Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes

Environmental micro-molar H2O2 reduces the efficiency of glyphosate biodegradation in soil

Glyphosate is one of the most widely used pesticides globally. The environmental micro-molar hydrogen peroxide (H2O2)-driven Fenton reaction has been reported to degrade herbicides in natural water. However, the impact of micro-molar H2O2 (50 μM) on the degradation of glyphosate in soil and glyphosate-degrading bacteria remains unclear. In this study, degradation of glyphosate in the sterilized and unsterilized soil system and MSM medium under micro-molar H2O2 was investigated; bacterial diversity, enzyme activity and gene abundance in the soil following micro-molar H2O2 addition were also investigated. The results indicated that the addition of micro-molar H2O2 facilitated the degradation of glyphosate in a sterilized environment, resulting in a 76.30% decrease in glyphosate within 30 days. The degradation of glyphosate increased by 52.32% compared to the control treatment. However, in an unsterilized environment, the addition of micro-molar H2O2 leads to a reduction in the biodegradation efficiency of glyphosate. Bacteria, enzymes and specific genes were found to be affected to varying degrees. Firstly, micro-molar H2O2 affects the relative abundance of functional bacteria related to glyphosate degradation, such as Afipia, Microcoleus and Pseudomonas. Secondly, micro-molar H2O2 resulted in a decrease in soil phosphatase activity. Thirdly, the expression of resistance genes was affected, particularly the glyphosate resistance gene aroA. The findings presented a novel research perspective on the degradation of soil glyphosate by micro-molar H2O2.

Does hydrogen peroxide help mitigate the incidence of Cutibacterium acnes in cervical spine surgeries?

Background

Surgical site infection (SSI) is a common yet serious complication of cervical spine surgery. While initially thought to be clinically insignificant, Cutibacterium acnes (C. acnes) is an important cause of infection. The purpose of this study was to investigate the ability of a hydrogen peroxide (H2O2) application during standard presurgical skin preparation to reduce the burden of C. acnes in patients undergoing cervical spine surgery.

Methods

This was a retrospective review of prospectively collected data. Subjects were randomly assigned to either standard surgical preparation plus H2O2 (experimental) or without H2O2 (control). Prescrub, postscrub, and dermal cultures were obtained to assess the C. acnes burden after cultures on an aerobic and anaerobic growth medium were held for 21 days. Multivariate analysis was conducted to determine factors associated with presence of C. acnes. Outcome measures included the results of intraoperative cultures and the development of a SSI within 90 days postoperatively.

Results

Patients (n=86) undergoing elective 2- or 3-level fusion via anterior approach were included. Prior to application of the antiseptic solution, 65% (28/43) of the experimental cohort and 77% (33/43) of the control cohort had positive C. acnes cultures (p=.34). Following application of antiseptic solution, there were no differences in positive C. acnes culture rates between the experimental and control cohorts in the epidermal (30% vs. 28%, p=1.00) or dermal (40% vs. 42%, p=1.00) cultures. No differences in the rates of C. acnes eradication from preantiseptic to postantiseptic application occurred for epidermal (p=1.00) or dermal (p=1.00) skin layers. None of the factors were associated with positive C. acnes epidermal cultures on multivariable logistic regression analysis (p>.05).

Conclusions

While there is potential for H2O2 to reduce the positive culture rate of C. acnes in cervical spine patients, no difference was seen when compared to standard surgical skin preparation.

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial

BACKGROUND

The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up.

METHODS

This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up.

RESULTS

Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168).

CONCLUSION

The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection.

LEVEL OF EVIDENCE

III.

Effects of antiseptic irrigation solutions on osseointegration in a cementless tibial implantation mouse model

Despite the success of standard antiseptic irrigation solutions in reducing periprosthetic joint infection (PJI) rates, there is still a need for more effective solutions. Synergistic use of povidone-iodine (PI) and hydrogen peroxide (H2O2) has shown promising results; however, the optimal solution concentration balancing bactericidal activity and osseointegration remains unknown. This study aims to evaluate the impact of these antiseptic irrigation solutions on osseointegration and the bone-implant interface strength in vivo. Forty C57BL/6 mice underwent bilateral tibial implantation surgery and were randomly allocated into three groups receiving 0.3% PI, 10% PI mixed with 3% H2O2, or saline as irrigation solutions intraoperatively. Assessments were performed on postoperative Days 1 and 28, including plain radiographs, microcomputed tomography (microCT) evaluation, histological analysis, immunohistochemistry, and biomechanical pull-out testing. No wound complications were observed. MicroCT scans revealed no differences in peri-implant trabecular bone parameters. Biomechanical pull-out testing showed no differences in the bone-implant interface strength across groups. Histological analysis indicated no differences in bone and bone marrow percentage areas among treatment groups. Immunohistochemical analysis demonstrated no differences among groups in peri-implant osteocalcin, osterix, or endomucin-positive cells. In conclusion, using either antiseptic irrigation solution showed no differences in osseointegration parameters compared to the control group, demonstrating safety and the absence of toxicity. CLINICAL RELEVANCE: Dilute 0.3% povidone-iodine and a 1:1 combination of 10% povidone-iodine mixed with 3% hydrogen peroxide can be safely used during primary and revision total joint arthroplasty without compromising osseointegration or causing wound complications.

