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Vol 9, No 4, July/August 2001
219
According to hospital discharge
data, there are approximately 6 mil-
lion fractures in the United States
annually and 7.5 million open
wounds.
1
On the basis of statistics
from European studies, it has been
estimated that 4% of fractures are
open, suggesting that there are
nearly 250,000 open fractures annu-
ally in this country.
2
Compared
with closed fractures, open fractures
have a higher incidence of infection,
nonunion, and other adverse out-
comes that lead to increased cost of
treatment and result in less satisfac-
tory recovery for the patient.
Many of the factors that increase
the risk of infection in open frac-
tures are beyond the control of the
surgeon, such as the severity of the
injury, delay in initiation of medical
care, and the health status of the
patient. However, some treatment
decisions are strongly believed to
make a difference in the incidence

of infection. These include timing of
surgical treatment, use of systemic
and local antibiotics, adequacy of
surgical wound care, fracture stabil-
ity, and early wound closure or flap
coverage.
The adequacy of initial surgical
wound care may be the most impor-
tant single factor under the surgeon’s
control. This element consists of
adequate sharp debridement, with
removal of all debris and devitalized
tissue, and thorough irrigation. De-
velopment of a wound infection is a
multistage process that occurs over
time. It requires contamination with
sufficient numbers of viable bacteria,
adhesion of the bacteria to wound
surfaces, proliferation of bacterial
colonies on the surface, and exten-
sion of the colonies beyond the origi-
nal locations. The goal of initial
wound care is to decrease the bacter-
ial load, eliminate the devitalized tis-
sue that serves as a medium for bac-
terial growth, and prevent further
contamination, thereby facilitating
the action of host defense systems.
Wound irrigation is universally
recommended as an essential part

of open fracture treatment, although
there is relatively little information
available defining the details of
variables such as volume, delivery
method, and optimal irrigation
solution additives (Table 1). How-
ever, on the basis of the current
knowledge about this topic, there
are some widely accepted guide-
lines.
Volume
Most texts recommend “copious,”
“ample,” or “adequate” amounts of
irrigation, without giving specific
Dr. Anglen is Associate Professor of Orthopae-
dic Surgery, University of Missouri-Columbia,
Columbia.
Reprint requests: Dr. Anglen, University of
Missouri-Columbia, One Hospital Drive,
MC213, Columbia, MO 65212.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Abstract
Wound irrigation to remove debris and lessen bacterial contamination is an essen-
tial component of open fracture care. However, considerable practice variation
exists in the details of technique. Volume is an important factor; increased volume
improves wound cleansing to a point, but the optimal volume is unknown. High-
pressure flow has been shown to remove more bacteria and debris and to lower the
rate of wound infection compared with low-pressure irrigation, although recent in
vitro and animal studies suggest that it may also damage bone. Pulsatile flow has

not been demonstrated to increase efficacy. Antiseptic additives can kill bacteria in
the wound, but host-tissue toxicities limit their use. Animal and clinical studies of
the use of antiseptics in contaminated wounds have yielded conflicting outcomes.
Antibiotic irrigation has been effective in experimental studies in some types of
animal wounds, but human clinical data are unconvincing due to poor study
design. There are few animal or clinical studies of musculoskeletal wounds.
Detergent irrigation aims to remove, rather than kill, bacteria and has shown
promise in animal models of the complex contaminated musculoskeletal wound.
J Am Acad Orthop Surg 2001;9:219-226
Wound Irrigation in Musculoskeletal Injury
Jeffrey O. Anglen, MD
Perspectives on Modern Orthopaedics
volume recommendations. Some
authors have suggested amounts
ranging from 7 to 15 L per wound
without reference to any data.
Others have described the figure as
“arbitrary.”
3
In a study examining the removal
of clay particles from guinea pig
wounds by irrigation, Rodeheaver et
al
4
found that volume was not im-
portant over a range from 100 to 400
mL. In a study of removal of bacte-
ria adherent to bovine muscle by
irrigation with benzalkonium chlo-
ride or saline, Gainor et al

