Hydrogen Peroxide Wound Irrigation in Orthopaedic Surgery

Reactive oxygen species, electrode potential and pH affect CoCrMo alloy corrosion and semiconducting behavior in simulated inflammatory environments

Crevice corrosion in modular taper junctions of hip or knee replacements using cobalt-chrome-molybdenum (CoCrMo) alloys remains a clinical concern. Non-mechanically-driven corrosion has been less explored compared to mechanically assisted crevice corrosion. This study hypothesized that solution chemistry within crevices, inflammation, and cathodic electrode potential shifts during fretting result in low pH and generate reactive oxygen species (ROS), affecting oxide film behavior. This study investigated how resistance and capacitance of the CoCrMo oxide film (i.e., corrosion resistance) are modified in simulated in vivo crevice environments of modular taper junctions. Six solutions were evaluated (two pH levels: 1 and 7.4 and four hydrogen peroxide (H2O2) concentrations: 0, 0.001, 0.01 and 0.1 M). Rp versus voltage and Mott-Schottky plots were created from symmetry-based electrochemical impedance spectroscopy (sbEIS). At pH 1, the semiconductor transition to p-type occurs at more anodic potentials and higher flat band potentials were found. H2O2 decreased the flat band potential and slope in the Mott-Schottky plot. Higher H2O2 in pH 7.4 solution significantly modified the oxide film, leading to increased donor density (p = 0.0004) and a 150-fold reduction in Rp in the cathodic potential range at -1 V (p = 0.0005). The most unfavorable condition (0.1 M H2O2 pH 1) resulted in a 250-fold lower resistance compared to phosphate buffered saline (PBS) pH 7.4 at -1 V (p = 0.0013). This study highlights the corrosion susceptibility of CoCrMo under adverse chemical and potential conditions, identifying increased defects in the oxide film due to ROS, hydrogen ions and electrode potential. STATEMENT OF SIGNIFICANCE: Corrosion of cobalt chrome molybdenum alloy caused by direct chemical attack in the crevice region of hip replacements, such as modular taper junctions, remains a clinical concern. The junction environment contains adverse chemical compositions, including high acidity and reactive oxygen species (ROS) due to inflammatory responses against the corrosion products. We simulate inflammatory environments with different pH levels and hydrogen peroxide, representative of ROS. We employ electrochemical impedance spectroscopy and apply stepwise voltage over the range induced by tribocorrosion processes. We relate the effect of adverse chemical components on corrosion and semiconducting behavior of the oxide film using Mott-Schottky analysis. This study shows how pH and ROS concentration compromises the oxide film potentially leading to non-mechanically induced corrosion.

Oxide degradation precedes additively manufactured Ti-6Al-4V selective dissolution: An unsupervised machine learning correlation of impedance and dissolution compared to Ti-29Nb-21Zr

Additively manufactured (AM) Ti-6Al-4V devices are implanted with increasing frequency. While registry data report short-term success, a gap persists in our understanding of long-term AM Ti-6Al-4V corrosion behavior. Retrieval studies document β phase selective dissolution on conventionally manufactured Ti-6Al-4V devices. Researchers reproduce this damage in vitro by combining negative potentials (cathodic activation) and inflammatory simulating solutions (H2O2-phosphate buffered saline). In this study, we investigate the effects of these adverse electrochemical conditions on AM Ti-6Al-4V impedance and selective dissolution. We hypothesize that cathodic activation and H2O2 solution will degrade the oxide, promoting corrosion. First, we characterized AM Ti-6Al-4V samples before and after a 48 h -0.4 V hold in 0.1 M H2O2/phosphate buffered saline. Next, we acquired nearfield electrochemical impedance spectroscopy (EIS) data. Finally, we captured micrographs and EIS during dissolution. Throughout, we used AM Ti-29Nb-21Zr as a comparison. After 48 h, AM Ti-6Al-4V selectively dissolved. Ti-29Nb-21Zr visually corroded less. Structural changes at the AM Ti-6Al-4V oxide interface manifested as property changes to the impedance. After dissolution, the log-adjusted constant phase element (CPE) parameter, Q, significantly increased from -4.75 to -3.84 (Scm-2(s)α) (p = .000). The CPE exponent, α, significantly decreased from .90 to .84 (p = .000). Next, we documented a systematic decrease in oxide polarization resistance before pit nucleation and growth. Last, using k-means clustering, we established a structure-property relationship between impedance and the surface's dissolution state. These results suggest that AM Ti-6Al-4V may be susceptible to in vivo crevice corrosion within modular taper junctions.

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.