Does hydrogen peroxide application to the dermis following surgical incision affect Cutibacterium acnes cultures in total shoulder arthroplasty in male patients? A randomized controlled trial

BACKGROUND

Periprosthetic joint infections occur in 1%-4% of primary total shoulder arthroplasties (TSAs). Cutibacterium acnes is the most commonly implicated organism and has been shown to persist in the dermis despite use of preoperative antibiotics and standard skin preparations. Studies have shown decreased rates of cultures positive for C acnes with use of preoperative benzoyl peroxide or hydrogen peroxide (H2O2), but even with this positive deep cultures remain common. We sought to determine whether an additional application of H2O2 directly to the dermis following skin incision would further decrease deep culture positivity rates.

METHODS

We performed a randomized controlled trial comparing tissue culture results in primary TSA in patients who received a standard skin preparation with H2O2, ethanol, and ChloraPrep (CareFusion, Leawood, KS, USA) vs. an additional application of H2O2 to the dermis immediately after skin incision. Given the sexual dimorphism seen in the shoulder microbiome regarding C acnes colonization rates, only male patients were included. Bivariable and multivariable analyses were performed to compare rates of positive cultures based on demographic and surgical factors.

RESULTS

Dermal cultures were found to be positive for C acnes at similar rates between the experimental and control cohorts for the initial (22% vs. 28%, P = .600) and final (61% vs. 50%, P > .999) dermal swabs. On bivariable analysis, the rate of positive deep cultures for C acnes was lower in the experimental group, but this difference was not statistically significant (28% vs. 44%, P = .130). However, patients who underwent anatomic TSA were found to have a significantly greater rate of deep cultures positive for C acnes (57% vs. 28%, P = .048); when controlling for this on multivariable analysis, the experimental cohort was found to be associated with significantly lower odds of having positive deep cultures (odds ratio, 0.37 [95% confidence interval, 0.16-0.90], P = .023). There were no wound complications in either cohort.

CONCLUSIONS

An additional H2O2 application directly to the dermis following skin incision resulted in a small but statistically significant decrease in the odds of having deep cultures positive for C acnes without any obvious adverse effects on wound healing. Given its cost-effectiveness, use of a post-incisional dermal decontamination protocol may be considered as an adjuvant to preoperative use of benzoyl peroxide or H2O2 to decrease C acnes contamination.

Effect of making skin incision with electrocautery on positive Cutibacterium acnes culture rates in shoulder arthroplasty: a prospective randomized clinical trial

BACKGROUND

Cutibacterium acnes remains the most commonly detected organism in shoulder arthroplasty. C acnes infection is thought to occur during shoulder arthroplasty through contamination of the surgical field with C acnes from the incised dermis. The purpose of this study was to examine whether using electrocautery for making skin incisions would decrease C acnes culture rates at the incised dermis compared to using scalpels during shoulder arthroplasty.

METHODS

Patients undergoing primary shoulder arthroplasty were randomized into 2 groups, electrocautery vs. scalpel incision group. All patients received a standard preoperative antiseptic preparation including chlorhexidine gluconate showers, intravenous antibiotic administration, and topical application of hydrogen peroxide, povidone iodine, isopropyl alcohol, and DuraPrep. Cultures were obtained from the incised dermal edge immediately after skin incision and later from surgeon's gloves and forceps immediately prior to humeral component implantation. The primary outcome was positive C acnes culture rates compared between the groups.

RESULTS

A total of 64 patients (32 in each group) were enrolled. There were 24 males in each group. Regarding dermis cultures, 10 patients (31%) in the scalpel group were positive with 8 of them positive for C acnes, whereas no patients in the electrocautery group were positive (P < .001). Regarding glove cultures, the electrocautery group had 8 patients positive C acnes, while the scalpel group had 8 (P = .777). Regarding forceps cultures, the electrocautery group had 4 patients positive for C acnes, and the scalpel group had 6 (P = .491). All positive cultures were exclusively from male patients. There were no wound complications or infection in the electrocautery group while the scalpel group had 1 acute postoperative infection.

CONCLUSIONS

Making skin incisions using electrocautery resulted in 0 C acnes culture at the incised dermis, suggesting its potential effect against C acnes. However, despite this initial antibacterial effect, C acnes still appeared on surgeon's gloves and forceps during surgery of male patients. All positive cultures were from male patients, suggesting that the source of C acnes was specifically related to the male body. While the study hypothesis was supported by the results, the present study also raises new questions and calls for further research.

