Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections

Abstract

Abstract. Irrigation and debridement in the treatment of periprosthetic joint infection (PJI) serve an integral role in the eradication of bacterial burden and subsequent re-infection rates. Identifying the optimal irrigation agent, however, remains challenging, as there is limited data on superiority. Direct comparison of different irrigation solutions remains difficult because of variability in treatment protocols. While basic science studies assist in the selection of irrigation fluids, in vitro results do not directly translate into clinical significance once implemented in vivo. Dilute povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid, sodium hypochlorite, hypochlorous acid, and preformed combination solutions all have potential against a broad spectrum of PJI pathogens with their own unique advantages and disadvantages. Future clinical studies are needed to identify ideal irrigation solutions with optimal bactericidal properties and low cytotoxicity for PJI treatment.

Current treatments for biofilm‐associated periprosthetic joint infection and new potential strategies

“…During DAIR, multiple irrigation protocols and solutions are being used; however, they are not standardized. Most frequently used solutions include normal saline, providone‐iodine, chlorhexadine gluconate, hydrogen peroxide, bacitracin, and hypochlorite (refer to this review for an overview of commonly used lavage solutions and their efficacy 35 ). A combination can also be used, but certain combinations can be toxic and most are cytotoxic at therapeutic doses where biofilm eradication is apparent 35–38 .…”

“…Most frequently used solutions include normal saline, providone‐iodine, chlorhexadine gluconate, hydrogen peroxide, bacitracin, and hypochlorite (refer to this review for an overview of commonly used lavage solutions and their efficacy 35 ). A combination can also be used, but certain combinations can be toxic and most are cytotoxic at therapeutic doses where biofilm eradication is apparent 35–38 . Even with these factors in mind, failure rates using DAIR for knee and hip PJI range from 31% to 63% 39,40 …”

“…A combination can also be used, but certain combinations can be toxic and most are cytotoxic at therapeutic doses where biofilm eradication is apparent. [35][36][37][38] Even with these factors in mind, failure rates using DAIR for knee and hip PJI range from 31% to 63%. 39,40 • One-stage revision is a common procedure in Europe and gaining popularity in the United States.…”

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty

“…The other ingredient, betaine, functions as a surfactant to aid with tissue debridement, while the poly-hexanide is a preservative. The 2 compounds work synergistically to lower the surface tension to below that of water in order to improve biofilm removal 43 .…”

Common Wound Irrigation Solutions Produce Different Responses in Infected vs Sterile Host Tissue: Murine Air Pouch Infection Model

“…The irrigant Bactisure (ethanol, acetic acid, sodium acetate, benzalkonium chloride, water; Zimmer-Biomet, Warsaw, IN) has shown success in reducing bacterial loads in vitro and in vivo. Its bactericidal effect is due to the surfactant properties, chelating agents, and salts that disrupt the extracellular matrix, making bacteria more susceptible to the body’s immune system as well as preventing biofilm formation [ 13 ]. Unfortunately, drawbacks do exist with these irrigants [ 7 , [14] , [15] , [16] ].…”