Impact of a Novel Antiseptic Lavage Solution on Acute Periprosthetic Joint Infection in Hip and Knee Arthroplasty

Background: Periprosthetic joint infection (PJI) represents a challenge following hip or knee arthroplasty, demanding immediate intervention to prevent implant failure and systemic issues. Bacterial biofilm development on orthopedic devices worsens PJI severity, resulting in recurrent hospitalizations and significant economic burdens. The objective of this retrospective cohort study is to evaluate the efficacy of this novel antiseptic solution, never previously evaluated in vivo, in managing early post-operative or acute hematogenous PJI following primary hip and knee joint replacements. Methods: The inclusion criteria consist of patients with total hip arthroplasty (THA) or knee arthroplasty diagnosed with acute PJI through preoperative and intraoperative investigations, in accordance with the MSIS ICM 2018 criteria. The minimum required follow-up was 12 months from the cessation of antibiotic therapy. This novel antiseptic lavage solution is composed of ethanol, acetic acid, sodium acetate, benzalkonium chloride and water. Data included demographic characteristics, diagnostic criteria, surgical techniques, post-operative treatment and follow-up outcomes. Results: A total of 39 patients treated with Debridement, Antibiotics Pearls and Retention of the Implant (DAPRI) procedures using this solution between May 2021 and April 2023 were analyzed. At a mean follow-up of 24.6 ± 6.4 months, infection recurrence-free survival rates were 87.2%, with no local allergic reactions or relevant systemic adverse effects detected. Persistent PJI necessitated two-stage revision surgery. Conclusions: This novel antiseptic lavage solution shows promise as an adjunctive tool in the treatment of PJI, demonstrating support in infection control while maintaining a favorable safety profile.

The stability of Staphylococcal bacteriophages with commonly used prosthetic joint infection lavage solutions

The aim of this study was to assess the viability of four Staphylococcal bacteriophages when exposed to different concentrations of commonly used lavage solutions in the surgical treatment of prosthetic joint infections (PJI). Four tailed Staphylococcal bacteriophages and six different lavage solutions (chlorhexidine 4%, hydrogen peroxide 3%, acetic acid 3%, povidone iodine 10%, sodium hypochlorite 0.5%, and Vashe solution) at 100%, 1%, and 0.01% concentrations were used in this experiment. In addition, the temporal impact of exposing bacteriophages to these lavage solutions was also evaluated at 5-min exposures and 24-h exposures. The results show that the titers of the four bacteriophages were statistically significantly decreased for all lavage solutions (100% and 1%) at 5-min exposures and 24-h exposures. However, with 0.01% concentrations of the lavage solutions, only acetic acid caused a statistically significant decrease in bacteriophage titers compared to normal saline control. Our findings suggest that tailed Staphylococcal bacteriophages do not remain stable in high concentrations of the most commonly used lavage solutions. However, at very dilute concentrations the bacteriophages do remain viable. This has important clinical ramifications in that it shows when using bacteriophage therapy for PJI it is critical to thoroughly wash out any lavage solutions before the introduction of therapeutic bacteriophages especially when acetic acid is used.

Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection

OBJECTIVE

Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients.

METHODS

We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months.

RESULTS

The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively.

CONCLUSION

Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.

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.

[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.

An antibiotic envelope to reduce infections in deep brain stimulation surgery

The therapeutic benefits of Deep Brain Stimulation (DBS) surgery in patients with movement disorderssuch as Parkinson's Diseaseare life-altering. Surgical site infections (SSI), however, can result in increasedhospitalisations, prolonged antibiotics and neurological sequelae. We performed aretrospective review to evaluate the effectiveness of an antibiotic envelope to reduce SSI in DBS surgeries.This study includedall DBS surgeries performed between August 2020 to May 2022 using a single-use, multifilament, antibiotic-coated mesh envelope wrapped around the DBS implantable pulse generator (IPG)(TYRX™ Absorbable Antibacterial Envelope,Medtronic Fridley, MN, USA). Standardised infection-prevention measures were applied and various patient-specific and surgery-specific factors were analysed.44 patients were analysed with 26 (59.1 %) primary implantations and 18 (40.9 %) revision surgeries.The median age was 65 years old with an average follow-up of 13.5 months (range 3-24 months). The mean Body Mass Indexwas 24.0 (range 16.7-35.6). 8 (18.2 %) patients had underlying diabetes mellitus. There were only 2 (4.5 %) SSIs reported with neither involvingthe subcutaneous IPG and antibiotic envelope. 1 superficial-incisional SSI (2.3 %) was from a prior retro-auricular abscess around a lead-wirerequiring antibiotics and subcutaneous implanttransposition. The other was a deep-incisional SSI (2.3 %) from repetitive trauma causingdelayed scalp wound dehiscence and lead-wire extrusion, requiring antibiotics and wound revision. Both subjects were discharged well with no implants removed. Theantibioticenvelope therefore appears to be a safe and well-tolerated adjunct that may reduce SSIs in DBS surgery. Further prospective work withlarger sample sizes in a multi-institution setting is required.