[Effectiveness of one-stage total knee arthroplasty in treatment of advanced active knee tuberculosis]

Objective

To investigate the effectiveness of one-stage total knee arthroplasty (TKA) in the treatment of advanced active knee tuberculosis.

Methods

The clinical data of 38 patients with advanced active knee tuberculosis who received one-stage TKA between January 2011 and December 2020 were retrospectively analyzed. There were 20 males and 18 females. The age ranged from 20 to 84 years, with an average of 52.8 years. The body mass index ranged from 17 to 36 kg/m 2, with an average of 23.05 kg/m 2. The preoperative C reactive protein (CRP) was (23.49±4.72) mg/L, erythrocyte sedimentation rate (ESR) was (45.95±8.82) mm/1 h. The Hospital for Special Surgery (HSS) score was 48.8±9.1. During the operation, the infected lesions of the knee joint were completely removed, and the operative area was repeatedly soaked with 3% hydrogen peroxide solution and 0.5% povidone iodine solution. The intraoperative pathological examination confirmed the tuberculosis of the knee joint, and systemic anti-tuberculosis treatment was performed. The operation time, postoperative hospitalization stay, postoperative anti-tuberculosis chemotherapy time, and complications were recorded. CRP and ESR were recorded and compared before and after operation. Anteroposterior and lateral X-ray films of the knee joint were taken to evaluate whether the prosthesis had signs of loosening and sinking, and to determine whether there was recurrence of tuberculosis. The knee joint function was evaluated by HSS score. With treatment failure due to any reason as the end event, the survival time of prosthesis was analyzed by Kaplan-Meier survival curve.

Results

All operations were successfully completed without fracture, vascular and nerve injury, deep vein thrombosis, and other complications. All incisions healed by first intention after operation. The operation time ranged from 80 to 135 minutes, with an average of 102.76 minutes; postoperative hospitalization stay was 5-16 days, with an average of 9.7 days; the duration of postoperative anti-tuberculosis chemotherapy ranged from 1 to 18 months, and the median duration was 12 months. All 38 cases were followed up 3-133 months (mean, 63.7 months). At last follow-up, CRP was (4.88±1.24) mg/L and ESR was (13.00±2.97) mm/1 h, both of which were significantly lower than those before operation ( t=20.647, P<0.001; t=20.886, P<0.001). During the follow-up, 3 patients (7.89%) had tuberculosis recurrence. Two patients had tuberculosis recurrence due to withdrawal of anti-tuberculosis chemotherapy at 1 and 2 months after operation, respectively. One patient was cured after debridement, preservation of prosthesis and anti-tuberculosis chemotherapy for 12 months, and 1 patient was cured after oral administration of anti-tuberculosis drugs for 12 months. Another 1 patient had recurrent tuberculosis and mixed infection ( Corynebacterium gehreni) at 2 months after operation, and the infection was not controlled after debridement, and finally the thigh was amputated. Except for the patients with recurrent infection, no complications such as prosthesis loosening, periprosthetic fracture, and periprosthetic infection were found. At last follow-up, the HSS score of the knee joint was 86.8±4.8, and the knee joint function significantly improved when compared with that before operation ( t=-31.198, P<0.001). Prosthesis survival time was (122.57±5.77) months [95% CI (111.25, 133.88) months], and the 10-year survival rate was 92.1%.

Conclusion

One-stage TKA combined with postoperative antituberculous chemotherapy in the treatment of advanced active knee tuberculosis can achieve satisfactory infection control and joint function.

Intraoperative Intra-articular Antibiotic Injection Reduces Infection in Shoulder Arthroplasty

Deep infection is a debilitating complication after shoulder arthroplasty. The authors hypothesized that an intra-articular, intraoperative injection of antibiotics would result in a lower infection rate compared with intravenous antibiotics alone. Before 2007, 164 patients (group A) did not receive intra-articular antibiotics. From 2007 to 2018, 1324 patients (group B) received intra-articular antibiotics. Patients received intra-articular gentamicin at the end of surgery with the addition of 1 g of cefazolin in January 2014. Records were retrospectively reviewed for comorbidities, type of surgery, and infection. The cohort that received intra-articular antibiotics was compared with the cohort that did not to determine the effect of prophylactic intra-articular antibiotic administration in preventing infection. There was 1 deep infection in the antibiotic group compared with 5 in the non-antibiotic group (P<.001). Superficial infections developed in 2 cases of patients treated with antibiotics; there were no superficial infections in patients treated without antibiotics (P=.62). One previous study evaluated intra-articular injection of antibiotics for shoulder arthroplasty and found significantly lower rates of infection with the injection of intra-articular gentamicin. In this retrospective follow-up study, the injection of intra-articular gentamicin or gentamicin and cefazolin effectively decreased rates of postoperative infection. At mean follow-up of 399 days, intra-articular antibiotics at the time of surgery resulted in significantly fewer deep infections. Given the minimal risk of adverse events and minimal cost, this is a valid method of reducing infections in total shoulder arthroplasty. [Orthopedics. 2023;46(5):310-314.].

Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty.

RECENT FINDINGS

The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Extended skin cleaning on the shoulder with chlorhexidine reduces the cutaneous bacterial load but fails to decrease suture contamination in patients undergoing arthroscopy rotator cuff repair

BACKGROUND

It remains unclear whether preoperative skin cleaning of the chin, neck, and chest with chlorhexidine soap can reduce suture contamination by Cutibacterium acnes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included patients who underwent primary arthroscopic rotator cuff repair. Exclusion criteria included age <18 years, previous shoulder surgery, history of shoulder infection, and allergy to chlorhexidine. Patients were randomized into 3 groups. Patients in the control group cleaned their skin with soap and water, as usual. Patients in the shoulder group cleaned their shoulders with chlorhexidine soap 3 days before surgery, whereas patients in the extended shoulder group additionally cleaned their chest, back, neck, and face with chlorhexidine soap. On the day of surgery, skin swab samples were obtained from the shoulder after surgical draping. After rotator cuff repair, sutures were cut from the anchor ends. Both traditional culture methods and polymerase chain reaction (PCR) were used.

RESULTS

Ninety patients were enrolled (32 in the control group, 29 in the shoulder group, and 29 in the extended shoulder group) in the present study. The culture-positive rate from the posterior shoulder skin samples in the extended shoulder group (17.2%) was significantly lower than that in the control (40.6%) and shoulder (48.3%) groups (P = .036), whereas the culture-positive rates were not different among the 3 groups in other skin samples as well as the suture samples. The detection rates of C acnes in suture samples were 12.5%, 13.8%, and 17.2% in the control, shoulder, and extended shoulder groups, respectively (P = .603).

CONCLUSION

Extensive skin cleaning of the shoulder region with chlorhexidine helps reduce the shoulder cutaneous bacterial load, but the detection of C acnes suture contamination in patients undergoing arthroscopic rotator cuff repair remained untouched regardless of the use of chlorhexidine soap in skin cleaning on the preoperative days.

Non-Thermal Plasma Decontamination Using a Multi-Hollow Surface Dielectric Barrier Discharge: Impact of Food Matrix Composition on Bactericidal Efficacy

The non-thermal plasma (NTP) treatment of food products as an alternative for thermal processing has been investigated over the last few years. This quasi-neutral gas contains a wide variety of reactive oxygen and nitrogen species (RONS), which could be lethal for bacterial cells present in the product. However, apart from only targeting bacteria, the RONS will also interact with components present in the food matrix. Therefore, these food components will protect the microorganisms, and the NTP treatment efficiency will decrease. This effect was investigated by supplementing a plain agar medium with various representative food matrix components. After inoculation with Escherichia coli O157:H7 (STEC) MB3885, the plates were treated for 30 s by a multi-hollow surface dielectric barrier discharge (MSDBD) generated in either dry air or air at 75% humidity, at constant power (25.7 ± 1.7 W). Subsequently, the survival of the cells was quantified. It has been found that the addition of casein hydrolysate (7.1 ± 0.2 m%), starch (2.0 m%), or soybean oil (4.6 m%) decreased the inactivation effect significantly. Food products containing these biomolecules might therefore need a more severe NTP treatment. Additionally, with increasing humidity of the plasma input gas, ozone levels decreased, and the bactericidal effect was generally less pronounced.

Evaluation of the effectiveness of skin preparation methods for the reduction of Cutibacterium acnes (formerly Propionibacterium acnes) in shoulder surgery: a systematic review

Background

Cutibacterium acnes (C. acnes) is the most common pathogen responsible for post-operative shoulder infections. The purpose of this study was to evaluate the effectiveness of skin preparation methods against C. acnes in shoulder surgery.

Methods

A systematic review was conducted evaluating the effectiveness of skin preparation methods in the reduction of C. acnes in patients undergoing shoulder surgery. Outcomes were assessed based on the effectiveness of the method used; side effects and cost were also analysed.

Results

Of the 19 included studies, 9 evaluated pre-surgical home treatments: 8 assessed benzoyl peroxide (BPO) and 6 concluded it is effective in reducing C. acnes. Nine studies assessed surgical skin preparation and concluded that Chlorhexidine gluconate (CHG) was not effective; in contrast hydrogen peroxide reduced C. acnes. Finally, one study evaluated an aseptic protocol using CHG and concluded that it was not effective.

