Intraoperative Irrigation Research Articles

Intraoperative fluid irrigation for traumatic wounds

Intraoperative fluid irrigation for traumatic wounds

Intra-operative wound irrigation to reduce surgical site infections after abdominal surgery: a systematic review and meta-analysis.

Surgical site infection (SSI) remains to be one of the most frequent infectious complications following abdominal surgery. Prophylactic intra-operative wound irrigation (IOWI) before skin closure has been proposed to reduce bacterial wound contamination and the risk of SSI. However, current recommendations on its use are conflicting especially concerning antibiotic and antiseptic solutions because of their potential tissue toxicity and enhancement of bacterial drug resistances. To analyze the existing evidence for the effect of IOWI with topical antibiotics, povidone-iodine (PVP-I) solutions or saline on the incidence of SSI following open abdominal surgery, a systematic review and meta-analysis of randomized controlled trials (RCTs) was carried out according to the recommendations of the Cochrane Collaboration. Forty-one RCTs reporting primary data of over 9000 patients were analyzed. Meta-analysis on the effect of IOWI with any solution compared to no irrigation revealed a significant benefit in the reduction of SSI rates (OR = 0.54, 95 % confidence Interval (CI) [0.42; 0.69], p < 0.0001). Subgroup analyses showed that this effect was strongest in colorectal surgery and that IOWI with antibiotic solutions had a stronger effect than irrigation with PVP-I or saline. However, all of the included trials were at considerable risk of bias according to the quality assessment. These results suggest that IOWI before skin closure represents a pragmatic and economical approach to reduce postoperative SSI after abdominal surgery and that antibiotic solutions seem to be more effective than PVP-I solutions or simple saline, and it might be worth to re-evaluate their use for specific indications.

What Should Be Considered to Cause the Early Post-Craniotomy Seizure: Antibiotics (Cefazolin) Irrigation.

ObjectivePost-craniotomy seizure (PCS) is reported only rarely. However, our department noted a 433% increase in PCS for a year beginning September 2010, especially after cerebrovascular surgery. Our goal was to identify the cause of our unusual outbreak of PCS.MethodsFor almost one year after September 2010, cases of PCS increased significantly in our department. We analyzed 973 patients who had received a major craniotomy between January 2009 and November 2011. We included seizures that occurred only in the first 24 postoperative hours, which we defined as early PCS. After verifying the presence of PCS, we analyzed multiple seizure-provoking factors and their relation to the duration and character of seizure activity.ResultsOverall PCS incidence was 7.2% (70/973). Cefazolin (2 g/L saline) was the antibiotic drug used for intraoperative irrigation in 88.4% of the operations, and no PCS occurred without intraoperative cefazolin irrigation. When analyzed by operation type, clipping surgery for unruptured aneurysms was the most frequently associated with PCS (80%). Using logistic regression, only 2 g cefazolin intraoperative irrigation (p=0.024) and unruptured aneurysm clipping surgery (p<0.001) were associated with early PCS. The seizure rate of unruptured aneurysm clipping surgery using 2 g cefazolin intraoperative irrigation was 32.9%.ConclusionIntraoperative cefazolin irrigation must be avoided in patients undergoing craniotomy, especially for clipping of unruptured aneurysms, because of the increased risk of early PCS.

National Practice Patterns of Infection Prophylaxis for Sacral Neuromodulation Device: A Survey of High Volume Providers

IntroductionSacral neuromodulation using the InterStim® device is a safe, effective treatment for urgency, frequency, urgency incontinence, nonobstructive urinary retention and fecal incontinence. However, there is no standard recommendation regarding infection prophylaxis. Therefore, we surveyed the infection prophylaxis patterns of high volume device providers to describe current practice patterns of perioperative infection prophylaxis. MethodsA web based survey was sent to 35 high volume providers, including urologists, gynecologists and colorectal surgeons. ResultsOur response rate was 89% (31 of 35 participants). Of the providers 51% were urologists, 39% were gynecologists and 10% were colorectal surgeons. Of the respondents 74% had performed more than 200 procedures and 22% had done more than 500. The testing period was generally 1 to 2 weeks. Only 13% of the surveyed providers routinely screened for methicillin resistant Staphylococcus aureus. All providers administered antibiotics preoperatively, most commonly cefazolin or vancomycin, and 81% administered antibiotics postoperatively, most commonly cephalexin and trimethoprim-sulfamethoxazole. Most providers prescribed 5 to 7 days of treatment but 6 (19%) prescribed no postoperative antibiotics. In addition, 71% of respondents used adjunctive measures, frequently intraoperative wound irrigation and/or a preoperative chlorhexidine shower. After stages 1 and 2, 19% of providers prohibited showering for more than 3 days postoperatively while 61% permitted showering after 1 or 2 days and 19% recommended no bathing restriction. ConclusionsWe present the infection prevention practices of high volume InterStim sacral neuromodulation device implanters in the United States. Further study is warranted to guide evidence-based practice in InterStim infection prophylaxis.

