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Updated: Dec 6, 2025
Assessing Biofilm Dispersal in Murine Wounds
Published on: August 7, 2021
Why Irrigate for the Same Contamination Rate: Wound Contamination in Pediatric Spinal Surgery Using Betadine Versus
Lara L Cohen1, Richard M Schwend2, John M Flynn3
1Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
Insights
Surgical site infection risk in pediatric spine fusion is high, especially in neuromuscular disease. This pilot study found povidone-iodine (PVP-I) irrigation did not significantly reduce bacterial contamination compared to sterile saline (SS).
Area of Science:
- Pediatric Orthopedics
- Surgical Infection Prevention
- Spinal Surgery
Background:
- Pediatric posterior spine fusion (PSF) carries a significant risk of surgical site infection (SSI), with rates up to 4.3% in idiopathic cases and 24% in neuromuscular disease patients.
- Pre-closure tissue cultures in pediatric PSF are frequently positive (23%), particularly in neuromuscular cases, indicating a high bacterial burden.
- Evaluating novel irrigation techniques is crucial to mitigate SSI risk in this vulnerable population.
Purpose of the Study:
- To assess the feasibility of a full randomized controlled trial (RCT) comparing povidone-iodine (PVP-I) versus sterile saline (SS) irrigation for reducing bacterial contamination before closure in pediatric PSF.
- To determine if PVP-I irrigation is more effective than SS in lowering the rate of positive bacterial cultures in surgical wounds prior to closure.
- To inform the design of future definitive RCTs by evaluating recruitment and outcomes in high-risk and low-risk pediatric PSF patients.
Main Methods:
- A multicenter, single-blind, pilot randomized controlled trial involving 175 pediatric patients undergoing PSF, stratified into low-risk (LR) and high-risk (HR) for infection (3:1 ratio).
- Surgical wounds underwent debridement and soaking with either 0.35% PVP-I or SS for 3 minutes before closure, with wound cultures collected pre- and post-irrigation.
- Irrigation involved 2 liters of saline, followed by a second wound culture to assess bacterial load.
Main Results:
- Of 153 subjects who completed the protocol, 77 received PVP-I and 76 received SS irrigation.
- Pre-irrigation positive cultures were similar: 18% (PVP-I) vs. 17% (SS). Post-irrigation, rates remained comparable: 16% (PVP-I) vs. 18% (SS).
- Infection rates at 30 days were 8% in high-risk subjects (1/PVP-I, 2/SS), with no infections in low-risk subjects.
Conclusions:
- Bacterial contamination of surgical wounds before closure in pediatric PSF remains high, irrespective of whether povidone-iodine or sterile saline irrigation is used.
- The study suggests that a definitive RCT to definitively prove efficacy would be challenging due to the similar rates of tissue positivity across irrigation groups.
- Current irrigation protocols may require re-evaluation to significantly impact bacterial contamination rates in pediatric PSF procedures.
Background:
The risk of surgical site infection in pediatric posterior spine fusion (PSF) is up to 4.3% in idiopathic populations and 24% in patients with neuromuscular disease. Twenty-three percent of pediatric PSF tissue cultures are positive before closure, with a higher rate in neuromuscular patients. Our primary aim was to evaluate the feasibility of a complete randomized controlled trial to study the efficacy of surgical site irrigation with povidone-iodine (PVP-I) compared with sterile saline (SS) to reduce the bacterial contamination rate before closure in children undergoing PSF.
Methods:
One hundred seventy-five subjects undergoing PSF were enrolled in a multicenter, single-blind, pilot randomized controlled trial. We recruited patients at low-risk (LR) and high-risk (HR) for infection 3:1, respectively. Before closure, a wound culture was collected. Nonviable tissues were debrided and the wound was soaked with 0.35% PVP-I or SS for 3 minutes. The wound was then irrigated with 2 L of saline and a second sample was collected.
Results:
One hundred fifty-three subjects completed the protocol. Seventy-seven subjects were allocated to PVP-I (18 HR, 59 LR) and 76 to SS (19 HR, 57 LR). Cultures were positive in 18% (14/77) of PVP-I samples (2 HR, 12 LR) and in 17% (13/76) of SS samples (3 HR, 10 LR) preirrigation and in 16% (12/77) of PVP-I samples (5 HR, 7 LR) and in 18% (14/76) of SS samples (4 HR, 10 LR) postirrigation. Eight percent (3/37) HR subjects (1 PVP-I, 2 SS) experienced infection at 30 days postoperative. No LR subjects experienced infection.
Conclusions:
Positive cultures were similar across treatment and risk groups. The bacterial contamination of wounds before closure remains high regardless of irrigation type. A complete randomized controlled trial would be challenging to adequately power given the similarity of tissue positivity across groups.
Level Of Evidence:
Level II-pilot randomized controlled trial.