Conclusions

It was demonstrated that BPO as home treatment is effective in reducing C. acnes load on skin; it rarely causes side effects and is also cost-effective. This study highlights non-effectiveness of CHG. There was some evidence that the addition of hydrogen peroxide could have a positive effect in the reduction of C. acnes skin load; however, more studies are required.

Effect of Aqueous Extracts of Quercus resinosa on the Mechanical Behavior of Bigels

Quercus resinosa leaves are rich in polyphenol compounds, however, they are unstable to several chemical and physical factors that limit their activity. Several methods have been developed to solve such problems, among which bigels can be mentioned and obtained using hydrogels and oleogels. The mechanical characterization of this type of materials is by using rheological methods. Although the use of these methods is well documented, the Carreau-Yasuda model has been little used to evaluate the effect of polyphenols on the mechanical behavior of bigels. Therefore, bigels were obtained from hydrogels (guar gum/xanthan gum, 0.5/0.5% w/v) and oleogels (sesame oil/sorbitan monostearate 10% w/w). Micrographs, linear viscoelasticity range, frequency sweep, and single shear tests were performed. The data were analyzed using ANOVA and Tukey test (p < 0.05); micrographs showed linear relationship between polyphenols concentration and droplet size. Liquid fraction of bigels showed a pseudoplastic behavior, while the parameters of Carreau-Yasuda model showed that the highest value of the complex viscosity at zero shear was at the lowest concentration of extract; the relaxation time presented the lowest value at higher concentrations of extracts. These results indicate that the presence of polyphenols modifyes the mechanical behavior of bigels.

Techniques for Decreasing Bacterial Load for Open Shoulder Surgery

»

Benzoyl peroxide (BPO) 5% has been shown to reduce Cutibacterium acnes load on the skin. BPO 5% with miconazole nitrate (MN) 2% may be beneficial, whereas BPO 5% with clindamycin cream 1% to 1.2% does not seem to have additive effects when compared with BPO 5% alone. Chlorhexidine gluconate solutions reduce the total bacterial load on the skin, but do not seem to have a significant effect on C. acnes.

»

ChloraPrep seems to be the best surgical skin preparation to decrease overall positive skin cultures. Preincisional hydrogen peroxide 3% application has been shown to be a cost-effective practice to inhibit growth of C. acnes. Vancomycin powder before deltopectoral interval closure has antimicrobial effects against C. acnes and is a cost-effective practice. Finally, Bactisure surgical lavage is protective against the formation of biofilms.

»

IV cefazolin has been shown to be more effective for shoulder arthroplasty infection prophylaxis than antibiotic alternatives such as vancomycin. Thus, patients with a questionable history of penicillin allergy should undergo additional testing.

»

For shoulder surgery infection prophylaxis, we recommend the use of BPO 5% cream for 5 days preoperatively with chlorhexidine wipes the night before and the morning of surgery. IV cefazolin should be administered perioperatively, and patients with a questionable history of penicillin allergy should be tested. Surgeons should consider preincisional application of hydrogen peroxide 3% for 5 minutes, followed by standard ChloraPrep preparation. Normal saline should be used for preclosure lavage. Finally, application of vancomycin powder deep to the deltopectoral interval closure should be considered.

Irrigation Solutions and Antibiotic Powders: Should I Use Them in Primary and Revision Total Joint Arthroplasty?

BACKGROUND

The prevention and treatment of periprosthetic joint infection is of utmost importance to orthopedic surgeons. Irrigation solutions have become a popular additive to the prevention and treatment armamentarium.

METHODS

This symposium summarizes the mechanism of action, basic science, and clinical research to date on the use of irrigation solutions. The four most commonly used irrigation solutions, povidone iodine, chlorhexidine, hydrogen peroxide, and acetic acid, are discussed. In addition, the role of antibiotic powers is reviewed.

RESULTS

Each solution has its risks and benefits that must be weighed by the surgeon. There is no clear irrigation solution that is superior. The role of additive antibiotic powder (vancomycin) remains controversial.

CONCLUSION

More rigorous prospective clinical trials are needed to determine the optimal irrigation solution for the prevention and treatment of periprosthetic joint infection.

Synergistically active piezoelectrical H2O2 production composite film achieved from catalytically inert PVDF-HFP matrix and SiO2 fillers

Local and decentralized H 2 O 2 production via piezoelectrical process promise smart biological utilization as well as environmental benefits. However, stable, bio/environmental- safe, and easily applied H 2 O 2 generation materials are still lacking. Here we report a novel flexible H 2 O 2 generation polymeric film composed of catalytically inert PVDF-HFP (Poly(vinylidene fluoride-co-hexafluoropropylene)) matrix and SiO 2 nanoparticle fillers. The film is bio-/environmentally benign at resting states, but effectively produces H 2 O 2 upon ultrasonic motivation at a production rate of 492 μmol [[EQUATION]] in one hour. Experimental and simulation methods in combination indicate that the effective H 2 O 2 generation capabilities stem from the synergistic existence of piezoelectrical fields and the air-liquid-solid three-phase regions around the porous film. The chemical conversions are motivated by the adsorbed charges. The silicon hydroxyl groups properly stabilize the *OOH intermediate and facilitate the chemical conversions of 2e - ORR of ambient O 2 . We expect the report to inspire H 2 O 2 piezoelectrical generation materials and promote the novel production strategies of H 2 O 2 as well as piezoelectrical functional materials.

