Effects of hydrogen peroxide solutions on artificial hip joint implants

Debridement, antibiotics and implant retention (DAIR) is successful in the management of acutely infected unicompartmental knee arthroplasty: a case series

BACKGROUND

Infections are rare and poorly studied complications of unicompartmental knee arthroplasty (UKA) surgery. They are significantly less common compared to infections after total knee arthroplasties (TKAs). Optimal management of periprosthetic joint infections (PJIs) after a UKA is not clearly defined in the literature. This article presents the results of the largest multicentre clinical study of UKA PJIs treated with Debridement, Antibiotics and Implant Retention (DAIR).

MATERIALS AND METHODS

In this retrospective case series, patients presenting between January 2016 and December 2019 with early UKA infection were identified at three specialist centres using the Musculoskeletal Infection Society (MSIS) criteria. All patients underwent a standardized treatment protocol consisting of the DAIR procedure and antibiotic therapy comprising two weeks of intravenous (IV) antibiotics followed by six weeks of oral therapy. The main outcome measure was overall survivorship free from reoperation for infection.

RESULTS

A total of 3225 UKAs (2793 (86.2%) medial and 432 (13.8%) lateral UKAs) were performed between January 2016 and December 2019. Nineteen patients had early infections necessitating DAIR. The mean follow-up period was 32.5 months. DAIR showed an overall survivorship free from septic reoperation of 84.2%, with overall survivorship free from all-cause reoperation of 78.95%.The most common bacteria were Coagulase-negative Staphylococci, Staphylococcus aureus and Group B Streptococci. Three patients required a second DAIR procedure but remained free from re-infection at follow-up obviating the need for more demanding, staged revision surgery.

CONCLUSIONS

In infected UKAs, the DAIR procedure produces a high rate of success, with a high survivorship of the implant.Key messagesDebridement, Antibiotics and Implant Retention (DAIR) is a successful and minimally invasive surgical option for the management of periprosthetic joint infections (PJIs) after UKA.The surface area available for bacteria to colonise is much smaller in UKAs compared to total knee arthroplasties (TKAs), and this may account for the higher success rates of the DAIR procedure in infected UKAs versus infected TKAs.A second DAIR procedure can be considered in the management of the early recurrence of PJIs with a well-fixed UKA.

A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery

» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.

The role of hydrogen peroxide in hip arthroplasty: A narrative review

Hydrogen peroxide has become more commonly used in hip arthroplasties due to high risk of periprosthetic infections. Its purported roles include irrigation, haemostasis, reduction of aseptic loosening and attachment of antibiotics. However, current literature does not provide conclusive evidence on the efficacy of hydrogen peroxide in preventing aseptic loosening, with some controversy around whether it in fact contributes to aseptic loosening. The complications of hydrogen peroxide across medicine are well distinguished; however, the risks within orthopaedic surgery and hip arthroplasties are not well known. Beyond cytotoxicity, the most dangerous reported risk associated with hydrogen peroxide in hip arthroplasties was an oxygen embolism in an unvented femoral canal and acrylic bone cement, consequentially leading to cardiac arrest. However, it may be inappropriate to solely attribute the oxygen embolism to the use of hydrogen peroxide and thus if used appropriately, hydrogen peroxide may have a justifiable role in hip arthroplasty surgery. In this narrative review, we present the current uses of hydrogen peroxide while evaluating its associated risks. We have summarised the key indications and aggregated recommendations to provide guidelines for the use of hydrogen peroxide in hip arthroplasty.

What is the optimal protocol to decontaminate a dropped custom polyethylene component?

BACKGROUND

With advancements in manufacturing technology, custom orthopedic implants have become commercially available. A new concern with these implants is what to do when custom heat-sensitive components are contaminated. While intraoperative decontamination protocols for dropped autograft tissue have been described, no literature describes an intraoperative protocol for decontaminating one-of-a-kind polyethylene implants. The purpose of this work is to describe and evaluate polyethylene decontamination protocols using materials found in the average operating suite that could be used intraoperatively.

METHODS

Sixteen custom polyethylene inserts were contaminated with potting soil and processed in one of four protocols: 1) hydrogen peroxide, 2) chlorhexidine gluconate, 3) povidone-iodine, or 4) control. Following processing, the implants were cultured with swabs or sonication. Each implant was evaluated with one aerobic, one anaerobic, and one fungal culture.

RESULTS

All cultures from implants processed with both the chlorhexidine and povidone-iodine protocols were negative. One colony of Ralstonia species was isolated on the aerobic culture from one of the implants processed with hydrogen peroxide. The remainder of the cultures from implants processed with the hydrogen peroxide protocol were negative. All of the cultures for each culture modality from all of the control implants were positive with florid proliferation.