The effects of acute hydrogen peroxide exposure on respiratory cilia motility and viability

COVID-19 has seen the propagation of alternative remedies to treat respiratory disease, such as nebulization of hydrogen peroxide (H₂O₂). As H₂O₂ has known cytotoxicity, it was hypothesised that H₂O₂ inhalation would negatively impact respiratory cilia function. To test this hypothesis, mouse tracheal samples were incubated with different H₂O₂ concentrations (0.1-1%) then cilia motility, cilia generated flow, and cell death was assessed 0-120 min following H₂O₂ treatment. 0.1-0.2% H₂O₂ caused immediate depression of cilia motility and complete cessation of cilia generated flow. Higher H₂O₂ concentrations (≥0.5%) caused immediate complete cessation of cilia motility and cilia generated flow. Cilia motility and flow was restored 30 min after 0.1% H₂O₂ treatment. Cilia motility and flow remained depressed 120 min after 0.2-0.5% H₂O₂ treatment. No recovery was seen 120 min after treatment with ≥1% H₂O₂. Live/dead staining revealed that H₂O₂ treatment caused preferential cell death of ciliated respiratory epithelia over non-ciliated epithelia, with 1% H₂O₂ causing 35.3 ± 7.0% of the ciliated epithelia cells to die 120 min following initial treatment. This study shows that H₂O₂ treatment significantly impacts respiratory cilia motility and cilia generated flow, characterised by a significant impairment in cilia motility even at low concentrations, the complete cessation of cilia motility at higher doses, and a significant cytotoxic effect on ciliated respiratory epithelial cells by promoting cell death. While this data needs further study using in vivo models, it suggests that extreme care should be taken when considering treating respiratory diseases with nebulised H₂O₂.

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.

Antiseptic Irrigation Solutions Used in Total Joint Arthroplasty: A Critical Analysis Review

»

There are limited data that directly compare the efficacy of antiseptic irrigation solutions used for the prevention and treatment of periprosthetic joint infections in orthopaedic procedures; there is a notable lack of prospective data.

»

For prevention of periprosthetic joint infections, the strongest evidence supports the use of low-pressure povidone-iodine.

»

For the treatment of periprosthetic joint infections, delivering multiple solutions sequentially may be beneficial.

Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections

Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.

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.

Prevention and Treatment of Hardware-Related Infections in Deep Brain Stimulation Surgeries: A Retrospective and Historical Controlled Study

Background

Hardware-related infection in deep brain stimulation (DBS) is one of the most commonly reported complications frequently resulting in the removal of implantable pulse generator (IPG).

Objective

The aim of this study was to establish a useful strategy to better prevent and treat those infections and to improve the preservation rates of IPG.

Methods

We conducted a retrospective and historical controlled study of all adult patients (≥18 years old) who had undergone initial DBS implantation at a single center. All participants were enrolled in the control group (between June 2005 and June 2014) or intervention group (between July 2014 and May 2019) based on their surgery dates. We used the intraoperative irrigation with hydrogen dioxide solution in the intervention group. Based on the dates of diagnosis, patients with hardware-related infection after DBS were enrolled in group A (between June 2005 and June 2014) or group B (between July 2014 and May 2019). IPG-sparing algorithm (Isa) was applied for group B. The early-onset IPG infections of the control and intervention groups were evaluated. The IPG preservation rates in both groups A and B were statistically analyzed.

Results

Six cases of early IPG infection and subsequent IPG removal occurred in the control group, while none occurred after intraoperative usage of the hydrogen dioxide in the intervention group. IPG preservation rate of infected cases in group B was significantly higher than that in group A (70% vs.16%, p = 0.004).

Conclusion

The combined application of hydrogen dioxide solution and Isa seems to be an effective strategy to prevent IPG infection.

Chitosan-Based Hydrogel for the Dual Delivery of Antimicrobial Agents Against Bacterial Methicillin-Resistant Staphylococcus aureus Biofilm-Infected Wounds

Chronic wound infections caused by antibiotic-resistant bacteria have become a global health concern. This is attributed to the biofilm-forming ability of bacteria on wound surfaces, thus enabling their persistent growth. In most cases, it leads to morbidity and in severe cases mortality. Current conventional approaches used in the treatment of biofilm wounds are proving to be ineffective due to limitations such as the inability to penetrate the biofilm matrix; hence, biofilm-related wounds remain a challenge. Therefore, there is a need for more efficient alternate therapeutic interventions. Hydrogen peroxide (HP) is a known antibacterial/antibiofilm agent; however, prolonged delivery has been challenging due to its short half-life. In this study, we developed a hydrogel for the codelivery of HP and antimicrobial peptides (Ps) against bacteria, biofilms, and wound infection associated with biofilms. The hydrogel was prepared via the Michael addition technique, and the physiochemical properties were characterized. The safety, in vitro, and in vivo antibacterial/antibiofilm activity of the hydrogel was also investigated. Results showed that the hydrogel is biosafe. A greater antibacterial effect was observed with HP-loaded hydrogels (CS-HP; hydrogel loaded with HP and CS-HP-P; hydrogel loaded with HP and peptide) when compared to HP as seen in an approximately twofold and threefold decrease in minimum inhibitory concentration values against methicillin-resistant Staphylococcus aureus (MRSA) bacteria, respectively. Similarly, both the HP-releasing hydrogels showed enhanced antibiofilm activity in the in vivo study in mice models as seen in greater wound closure and enhanced wound healing in histomorphological analysis. Interestingly, the results revealed a synergistic antibacterial/antibiofilm effect between HP and P in both in vitro and in vivo studies. The successfully prepared HP-releasing hydrogels showed the potential to combat bacterial biofilm-related infections and enhance wound healing in mice models. These results suggest that the HP-releasing hydrogels may be a superior platform for eliminating bacterial biofilms without using antibiotics in the treatment of chronic MRSA wound infections, thus improving the quality of human health.

