Fluid lavage in patients with open fracture wounds (FLOW): an international survey of 984 surgeons

Abstract

BackgroundAlthough surgeons acknowledge the importance of irrigating open fracture wounds, the choice of irrigating fluid and delivery pressure remains controversial. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds.MethodsWe used a cross-sectional survey and a sample-to-redundancy strategy to examine surgeons' preferences in the initial management of open fracture wounds. We mailed this survey to members of the Canadian Orthopaedic Association and delivered it to attendees of an international fracture course (AO, Davos, Switzerland).ResultsOf the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, the majority of surgeons surveyed, 676 (70.5%), favoured normal saline alone. Bacitracin solution was used routinely by only 161 surgeons (16.8%). The majority of surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound. There was, however considerable variation in what pressures constituted high versus low pressure lavage. The overwhelming majority of surgeons, 889 (94.2%), reported they would change their practice if a large randomized controlled trial showed a clear benefit of an irrigating solution – especially if it was different from the solution they used.ConclusionThe majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds. However, opinions varied as regards the comparative efficacy of different solutions, the use of additives and high versus low pressure. Surgeons have expressed considerable support for a trial evaluating both irrigating solutions and pressures.

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds

“…We estimated a similar controlgroup reoperation rate for normal saline, 13,26,27 and the study therefore also had 98% power to detect a 25% lower relative risk with soap -a treatment effect that was endorsed by 80% of surgeons in our international survey as important enough to change practice. This sample size was based on the size of the irrigation-pressure groups and was calculated to ensure that the study would have a power of 80% to identify differences among the three irrigation-pressure groups in effects of pairwise comparisons at an adjusted alpha level of 0.0188, on the basis of a rate of reoperation within 12 months of 30% in a control group and a 25% lower relative risk with one irrigation pressure than with another.…”

“…[4][5][6][7][8][9][10][11][12][13] High pressure may be more effective than low pressure in removing particulate matter and bacteria 7-10 but at the expense of bone damage 8,11 and a resultant delay in bone healing. [4][5][6][7][8][9][10][11][12][13] High pressure may be more effective than low pressure in removing particulate matter and bacteria 7-10 but at the expense of bone damage 8,11 and a resultant delay in bone healing.…”

Fluid Lavage of Open Wounds (FLOW): design and rationale for a large, multicenter collaborative 2 × 3 factorial trial of irrigating pressures and solutions in patients with open fractures

“…We based these volumes on our international survey data [35] to reflect current standards and management protocols.…”

Open Tibial Fractures: Updated Guidelines for Management

“…Although the predominant preferences were normal saline solution alone and low-pressure irrigation, only 71% of respondents endorsed these practices 9 . Furthermore, it has been suggested that types I, II, and III fractures should be irrigated with 3, 6, and 9 L of solution, respectively 8 .…”

“…The importance of proceeding with evidence-based interventions that optimize patient outcomes in the setting of these potentially devastating injuries cannot be overstated. Despite the growing body of literature surrounding the treatment of open tibial shaft fractures, several crucial aspects in the surgical management of these patients remain equivocal and thus varied across the global orthopaedic community 9 .…”