Impact of intraoperative hydrodebrider treatment on postoperative sinonasal inflammation.

The impact of intraoperative hydrodebrider sinus irrigation (HSI) during endoscopic sinus surgery (ESS) on postoperative inflammation, endoscopy, and patient-reported outcomes has not been studied. A clinical trial of 12 patients with symmetric chronic rhinosinusitis were prospectively randomized to HSI on one side after undergoing bilateral ESS. The contralateral side was not treated with any irrigation and served as an internal control. Preoperative computed tomography, endoscopic, 22-item Sino-Nasal Outcome Test (SNOT-22), and symptom visual analog scale (VAS) scores for each side were obtained. At 1 and 3 months postsurgery, endoscopy, SNOT-22, and sinus VAS were recorded. Sinonasal mucus levels of interleukin (IL)-6, IL-10, IL-17a, and tumor necrosis factor (TNF) alpha were measured at the time of surgery, 1 and 3 months, postoperatively, from each side. VAS scores improved on both sides (p < 0.05) and SNOT-22 improved at all postoperative time points (p < 0.05). Endoscopic scores of HSI-treated sides did not improve compared with baseline. HSI had no additional significant impact on postoperative VAS at any time point. HSI significantly decreased IL-17a levels when compared with the control side at 1 month (p = 0.034) and 3 months (p = 0.031). No significant change was seen in TNF-alpha, IL-6, or IL-10 on either side at any time point. Intraoperative HSI at the time of ESS failed to establish any improvement in postoperative endoscopy or most local cytokine levels after ESS.

Absorption of Irrigation Fluid Occurs Frequently during High Power 532 nm Laser Vaporization of the Prostate

Absorption of irrigation fluid was not detected during GreenLight™ laser vaporization of the prostate using the first generation 80 W laser. However, data are lacking on intraoperative irrigation fluid absorption using the second generation 120 W high power laser. We assessed whether fluid absorption occurs during high power laser vaporization of the prostate. We performed this prospective investigation at a tertiary referral center in patients undergoing 120 W laser vaporization for prostatic bladder outlet obstruction. Normal saline containing 1% ethanol was used for intraoperative irrigation. The expired breath ethanol concentration was measured periodically during the operation using an alcometer. The volume of saline absorption was calculated from these concentrations. Intraoperative changes in hematological and biochemical blood parameters were also recorded. Of 50 investigated patients 22 (44%) had a positive breath ethanol test. Median absorption volume in the absorber group was 725 ml (range 138 to 3,452). Ten patients absorbed more than 1,000 ml. Absorbers had a smaller prostate, more capsular perforation, higher bleeding intensity and more laser energy applied during the operation. Three patients (13%) had symptoms potentially related to fluid absorption. Hemoglobin, hematocrit and serum chloride were the only blood parameters that changed significantly in the absorber group. The changes were significantly different than those in nonabsorbers. Fluid absorption occurs frequently during high power laser vaporization of the prostate. This should be considered in patients who present with cardiopulmonary or neurological symptoms during or after the procedure.