Hydrogen Peroxide: Its Use in an Extensive Acute Wound to Promote Wound Granulation and Infection Control - Is it Better Than Normal Saline?

Background: Hydrogen peroxide (H₂O₂) is used as a topical antiseptic in contaminated wounds caused by road traffic accidents. It kills bacteria by producing oxidation through local, nascent, free oxygen radicals. It also removes dirt from the wound due to its frothing action. H₂O₂ is synthesized by various cells as an active biochemical agent that affects cell biological behavior through complex chemical reactions. H₂O₂ has also been used as a wound cleaning agent, removing debris, preventing infection, and causing hemostasis due to its exothermic reaction with blood. Despite its widespread use, there is scanty literature on its use to promote granulation tissue formation. Objective: In the orthopaedics literature, studies on H₂O₂ use are very limited and its potential is underestimated. In the present study, we would like to report our protocol of use of H₂O₂ for its tremendous potential for stimulating granulation and early wound healing. Material and Methods: A total of 53 patients with large acute extensive lower limb contaminated wounds reported to the emergency department have been included with and without lower limb fracture. In group A (43 patients) wound management was done using 7% H₂O₂ and group B (10 patients) was treated by only saline dressing as a control group. Results: In the present study, daily dressing by 7% H₂O₂ solution and provide solution gives excellent results compared to the Saline group. Granulation tissue appeared much earlier with a mean SD 6.3 ± 6.8 days in the hydrogen peroxide group as compared to the Saline group where granulation tissue appeared in 9.3 ± 8.4 days. Conclusion: Spontaneous wound healing is a controlled balance between destructive and healing processes. It is mandatory to remove damaged tissue to promote healing by secondary intention and minimize infection. The dynamic effect of H₂O₂ promotes faster healing, stimulates granulation, and minimizes infection by oxidative stress.

Wound irrigation for preventing surgical site infections

Wound irrigation (i.e. washing out a wound before wound closure) aims to reduce the microbial burden by removing tissue debris, metabolic waste, and tissue exudate from the surgical field before site closure. Although it is a popular procedure in every day surgical practice, the lack of procedure standardization, leads to studies with high heterogeneity and often controversial results. Thus, there are studies that advocate its use, while others discourage its implementation in clinical practice to reduce the risk of surgical site infection. The present article reviews the current literature on wound irrigation for preventing surgical site infections. Several irrigants are presented. Chlorexidine is generally considered to be less effective than povidone-iodine, while antibiotics are not that common nowadays, as they require prolonged exposure with the target to act. Hydrogen peroxide has several potential complications, which eliminate its use. Any differences in the incidence of surgical site infections between different irrigants, especially between antibacterial and non-bacterial ones, should be viewed sceptically. More randomized controlled studies are needed to provide better quality of evidence regarding the irrigants' effectiveness and safety.

Dissociation of hydrogen peroxide in water and methanol through a biased molecular dynamics investigation

The two dissociation channels of HOOH, namely, HOOH and HOOH, in water and methanol are investigated using umbrella-sampling ab initio molecular dynamics. Our potential of mean force calculations reveals the HOOH dissociation to be more favorable in methanol with a free energy barrier of 7.56 kcal/mol, while the HOOH dissociation possesses a free energy barrier of 11.46 kcal/mol. In water, the HOOH dissociation channel is more favorable (8.25 kcal/mol), while the HOOH dissociation process requires a higher free energy (11.28 kcal/mol). Such reaction favorability can be explained by inspecting the formation of secondary radical species during the course of multiple hydrogen donating-accepting processes in each reaction channel. The radical species, that is, H₃ O^• (observed in water) and CH₃ OH₂ ^• (observed in methanol), are the first subordinate species upon the HOOH dissociation. For the HOOH dissociation channel in methanol, the secondary species such as water and formaldehyde can be observed, while the re-generation of HOOH in water can be spotted.

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.

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

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.

Role of hydrogen peroxide in intra-operative wound preparation based on an in vitro fibrin clot degradation model

Three per cent hydrogen peroxide (H₂O₂) is widely used to irrigate acute and chronic wounds in the surgical setting and clinical experience tells us that it is more effective at removing dried-on blood than normal saline alone. We hypothesise that this is due to the effect of H₂O₂ on fibrin clot architecture via fibrinolysis. We investigate the mechanisms and discuss the clinical implications using an in vitro model. Coagulation assays with normal saline (NaCl), 1% and 3% concentrations of H₂O₂ were performed to determine the effect on fibrin clot formation. These effects were confirmed by spectrophotometry. The effects of 1%, 3% and 10% H₂O₂ on the macroscopic and microscopic features of fibrin clots were assessed at set time intervals and compared to a NaCl control. Quantitative analysis of fibrin networks was undertaken to determine the fibre length, diameter, branch point density and pore size. Fibrin clots immersed in 1%, 3% and 10% H₂O₂ demonstrated volume losses of 0.09-0.25mm³/min, whereas those immersed in the normal saline gained in volume by 0.02±0.13 mm³/min. Quantitative analysis showed that H₂O₂ affects the structure of the fibrin clot in a concentration-dependent manner, with the increase in fibre length, diameter and consequently pore sizes. Our results support our hypothesis that the efficacy of H₂O₂ in cleaning blood from wounds is enhanced by its effects on fibrin clot architecture in a concentration- and time-dependent manner. The observed changes in fibre size and branch point density suggest that H₂O₂ is acting on the quaternary structure of the fibrin clot, most likely via its effect on cross-linking of the fibrin monomers and may therefore be of benefit for the removal of other fibrin-dependent structures such as wound slough.