CONCLUSION

In the rare situation that a custom polyethylene insert becomes contaminated intraoperatively, the surgeon should consider all salvage options. Chlorhexidine and povidone-iodine decontamination protocols eliminated bacterial growth following culture swabs or sonicate taken from the contaminated polyethylene inserts while hydrogen peroxide failed in one case to completely eradicate growth.

The Evidence Behind Peroxide in Orthopedic Surgery

Peroxide is a strong oxidizing agent and disinfectant frequently used in orthopedic surgery. The authors conducted a systematic literature review of peroxide in orthopedic surgery, evaluating use, complications, efficacy, and appropriate concentrations. One hundred seventy-five reports were identified, with 24 being eligible for analysis. Orthopedic surgeons used peroxide for irrigation and bacterial reduction in various procedures. Complications included cytotoxicity, allergic reactions, suture damage, and inflammation. Use of the standard concentration of 3% peroxide and standard time in situ are without evidence. Laboratory studies suggest that diluted concentrations retain the benefit of bacterial decolonization without increasing the risk for complications. [Orthopedics. 2018; 41(6):e756-e764.].

Hydrogen Peroxide Wound Irrigation in Orthopaedic Surgery

As the burden of deep hardware infections continues to rise in orthopaedics, there is increasing interest in strategies for more effective debridement of colonized tissues and biofilm. Hydrogen peroxide has been used medically for almost a century, but its applications in orthopaedic surgery have yet to be fully determined. The basic science and clinical research on the antiseptic efficacy of hydrogen peroxide have demonstrated its efficacy against bacteria, and it has demonstrated potential synergy with other irrigation solutions such as chlorhexidine and povidone-iodine. While hydrogen peroxide is effective in infection reduction, there are concerns with wound healing, cytotoxicity, and embolic phenomena, and we recommend against hydrogen peroxide usage in the treatment of partial knee replacements, hemiarthroplasties, or native joints. Additionally, due to the potential for oxygen gas formation, hydrogen peroxide should not be used in cases of dural compromise, when pressurizing medullary canals, or when irrigating smaller closed spaces to avoid the possibility of air embolism. Finally, we present our protocol for irrigation and debridement and exchange of modular components in total joint arthroplasty, incorporating hydrogen peroxide in combination with povidone-iodine and chlorhexidine.

Hydrogen peroxide in orthopaedic surgery - is it worth the risk?

Hydrogen peroxide (H₂O₂) is commonly used in orthopaedic surgery during cemented arthroplasty and wound washouts. Its purported roles include antisepsis, haemostasis, mechanical debridement, and optimising the cement-bone interface during cementing. However, despite its apparent harmless mechanism of action, H₂O₂ has been implicated in fatal and near fatal complications caused through oxygen emboli. We present a case of oxygen embolism and review the existing literature to highlight its potential risks and its lack of therapeutic value. We believe there is little role for its use in orthopaedic surgery.

Hydrogen Peroxide – A Party Trick from the Past?

Hydrogen peroxide solutions are found in almost every operating theatre and are used by many surgical specialties, often with little knowledge of their inherent risk. We reviewed the literature and evidence related to the use of hydrogen peroxide in surgery. We found little evidence supporting the use of hydrogen peroxide solutions intraoperatively, a large number of reports of sometimes-fatal oxygen embolism and other evidence of tissue toxicity. We conclude that the use of hydrogen peroxide as an antiseptic has no direct benefit, but is associated with significant risk, and therefore should be reconsidered.

Optimisation of the hydrogen peroxide pre-treatment of titanium: surface characterisation and protein adsorption

BACKGROUND

Researchers have attempted to enhance titanium osseointegration by modifying its surface properties, including via H(2)O(2) pre-treatment, with reported treatment regimes varying from minutes/hours, to weeks.

OBJECTIVE

This study examined the effects of various H(2)O(2) treatments on titanium surface topography/roughness, chemical composition/oxide thickness, hydrophilicity and plasma protein adsorption.

MATERIALS AND METHODS

Titanium discs were treated with 30% H(2)O(2) for 0-24 h or 1-4 weeks and subjected to atomic force microscopy (AFM), scanning electron microscopy (SEM), profilometry, X-ray photon spectroscopy and contact angle analysis. For protein adsorption, whole plasma and FITC-conjugated serum albumin were added to 0-24 h and 1-4 week H(2)O(2)-treated discs and examined by SEM and fluorescence microscopy, respectively.