5
found
that increasing volume from 0.1 L to
1.0 L increased bacterial removal
with both solutions. Increasing to 10
L had no effect on removal with
saline but dramatically improved
bacterial removal by benzalkonium.
Using a model of contaminated
dorsal soft-tissue wounds in dogs,
Peterson
6
found that increasing
saline irrigation volume from 0 to
1,000 mL in 250-mL increments re-
sulted in a steady decrease in the
clinical wound infection score (with
ratings for erythema, induration,
exudate, healing rate, and abscess
formation).
There have been no reported
human clinical studies related to
the volume of irrigation. Nonethe-
less, it appears clear that increasing
volume improves removal of dirt
and bacteria to a point, subject to
some variability between solutions.
Given the availability of 3-L irriga-
tion bags, a reasonable protocol is 3
L for grade 1 fractures, 6 L for

grade 2 fractures, and 9 L for grade
3 fractures. However, there are no
outcome data to support these rec-
ommendations.
Delivery Method
Many irrigation systems can pro-
vide a pulsatile flow of fluid, al-
though there is little evidence that
pulsatile flow per se, separate from
the issue of the benefit of increased
pressure, provides any advantage.
In one study involving quantitative
culture of rabbit wounds contami-
nated with Staphylococcus aureus,
7
pulsatile flow was found to be less
effective than continuous flow in
bacterial removal at a variety of
pressures (0.5, 10, and 25 psi). The
authors used a device that delivered
300 mL of saline at varying pres-
sures. It could also be adjusted to
provide pulsatile flow at 8 cycles
per second, with delivery of fluid
through a 1.5-mm-diameter outlet
for 1/16 of a second in each cycle. In
another study using guinea pig dor-
sal wounds contaminated with soil,
4
pulsatile flow of saline was com-

pared with continuous flow at pres-
sures of both 1 and 10 psi. There
was no difference in the amount of
soil removal between the two types
of flow at the same pressure.
High-pressure irrigation (jet
lavage) has been shown to be more
effective in removing particulate
matter, necrotic tissue, and bacteria
than low-pressure irrigation meth-
ods, such as use of a bulb syringe, in
both in vitro
8,9
and in vivo
4,7,10,11
studies. This seems to be particularly
true when there has been a delay in
treatment and when the wound has
been contaminated with foreign
material. Madden et al
7
created dor-
sal soft-tissue wounds in rabbits and
contaminated them with S aureus or
Escherichia coli. The wounds were
then irrigated with 300 mL of saline
after a delay of 5 minutes, 2 hours,
or 4 hours at pressures of 0.5, 10, or
25 psi. Increasing pressure in-
creased bacterial removal at all

times, but with the 2- and 4-hour
delays, only irrigation at 25 psi sig-
nificantly (P<0.01) decreased the
incidence of gross infection. Brown
et al
11
studied rat wounds contam-
inated with E coli both with and
without the addition of sterile gar-
den soil and crushed tissue. Jet
Wound Irrigation
Journal of the American Academy of Orthopaedic Surgeons
220
Table 1
Irrigation Variables
Variable Effect Recommendation
Volume In animal studies, increasing volume removes more Grade 1 fractures, 3 L; grade 2 fractures, 6 L;
particulate matter and bacteria, but the effect plateaus grade 3 fractures, 9 L
at a level dependent on the system
Pressure Increased pressure removes more debris and bacteria; Use a power irrigation system that
however, the highest pressure settings damage bone, provides a variety of settings; select a
delay fracture healing, and may increase risk of low or middle-range setting
infection by damaging soft tissue
Pulsation In theory, improves removal of surface debris by means Not established
of tissue elasticity; limited studies have not confirmed
the effect or have suggested decreased efficacy
lavage at 50 psi was more effective
in removing bacteria than gravity or
bulb-syringe lavage with the same
saline volume in both types of