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BACKGROUND

Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.

METHODS

A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.

RESULTS

Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.

CONCLUSION

Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.

The management of the shoulder skin microbiome (Cutibacterium acnes) in the context of shoulder surgery: a review of the current literature

BACKGROUND

This review aims to establish current knowledge of the shoulder skin microbiome and how to manage the bacteria that reside within it.

METHODS

A review was undertaken of the current literature through OvidSP. All abstracts were reviewed by three independent researchers.

RESULTS

Thirty-five studies met the inclusion criteria. With forward referencing an additional 14 were included. None commented on organisms specific to the shoulder microbiome other than Cutibacterium acnes. Therefore, this review is focussed on the current knowledge of C. acnes.

DISCUSSION

C. acnes is a skin commensal within the pilo-sebaceous glands reported to be the primary pathogen in up to 86% of shoulder joint infections. Pre-operative culture of unprepared skin can be indicative of underlying joint infection in shoulder arthroplasty revision. Intra-articular biopsies may have a high false positive due to skin contamination. Correlating the number of positive samples and certain associated signs can give a greater than 90% probability of a true infection. Standard surgical skin preparation, peri-surgical intravenous antibiotics and oral pre-operative antibiotics do not reduce bacterial load within the skin. However, topical benzoyl peroxide and clindamycin have both demonstrated significantly reduced bacteria load. Phylogenetically there are six main types. Patients may have more than one phenotype present during infection.

Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial

INTRODUCTION

Prosthetic joint infections (PJIs) following shoulder arthroplasty are a major source of morbidity and are most commonly caused by Cutibacterium acnes, a bacteria found concentrated in the dermis. Skin preparation using hydrogen peroxide has been shown to reduce positive cultures; however, direct application to the dermis has not been investigated. The purpose of this study is to determine whether the application of hydrogen peroxide to the dermis affects the incidence of positive C acnes cultures.

METHODS

A prospective, randomized controlled trial of patients undergoing primary shoulder arthroplasty by a single fellowship-trained surgeon was performed between February and November 2020. Enrolled patients were randomized to either receive standard skin preparation and antibiotic prophylaxis with or without an additional application of hydrogen peroxide to the dermis following incision. Culture samples were taken from the skin, dermis, glenohumeral joint, and air. Laboratory personnel and patients were blinded to randomization, and all cultures were held for 14 days. Culture positivity rate along with culture site, day of culture positivity, and bacterial abundance of positive cultures were analyzed. Stratified analysis by gender and age of ≤69 years was also performed.

RESULTS

Sixty patients undergoing primary arthroplasty were randomized. The group receiving hydrogen peroxide (n =30) and the control group (n = 30) were similar in age (71.1 ± 7.1 vs. 73.4 ± 9.8; P = .30), body mass index (29.4 ± 5.7 vs. 28.5 ± 6.0; P = .57), gender (P = .64), hand dominance (P = .65), and surgery type (P = .90). The overall rate of at least 1 positive culture was 18%. All positive cultures were C acnes. The positive culture rate in the hydrogen peroxide (20%) and control group were similar (16%; P > .99). There were no positive glenohumeral joint cultures and no wound complications. There was no significance difference in the culture site, day of culture positivity, and bacterial abundance. Stratification analysis by gender and age also demonstrated similar rates of C acnes between study groups.

CONCLUSION

Standard skin preparation and antibiotic prophylaxis results in an overall low rate of skin and dermis culture positivity. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C acnes cultures during shoulder arthroplasty and did not increase wound complications.

Is there value in the routine practice of discarding the incision scalpel from the surgical field to prevent deep wound contamination with Cutibacterium acnes?

BACKGROUND

Cutibacterium acnes is found in skin flora of the shoulder and is the most common microbe identified in periprosthetic shoulder infections. The purpose of this study is to determine if there is C acnes present on the incision scalpel in patients undergoing shoulder arthroplasty despite extensive skin preparation techniques to prevent wound contamination.

