A Novel Irrigant to Eliminate Planktonic Bacteria and Eradicate Biofilm Superstructure With Persistent Effect During Total Hip Arthroplasty

Current Strategies in Developing Antibacterial Surfaces for Joint Arthroplasty Implant Applications

Prosthetic joint infections (PJIs) remain a significant challenge, occurring in 1% to 2% of joint arthroplasties and potentially leading to a 20% to 30% mortality rate within 5 years. The primary pathogens responsible for PJIs include Staphylococcus aureus, coagulase-negative staphylococci, and Gram-negative bacteria, typically treated with intravenous antibiotic drugs. However, this conventional approach fails to effectively eradicate biofilms or the microbial burden in affected tissues. As a result, innovative strategies are being explored to enhance the efficacy of infection prevention through the development of antibacterial-coated implants. These coatings are required to demonstrate broad-spectrum antimicrobial activity, minimal local and systemic toxicity, favorable cost-effectiveness, and support for bone healing. In the present review, the analysis of various methodologies for developing antibacterial coatings was performed, emphasizing studies that conducted in vivo tests to advance potential clinical applications. A diversity of techniques employed for the development of coatings incorporating antimicrobial agents highlights promising avenues for reducing infection-related surgical failures.

The Use of a Novel Antiseptic Irrigant Solution in Combination with Vancomycin Powder Significantly Reduces the Risk of Surgical Site Infections in Orthopedic Trauma Patients

Objectives

This study aims to evaluate whether using a novel antiseptic irrigant solution combined with vancomycin powder can effectively reduce the incidence of surgical site infections (SSIs) in orthopedic trauma patients. Specifically, we seek to determine if this combined approach significantly decreases SSI rates compared to using vancomycin powder alone. The study also aims to assess the safety and efficacy of the phosphate buffer solution, particularly its ability to reduce biofilm formation on surgical implants without causing cytotoxic effects. Ultimately, our goal is to provide insights into potential clinical practice changes that can enhance infection prevention strategies in orthopedic trauma surgeries.

Methods

This retrospective study analyzed 450 orthopedic trauma surgeries for lower extremity fractures at a Level Two hospital in Oregon, USA, between January 2021 and October 2023. Patients were stratified based on intraoperative irrigation with either vancomycin alone or vancomycin combined with a phosphate buffer irrigation solution. Data analysis included demographic characteristics, operative details, and occurrences of SSIs within 90 days postoperatively.

Results

Among the 450 surgeries analyzed, 18 (8.1%) SSIs occurred in the vancomycin cohort compared to 3 (1.3%) in the vancomycin and Phosphate buffer cohort. Adjusted logistic regression revealed an 89% reduction in the odds of SSIs in the vancomycin and Phosphate buffer cohort (OR: 0.11, 95% CI 0.02-0.35, P=0.001), adjusting for age, tobacco use, operative time, and procedure type.

Conclusion

This study underscores the promising role of combined vancomycin and Phosphate buffer irrigation in reducing SSI rates in orthopedic trauma surgeries. Further prospective studies are warranted to validate these findings and explore optimal infection prevention strategies in diverse surgical settings.

Assessing the Effects of Surgical Irrigation Solutions on Human Neutrophil Interactions with Nascent Staphylococcus aureus Biofilms

Staphylococcus aureus (S. aureus) is the leading cause of surgical site infections (SSIs) and is capable of biofilm growth on implanted foreign devices. The use of surgical irrigation solutions has become a common strategy to combat bacterial contamination events that occur during surgery. Despite their antimicrobial activity, SSI rates remain consistent, suggesting that low-level contamination persists. In these cases, circulating neutrophils must traffic from the blood to contamination sites to aid in bacterial clearance. The influence of irrigation solutions on neutrophils' ability to engage with bacteria has not been explored. The effects of three commonly used irrigation solutions: Xperience (sodium lauryl sulfate), Irrisept (chlorhexidine gluconate), and Betadine® (povidone-iodine) on nascent S. aureus biofilms alone and in the presence of human neutrophils were assessed at manufactured and diluted concentrations. All three solutions, at a 10% dilution, inhibited bacterial growth as demonstrated by culture assays and confocal video microscopy of bacterial aggregate formation. The effects of 10% dilutions of each of these solutions on neutrophil membrane integrity (by flow cytometry and propidium iodide staining) and motility (by confocal video microscopy of neutrophil track length) were investigated with differing outcomes for each irrigation solution. At this concentration only Irrisept preserved neutrophil membrane integrity and motility. Together, this study examines an overlooked aspect of surgical irrigation solutions by investigating their impact on innate immunity and highlights the feasibility of formulations wherein solution effectiveness is complemented by neutrophil function to reduce risks of infection.

