Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

Fracture-related infection blood-based biomarkers: Diagnostic strategies

Fracture-related infections are significant postoperative complications that carry substantial patient burden and additional healthcare costs. Despite their impact on outcome, early diagnosis of these infections remains challenging due to current available tests lacking acceptable diagnostic parameters. This review compiles existing information on blood-based biomarkers that have been evaluated as early diagnostic tools and highlights the challenges in their reliability. To begin to overcome these challenges new avenues of biomarker discovery utilizing "omics" technologies and novel analytical methods are being investigated in recent years. It appears that, despite their complexity, these newer approaches may be the future in biomarker discovery for fracture-related infection diagnosis.

Povidone Iodine vs Chlorhexidine Gluconate for Preoperative Skin Antisepsis: A Systematic Review and Meta-analysis of Randomised Controlled Trials

BACKGROUND

Surgical site infection (SSI) remains a challenge in healthcare, contributing to prolonged hospital stays, increased healthcare costs, and adverse patient outcomes, including mortality. Effective preoperative skin disinfection interventions, such as povidone-iodine (PVI) and chlorhexidine (CHG), are widely used but their efficacy remains debated. To address this gap, this meta-analysis aims to evaluate the efficacy of PVI and CHG.

METHOD

We searched PubMed, Embase, and Cochrane databases up to June 2024 to identify studies comparing PVI versus CHG for preoperative skin antisepsis. We calculated odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CIs). A random-effects model was used with statistical significance set at p < 0.05. Data were analysed using R software (version 4.4.0), and heterogeneity was assessed using I2 statistics.

FINDINGS

Sixteen randomised controlled trials (RCTs) were included, involving a total of 13,721 patients, among whom 6,836 (49.8%) received PVI. Compared to CHG, PVI was associated with a non-significant reduction in deep SSI (OR 1.00; 95% CI 0.66 - 1.50; p = 0.994), but an increased risk of overall SSI (OR 1.25; 95% CI 1.06 - 1.48; p = 0.007) and superficial SSI (OR 1.67; 95% CI 1.25 - 2.24; p < 0.001).

CONCLUSION

PVI as preoperative skin antisepsis demonstrated a non-significant reduction in deep SSI compared to CHG but was associated with an increased risk of overall and superficial SSI. Despite these findings, PVI remains an effective option, especially in resource-limited settings. Further research is needed to optimise its use and improve infection prevention strategies in clinical practice.

Uncovering the Benefits of Povidone Iodine Compared to Other Therapeutic Agents in Wound Infection Prevention and Healing Outcomes: A Scoping Review

Background

The selection of an appropriate chemical solution in wound care reduces the severity of wounds and accelerates the healing process. Povidone-iodine (PV-I), a chemical solution popularly known as an antiseptic, is frequently used in studies of wound care to prevent wound infection and accelerate woud the process of wound healing.

Objective

To identify the latest evidence on the benefits of PV-I in wound infection prevention and healing in all areas.

Methods

This review is a scoping review by Arskey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) is used for reporting. The literature search used databases including PubMed, CINAHL, and search engines such as Scopus. This study was conducted using thematic analysis.

Results

This review yielded 19 out of 2109 studies that were identified in the initial search. Four outcomes comprised 20 sub-outcomes have been identified. Although strong evidence is lacking, PV-I in the form of foam is effective in improving wound healing, shortening healing time, and producing fewer adverse events than hydrocelluers. Moreover, saline and PV-I are effective as skin disinfectants when compared to saline alone in reducing surgical site infection (SSI), and they are also more effective than hypochlorous acid in improving wound healing. Nevertheless, there was no difference between PV-I and hypochlorous acid in the prevention of SSI and bacterial growth. In terms of healing time, silver foam and hyaluronic acid were more favorable than PV-I. Moreover, the use of chlorhexidine to improve SSI and silver dressing to improve hospital stay is more favorable than that of PV-I.