wound, and only the jet lavage sig-
nificantly (P<0.05) lowered contami-
nation in devitalized wounds with
foreign material present.
There is some evidence that high-
pressure irrigation may have delete-
rious effects as well. One animal
study involved irrigating a wound
and then inoculating it with a nor-
mally subinfective dose of staphylo-
cocci. Those wounds that had un-
dergone both high-pressure (70-psi)
and low-pressure (8-psi) irrigation
showed a higher infection rate than
nonirrigated control wounds, sug-
gesting impairment of infection-
fighting ability.
12
The same study
demonstrated that irrigation fluid
(but not bacteria) was driven into
the tissues around the wound by
the high-pressure irrigation. An in
vitro study showed more gross
damage and microscopic fissures in
cortical bone that had undergone
high-pressure (70-psi) irrigation
compared with bone subjected to
lower-pressure (14-psi) irrigation.
8

In a rabbit articular fracture model,
Dirschl et al
13
showed a decrease in
new bone formation around articu-
lar osteotomies in the first week
after high-pressure (70-psi) irriga-
tion, compared with control sites
treated with low-pressure (bulb)
irrigation.
Using highly contaminated (1×
10
8
bacterial suspension) sections
from human tibiae, Bhandari et al
14
demonstrated that pulsatile lavage
with a nozzle pressure of 70 psi
resulted in more positive cultures at
1 to 4 cm from the contaminated sur-
face than were found in nonirrigated
control specimens. The irrigation
procedure removed more than 99%
of the bacteria from the contam-
inated surface, but did result in
some propagation of bacteria down
the medullary canal. However, the
number of colony-forming units re-
covered from specimens contami-
nated with S aureus was quite low

(range, 1 to 11), which is probably
below the infection-causing thresh-
old. The use of E coli appeared to
result in higher counts, but the differ-
ence was not statistically significant.
The authors also quantitated macro-
scopic structural damage to the bone
and found it to be maximal at the irri-
gated surface. The clinical signifi-
cance of these findings is unclear.
A new delivery strategy being
investigated involves the use of an
irrigation tip that provides fluid
flow parallel to the surface rather
than perpendicular to it.
15
The goal
is to generate high rates of fluid
flow, which may be less damaging
to the bone surface and yet will
maintain effectiveness in removal of
debris, but this has yet to be verified.
The nozzle pressure of the irriga-
tion system has generally been
reported in studies of irrigation
pressure and its effects on bone.
However, the actual impact pressure
at the bone surface may be signifi-
cantly less. Impact pressure varies
with nozzle-tip design, as well as the

distance from the surface of the bone
and the degree of inclination. For
example, surface-impact pressures
measured with an electronic pres-
sure transducer and oscilloscope
for the Pulsavac system (Zimmer,
Warsaw, Ind) at a distance of 1.5
inches vary from 0.12 to 8.8 psi
depending on setting and tip design
(Timothy Donaldson, written com-
munication, December 2000). These
are markedly lower than the nozzle
and tubing pressure values that are
typically reported. It is important
for future studies to standardize the
measurement variables and to at-
tempt to develop a “dose-response”
curve relating pressure to bacterial
removal and bone damage while
controlling for time of fluid expo-
sure. Similarly, the clinical signifi-
cance of both macroscopic and
microscopic changes needs to be
clarified.
Some lavage systems allow the
operator to adjust the pressure and
flow rate of the irrigator. For now,
it seems prudent to utilize higher
pressure settings in severely contam-
inated wounds and delayed treat-