METHODS

The authors collected a consecutive case series of patients meeting inclusion criteria. Patients were included if they underwent either primary or revision shoulder arthroplasty at the tertiary care hospital with the senior author during the study period. Culture swab samples, testing for presence of C acnes, were collected from 17 consecutive patients who underwent shoulder arthroplasty with a single fellowship-trained surgeon between November 2019 and March 2020. Culture reports were recorded as "positive" or "negative" after 21 days. Institutional review board approval of the study protocol was obtained. The null hypothesis was that there would be no cases with knife blades "culture positive" for C acnes.

RESULTS

17 patients were identified and fit inclusion criteria. There were 12 men (mean age 64.3 years, range 48-79 years) and 5 women (mean age 69.8 years, range 59-79 years). Two patients (11.8%) were found to have C acnes growth on the skin knife. Both patients were male and older than 70 years undergoing primary reverse shoulder arthroplasty with no history of previous shoulder infections.

CONCLUSION

The presence of C acnes on the skin blade in 2 patients validates concerns that there is C acnes present in dermal tissue despite extensive attention to eradication of these microbes. There was a high rate of C acnes contamination on scalpel blades used for initial skin incisions and the authors conclude that there is value in discarding these blades from the surgical field.

Hydrogen Peroxide Does Not Significantly Reduce Cutibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate the efficacy of application of the 3% hydrogen peroxide (HP)-soaked gauze as an addition to the standard preoperative sterile skin preparation for Cutibacterium acnes suture contamination in arthroscopic rotator cuff repairs.

METHODS

A prospective randomized study was undertaken to evaluate 151 consecutive patients undergoing arthroscopic rotator cuff repair. Each shoulder was prepared with 1 of the 2 randomly selected protocols: chlorhexidine alcohol (1% chlorhexidine gluconate in 70% isopropyl alcohol)(control group) and chlorhexidine alcohol with 3% HP (HP-treated group). In the HP-treated group, the 3% HP-soaked gauze was applied over the shoulder for 5 minutes before the application of the chlorhexidine-alcohol. The first cut-tails of the anchor suture after cuff fixation were submitted to aerobic and anaerobic cultures. Patients were clinically evaluated for infection 10 days, 28 days, 3 months, 6 months, and 12 months after surgery.

RESULTS

The rate of C acnes-positive cultures was 13.0% (10 of 77 cases) in the control group and 6.8% (5 of 74 cases) in the HP-treated group. The HP-treated group showed a trend of lower C acnes-positive culture rate, which did not reach statistical significance (relative risk, 0.52; 95% confidence interval, 0.19 and 1.45; number needed to treat, 16.1; P = .20). One case of coagulase-negative Staphylococcus (Staphylococcus intermedius) was isolated in the HP-treated group (1 of 74 cases, 1.3%). No other bacteria were isolated. No infections occurred in any of the patients treated in this study during the minimum 3-month follow-up period. One patient in the HP-treated group complained of skin irritation.

CONCLUSIONS

The use of a 3% HP-soaked gauze as an addition to the standard preoperative sterile skin preparation for arthroscopic rotator cuff repairs showed only a marginal effect (statistically insignificant) in reducing the C acnes suture contamination rate in the arthroscopic rotator cuff repair patients.

LEVEL OF EVIDENCE

I, prospective, randomized trial.

Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review

PURPOSE OF REVIEW

Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years.

RECENT FINDINGS

The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.

Correlation between physicochemical properties of superparamagnetic iron oxide nanoparticles and their reactivity with hydrogen peroxide

The present study focuses on the effects of the physicochemical properties of superparamagnetic PEG-modified, positively charged, and negatively charged iron oxide nanoparticles (SPIONs) on their reactivity with hydrogen peroxide. Our hypothesis was that the reactivity of SPIONs in this reaction would depend on their surface properties. The comparative study of the nanoparticles with DLS and TEM revealed the average sizes of PEG-modified, positively charged, and negatively charged SPIONs. We observed that the reactivity of negatively charged SPIONs with hydrogen peroxide was less than that of positively charged SPIONs and that of these second nanoparticles was less than that of PEG-modified SPIONs. This difference in the reactivity of these SPIONs with hydrogen peroxide was attributed to the presence of carboxyl or amine groups on their surface. However, the values of the rate constants of the reactions of PEG-modified, positively charged, and negatively charged SPIONs with hydrogen peroxide showed that the reaction of negatively charged SPIONs with hydrogen peroxide was more rapid than that of PEG-modified SPIONs and the reaction of these second SPIONs with hydrogen peroxide was more rapid than that of positively charged SPIONs. The surface study of the SPIONs using XPS showed that the high-resolution spectra of these nanoparticles changed after reaction with hydrogen peroxide, which indicates their surface modifications. These investigations can help develop more appropriate nanoparticles with controlled physicochemical properties.

Induction heating for eradicating Staphylococcus epidermidis from biofilm

Aims

Induction heating is a noninvasive, nonantibiotic treatment modality that can potentially be used to cause thermal damage to the bacterial biofilm on the metal implant surface. The purpose of this study was to determine the effectiveness of induction heating on killing Staphylococcus epidermidis from biofilm and to determine the possible synergistic effect of induction heating and antibiotics.

