Prevention and Treatment of Surgical Site Infections in Orthopaedic Surgery: An Italian Delphi Consensus on Risk...

Introduction: Surgical site infections (SSIs) and prosthetic joint infections remain among the most serious complications in orthopedic surgery, and chemical debridement is recommended for all septic revisions. The combination of polyhexanide (PHMB) and poloxamer (PLX), with in vitro antimicrobial and antibiofilm activity, represents a promising antiseptic solution. An Italian Delphi consensus was conducted to define the indications and clinical applications of PHMB/PLX as an antiseptic solution. Materials and Methods: A steering committee convened a panel of orthopedic surgeons, infectious disease specialists, and wound care specialists with expertise in musculoskeletal infections. A modified three-phase Delphi process was conducted. Twelve clinical questions and four outcome measures were developed through literature review and iterative discussion. Two Delphi rounds were conducted using a 9-point Likert scale, and statements were rated according to the GRADE method. Results: Twelve statements were developed, and all achieved strong consensus after two Delphi rounds. The panel identified key patient-related risk factors (smoking, diabetes, obesity, immunosuppression) and procedure-related risks (open fractures, primary/revision arthroplasty, prolonged operative time). Antiseptic irrigation was considered superior to saline, and PHMB-PLX was considered potentially useful based on expert opinion as an addition to mechanical debridement given its antibiofilm activity and good cytocompatibility. Low-pressure irrigation and short exposure times are the preferred application methods, while avoiding use on cartilage or neural tissues. Conclusions: The Delphi panel reached strong consensus supporting the intraoperative use of PHMB-PLX due to its potential as an antiseptic adjunct, supported by expert consensus and translational evidence for preventing and treating SSIs in orthopedic surgery. The panel recommended conducting high-quality clinical research to verify these findings and improve standardized irrigation protocols.