Single-stage revision for the infected total knee arthroplasty : the Cardiff experience

Aims

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up.

Methods

A total of 84 patients, with a mean age of 68 years (36 to 92), underwent single-stage revision TKA for confirmed PJI at a single institution between 2006 and 2016. In all, 37 patients (44%) were treated for an infected primary TKA, while the majority presented with infected revisions: 31 had undergone one previous revision (36.9%) and 16 had multiple prior revisions (19.1%). Contraindications to single-stage exchange included systemic sepsis, extensive bone or soft-tissue loss, extensor mechanism failure, or if primary wound closure was unlikely to be achievable. Patients were not excluded for culture-negative PJI or the presence of a sinus.

Results

Overall, 76 patients (90.5%) were infection-free at a mean follow-up of seven years, with eight reinfections (9.5%). Culture-negative PJI was not associated with a higher reinfection rate (p = 0.343). However, there was a significantly higher rate of recurrence in patients with polymicrobial infections (p = 0.003). The mean Oxford Knee Score (OKS) improved from 18.7 (SD 8.7) preoperatively to 33.8 (SD 9.7) at six months postoperatively (p < 0.001). The Kaplan-Meier implant survival rate for all causes of reoperation, including reinfection and aseptic failure, was 95.2% at one year (95% confidence interval (CI) 87.7 to 98.2), 83.5% at five years (95% CI 73.2 to 90.3), and 78.9% at 12 years (95% CI 66.8 to 87.2).

Conclusion

One-stage exchange, using a strict debridement protocol and multidisciplinary input, is an effective treatment option for the infected TKA. This is the largest single-surgeon series of consecutive cases reported to date, with broad inclusion criteria.

Cite this article: Bone Jt Open 2021;2(5):305–313.

Origin and Use of Hydrogen Peroxide in Neurosurgery

Hydrogen peroxide (H2O2) is a chemical with a wide range of applications. This includes its use in the medical field, in which its use has been ubiquitous but is most useful as an antiseptic and in achieving hemostasis. Neurosurgeons have been using H2O2 for well over a century, primarily for its hemostatic and antiseptic effects. This is in spite of the fact that the actual effectiveness of H2O2 as an antiseptic is questionable, and its use, in general, may be more dangerous than it appears. We review the application of H2O2 in medicine generally and, more specifically, in neurosurgery. This review outlines the reasoning behind the use of H2O2 as an antiseptic and details why it may not be as effective as one might think. We also detail its use as a hemostatic agent in neurosurgery, reviewing a number of techniques in which it has been useful in this role. Finally, we review the documented cases of complications associated with the use of H2O2 in neurosurgery. Ultimately, we conclude that the use of H2O2 in neurosurgery be reconsidered because of its lack of effectiveness as an antiseptic and potentially fatal complications.

Novel treatment dynamics for biofilm-related infections

Introduction: As a result of progress in medical care, a huge number of medical devices are used in the treatment of human diseases. In turn, biofilm-related infection has become a growing threat due to the tolerance of biofilms to antimicrobials, a problem magnified by the development of antimicrobial resistance worldwide. As a result, successful treatment of biofilm-disease using only antimicrobials is problematic.Areas covered: We summarize some alternative approaches to classic antimicrobials for the treatment of biofilm disease. This review is not intended to be exhaustive but to give a clinical picture of alternatives to antimicrobial agents to manage biofilm disease. We highlight those strategies that may be closer to application in clinical practice.Expert opinion: There are a number of outstanding challenges in the development of novel antibiofilm therapies. Screening for effective antibiofilm compounds requires models relevant to all clinical scenarios. Although in vitro research of anti-biofilm strategies has progressed significantly over the past decade, there is a lack of in vivo research. In addition, the complexity of biofilm biology makes it difficult to develop a compound that is likely to provide the single 'magic bullet'. The multifaceted nature of biofilms imposes the need for multi-targeted or combinatorial therapies.

Wound Irrigation in Orthopedic Open Fractures: A Review

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

Formulation of a reactive oxygen producing calcium sulphate cement as an anti-bacterial hard tissue scaffold

Prophylactic antibiotic bone cements are extensively used in orthopaedics. However, the development of antimicrobial resistance to antibiotics, demonstrates a need to find alternative treatments. Herein, an antimicrobial honey (SurgihoneyRO-SHRO) has been successfully incorporated into a calcium sulphate (CS) based cement to produce a hard tissue scaffold with the ability to inhibit bacterial growth. Antimicrobial properties elicited from SHRO are predominantly owed to the water-initiated production of reactive oxygen species (ROS). As an alternative to initially loading CS cement with SHRO, in order to prevent premature activation, SHRO was added into the already developing cement matrix, locking available water into the CS crystal structure before SHRO addition. Promisingly, this methodology produced > 2.5 times (715.0 ± 147.3 μM/mL/g) more ROS over 24 h and exhibited a compressive strength (32.2 ± 5.8 MPa) comparable to trabecular bone after 3 weeks of immersion. In-vitro the SHRO loaded CS scaffolds were shown to inhibit growth of clinically relevant organisms, Staphylococcus aureus and Pseudomonas aeruginosa, with comparable potency to equivalent doses of gentamicin. Encouragingly, formulations did not inhibit wound healing or induce an inflammatory response from osteoblasts. Overall this study highlights the prophylactic potential of CS-SHRO cements as an alternative to traditional antibiotics.

