Tactical use of irrigants in open orthopaedic procedures: 'what to use & when'

Area of Science:

• Orthopaedic Surgery
• Infectious Diseases
• Biomedical Engineering

Background:

• Musculoskeletal infections (MSIs) present significant healthcare challenges.
• Surgical wound irrigation is vital for reducing microbial load in orthopaedic procedures.
• Optimal use of lavage agents for musculoskeletal infections remains unclear.

Purpose of the Study:

• To classify orthopaedic wounds for tactical selection of irrigants.
• To stratify irrigant products based on their modes of action and host toxicity.
• To recommend a tailored, stepwise strategy for irrigant selection in musculoskeletal infections.

Main Methods:

• Classifying orthopaedic wounds into aseptic, acute septic, and chronic septic categories based on microbial bioload and biofilm presence.
• Stratifying irrigant products by their modes of action: single (dilutional), dual (dilutional and chemical), and multi-modal (dilutional with multiple mechanisms).
• Evaluating host toxicity in relation to irrigant product complexity and considering irrigant delivery methods and volume.

Main Results:

• A classification system for orthopaedic wounds (aseptic, acute septic, chronic septic) aids in irrigant selection.
• Irrigants can be categorized by their action (dilutional, chemical, multi-modal), with toxicity increasing with complexity.
• A tailored, stepwise strategy is recommended, escalating irrigant potency with infection severity.

Conclusions:

• A stepwise, tailored strategy for selecting surgical wound irrigants is recommended for musculoskeletal infections.
• Irrigant selection should align with wound classification (aseptic, acute septic, chronic septic) and microbial bioload.
• Balancing efficacy with host toxicity is crucial, progressing from simple dilutional lavage to potent multi-modal agents for complex infections.