Risk Factors in Chronic Subdural Hematoma: Comparison of Irrigation with Artificial Cerebrospinal Fluid and Normal Saline in a Cohort Analysis

BackgroundChronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists.ObjectiveTo identify the potential of ACF irrigation to prevent CSDH recurrence. More specifically, to investigate the perioperative and intraoperative prognostic factors, and to identify controllable ones.MethodsTo examine various prognostic factors, 120 consecutive patients with unilateral CSDH treated with burr-hole drainage between September 2007 and March 2013 were analyzed. Intraoperative irrigation was performed with one of two irrigation solutions: normal saline (NS; n = 60) or ACF (n = 60). All patients were followed-up for at least 6 months postoperatively. We also examined the morphological alternations of the hematoma outer membranes after incubation with different solutions.ResultsEleven patients (9.2%) had recurrence. Nine patients (15%) required additional surgery in the NS group, whereas only 2 patients (3.3%) in the ACF group required additional surgery. Among preoperative and intraoperative data, age (<80 years old, P = .044), thrombocyte (>22.0, P = .037), laterality (right, P = .03), and irrigation solution (ACF, P = .027) were related to smaller recurrence rates by log-rank tests. Only the type of irrigation solution used significantly correlated with recurrence in favor of ACF in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04–0.99; P = .049) and logistic regression models (odds ratio, 0.17, 95% CI: 0.03–0.92; P = .04) using these factors. Histological examinations of the hematoma membranes showed that the membranes incubated with NS were loose and infiltrated by inflammatory cells compared with those incubated with ACF.ConclusionIrrigation with ACF decreased the rate of CSDH recurrence.

Research

The June 2014 Research Roundup360 looks at:Intraoperative irrigation a balance of toxicities; Ibandronate effective in bone marrow oedema; Risk stratification in damage control surgery; Osteoblast like cells potentially safe; Better wear and antibacterial?; Assessing outcomes in hip fracture.

MP71-20 ABSORPTION OF IRRIGATION FLUID IS FREQUENTLY DETECTABLE DURING 180W 532-NM LASER VAPORIZATION OF THE PROSTATE: RESULTS FROM A PROSPECTIVE INVESTIGATION USING BREATH ETHANOL MEASUREMENTS

INTRODUCTION AND OBJECTIVES: Laser vaporization (LV) of the prostate using the 532-nm laser is a recommended treatment option for patients with prostatic bladder outlet obstruction and particularly for those with significant cardiovascular comorbidities. Despite the excellent coagulation properties of the laser, fluid absorption was frequently detectable during 120W LV of the prostate. For the nextgeneration 180W laser, a better coagulation technology has been announced. If fluid absorption occurs during LV using this improved but also more powerful laser is unknown. METHODS: Intraoperative fluid absorption was investigated during routine LV using the 180W Greenlight XPS laser (AMS, USA) in 32 consecutive patients. For this purpose intraoperative irrigation was performed using saline containing 1% ethanol. Measurements of breath ethanol were performed every 10 minutes during the operation with a conventional alcometer. The volume of fluid absorption was calculated from these results. Intraoperative changes in hemoglobin (Hb), hematocrit (Hct), venous pH and serum Na, K, Cl, HCO3 were also recorded. Statistical analysis was done using Mann Whitney U test and Wilcoxon signed-rank test. RESULTS: Median age was 73 y (range: 56 85 y), median prostate volume 50 ml (20 99 ml). The median operative time was 60 min (30-150 min), the intraoperative irrigation volume 21 L (6 42 L), and the applied laser energy 175 kJ (70 e 544 kJ). 17 patients (53%) had a positive ethanol test. The median calculated absorption volume in these patients was 827 ml (138 e 4808 ml). In the absorber group, a significant decrease in Hb, Hct, HCO3, pH (p1⁄40.001, 0.004, 0.002 and 0.02, respectively), and a significant increase in serum Cl (p1⁄40.007) were detectable. The changes in Hb, Hct, Cl and HCO3 were significantly greater compared to the non-absorber group (p1⁄40.005, 0.02, 0.001 and 2000ml) were prolonged metabolic acidosis and somnolence, hypothermia, jugular venous distension and significant postoperative weight gain. CONCLUSIONS: Intraoperative fluid absorption occurs in a significant proportion of patients during 180W LV of the prostate. Fluid absorption can be excessive and thus clinically relevant. Early identification of fluid absorption using the ethanol breath test enables timely interventions. If ethanol monitoring is not available, changes in Hb, Hct, pH, HCO3 and Cl can be used to detect potentially dangerous fluid absorption.

