Wound irrigation within the surgical treatment of osteomyelitis

iprs000008 10.3205/iprs000008 urn:nbn:de:0183-iprs0000083 Review Article Wound irrigation within the surgical treatment of osteomyelitis Wundspülung im Rahmen der chirurgischen Osteitis-Therapie Tiemann Tiemann A. H. AH Prof. Dr. med.

BG-Kliniken Bergmannstrost, Klinik für Unfall- und Wiederherstellungschirurgie, Abteilung für Septische und Rekonstruktive Chirurgie, Merseburgerstr. 165, D-06112 Halle, Germany, Phone: +49(0)345-1326632BG-Kliniken Bergmannstrost, Klinik für Unfall- und Wiederherstellungschirurgie, Abteilung für Septische und Rekonstruktive Chirurgie, Halle, Germany

andreas.tiemann@bergmannstrost.com author Hofmann Hofmann G. O. GO Prof. Dr. med. Dr. rer. nat.

BG-Kliniken Bergmannstrost, Klinik für Unfall- und Wiederherstellungschirurgie, Halle, Germany Friedrich-Schiller-Universität Jena, Kliniken für Unfall-, Hand- und Wiederherstellungschirurgie, Jena, Germany

andreas.tiemann@bergmannstrost.com author German Medical Science GMS Publishing House

Düsseldorf

610 osteomyelitis lavage systems wound irrigation Osteomyelitis Lavage-Systeme Wundspülung 2012010920160310 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution License. You are free: to Share - to copy, distribute and transmit the work, provided the original author and source are credited. Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen. Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden. 2193-8091 1 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW GMS Interdiscip Plast Reconstr Surg DGPW 08 20160309ISSN added Auch heute stellt die chirurgische Herdsanierung in Kombination mit der intraoperativen Wundspülung die Basistherapie zur Beseitigung von Knocheninfektionen dar. Neben dem umfassenden Wissen über die chirurgischen Möglichkeiten ist die profunde Kenntnis der Lavage-Systeme ebenso wie der möglichen antiseptischen Spül-Lösungen eine conditio sine qua non.In diesem Artikel werden die typischen modernen Lavage-Systeme analysiert und ihre Vor- und Nachteile beschrieben.Zusätzlich widmen wir uns den gängigen antiseptischen Lösungen zur Wundspülung und ihrem Wert bei der Osteomyelitistherapie.Schlussendlich werden die beiden grundsätzlichen Philosophien der Revisions-/Lavage-Konzepte bei der Behandlung der Osteomyelitis dargestellt und diskutiert. The basic treatment of osteomyelitis remains even today the surgical debridement in combination with a wound irrigation by lavage systems. Next to a comprehensive knowledge of the surgical techniques a profound knowledge of the lavage systems, the rinsing solutions used and the philosophies of revision programs are a must.In this article the typical hardware of modern lavage systems is analysed, their advantages and disadvantages are pointed out.In addition we investigate the value of common antiseptic wound irrigatio</PlainText></TextGroup>n solutions for their use in osteomyelitis therapy.</Pgraph><Pgraph>Finally the two basic philosophies of wound revision and irrigation in the course of osteomyelitis therapy are presented and discussed.</Pgraph></Abstract> <TextBlock linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>The therapy of osteomyelitis ist based on three principles:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Local surgical debridement </ListItem><ListItem level="1">Application of antibiotics </ListItem><ListItem level="1">Use of adjuvant therapies (for example hyperbaric oxygenation HBO ...)</ListItem></UnorderedList></Pgraph><Pgraph>The local treatment itself is based on another five principles <TextLink reference="41"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Local bone and soft tissue debridement </ListItem><ListItem level="1">Stabilization of the bone</ListItem><ListItem level="1">Local antibiotic therapy</ListItem><ListItem level="1">Reconstruction of the soft tissue</ListItem><ListItem level="1">Reconstruction of the osseous defect zone</ListItem></UnorderedList></Pgraph><Pgraph>This surgical eradication of the infected part of the bone and the surrounding soft tissue still remains <Mark1>the</Mark1> basic treatment of osteomyelitis. The systematic debridement of all infected tissue is given support by extensive fluid irrigation <TextLink reference="41"></TextLink>. This approach to the problem of infected wounds and osteomyelitis is proposed by various authors <TextLink reference="2"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>, <TextLink reference="38"></TextLink>. </Pgraph><Pgraph>In a contaminated situation the quantity of bacteria present is one of the main factors for the formation and/or the persistence of the infect. Thus one of the defined goals and the initial step in infection treatment is the decrease of the bacterial colonization and the removement of the necrotic tissue by