ment situations when bacterial
removal is the most important issue,
and lower pressure settings or bulb-
syringe irrigation when the level of
contamination is less and treatment
is prompt.
Irrigation Additives
Since prehistoric times, wounds have
been washed with a variety of fluids,
including water, wine, milk, vinegar,
turpentine, oils, and even urine. In
the biblical story of the Good Samar-
itan, wounds were treated by pour-
ing in wine and oil (Luke 10:33-34).
In modern times, wounds are usually
irrigated with sterile saline, either
alone or with additives. For conve-
nience, the various additives can be
divided into three categories: anti-
septics, antibiotics, and surfactants
(Table 2). Chelating agents were also
used in irrigation in one animal
study, but were shown to be of no
benefit or possibly even to have been
detrimental.
4
Antiseptics
It is well known that decreasing
the bacterial load of the inoculum
will lessen the rate of clinical infec-

tion. The purpose of antiseptic ad-
ditives is to kill bacteria in the
wound and thus lessen the patho-
gen load that must be handled by
the host immune system. A partial
list of antiseptics that have been
used either clinically or experimen-
tally includes hydrogen peroxide,
povidone-iodine (Betadine) solu-
tion, povidone-iodine scrub, chlor-
hexidine gluconate (Hibitane), hexa-
chlorophene (pHisoHex), sodium
hypochlorite (Dakin’s solution), benz-
alkonium chloride (Zephiran), and
various alcohol-containing solutions.
Jeffrey O. Anglen, MD
Vol 9, No 4, July/August 2001
221
All antiseptics function similarly,
by damaging the cell wall or cell
membrane of the pathogen, leading
to changes in permeability. Each
has a broad but slightly different
spectrum of activity, and all are toxic
to some bacteria, spores, fungi, and
viruses. Antiseptics are also toxic to
host cells, such as leukocytes, eryth-
rocytes, fibroblasts, keratinocytes, and
osteocytes. Cell and tissue culture
studies uniformly show that antisep-

tics have concentration-dependent
detrimental effects on the viability
and function of host cells.
16,17
Some
antiseptics can be diluted enough to
be nontoxic to cells in culture while
retaining some bactericidal activ-
ity (e.g., povidone-iodine solution,
Dakin’s solution). The dilutions uti-
lized in the cell culture experiments
have been below the strengths gener-
ally utilized in clinical practice.
16
Other antiseptics lose their bacteri-
cidal activity before they lose their
tissue toxicity during dilution (e.g.,
hydrogen peroxide, acetic acid).
16
However, the relevance of deleteri-
ous effects on cells in culture as com-
pared with cells within a functioning
organ is at best tenuous.
In evaluating animal studies of
antiseptic irrigation, two issues are
important: interference with wound
healing (toxicity to host tissues) and
efficacy in preventing infection. All
antiseptics—and indeed, all irriga-
tion fluids other than saline (includ-

ing water)—have been shown to
have some negative effects on micro-
vascular flow and endothelial integ-
rity in live animal studies.
18
Benzalkonium chloride exposure
has been shown to decrease the ten-
sile strength of skin in dorsal rat
incisions 7 days after suture repair.
19
Hypochlorite solutions (such as
chloramine) have been shown to be
particularly injurious to microvascu-
lar circulation.
18
Chlorhexidine has
been shown to delay early skin
healing and to decrease the tensile
strength of healing skin wounds in
animal models.
20
Povidone-iodine solution has
been evaluated in various animal
models. Unfortunately, the results
from the studies are contradictory,
even when the same species and the
same concentrations were used.
Several studies have shown that
povidone-iodine scrub and other
combinations of antiseptic and de-

tergent are particularly damaging to
wounds, although either alone may
be less toxic.
20
The data with regard
to infection prevention are equally
unconvincing; of four studies in-
volving contaminated guinea pig
wounds and povidone-iodine irri-
gation, two showed a decreased
infection rate,
21
and two showed no
effect.
21-23
Differences in type and
quantity of inoculum, irrigation
method, time from inoculation to
irrigation, and bacterial recovery
techniques prevent direct compar-
isons. In many of these studies,
low-pressure, low-volume irrigation
or soaking methods were used.
In human studies, most informa-
tion is related to the use of povidone-
iodine. The results have been mixed.
Data on efficacy have been derived
primarily from general surgical stud-
ies evaluating the use of povidone-
iodine spray in abdominal wounds.