Selection of an Optimal Antiseptic Solution for Intraoperative Irrigation

With increasing bacterial antibiotic resistance and an increased infection risk due to more complicated surgical procedures and patient populations, prevention of surgical infection is of paramount importance. Intraoperative irrigation with an antiseptic solution could provide an effective way to reduce postoperative infection rates. Although numerous studies have been conducted on the bactericidal or cytotoxic characteristics of antiseptics, the combination of these characteristics for intraoperative application has not been addressed. Bacteria (Staphylococcus aureus and S. epidermidis) and human cells were exposed to polyhexanide, hydrogen peroxide, octenidine dihydrochloride, povidone-iodine, and chlorhexidine digluconate at various dilutions for two minutes. Bactericidal properties were calculated by means of the quantitative suspension method. The cytotoxic effect on human fibroblasts and mesenchymal stromal cells was determined by a WST-1 metabolic activity assay. All of the antiseptics except for polyhexanide were bactericidal and cytotoxic at the commercially available concentrations. When diluted, only povidone-iodine was bactericidal at a concentration at which some cell viability remained. The other antiseptics tested showed no cellular survival at the minimal bactericidal concentration. Povidone-iodine diluted to a concentration of 1.3 g/L could be the optimal antiseptic for intraoperative irrigation. This should be established by future clinical studies.

To Wash or Not to Wash: That Is the Question

There has been heightened interest in the prevention and minimization of perioperative infections1. These efforts have included, but are not limited to, the NSQIP (National Surgical Quality Improvement Program) and SCIP (Surgical Care Improvement Program). Notwithstanding this heightened interest, the substantial morbidity and increased costs of perioperative infections are best avoided. A few recent clinical studies have indicated decreased infection rates in surgical procedures in which the surgeons employed intraoperative irrigation with an antiseptic solution. Brown et al. reported a reduction in the ninety-day infection rate in hip and knee arthroplasties from 0.97% (in wounds irrigated with 1 L of normal saline solution prior to closure) to 0.15% with a three-minute irrigation with dilute (0.35%) Betadine and a 10% povidone-iodine skin application prior to final closure2. Cheng et al. performed a prospective randomized spine surgery trial and reported no infections in 208 patients following irrigation with dilute (3.5%) Betadine compared with one superficial and six deep infections in 206 patients treated without irrigation (p < 0.01)3. However, there have been few such studies, and the antiseptic agents and their concentration have varied among the studies, presumably on the basis of which antiseptic solutions were readily available and on empirical practices. To our knowledge, there have been no in vivo studies comparing the efficacy or toxicity …

Using Incidental Side Branches of Vessels for Intraoperative Cannulation and Irrigation of the Microvascular Anastomosis

Using Incidental Side Branches of Vessels for Intraoperative Cannulation and Irrigation of the Microvascular Anastomosis

Perioperative Skin Preparation

Liaison: Anthony T Tokarski BS Leaders: David Blaha MD (US), Michael A. Mont MD (US), Parag Sancheti MS, DNB, MCh (International) Delegates: Lyssette Cardona MD, MPH, MHA, AAHIVS, FIDSA, Gilberto Lara Cotacio MD, Mark Froimson MD, Bhaveen Kapadia MD, James Kuderna MD, PhD, Juan Carlos Lopez MD, Wadih Y Matar MD, MSc, FRCSC, Joseph McCarthy MD, Rhidian Morgan-Jones MB BCh, FRCS, Michael Patzakis MD, Ran Schwarzkopf MD, Gholam Hossain Shahcheraghi MD, Xifu Shang MD, Petri Virolainen MD, PhD, Montri D. Wongworawat MD, Adolph Yates Jr, MD

Recurrence of the Chronic Subdural Hematoma after Burr-Hole Drainage with or without Intraoperative Saline Irrigation.

ObjectiveAlthough standard method has not been established for the chronic subdural hematoma (CSDH), burr-hole trephination and closed system drainage with or without irrigation has been widely accepted as the treatment of choice. The aim of this study is to analysis the post-operative recurrence rates after burr-hole trephination of the CSDH according to the conduction of irrigation.MethodsWe retrospectively reviewed 184 patients with CSDH who underwent surgical treatment between January 2009 and December 2013. And 152 patients fulfilled the inclusion criteria as follows: 1) CSDH diagnosed on computed tomography (CT), 2) unilateral hematoma, 3) burr-hole trephination with closed system drainage, and 4) follow-up CT for at least 3 months. Those patients were divided into two groups. Group A (n=38) underwent burr-hole trephination without irrigation, and Group B (n=114), burr-hole trephination with saline irrigation.ResultsThe overall post-operative recurrence rate was 19.1% (n=29) in this study. The majority of recurrence showed in Group B. Twenty-eight patients (24.6%) of Group B had recurrence and only 1 patient (2.6%) of Group A showed recurrence. The recurrence rate was significantly higher in Group B compared with Group A (p=0.003). Another affecting factor for the recurrence was the amount of postoperative pneumocephalus (p=0.02). No catastrophic complications were found in postoperative course.ConclusionAlthough there was no difference of clinical outcome in both groups, the recurrence rate was higher in saline irrigation group compared with no irrigation group. We suggest that saline irrigation procedure be reserved only for selected cases in CSDH burr-hole surgery.