the above named irrigation <TextLink reference="2"></TextLink>. The quality and efficiency of the fluid lavage depends on various factors. According to Carr 2006 and others it is based on <TextLink reference="10"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="29"></TextLink>, <TextLink reference="30"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">The technique</ListItem><UnorderedList><ListItem level="2">Irrigation pressure (low vs. high pressure irrigation) </ListItem></UnorderedList><UnorderedList><ListItem level="2">Showering, bathing, washing under a running solution</ListItem></UnorderedList><UnorderedList><ListItem level="2">Total immersion in a whirlpool</ListItem></UnorderedList><ListItem level="1">The solution </ListItem><UnorderedList><ListItem level="2">Type of solution (physiological saline, water, antiseptic solution, soaps ...)</ListItem></UnorderedList><UnorderedList><ListItem level="2">Amount of irrigation solution</ListItem></UnorderedList><ListItem level="1">The equipment</ListItem><UnorderedList><ListItem level="2">Syringes, needles, catheters </ListItem></UnorderedList></UnorderedList></Pgraph><Pgraph>The knowledge of these key facts in the implementation of the fluid wound cleansing as well as the proper time to use them (“stage lavage concept” vs. “individual lavage concept”) is the basis for successful cure of osteomyelitis.</Pgraph></TextBlock> <TextBlock linked="yes" name="Technique of irrigation"> <MainHeadline>Technique of irrigation</MainHeadline><Pgraph>As long ago as 1987 Plaumann et al. recommended the use of pulsative lavage irrigation for the treatment of septic complications in trauma surgery. Benefit was seen by these authors during the removal of pus, foreign bodies, sequestra especially from wound cavities <TextLink reference="35"></TextLink>.</Pgraph><Pgraph>The irrigation systems are used in order to support the surgical site debridement during the infect eradication phase of an infected wound or osteomyelitis.</Pgraph><Pgraph>According to the literature it should lead to <TextLink reference="4"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="34"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Mechanical wound cleansing</ListItem><ListItem level="1">Removement of foreign bodies</ListItem><ListItem level="1">Removement of sequestra</ListItem><ListItem level="1">Removement of necrotic tissue</ListItem><ListItem level="1">Decrease of the bacterial load of the affected tissues</ListItem><ListItem level="1">Decrease of the bacterial load on contaminated surfaces (implants, prostheses ...).</ListItem></UnorderedList></Pgraph><Pgraph>As shown above there exist various methods of irrigation for the cleansing of infected surgical sites. </Pgraph><Pgraph>Focussing the technical aspect of irrigation systems, one may differentiate between:</Pgraph><Pgraph><UnorderedList><ListItem level="1">No pressure systems</ListItem><ListItem level="1">Low pressure systems</ListItem><ListItem level="1">High pressure systems</ListItem></UnorderedList></Pgraph><Pgraph>And</Pgraph><Pgraph><UnorderedList><ListItem level="1">Systems with pulsatile lavage irrigation </ListItem><ListItem level="1">Systems with constant lavage flow</ListItem></UnorderedList></Pgraph><Pgraph>The debate continues wether constant fluid lavage or pulsatile lavage irrigation has greater efficiancy <TextLink reference="13"></TextLink>. In addition there is no clear choice for the lavage device either <TextLink reference="33"></TextLink>.</Pgraph><Pgraph>In their 2003 study Bahrs et al. compaired the efficiency of three different irrigation systems (conventional 50 ml syringe, manual pump irrigation, jet lavage) in terms of the reduction of bacteria (P. aeruginosa, S. aureus and E. faecalis) on biological and metal surfaces in vitro <TextLink reference="4"></TextLink>. They could demonstrate, that an effective statistically relevant reduction was achieved by any of the systems regardless what kind of surface was tested. The manual pump irrigation achieved significantly better results on biological surfaces than on the metal surfaces.</Pgraph><SubHeadline>Low pressure irrigation systems (LPIS)/high pressure irrigation systems (HPIS)</SubHeadline><Pgraph>When we analyse the aspects of pressure irrigation, there must be differentiated between LPIS and HPIS. As a matter of fact in the case of LPIS the pressure of the solution jet is between 0.5 and 1.0 bar. In HPLS it amounts from 1.4 to 4.8 bar. In addition one has to differentiate between continous flow and pulsatile irrigation methods. The pulsatile lavage is widely accepted in orthopedic and trauma surgery <TextLink reference="20"></TextLink>. Nevertheless the debate continues to wether pulsatile lavage or continuous lavage has greater efficiency and less side effects in the cleansing of contaminated surgical sites <TextLink reference="13"></TextLink>. LPIS seem to be the better option for the soft tissue <TextLink reference="15"></TextLink>, <TextLink reference="39"></TextLink>.