Histological Aspects of a Novel Technique Used for the Management of Infections Secondary to Sinus Bone Grafting

Recently, a technical note describing a promising method for the management of infections after sinus bone grafting by irrigating the corresponding area with hydrogen peroxide based solution with an aid of a drain has been published. The aim of this paper was to present the histological and radiological results of the above mentioned technique. A total of 17 patients who have presented with infections secondary to sinus bone grafting enrolled in the study. During implant placement, bone was collected from the originally grafted site with a trephine burr for radiological examination via micro-computed tomography and histological examination. According to the results of the current study, Bio-Oss acted as a scaffold, and mature fibrous bone formed trabeculae, which assembled to an interlinked trabecular structure. Average results obtained from the microradiography confirmed the higher percentage of Bio-Oss (27.21% ± 3.31%) at the corresponding area; whereas the amount of newly formed bone was slightly lower (6.79% ± 1.13%) As a conclusion, this simple and minimally invasive technique might be beneficial in avoiding removal of bone graft material and could help in rescuing the former laborious procedure.

Low-budget, single-session elimination of CIED pocket infection

BACKGROUND

The dramatic increase in the use of cardiovascular implantable electronic devices (CIED) was associated with an increased rate of CIED infection, which has a high management cost.

AIM OF THE STUDY

To test the safety and efficacy of a single-session protocol, aiming to reuse the infected pocket side and the same device and leads in patients with CIED pocket infection.

PATIENTS AND METHODS

We included patients with isolated pocket infection between January 2015 and November 2019. The Patient was prepared by taking a swab for culture and sensitivity before the procedure. The pocket was debrided and the capsule was removed, the pocket was rinsed with povidone-iodine and hydrogen peroxide mixture, then packed with gauze sponge soaked with povidone-iodine. The device was debrided using ultrasonic irrigation and sterilized using gas plasma. The device was reimplanted and the wound was closed in layers.

RESULTS

During the period of the study, we had 12 patients with isolated pocket infection. Nine presented with erosion, two with impending erosion, and one with a chronic sinus. Patient's age was 61.5 ± 7.64 years. The infection was diagnosed 14.2 ± 8.22 weeks post device implantation. They were admitted for 7.6 ± 1.54 days postprocedure. The follow-up duration was 26.5 ± 15 (1.7-52) months. Only one patient (8%) had a recurrence of the infection after 50 days of the procedure.

CONCLUSION

Our protocol was successful in treating 92% of device-related pocket infection without the need to replace the device or the pocket side.

A rare and uncommon complication after use of hydrogen peroxide (H2O2): A review of use of H2O2 in orthopaedics

Hydrogen peroxide (H2O2) is a commonly used chemical agent in orthopaedic practice for antisepsis, haemostasis and preparation of bone bed for cementation. However, the associated risks of H2O2 usage are not widely known. We report a case of suspected air embolism after use of H2O2 during drainage of a septic arthritis of the shoulder.

Upon our literature review, we were able to demonstrate H2O2 to be beneficial in antisepsis and care of chronic wounds. However, it has not been proven to be superior to other antiseptics commonly used in orthopaedic surgery. Regarding its use in cementation, there is evidence to show it is more effective than saline however, the use of pulsatile lavage appears to be the most important factor affecting the quality of cementation. H2O2 has not been shown to be helpful with haemostasis. Prior to the use of H2O2, one should be cautious and understand its associated risks and precautions.

The In Vitro Efficacy of Doxycycline over Vancomycin and Penicillin in the Elimination of Cutibacterium Acnes Biofilm