Chronic subdural hematoma: complication avoidance

Background and objectiveChronic subdural hematoma (CSDH) is defined as the presence of a typical neomembrane, typical liquefied blood within the hematoma cavity, and 3 weeks of more of acute subdural hematoma. It has been classified into separate, laminar, homogenous, and trabecular types. This study analyzed the complications after burr hole evacuation in CSDHs and the best methods to avoid or at least minimize them.Materials and MethodsA total of 28 patients who were suffering from complications after evacuation of CSDH were analyzed. Data on patients and treatment protocol were collected. Medical problems were also managed. Complications were studied as regards their causes and avoidance.ResultsThe highest incidence of complications is observed in the seventh decade of life. Recurrence was the most common complication especially in the separate type. The recurrence rate was higher among patients operated through a single burr hole. Extradural hematomas, although rare, were observed in three patients. Acute subdural hematoma and cerebral infarction had the worst prognosis.ConclusionSubgaleal dissection and insertion of a subgaleal drain are important for absorption and suction of the residual air and blood. In addition, intraoperative copious saline irrigation and postoperative meticulous follow-up are important for patients with a high risk of recurrence, especially those with hematomas of the separate type. During evacuation of the hematoma, we must avoid sudden decompression of the brain as it leads to cerebral infarction or intracranial hemorrhage. It is important to inform the anesthetist before performing the drainage that the blood pressure should be closely monitored and maintained at normal levels while infusing normal saline during surgery to avoid hypotension, which may lead to infarction. Any source of blood from the extradural space must be adequately dealt with.

Simple Steps to Minimize Spine Infections in Adolescent Idiopathic Scoliosis

To examine the surgical site infection (SSI) rates in patients undergoing posterior spinal fusion surgery for adolescent idiopathic scoliosis (AIS) after implementation of a change in antibiotic prophylaxis and intraoperative irrigation. A retrospective review of all consecutive spinal fusions for AIS from 1996 to 2008 was performed. In 2003, 2 changes in our protocol were implemented: (1) routine antibiotic prophylaxis was changed from cefazolin alone to vancomycin and ceftazidime; (2) intraoperative irrigation technique was changed from bulb syringe to pulse lavage irrigation. We compared the rates of deep SSI requiring irrigation and debridement before institution of these changes (1996 to 2002) to the rates after these changes (2003 to 2008). Before the change in the antibiotic and lavage regimen, 261 spinal fusions were performed. Of these, 28/261 (11%) patients underwent irrigation and debridement for SSI. The most common infecting pathogen was coagulase-negative Staphylococcus aureus (47%). Between the years 2003 and 2008, 263 spinal fusions were performed. Only 2/263 (0.7%) patients underwent irrigation and debridement for SSI. This decrease in infection rate is highly significant (P<0.001). Routine use of vancomycin and ceftazidime and pulsatile lavage for posterior spinal fusion in AIS patients decreased the rates of postoperative infection by 10 fold. As 2 variables were changed, it is impossible to know the relative effect of each. However, as spine infections can be so devastating, and the potential risks of these changes are small, we recommend both the new antibiotic and irrigation protocol. Level III.