Some studies have shown a de-
creased infection rate
24
; others have
shown no difference
25
or an in-
creased rate of infection.
26
Similarly,
chlorhexidine use in general surgical
operations has been examined with
Wound Irrigation
Journal of the American Academy of Orthopaedic Surgeons
222
Table 2
Irrigation Additives
Class Examples Advantages Disadvantages Recommendation
Antiseptics Povidone-iodine, Broad spectrum of Toxic to host cells, may Findings from both animal
chlorhexidine, activity against bacteria, impair immune cell and clinical studies are con-
hydrogen peroxide fungi, viruses; kills function and delay or tradictory; toxicity is more
pathogens in the wound weaken wound healing clearly established than
benefits; should not be used
Antibiotics Bacitracin, Bactericidal or bacterio- Cost, rare toxicity or Clinical efficacy in pre-
polymyxin, static activity in the allergic reaction, pro- venting infection not
neomycin wound, if in adequate motion of bacterial proved; should not be
concentration and resistance used routinely
duration
Surfactants Castile soap, Interfere with bacterial Mild host-cell toxicities Clinical efficacy not
green soap, adhesion to surfaces; proved; consider use

benzalkonium emulsify and remove in highly contaminated
chloride debris wounds, first irrigations
mixed results and is not widely uti-
lized.
21
The use of 0.2% chlorhexi-
dine during arthroscopic reconstruc-
tion of the anterior cruciate ligament
has been shown to cause marked
chondrolysis in articular cartilage.
27
Taken together, the evidence that
the use of antiseptics in surgical
wounds lowers the infection rate is
not convincing, and there is little
information regarding their use in
musculoskeletal wounds. On the
contrary, substantial evidence sug-
gests that wounds can be damaged
by antiseptic use. Therefore, anti-
septic irrigation should not be used,
as it offers risks without demon-
strated benefit.
Antibiotics
Antibiotics differ from antiseptics
in their mechanism of action as well
as in their origin. Many antibiotics
function through interference with
some aspect of bacterial cell physiol-
ogy; these agents affect only cells in

the actively growing phase of the
cell cycle. Other antibiotics are di-
rectly damaging to cell membranes
on contact. However, overall, the
spectrum of activity of antibiotics is
usually narrower and more specific
than that of antiseptics.
Historically, the use of sulfanil-
amide powder in open wounds
resulted in increased wound prob-
lems due to local toxicity. Penicillins,
cephalosporins, and aminoglyco-
sides have been added to irrigation
fluid in the past, but currently the
most widely used additives are baci-
tracin (which interferes with cell
wall synthesis), polymyxin (which
directly alters cell-membrane per-
meability), and neomycin (which,
although an aminoglycoside, acts
topically through a mechanism that
is unknown). Combinations of these
agents in varying concentrations are
also used.
The effectiveness of topical anti-
biotics has been suggested by the
results of in vitro studies of bacterial
growth in suspension or on agar.
Benjamin and Volz
28

showed that a
combination of bacitracin and neo-
mycin applied with a plastic spray
bottle would kill bacterial colonies
growing on sheep’s blood agar.
The results of these studies are not
surprising, but may not be relevant
to the clinical situation.
Animal studies have been per-
formed on several different species,
including guinea pigs, dogs, goats,
pigs, rabbits, and rats, using a vari-
ety of antibiotic agents.
29-31
Wound
contaminants have included S au-
reus, Staphylococcus epidermidis, E coli,
P aeruginosa, Proteus mirabilis, and
human feces. In most animal stud-
ies, antibiotic irrigation has been
more effective than saline irrigation
in reducing the infection rate, and
has caused little or no tissue toxicity.
Two studies involved a skeletal
injury. Rosenstein et al
31
showed
that instillation of 50 mL of bacitracin
solution into the intramedullary
canal of canine femora inoculated