Methods

S. epidermidis biofilms were grown on titanium alloy (Ti6Al4V) coupons for 24 hours (young biofilm) and seven days (mature biofilm). These coupons with biofilm were heated to temperatures of 50°C, 55°C, 60°C, 65°C, 70°C, 80°C, and 90°C for 3.5 minutes and subsequently exposed to vancomycin and rifampicin at clinically relevant concentrations.

Results

For the young biofilm, total eradication was observed at 65°C or higher for 3.5 minutes followed by 24 hours of vancomycin 10 mg/l and rifampicin 1 mg/l. For the mature biofilm, total eradication was observed at 60°C for 3.5 minutes followed by 24 hours of vancomycin 10 mg/l and rifampicin 1 mg/l. Total eradication was also observed at 60°C for 3.5 minutes followed by 24 hours of vancomycin 1 mg/l and rifampicin 1 mg/l followed by another thermal shock of 60°C for 3.5 minutes (two thermal shocks).

Conclusion

Induction heating of Ti6Al4V coupons is effective in reducing bacterial load in vitro for S. epidermidis biofilms. Induction heating and antibiotics have a synergistic effect resulting in total eradication of the biofilm at 60°C or higher for clinically relevant concentrations of vancomycin and rifampicin.

Cite this article:Bone Joint Res. 2020;9(4):192–199.

Response of Potato (Solanum Tuberosum L.) Plants to Spraying by Hydrogen Peroxide

The biocidal properties of hydrogen peroxide (H2O2) could be used in plant protection. However, the effects of H2O2 foliar spraying on the performance of the potato photosynthetic apparatus are still unclear. A pot experiment was conducted to investigate the effect of foliar spraying, which was done twice, with various H2O2 concentrations (1, 3, 6, 12, and 18%) on the potato photosynthetic apparatus efficiency and antioxidant capacity. The measurements were taken four times: on the first and seventh day after each application. Foliar spraying with 1% H2O2 concentration was the most stimulating for the course of physiological processes in leaves. Further increased doses of H2O2 enhanced stress in plants which is manifested by a decrease in pigment levels, photosynthetic attributes, antioxidant capacity in leaves, and fresh mass above-ground parts of potato plants. The intensive effect of spraying was particularly observed on the first day after application, while later, the activity of the photosynthetic apparatus and antioxidant capacity increased. The study provides information that foliar spraying with 1% H2O2 can be taken into account in further research on the development of a potato plant protection methods.

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial

BACKGROUND

Hydrogen peroxide is an inexpensive and effective antimicrobial agent that can be implemented in surgical skin preparations. The purpose of this study was to evaluate the decolonization effect of Cutibacterium acnes when adding hydrogen peroxide to a standard sterile preparation for shoulder surgery.

METHODS

This was a single-institution, prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy (April 2018 and May 2019). Patients were randomized to a standard skin preparation vs. an additional sterile preparation with 3% hydrogen peroxide. After draping, a 3-mm punch biopsy was obtained from the posterior arthroscopic portal site of all patients. Anaerobic and aerobic culture substrates were used and held for 13 days.

RESULTS

Seventy male patients were randomized into the hydrogen peroxide group and 70 male patients were in the traditional group. Twelve (17.1%) patients in the hydrogen peroxide group and 24 (34.2%) patients in the traditional group had positive cultures for C acnes (P = .033). Cultures were positive at a mean of 4.5 days (range 3-7) in the hydrogen peroxide group and 4.1 days (range 3-8) in the traditional group (P = .48). There were no cases of skin reaction to the surgical preparation in either group.

DISCUSSION

The results of this study suggest that the addition of hydrogen peroxide to preoperative surgical site preparation can reduce the C acnes culture rate. Hydrogen peroxide is inexpensive and can be added to the typical skin preparation used prior to shoulder surgery without substantial risk of skin reactions.

Advances and Update on Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Reverse total shoulder arthroplasty (RTSA) is a procedure that has been increasingly utilized since its inception over 20 years ago. The purpose of this review is to present the most up to date practice and advances to the RTSA literature from the last 5 years.

RECENT FINDINGS

Recent literature on RTSA has focused on identifying complications, maximizing outcomes, and determining its cost-effectiveness. RTSA has become a valuable tool in the treatment of various shoulder pathologies from fractures to massive-irreparable rotator cuff tears. Maximizing outcomes, proper patient counseling, and limiting complications are vital to a successful procedure. RTSA can be a difficult procedure; however, when utilized appropriately, it can be an invaluable tool in the orthopedic surgeon's armament. Recent evidence suggests, more and more, that RTSA not only provides value to the patient, but it is also cost-effective.