</Pgraph><Pgraph>According to the literature the effect of pressure irrigation systems may be outlined as follows <TextLink reference="2"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="14"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">The reduction of the bacterial load correlates with the system pressure (HPIS > LPIS).</ListItem><ListItem level="1">The reduction of infected and necrotic soft tissue correlates with the system pressure (HPIS > LPIS).</ListItem><ListItem level="1">The level of efficiency of HPIS is higher than LPIS and higher than bulb syringe irrigation.</ListItem><ListItem level="1">The cleansing effect varies depending on the tissue treated.</ListItem><ListItem level="1">There is no substantial difference between pulsatile and continuous lavage systems.</ListItem></UnorderedList></Pgraph><Pgraph>These results are achieved by experimental studies in vitro, in animal models or in human cadaver studies and thus somehow limited.</Pgraph><Pgraph>Some invesigators believe, that the use of HPIS may have a negative effect on the soft tissue and the bone itself <TextLink reference="6"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>, <TextLink reference="11"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="36"></TextLink>. They believe that:</Pgraph><Pgraph><UnorderedList><ListItem level="1">HPIS may lead to deeper penetration of the bacteria within the soft tissue</ListItem><ListItem level="1">HPIS may lead to deep seeding of bacteria into the bone</ListItem><ListItem level="1">HPIS may damage the bone</ListItem><ListItem level="1">HPIS may impair bone- or fracture healing</ListItem><ListItem level="1">HPIS may lead to a reduction and promotion of stem cell differentiation toward the adipocyte cell type rather than osteoblasts</ListItem><ListItem level="1">As a result of their effect on the stem cell population HPIS may lead to a significant decrease in fracture callus strength</ListItem></UnorderedList></Pgraph><Pgraph>In their 2008 study Petrisor et al. examined the surgeon’s preferences of the management of open fracture wounds including their behaviour on the use of irrigation systems. These authors could prove, that the majority (71% ≈ 695 surgeons) performed irrigation with LPIS, 317 of whom (32.2%) performed it with a bulb syringe <TextLink reference="34"></TextLink>.</Pgraph><Pgraph>Theoretically the negative effect of HPIS especially on soft tissues might be comparable to the pathophysiology of high-pressure water jet injuries which involves the following three factors <TextLink reference="40"></TextLink>: </Pgraph><Pgraph>Physical: Initially the pure kinetic energy generated by the water jet may cause a local tissue destruction.</Pgraph><Pgraph>Chemical: Reaction of the involved tissue like vasculitis edema, venous obstruction, thrombosis, cellular death.</Pgraph><Pgraph>Biological: The jet injury may lead to inflammation, nec<TextGroup><PlainText>rosi</PlainText></TextGroup>s and soft tissue fibrosis.</Pgraph><Pgraph>In conclusion one may say, that, even if HPIS are more efficient from the mechanical point of view, the LPIS are the better choice from the biological one.</Pgraph></TextBlock> <TextBlock linked="yes" name="Irrigation solutions"> <MainHeadline>Irrigation solutions</MainHeadline><Pgraph>Next to the right choice of the irrigation system it is important to have notice of the proper irrigation solution. Purpose of the use of specific wound rinsing solutions (WRS) is the elimination of pathogens from the infection site additional to the surgical debridement. </Pgraph><Pgraph>The effect of WRS is based on 4 factors <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>:</Pgraph><Pgraph><UnorderedList><ListItem level="1">The rinsing effect: Reduction of the number of pathogens just by the amount of solution used</ListItem><ListItem level="1">The antimicrobial effect: Reduction of the number of pathogens antibacterial pathways</ListItem><ListItem level="1">Fast onset of the antimicrobial effect</ListItem><ListItem level="1">Safe application without side effects</ListItem></UnorderedList></Pgraph><SubHeadline>The rinsing effect</SubHeadline><Pgraph>According to the literature an extensive rinsing in addition to the surgical debridement is needed. Hofmann et al. recommend to use up to 5 l of WRS in order to rinse out the remaining pathogens after surgical debridement <TextLink reference="21"></TextLink>.</Pgraph><SubHeadline>WRS and their antimicrobial spectrum</SubHeadline><Pgraph>Many different antimicrobial and antiseptic WRS may be used. Table 1 <ImgLink imgNo="1" imgType="table"/> gives a brief exposure of the main substances that may be deployed <TextLink reference="3"></TextLink>.