with staphylococci decreased the
number of positive cultures 7 days
later. Conroy et al
29
found that baci-
tracin irrigation was no better than
saline irrigation at reducing positive
cultures in a complex musculoskel-
etal wound in the rat contaminated
with either S aureus or P aeruginosa.
The human studies are primarily
from the general surgery, obstetrics,
and urology literature. They involve
wound sprays, powders, and low-
volume drug solutions introduced or
instilled into body cavities or surgi-
cal wounds either during a surgical
procedure or at closure. The agent
was left in place or aspirated from
the wound after a specific period. In
a review of the literature, Roth et al
32
found that most studies had major
design defects, and those that had
only minor defects were, in their
opinion, inconclusive and uncon-
vincing. Golightly and Branigan
33
reviewed eight recent randomized,
controlled, prospective trials and

found that antibiotic irrigation did
not seem to add anything to systemic
prophylaxis; that effective dosages
were not established; and that sys-
temic absorption and toxicity do
occur, especially with neomycin.
Evaluating the literature from an
orthopaedic perspective, Dirschl and
Wilson
30
found a paucity of informa-
tion defining either the efficacy in
musculoskeletal wounds or the dif-
ferences between its use in soft-tissue
incisional wounds and in skeletal
injuries. They nonetheless recom-
mended “strong consideration” of
the practice of antibiotic irrigation for
such wounds, on the basis of infor-
mation extrapolated from the general
surgery literature.
There are two studies in the
orthopaedic literature regarding
the use of topical antibiotics in elec-
tive orthopaedic surgery cases.
Maguire
34
reported on a series of
1,200 patients who underwent
clean elective procedures and were

randomized to receive systemic
antibiotics (penicillin or tetracy-
cline), topical antibiotics (bacitracin
or neomycin wound spray at clo-
sure), or neither. Only the topical
antibiotic wound spray decreased
the infection rate. Nachamie et al
35
evaluated the data on 216 cases in
which 100 mL of 1% neomycin was
instilled into the wound at the con-
clusion of an elective procedure
and 247 cases in which it was not.
They found no difference in infec-
tion rate. There are no studies on
antibiotic irrigation in human open
fracture wounds.
Many surgeons who use antibiot-
ic irrigation are aware of the lack of
proven efficacy but believe that at
least it does no harm. However,
there are three important drawbacks
to the use of topical antibiotic for
irrigation. The first issue is patient
safety. There are reported cases of
anaphylaxis following bacitracin
irrigation,
36
as well as major compli-
cations due to other antibiotics. The

second concern in this era of cost
containment is the expense of un-
necessary antibiotics. The cost of
Jeffrey O. Anglen, MD
Vol 9, No 4, July/August 2001
223
100,000 U of bacitracin (the dose
commonly used per liter of irriga-
tion fluid) is over $50; if 10 L is used,
the cost is more than $500 per
wound per irrigation procedure.
The third concern is that the indis-
criminate or inadequate use of anti-
biotics may contribute to the develop-
ment of resistant strains of bacteria,
or at least a selection pressure to-
ward more resistant strains in the
wound. In summary, antibiotic irri-
gation is of no proven value in the
care of open fracture wounds and
does entail some risk, albeit small.
Surfactants
Before the antibiotic era, the use
of soap to cleanse open wounds was
recommended frequently. Koch
wrote in 1941 that “In our judge-
ment there is no method so effective
and none which carries so little risk
of injury . . . as the use of plain white
soap applied with soft cotton and

gloved hands.”
37
However, with the
advent of antibiotics, that practice
seems to have fallen by the wayside
and is not widely used today.
Soaps belong to that category of
substances called surfactants. The
surface-active molecules of surfac-
tants consist of two domains: a hy-
drophilic portion and a hydropho-
bic (or lipophilic) portion, which
are usually on opposite ends of the
molecule. The hydrophilic portion
may be charged: in amphoteric sur-
factants, both charges are present; in
cationic surfactants (invert soaps),
there is only a positive charge; and
in anionic surfactants (e.g., soaps),
there is only a negative charge.
Neither charge is present in nonionic
surfactants.
Surfactants function by disrupt-
ing the hydrophobic or electrostatic
forces that drive the initial stages of
bacterial surface adhesion. They
lower the surface tensions that
cause bacteria to clump together on
a surface, and they surround the
organisms in micelles, allowing