RESULTS

AFM, SEM and profilometry demonstrated that 1-6 h H(2)O(2)-treated discs exhibited subtle alterations in surface topography/roughness at the nanometre scale, although 24 h and 1-4 week H(2)O(2)-treated discs exhibited much greater increases in surface roughness, in the micrometre range. Maximal increases in surface oxide thickness and chemical modification were identified between 1 h-4 weeks and 3 h-4 weeks, respectively, although no increases in oxygen/titanium (O1s : Ti2p) molar ratio or in hydrophilicity were evident. Plasma and serum albumin adsorption increased on 1-24 h H(2)O(2)-treated discs, with further increases on 1-4 week H(2)O(2)-treated discs.

CONCLUSIONS

Based upon the present data and previous findings, this study supports the concept that surface topography/roughness and oxide composition/thickness, are more significantly modified by H(2)O(2) treatment and more influential to protein adsorption than hydrophilicity. Additionally, it can be hypothesized that the 24 h H(2)O(2) treatment of titanium surfaces, which induced micrometre scale changes in roughness and protein adsorption, to those associated with enhanced osteoblast attachment/behaviour, mineralisation and subsequent implant osseointegration, would be most beneficial.

Hydrogen peroxide and wound healing: a theoretical and practical review for hair transplant surgeons

BACKGROUND

In most hair restoration practices, hydrogen peroxide has been routinely used to remove blood during and after hair transplant surgery. In other specialties, hydrogen peroxide is also used in these ways: wound cleaning, prevention of infection, hemostasis, and removal of debris. Despite its widespread use, there are still concerns and controversy about the potential toxic effect of hydrogen peroxide.

OBJECTIVE

The objective was to review all available literature including in vivo and in vitro effects of hydrogen peroxide, as well as general wound healing research.

MATERIAL AND METHODS

Literature up to and including the past three decades was investigated.

RESULTS

Two pilot studies were found, and there are not enough data examining the real impact of using hydrogen peroxide in hair transplant surgery. In other specialties, H(2)O(2) appears to have positive effects, such as stimulation of vascular endothelial growth factor, induction of fibroblast proliferation, and collagen, or negative effects, such as cytotoxicity, inhibition of keratinocyte migration, disruption of scarless fetal wound repair, and apoptosis.

CONCLUSIONS

There are not enough data in hair restoration surgery about the use of hydrogen peroxide, and it is unknown and unclear what the optimum dilution should be. Positive and negative effects were found in other specialties. Further studies are recommended. The authors have indicated no significant interest with commercial supporters.

Safety of autologous drainage blood reinfusion following total knee arthroplasty prepared with hydrogen peroxide

In a clinical in vivo study, wound blood collected from an autologous reinfusion drain of patients undergoing elective total knee arthroplasty was examined to investigate if hydrogen peroxide bone surface preparation had an adverse effect on blood destined to be reinfused. The post-operative drain blood of thirty-eight patients was collected after pre-implantation bone preparation being performed either with or without the use of hydrogen peroxide. Filtered drain blood samples were analyzed and mean results for treatment / control groups respectfully were: haemoglobin (g/L) 98.6/100.9, p=0.7221; haemoglobin change from baseline (g/L) -39.1/-32.9, p=0.2117; MCV (fL) 94.6/93.1, p=0.2897; MCV change from baseline (fL) 2.0/2.5, p=0.6417; potassium (mmol/L) 4.5/4.6, p=0.8212; free haemoglobin (g/L) 1.2/1.3, p=0.4387; methaemoglobin (%) 0.2/0.2, p=0.8112; presence of echinocytes (%) 14/18, p=1.0000. These were all within safe limits for reinfusion. Under the study conditions, application of hydrogen peroxide followed by thorough lavage of the knee joint did not appear to result in any untoward degradation of the extravasated blood that might preclude its use for postoperative autologous drainage blood reinfusion.

Effect of additional hydrogen peroxide to H2O2⋯(H2O)n, n=1 and 2 complexes: Quantum chemical study

Hydrogen peroxide, H2O2, acts as a particularly strong reactant in aqueous environment. It has been demonstrated earlier that agglomerates with a single peroxide interacting with one and two water molecules manifest in several stable conformers within a narrow energy range. In the present study we seek structural changes brought out by adding an extra H2O2 to these systems at molecular level employing ab initio quantum chemical methods, viz., restricted Hartree-Fock and the second order Moller-Plesset perturbation theory. These clusters exhibit consistent trends in energy hierarchy at both the levels. Further, a many body interaction energy analysis quantifies the strength and cooperativity of hydrogen bonding in the (H2O2)2...(H2O)n, (n=1 and 2) clusters, bringing out structuring/destructuring effects attributed to attachment of water and hydrogen peroxide molecules.