</Pgraph><SubHeadline>WRS and their side effects</SubHeadline><Pgraph>In the last decades many scientific articles deal with the problem of the cytotoxic effect and the tissue toxicity of WRS. In 2003 Kalteis et al. measured the irritation score and the irritation thershold of some common WRS. Their results showed, that some of the antiseptic solutions may cause severe vascular injuries and thus may be considered to be cytotoxic (Dibromol<Superscript>®</Superscript>, Kodan<Superscript>®</Superscript>, Jodobac<Superscript>®</Superscript>, Octenisept<Superscript>®</Superscript>, Chlorhexidindigluconate 0.5% and 2-propanol 60%) <TextLink reference="23"></TextLink>. The authors could prove, that the tissue toxicity of Lavasept 0.2%<Superscript>®</Superscript> was significant lower than the one of the above named solutions. Langer et al. analysed the impact of topical antiseptics on skin microcirculation of hairless mice in 2004. They investigated Softasept<Superscript>®</Superscript>, Octenisept<Superscript>®</Superscript>, Lavasept<Superscript>®</Superscript> and 70% ethanol. Sodium chloride 0.9% served as control. All antiseptic solutions tested showed an influence to the skin microcirculation. This effect was the most aggressive in the alcoholic solutions <TextLink reference="28"></TextLink>. In 2008 Müller et al. investigated both the antimi<TextGroup><PlainText>cro</PlainText></TextGroup>bial effect and the cytotoxicity of antiseptic agents. These authors defined a biocompatibility index (BI) by measuring the antimicrobial activity against E. coli and S. aureus. On the other hand, in parallel, cytotoxicity was tested on cultured murine fibroblasts <TextLink reference="32"></TextLink>. A ranking was formed for the ratio BI<Subscript>E. coli</Subscript>/fibroblast toxicity and BI<Subscript>S. aureus</Subscript>/fibroblast toxicity.<LineBreak></LineBreak><LineBreak></LineBreak>BI<Subscript>E. coli</Subscript>/fibroblast toxicity:<LineBreak></LineBreak>Octenidine-dihydrochloride > polyhexamethylene big<TextGroup><PlainText>uan</PlainText></TextGroup>ide > chlorhexidine digluconate > PVP-I > benzalkonium chloride > cetylpyridinium chloride > triclosan > mild silver protein.<LineBreak></LineBreak><LineBreak></LineBreak>BI<Subscript>S. aureus</Subscript>/fibroblast toxicity:<LineBreak></LineBreak>Octenidine-dihydrochloride > polyhexamethylene big<TextGroup><PlainText>uan</PlainText></TextGroup>ide > chlorhexidine digluconate > cetylpyridinium chloride > benzalkonium chloride > PVP-I > triclosan > mild silver protein.<LineBreak></LineBreak><LineBreak></LineBreak>These findings support the results of Kalteis et al. 2003 and Langer et al. 2004 and show, that antiseptic capacity and cytotoxicity may diverge. Especially the toxic side effects of Octenisept<Superscript>®</Superscript> were pointed out again by Schupp and Holland-Cunz <TextLink reference="37"></TextLink>. They came to the conclusion not to recommend the use of Octenisept<Superscript>®</Superscript> in any wound cavity. In 2009 Hirsch et al. saw significant changes of cell activity and cell proliferation after wound irrigation with Lavasept<Superscript>®</Superscript>, Betaisodona<Superscript>®</Superscript> and Octenisept<Superscript>®</Superscript>, Protosan<Superscript>®</Superscript>, Braunol<Superscript>®</Superscript> <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>. These side effects were distinctly smaller when Lavasept<Superscript>®</Superscript> and Protosan<Superscript>®</Superscript> was used. In 2011 Bowling and co-workers introduced a very interesting pilot study. They analysed the effect of superoxidized aqueous solution versus standard saline solution (NaCl 0.9%) on the reduction of bacterial load and wound size on diabetic foot ulcers. No significant difference could be shown between the two solutions when being use for jet lavage <TextLink reference="7"></TextLink>. According to the authors the use of superoxidized aqueous solution as well as standard saline solution is safe and effective.</Pgraph><Pgraph>Finally we would make mention of investigations of Best et al. in 2007. They analysed the effect of chlorhexidine 0.05% on human cartilage <TextLink reference="5"></TextLink>. The authors measured the cartilage metabolism by using radiolabelled sulphur uptake. This metabolism was analysed for chlorhexidine 0.05% exposure on osteoarthritic and non-osteoarthritic human cartilage in-vitro. After brief exposure (1 min) the metabolism of non-osteoarthritic cartilage was not significantly affected. Osteoarthritic cartilage was impared markedly. After prolonged exposure (1 h) both cartilage types where affected significantly. Even if these results may have an effect on the future treatment of open joint injuries in young patients (no osteoarthritic changes) the use of chlorhexidine solution is not recommendable on soft tissue, because of the above shown side effects. </Pgraph><SubHeadline>Conclusion</SubHeadline><Pgraph>Counting the above named facts into consideration we recommend the use of standard saline solution (NaCl 0.9%) as the WRS used for jet lavage.