them to be rinsed from the wound.
The purpose of detergent irrigation
is to lower the bacterial load in the
wound by removing the bacteria,
rather than by killing them. Some
surfactants are also antiseptics.
In vitro studies have revealed
detrimental effects of surfactants on
living cells. Above a certain concen-
tration, they are toxic to white and
red blood cells. Anionic surfactants
can denature proteins and damage
cell membranes. Cationic surfac-
tants inhibit clotting and hemolyze
red blood cells. Both anionic and
cationic surfactants inhibit phagocy-
tosis. Nonionic detergents have
been described as being gentler on
tissues, but also have some tissue
toxicity, which varies with the size
of the hydrophilic portion. Both
anionic and cationic surfactants are
skin irritants; the intensity of the
irritation potential varies with indi-
vidual compounds.
38
In one rat
study, cationic surfactants de-
creased the tensile strength of skin
strips from healing wounds in a

concentration-dependent manner.
19
In another study, rat spinal wounds
treated with benzalkonium chloride
(a cationic surfactant with antiseptic
properties) showed no histologic
differences from those treated with
normal saline.
39
In vivo studies
have shown some wound irritation
with soaps and detergents, primarily
when they have been injected into
tissues or have been allowed to soak
into a wound without rinsing, which
is a different manner of usage than
clinically intended.
In vitro studies of efficacy have
shown surfactants to be better at
removing surface-adherent bacteria
than other types of irrigation solu-
tions. Castile soap (made with a
potassium salt of coconut oil) was
compared with saline and antibiotic
solutions with regard to the ability
to remove glycocalyx-producing
adherent bacteria from stainless
steel screws. The soap solution was
more effective by several orders of
magnitude, and that effect was

increased by the use of jet lavage.
40
This greater efficacy of soap solu-
tion has been confirmed in studies
involving various bacterial species
and surfaces.
39
The castile soap
solution was as good as or better
than antibiotic in removing two
species of staphylococci from steel,
titanium, and bone and in removing
Pseudomonas organisms from both
metallic surfaces.
A systematic evaluation of differ-
ent types of surfactants using a vari-
ety of microbiologic assays in vitro
showed oleic acid (the primary con-
stituent of castile soap), sodium
dodecyl sulfate, and benzalkonium
chloride to be better than saline in
removing various bacterial species
from steel surfaces.
9
Of the three,
only benzalkonium chloride was
active against a preformed bacterial
film. When the effectiveness of ben-
zalkonium chloride in removing
bacteria from contaminated bovine

muscle was tested, it was found to
perform significantly better (P≤0.001)
than saline irrigation.
5
With ade-
quate volume (10 L) delivered via
jet lavage, the recoverable residual
bacterial count could be driven to 0,
while irrigation with saline never
resulted in counts less than 1×10
5
.
In 1945, Peterson
6
studied the use
of soaps in a canine soft-tissue
wound model and found that while
soaking a wound with soap made
little difference in wound healing or
inflammation, it did increase the in-
fection rate in contaminated wounds.
Scrubbing with soap decreased the
infection rate over soaking alone.
However, in this very early study,
none of the data were subjected to
statistical analysis. In a guinea-pig
study, Singleton et al
41
found that
use of soaps decreased the infection