Conclusion

There is limited evidence regarding the effectiveness of wound care outcomes, and the efficacy of PV-I as a surface disinfectant for wound infection prevention remains controversial. Consequently, PV-I is not highly recommended for wound care, and further investigation into the effectiveness of PV-I as a surface disinfectant is required for various types of surgeries.

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

BACKGROUND

Chlorhexidine gluconate (CHG) solution is commonly used as an antiseptic irrigation for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG on articular cartilage has been reported, the full extent of CHG-related chondrotoxicity and its effects on the extracellular matrix and mechanical properties are unknown.

PURPOSE

To investigate the in vitro effects of a single 1-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants.

STUDY DESIGN

Controlled laboratory study.

METHODS

Articular cartilage explants (6 per group) were harvested from femoral condyles of the porcine stifle and sectioned at tidemark. Explants were bathed in CHG solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) for 1 minute, followed by complete phosphate-buffered saline wash and culture in chondrogenic medium. At 7 days after CHG exposure, cell viability, matrix content (collagen and glycosaminoglycan [GAG]), and compressive mechanical properties (creep indentation testing) were assessed.

RESULTS

One-minute CHG exposure was chondrotoxic to explants, with both 0.05% CHG (2.6% ± 4.1%) and 0.01% CHG (76.3% ± 8.6%) causing a decrease in chondrocyte viability compared with controls (97.5% ± 0.6%; P < .001 for both). CHG exposure at either concentration had no significant effect on collagen content, while 0.05% CHG exposure led to a significant decrease in mean GAG per wet weight compared with the control group (2.6% ± 1.7% vs 5.2% ± 1.9%; P = .029). There was a corresponding weakening of mechanical properties in explants treated with 0.05% CHG compared with controls, with decreases in mean aggregate modulus (177.8 ± 90.1 kPa vs 280.8 ± 19.8 kPa; P < .029) and shear modulus (102.6 ± 56.5 kPa vs 167.9 ± 16.2 kPa; P < .020).

CONCLUSION

One-minute exposure to CHG for articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. This raises concern for the risk of mechanical failure of the cartilage tissue after CHG exposure.

CLINICAL RELEVANCE

Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.

Large-scale, pragmatic randomized trials in the era of big data, precision medicine and machine learning. Valid and necessary, or outdated and a waste of resources?

During the past decade, more and more large-scale pragmatic clinical trials have been carried out in orthopedic trauma surgery. This trend is fueled by the common belief that the larger the numbers in a trial, the broader the eligibility criteria, and the less strict the regimentation of local treatment standards by protocol, the more trustworthy the findings would be. However, it must also be taken into account that the precision of an outcome measurement does not depend on the sample size alone, but the homogeneity of the studied population. Consequently, a small trial with stringent entry and assessment criteria may offer similarly precise answers as a large trial with less strict entry and assessment criteria because of the basic mathematical correlation between standard deviation and standard error of the mean. There is now a lively and controversial debate about the role of randomized controlled trials (RCT) in an era of stratified medicine driven by the ever increasing understanding and clinical measurability of molecular pathways, making a certain intervention more effective in patients who show a distinct genetic variant. Cluster and pattern recognition by artificial intelligence (AI) and its methodological variety applied to huge datasets and population-based cohorts further propel the spiral of knowledge. Advanced adaptive RCT concepts like enrichment designs, basket and bucket trials, master protocols etc. were developed to combine classic principles of the scientific method with big data, the latter of which have not arrived yet in trauma care. In spite of all biomedical and methodological achievements made, surprisingly such key questions remain unanswered as a) is a certain treatment causally responsible for making a difference in patient-centered outcomes compared to placebo, a control treatment, or the standard of care, b) do the results of a controlled experiment are relevant enough to change clinical practice, and c) under which conditions and assumptions shall we conduct large-scale pragmatic RCTs, focused confirmatory RCTs, or personalized analyses with or without AI support.