Cutibacterium acnes (formerly Propionibacterium acnes) is a significant pathogen in periprosthetic joint infections (PJIs) in total shoulder arthroplasty. Poor outcomes seen in PJIs are due to the established C. acnes bacterial biofilms. The prolonged nature of C. acnes infections makes them difficult to treat with antibiotics. The goal of this study was to determine the relative efficacy of vancomycin compared with penicillin and doxycycline against planktonic and mature biofilms. Clinical isolates from PJI patients as well as a laboratory strain of C. acnes were tested. Planktonic minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were obtained using modified clinical laboratory standard index assays. Biofilm MICs and MBCs were also obtained. The MIC was determined for both using the PrestoBlue viability stain. The MBC was determined using differential reinforced clostridial medium agar plates for colony-forming unit analysis. Using the PrestoBlue viability reagent, the planktonic MIC values for vancomycin were significantly higher than doxycycline. Across 10 strains of C. acnes, all three antibiotics had decreased efficacy when comparing planktonic and biofilm cultures. Although effective antibiotic doses ranged from 1 to 1,000 μg/mL, only doxycycline achieved inhibitory and bactericidal concentrations in all tested strains. Penicillin failed to achieve the minimum biofilm inhibitory concentration (MBIC) in 60% of tested strains, whereas vancomycin failed in 80% of tested strains. Penicillin, doxycycline, and vancomycin have similar abilities in inhibiting C. acnes growth planktonically. The MBIC for doxycycline was within the clinical dosing range, suggesting C. acnes biofilm offers minimal tolerance to these antibiotics. The MBIC for penicillin was within clinical dosing ranges in only 60% of trials, suggesting the relative tolerance of C. acnes to penicillin. The minimum biofilm bactericidal concentration (MBBC) of doxycycline showed efficacy in 90% of trials, whereas penicillin and vancomycin achieved MBBC in 15% of samples.

Formulation of an antimicrobial superabsorbent powder that gels in situ to produce reactive oxygen

The enzymatic oxidation of glucose to produce reactive oxygen species (ROS) provides honey with antimicrobial efficacy. This mechanism offers an alternative to traditional antibiotics; however, topical use of honey is limited due to its adherent and highly viscous properties. This study aims to overcome these issues by engineering a powder-based system that eases delivery and offers in situ activation of ROS. Starch based drying agents were utilised to enable freeze drying of a medical honey, with methylated-β-cyclodextrin (MCD) enabling the highest active incorporation (70%) while still producing a free-flowing powder. Addition of a superabsorbent, sodium polyacrylate (≤40%) was shown to facilitate in situ gelation of the powder, with an absorption capacity of up to 120.7 ± 4.5 mL g^-1. Promisingly efficacy of the optimised superabsorbent powder was demonstrated in vitro against several clinically relevant Gram-negative and Gram-positive bacteria (Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa). Alongside this no adverse effects were observed against human dermal fibroblasts. Application of the superabsorbent powder in an ex-vivo porcine wound model revealed capability to form a protective hydrogel barrier in less than 1 min. Overall, this novel ROS producing superabsorbent powder has potential to tackle topical infections without using traditional antibiotics.

Gas Embolism After Hydrogen Peroxide Use During Spine Surgery: Case Report and Literature Review

BACKGROUND

As an irrigant, an antiseptic, and a hemostatic agent, hydrogen peroxide (H₂O₂) is widely used in surgical treatment, but it has been surrounded by persistent controversy. Fatal or near-fatal embolic events caused by H₂O₂ have been reported sporadically in spine surgery.

CASE DESCRIPTION

In this report, we present an 87-year-old man who underwent lumbar instrumentation removal and debridement consequent to surgical site infection in a prone position. H₂O₂ was used to irrigate the infected screw tracks and surrounding tissues during the procedures. Soon after irrigation, the patient suddenly developed tachycardia, hypotension, and rapid oxygen desaturation, followed by bradycardia. Transesophageal echocardiography indicated gas embolism. After prompt first aid treatment, the patient's condition improved and the gas embolus disappeared within a few minutes without any evidence of organ embolism.

CONCLUSIONS

Spine surgeons should reconsider the pending results of using H₂O₂ during surgery. Prolonged prone positioning and semiclosed cavities may increase the risk of gas embolism. An early diagnosis and timely intervention may be the key measures to prevent the occurrence of fatal consequences caused by gas embolism.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions

INTRODUCTION

The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy.

AIM

This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H₂O₂], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use.

METHODS

A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review.

MAIN OUTCOME MEASURE

The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue.

RESULTS

All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H₂O₂ is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data.

CLINICAL IMPLICATION

Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention.

CONCLUSION

Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

The use of hydrogen peroxide in the treatment of burn wound infection: a systematic review, and survey of current clinical practice in the United Kingdom

BACKGROUND

Current treatment of burn wound infection (BWI) is with antibiotics and/or wound cleaning/superficial debridement. The overuse of antibiotics has contributed to antibiotic resistance. One possible solution is the use of hydrogen peroxide (H₂O₂). The aim of this study is to investigate the current use of H₂O₂ in the treatment of BWI through a comprehensive review of published evidence and a survey of current clinical practice.

METHODS

A systematic review was performed on the clinical use of H₂O₂ in the treatment of BWI using four major search engines from inception to 1^st July 2018. English-written full-text publications of any study design were included and data extraction was conducted in duplicate. An 11-question survey on the use of H₂O₂ in the treatment of BWI was sent to all burn services in the United Kingdom (UK).

RESULTS

The systematic review generated 1,168 papers, with only one fulfilling inclusion criteria. This was a randomised control trial (RCT) which demonstrated that soaking grafts with 2% H₂O₂ prior to grafting improved graft take rate in infected burn wounds compared with grafts treated with saline prior to grafting, concluding that H₂O₂ can be recommended in the treatment of BWI intraoperatively. A 72.7% (16 burns services) response rate was achieved to the survey. Of these, 75% of burn services (n = 12) do not currently use H₂O₂ in clinical practice. Of the 25% (n = 4) which do use H₂O₂, no service had a protocol for its use. The most common reasons for not using H₂O₂ were a lack of published evidence and fear of side-effects.