Clinical use and applications of a citrate-based antiseptic lavage for the prevention and treatment of PJI

Total joint arthroplasties (TJA) are some of the most commonly performed surgeries in the United States with the number of TJA expected to rise significantly over the next decade as the population ages and arthritic burden worsens. However, the rise in TJA volume correlates with a heightened risk of complications, notably prosthetic joint infections (PJI), despite their low occurrence rate of less than 2%. PJI imposes a significant burden on surgery success, patient well-being, and healthcare costs, with an estimated annual expense of 1.85 billion dollars for hip and knee PJI by 2030. This manuscript delves into the pathophysiology of PJI, exploring our current understanding of the role of bacterial biofilm formation on implanted foreign hardware, providing protection against the host immune system and antibiotics. The article reviews current agents and their efficacy in treating PJI, as well as their cytotoxicity toward native cells involved in wound healing, prompting the exploration of a novel citrate-based solution. The paper highlights the superior properties and efficacy of a novel citrate-based irrigation solution on the treatment and prevention of PJI via increased antimicrobial properties, greater biofilm disruption, increased exposure time, and reduced cytotoxicity compared to conventional solutions, positioning it as a promising alternative. It also provides a perspective on its clinical use in the operating theater, with a step-by-step approach in TJA, whether primary or revisionary.

Efficacy of a Novel Intraoperative Surgical Irrigant in Preventing Periprosthetic Joint Infections in Primary Knee, Hip, and Shoulder Arthroplasties: A Retrospective Analysis

OBJECTIVE

Primary joint arthroplasty (JA) is one of the most common operating room (OR) procedures, with knee and hip arthroplasties being listed in the top five most frequent OR procedures and while not as common, shoulder arthroplasties are increasing at greater rates than knee and hip arthroplasties. Periprosthetic joint/shoulder infections (PJI/PSI) are a devastating complication of primary JAs with infection prevention deemed as the single most important strategy in combating them. The objective of this study was to retrospectively evaluate the efficacy of XPERIENCE® Advanced Surgical Irrigation (XP) in preventing PJI following primary joint arthroplasty.

METHODS

This is a retrospective study of primary knee, hip and shoulder arthroplasties that were performed by multiple orthopedic surgeons at a single hospital setting. XPERIENCE was used as an intraoperative surgical irrigant either solely, or with other intraoperative practices for prevention of infection. Incidence of acute PJI occurring within 90 days of index surgery were retrospectively collated.

RESULTS

Four hundred and twenty-three (423) primary joint replacement surgeries treated intraoperatively with XP, were evaluated for acute PJI incidence. Retrospective evaluations determined that 95% of the subjects had at least one risk factor predisposing them to PJI. There were zero PJIs diagnosed in the knee and hip arthroplasty cohorts and zero PSIs diagnosed in the shoulder arthroplasty cohorts.

CONCLUSION

The absence of PJI/PSI diagnoses in the JA cohorts treated intraoperatively with XP indicates that it could be an efficacious antimicrobial irrigant in preventing PJI, and warrants being evaluated in prospective, randomized controlled clinical trials as the sole intraoperative irrigant, as well as in combination with the other intraoperative infection prevention regimens evaluated in this retrospective study.

Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center

Background: Total knee arthroplasty (TKA) is one of the most common inpatient and outpatient surgical procedures performed in the United States and is predicted to increase 401% by 2040. Surgical site infections (SSIs) at an incidence rate of approximately 2% are costly post-operative complications in TKA. Intra-operative surgical irrigants are used to decrease contaminating microbial bioburden within the surgical site to prevent SSI. The primary objective of this retrospective study was to evaluate the impact of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP; Next Science, Jacksonville, FL) on SSI incidence in primary TKA performed at an ambulatory surgery center (ASC). Patients and Methods: Primary TKAs were performed at a free-standing ASC. The novel surgical irrigant was used intra-operatively to rinse away debris and micro-organisms from the surgical site. Retrospective data collation included SSI rates, complication rates, and re-admissions due to SSI within 90 days of index surgery. Results: Among the 524 primary TKA surgeries, one peri-prosthetic joint infection (PJI) was diagnosed within 90 days of index surgery and one superficial incisional SSI was diagnosed within 30 days of index surgery. The PJI was attributed to an exogenously acquired upper respiratory tract infection rather than due to the failure of intra-operative regimes. The 0.19% PJI incidence rate indicated significant efficacy of XP in decreasing PJI. An overall complication rate of 7.82% was noted with none of the complications associated with usage of the novel surgical irrigant. Conclusions: XPERIENCE is a promising intra-operative antimicrobial irrigant that can be easily incorporated into a broader infection prevention strategy.