sep;71(3):596-606.
22. Jackson DM. [The diagnosis of the depth of
burning]. Br J Surg. 1953 May;40(164):588-96.
23. Platt J, Bucknall RA. An experimental
evaluation of antiseptic wound irrigation. J
Hosp Infect. 1984 Jun;5(2):181-8.
24. Bhandari M, Adili A, Schemitsch EH. The
efficacy of low-pressure lavage with different irri-
gating solutions to remove adherent bacteria from
bone. J Bone Joint Surg Am. 2001 Mar;83(3):412-9.
25. Penn-Barwell JG, Murray CK, Wenke JC.
Comparison of the antimicrobial effect of
chlorhexidine and saline for irrigating a
contaminated open fracture model. J Orthop
Trauma. 2012 Dec;26(12):728-32.
26. Conroy BP, Anglen JO, Simpson WA,
Christensen G, Phaup G, Yeager R, Gainor BJ.
Comparison of castile soap, benzalkonium
chloride, and bacitracin as irrigation solutions for
complex contaminated orthopaedic wounds. J
Orthop Trauma. 1999 Jun-Jul;13(5):332-7.
27. Anglen JO, Apostoles S, Christensen G, Gainor
B. The efficacy of various irrigation solutions in
removing slime-producing Staphylococcus. J Or-
thop Trauma. 1994 Oct;8(5):390-6.
28. Rosenstein BD, Wilson FC, Funderburk CH.
The use of bacitracin irrigation to prevent
|
infection in postoperative skeletal wounds. An
experimental study. J Bone Joint Surg Am. 1989
Mar;71(3):427-30.
29. Moussa FW, Gainor BJ, Anglen JO,
Christensen G, Simpson WA. Disinfecting
agents for removing adherent bacteria from
orthopaedic hardware. Clin Orthop Relat Res.
1996 Aug;(329):255-62.
30. Tarbox BB, Conroy BP, Malicky ES, Moussa
FW, Hockman DE, Anglen JO, Simpson WA,
Adelstein EH, Christensen G, Gainor BJ.
Benzalkonium chloride. A potential disinfecting
irrigation solution for orthopaedic wounds. Clin
Orthop Relat Res. 1998 Jan;(346):255-61.
31. Schenker ML, Yannascoli S, Baldwin KD,
Ahn J, Mehta S. Does timing to operative
debridement affect infectious complications
in open long-bone fractures? A systematic
review. J Bone Joint Surg Am. 2012 Jun 20;
94(12):1057-64.
32. Skaggs DL, Friend L, Alman B, Chambers HG,
Schmitz M, Leake B, Kay RM, Flynn JM. The effect
of surgical delay on acute infection following
554 open fractures in children. J Bone Joint Surg
Am. 2005 Jan;87(1):8-12.
33. Charalambous CP, Siddique I, Zenios M,
Roberts S, Samarji R, Paul A, Hirst P. Early versus
delayed surgical treatment of open tibial
fractures: effect on the rates of infection and
need of secondary surgical procedures to
promote bone union. Injury. 2005 May;36(5):
656-61. Epub 2005 Jan 22.
34. Bednar DA, Parikh J. Effect of time delay
from injury to primary management on the
incidence of deep infection after open fractures
of the lower extremities caused by blunt trauma
in adults. J Orthop Trauma. 1993;7(6):532-5.
35. Patzakis MJ, Wilkins J. Factors influencing
infection rate in open fracture wounds. Clin
Orthop Relat Res. 1989 Jun;(243):36-40.
36. Lack WD, Karunakar MA, Angerame MR,
Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III
open tibia fractures: immediate antibiotic
prophylaxis minimizes infection. J Orthop
Trauma. 2015 Jan;29(1):1-6.
37. Gustilo RB, Anderson JT. Prevention of
infection in the treatment of one thousand and
twenty-five open fractures of long bones: ret-
rospective and prospective analyses. J Bone
Joint Surg Am. 1976 Jun;58(4):453-8.
38. Dunkel N, Pittet D, Tovmirzaeva L, Suvà D,
Bernard L, Lew D, Hoffmeyer P, Uçkay I. Short
duration of antibiotic prophylaxis in open
fractures does not enhance risk of subsequent
infection. Bone Joint J. 2013 Jun;95-B(6):831-7.
39. Owens BD, Wenke JC. Early wound irrigation
improves the ability to remove bacteria. J Bone
Joint Surg Am. 2007 Aug;89(8):1723-6.
40. Gristina AG, Naylor PT, Myrvik QN.
Mechanisms of musculoskeletal sepsis.
Orthop Clin North Am. 1991 Jul;22(3):363-71.
41. Harrison-Balestra C, Cazzaniga AL, Davis SC,
Mertz PM. A wound-isolated Pseudomonas
aeruginosa grows a biofilm in vitro within 10
hours and is visualized by light microscopy.
Dermatol Surg. 2003 Jun;29(6):631-5.
42. Lee EW, Dirschl DR, Duff G, Dahners LE, Miclau
T. High-pressure pulsatile lavage irrigation of fresh
intraarticular fractures: effectiveness at removing
particulate matter from bone. J Orthop Trauma.
2002 Mar;16(3):162-5.
43. Longmire AW, Broom LA, Burch J. Wound
infection following high-pressure syringe and
needle irrigation. Am J Emerg Med. 1987 Mar;
5(2):179-81.
7