rate in soft-tissue wounds contami-
nated with human fecal material,
and that scrubbing augmented that
effect. Falconer et al
42
found that
guinea pig wounds contaminated
with staphylococci had a lower infec-
tion rate when irrigated with soap
Wound Irrigation
Journal of the American Academy of Orthopaedic Surgeons
224
and water than those irrigated with
saline in experiments with a 2- to 4-
hour delay between inoculation and
irrigation. The effect did not hold
true for groups with a 0.5- to 1-hour
delay or a 10- to 12-hour delay.
In a rat model of a complex mus-
culoskeletal wound with bone and
soft-tissue injury, the presence of
hardware, and staphylococcal inocu-
lation, benzalkonium chloride was
significantly (P<0.001) better than
normal saline at reducing the num-
ber of positive wound cultures.
39
When the authors attempted to
extend those findings to other bacte-
rial species, they found that al-

though benzalkonium chloride was
better than saline or castile soap at
decreasing positive cultures in
wounds inoculated with staphylo-
cocci, it was significantly worse
(P<0.05) when tested against Pseu-
domonas organisms.
29
In fact, wounds
inoculated with Pseudomonas organ-
isms and irrigated with benzalko-
nium chloride had a 75% incidence
of wound breakdown. This finding
suggests that there are interactions
between host tissue, pathogen, and
treating agent that are specific and
vary with each factor. There may be
specific wound-cleansing agents that
are more effective in certain types of
wounds or with certain types of
pathogen contamination—similar to
the situation with antibiotics, in
which sensitivity testing of bacterial
cultures guides therapy.
Based on the premise that break-
down of Gram-negative bacteria by
benzalkonium chloride causes the
release of endotoxin into the wound,
resulting in wound inflammation
and dehiscence, a sequential irriga-

tion strategy using different irrigants
was tried.
30
Sequential irrigation
with benzalkonium chloride, castile
soap, and normal saline reduced
the rate of infection compared with
saline alone in wounds contami-
nated with P aeruginosa, without the
wound breakdown observed with
benzalkonium chloride alone.
29
Subsequent studies involving this
complex wound model showed that
sequential irrigation strategies can
reduce the rate of infection com-
pared with saline alone in wounds
inoculated with combinations of
Gram-negative and Gram-positive
organisms.
43
Although there are no studies of
the use of soap or surfactant irri-
gation for human open fracture
wounds, the animal data suggest
that surfactant irrigation may prove
to be a useful adjunct to wound
cleansing. It carries a low risk and
should be considered in the heavily
contaminated or very dirty wound.

Summary
Irrigation of open fractures has been
and remains an important compo-
nent of wound treatment, with the
goal of reducing the amount of for-
eign material and necrotic debris
and the bacterial load on the host
immune system, thereby reducing
the incidence of infection. It is an
adjunct to surgical debridement but
cannot compensate for an inade-
quate surgical procedure. Despite
the near unanimous consensus on
the importance of irrigation, specific
practices concerning volume, deliv-
ery method, and fluid additives vary
considerably.
Animal studies have convincingly
shown that high-volume, high-
pressure irrigation is more effective
at removing bacteria and particulate
debris than low-volume, low-pressure
(e.g., bulb-syringe) irrigation. Al-
though the threshold volume is un-
known, most would agree that 6 to
10 L of fluid is a reasonable range
for irrigation of grade 2 or 3 open
fractures. Several types of power-
irrigator and jet-lavage systems are
available and have made it much

simpler to deliver high volumes of
fluid to a wound. Concerns about
damage to bone and other tissues
dictate avoiding the highest pres-
sure settings and selecting a middle
range setting on the irrigator.
Although a variety of irrigation
additives have been advocated, the
scientific literature offers no conclu-
sive evidence of their efficacy.
Antiseptic irrigation is potentially
damaging and without proven bene-
fit and should, therefore, be avoided.
Antibiotic usage in irrigation fluid
for open fractures, although wide-
spread and of generally low risk, is
likewise unproved and expensive.
Soap irrigation improves removal of
dirt and interferes with bacterial
adhesion at a low cost with low risk,
but its clinical efficacy has yet to be
established.
Jeffrey O. Anglen, MD
Vol 9, No 4, July/August 2001
225
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Wound Irrigation
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226