CONCLUSION

Only 1 paper suggests H₂O₂ to be effective in BWI treatment and there is no national consistency or protocol for the use of H₂O₂ in the treatment of BWI in the UK. More large-scale research is required to determine whether H₂O₂ may offer a solution to the need to use antibiotics to treat BWI.

[Effect of hydrogen peroxide on anti-infection and reducing postoperative drainage in multi-segmental lumbar surgery]

Objective

To investigate the effect of hydrogen peroxide on anti-infection and reducing postoperative drainage in multi-segmental lumbar surgery.

Methods

A clinical data of 510 patients with multi-segmental lumbar degenerative diseases who were treated with surgery between January 2017 and January 2018 was retrospectively analyzed. In study group, the incisions of 230 cases were washed with hydrogen peroxide before suture. In control group, the incisions of 280 cases were washed with normal saline before suture. There was no significant difference in gender, age, lesion type, disease duration, operative segment, and other clinical data between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage volume, and postoperative incidence of infection were recorded and compared between the two groups. The Centers for Disease Control and Prevention (CDC) standard was used to evaluate infection, which was divided into superficial infection and deep infection.

Results

All operations completed successfully. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). The postoperative drainage volume in the study group was significantly less than that in the control group ( t=-2.990, P=0.005). A total of 13 patients developed infection after operation, including 10 cases of superficial infection (2 cases in the study group and 8 cases in the control group) with the infection time of (7.3±1.5) days, and 3 cases of deep infection (all in the control group) with the infection time of (16.6±3.1) days. The incidences of superficial and deep infections in the study group were lower than those in the control group, but there was no significant difference between the two groups ( χ ²=2.595, P=0.123; P=0.256). All the superficial infections were Staphylococcus aureus infection and recovered after active dressing change. Among the patients with deep infections, 2 cases were infected by Staphylococcus aureus and 1 case was infected by Escherichia coli; and the incisions healed after being washed and sutured thoroughly, and active dressing change.

Conclusion

The incidence of postoperative infection and postoperative drainage volume can be reduced by washing the incision with hydrogen peroxide in multi-segmental lumbar surgery.

Oxygen Embolism and Pneumocephalus After Hydrogen Peroxide Application During Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Case Report and Literature Review

BACKGROUND

Hydrogen peroxide (H₂O₂) solution is commonly used to irrigate wounds because of its hemostatic and antiseptic properties. Previous studies suggest that H₂O₂ can result in toxicity to keratinocytes and fibroblasts, but complications after H₂O₂ application, including oxygen embolism, which is one of the most severe, have rarely been reported.

CASE DESCRIPTION

A 40-year-old woman was diagnosed with L4-5 lumbar spinal stenosis and subsequently underwent minimally invasive transforaminal lumbar interbody fusion treatment at another hospital. Hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occurred immediately after H₂O₂ irrigation. After the operation, she was able to be extubated but remained comatose. Postoperative computed tomography scan revealed intracranial air trapping in the right frontal lobe and multiple cerebral infarction foci.

CONCLUSIONS

When using a knee-prone surgical position or in cases of dural laceration, the application of undiluted H₂O₂ solution should be avoided, especially in a surgical wound within a closed cavity. When hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occur immediately after H₂O₂ irrigation, oxygen embolism should be strongly suspected.

Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty: An Analysis of 11,738 Cases

BACKGROUND

Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure.

METHODS

Using our institution's total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics.

RESULTS

The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score.

CONCLUSIONS

Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antimicrobial emulsions: Formulation of a triggered release reactive oxygen delivery system

The enzyme glucose oxidase mediates the oxidation of glucose to produce reactive oxygen species (ROS), such as hydrogen peroxide. This reaction and its products are key to providing honey with its antimicrobial properties. Currently, honey is an adherent, highly viscous product that produces ROS by means of a water-initiated reaction. These properties reduce clinical usability and present a formulation problem for long term stability. This study aims to engineer a water-in-oil emulsion containing an engineered honey (SurgihoneyRO™) that is easy to administer topically and is controllably activated in-situ. Paraffin oil continuous emulsions formulated using the emulsifier polyglycerol polyricinoleate displayed shear-thinning characteristics. Viscosities between 1.4 and 19.3 Pa·s were achieved at a shear rate representative of post-mixing conditions (4.1 s^-1) by changing the volume of the dispersed phase (30-60%). Notably, this wide viscosity range will be useful in tailoring future formulations for specific application mechanisms. When exposed to water and shear, these emulsion systems were found to undergo catastrophic phase inversion, evidenced by a change in conductivity from 0 μS in the non-aqueous state, to >180 μS in the sheared, inverted state. Encouragingly, sheared formulations containing ≥50% SurgihoneyRO™ generated sufficient levels of ROS to inhibit growth of clinically relevant Gram-positive and Gram-negative bacteria. This study demonstrates an ability to formulate ROS producing emulsions for use as an alternative to current topical antibiotic-based treatments. Promisingly, the ability of this system to release water-sensitive actives in response to shear may be useful for controlled delivery of other therapeutic molecules.

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.].