</Pgraph></TextBlock> <TextBlock linked="yes" name="Wound irrigation: philosophies"> <MainHeadline>Wound irrigation: philosophies</MainHeadline><Pgraph>There are two basic philosophies about how to manage the irrigation procedure during the infect eradication phase (time and number of revision operations needed in order to eradicate the bone infection).</Pgraph><SubHeadline>Staged revision program (revision procedures with fixed distance of time)</SubHeadline><Pgraph>This procedure was originaly introduced by visceral surgeons who needed a sufficient tool for the treatment of severe peritonitis <TextLink reference="1"></TextLink>. The patient was taken to the operation theater in a specific time scedule with fixed distance of time for revision surgery and lavage of the abdomen. The idea of this temporal programmed lavage system was assumed for the treatment of septic bone infections. Hofmann et al. recommended an electronical calender for the planing of the revision operations <TextLink reference="21"></TextLink>. The programmed lavage is continued until no pathogens could be detected in the microbial analysis of the samples taken from the surgical site. </Pgraph><SubHeadline>Individual revision program</SubHeadline><Pgraph>After the initial surgical debridement with additional jet lavage the next revision operations will be proceeded according to the local clinical situation and the paraclinical findings <TextLink reference="17"></TextLink>. There is no fixed time scedule. When there is no macroscopic evidence of infection anymore and the paraclinical parameters (WBC, CRP) are back to normal, the revision program is stopped, even, and this is the important difference to the above named revision program with fixed time distances, if pathogens might be detected in the samples taken from the surgical site.</Pgraph></TextBlock> <TextBlock linked="yes" name="Conclusion"> <MainHeadline>Conclusion</MainHeadline><Pgraph>The basic treatment of osteomyelitis remains even today the surgical debridement in combination with a wound irrigation by jet lavage systems. Next to a comprehensive knowledge of the surgical techniques a profound knowledge of the lavage systems, the rinsing solutions used and the philosophies of revision programs are a must.</Pgraph><Pgraph>According to the literature, there are many antiseptic solutions, that may be used for the lavage procedure. All of them have more or less severe side effects, that render them unusable for this specific purpose.</Pgraph><Pgraph>One may state the following résumé:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Basic osteomyelitis treatment: Surgical debridement obligatory including the wound irrigation.</ListItem><ListItem level="1">Wound irrigation procedure: Low pressure lavage systems</ListItem><ListItem level="1">Pulsatile or constant flow lavage: According to the literature there is no significant advantage for one method or the other.</ListItem><ListItem level="1">Irrigation fluid: Because of their severe side effects none of the common antiseptic solutions may be recommended. Standard saline solution (NaCL 0.9%) remains the correct choice. Further investigations in this field are indispensable.</ListItem><ListItem level="1">Amount of irrigation fluids: 5 l and more</ListItem><ListItem level="1">Staged revision program/individual revision program: No significant differences. Further investigations in this field are indispensable.</ListItem></UnorderedList></Pgraph></TextBlock> <TextBlock linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Adam U</RefAuthor> <RefAuthor>Ledwon D</RefAuthor> <RefAuthor>Hopt UT</RefAuthor> <RefTitle>Etappenlavage als Grundlage der Therapie diffuser Peritonitis</RefTitle> <RefYear>1997</RefYear> <RefJournal>Langenbecks Arch Chir</RefJournal> <RefPage>18-21</RefPage> <RefTotal>Adam U, Ledwon D, Hopt UT. Etappenlavage als Grundlage der Therapie diffuser Peritonitis. Langenbecks Arch Chir. 1997;382(Suppl 1):18-21. 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DOI: 10.1007/s11751-009-0059-y</RefTotal> <RefLink>http://dx.doi.org/10.1007/s11751-009-0059-y</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID>1</MediaID> <Caption><Pgraph><Mark1>Table 1: Examples for antimicrobial substances to be used for wound irrigation [3]</Mark1></Pgraph></Caption> </Table> <NoOfTables>1</NoOfTables> </Tables> <Figures> <NoOfPictures>0</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>