Change in Central Macular Thickness after 2.2-mm Microincision Coaxial versus 2.75-mm Small Incision Cataract Surgery

Purpose: To evaluate the central macular thickness and volume changes after conventional 2.75-mm small incision cataract surgery (SICS) and 2.2-mm microincision coaxial cataract surgery (MICS). Methods: We performed a retrospective chart review of 48 eyes undergoing uneventful phacoemulsification and divided the subjects into two groups, SICS and MICS. To evaluate the central macular thickness and volume changes after cataract surgery, optical coherence tomography (OCT) was used before and at one day, one week, one month, and two months postoperatively. Results: No statistically significant difference was found in the intraoperative phacoemulsification power, phaco time, or volume of intraoperative irrigation solution between the two groups (p > 0.05). The average central macular thickness increased in the MICS group compared to the SICS group at every postoperative time point, and the difference was statistically significant at postoperative one month (p = 0.04). The average central macular volume was elevated in the MICS group; however, the difference was not significant (p > 0.05). Conclusions: Central macular thickness and volume change were greater in the MICS group compared to the SICS group, and the difference in central macular thickness between the two groups was significant at postoperative one month. Careful follow-up examinations should be performed using OCT at this postoperative time point, especially in patients who received cataract surgery with smaller incision size. J Korean Ophthalmol Soc 2014;55(10):1460-1469

Postoperative fever specific to neuroendoscopic procedures.

The most common complication of neuroendoscopic surgery is postoperative fever without infection, although the details have not been discussed. The objective of this study was to clarify the clinical features and predicting factors of the postoperative fever following neuroendoscopic procedures. Between March 1998 and March 2013, 83 patients (46 males, 37 females; median age, 14.0years) who had undergone surgery via the transventricular approach under a neuroendoscopic view were included in this study. A total of 86 neuroendoscopic procedures were performed in 83 patients. The incidence and duration of postoperative fever (≥38.0 and ≥39.0°C) over the 7days after surgery were examined. Moreover, the following variables predictive of fever were investigated: age, sex, neuroendoscopic procedure, operative time, and intraoperative irrigation fluid. The incidence of postoperative fever was 65.1% (≥38.0°C) and 15.1% (≥39.0°C). The median level of the highest fever was 38.6°C. The fevers developed immediately after surgery and spontaneously disappeared within four postoperative days. Only age was related to postoperative fever (p = 0.032). The postoperative body temperature was negatively correlated with age in all 86 surgeries (p < 0.001, Spearman r = -0.396). In particular, patients under 10years of age tended to have postoperative fever (p = 0.005). The result of this study demonstrated a peculiar pattern of fever following neuroendoscopic procedures. This type of fever did not cause serious problems; however, special attention should be paid to the high incidence of postoperative fever in patients under 10years of age.

Intraoperative irrigation cytology of the remnant pancreas to detect remnant distinct pancreatic ductal adenocarcinoma in patients with intraductal papillary mucinous neoplasm undergoing partial pancreatectomy

Patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas may have concomitant distinct pancreatic ductal adenocarcinoma (PDAC). We evaluated the safety and usefulness of intraoperative irrigation cytology of the remnant pancreas (IICP) during pancreatectomy to detect remnant distinct PDAC in patients with IPMN. The records of all 48 patients with IPMN who underwent IICP during partial pancreatectomy at our institution from April 2007 to March 2012 were reviewed retrospectively. After division of the pancreas, a 4-French tube was inserted into the main pancreatic duct of the remnant pancreas from the cut edge, and fluid for cytologic examination was obtained by saline irrigation through the tube. If the third IICP was positive, patients underwent additional pancreatic resection. Clinical and pathologic outcomes were evaluated. The third IICP was positive in 5 patients. Postoperative pathologic examination showed that these patients all had remnant distinct PDAC in the additionally resected specimen, which was not detectable on preoperative imaging examination or on intraoperative macroscopic examination, ultrasonography, or palpation. This PDAC was stage 0 in 4 patients and stage III in 1 patient. No procedure-related complications were observed. One patient developed peritoneal metastasis after 10 months, 1 developed liver metastasis after 20 months, and 1 developed PDAC in the remnant pancreas after 24 months. IICP seems to be a safe and useful method for detection of early stage PDAC concomitant with IPMN that cannot be detected by preoperative imaging or intraoperative examination.

Development of vitamin C irrigation saline to promote graft healing in anterior cruciate ligament reconstruction

Summary Graft healing in anterior cruciate ligament (ACL) reconstruction is often slow and compromised. There are numerous treatment strategies targeting at the biological healing process in ACL reconstruction. Most of these treatments attempt to promote graft incorporation at the tendon to bone interface, although the intra-articular mid substance would be more problematic. As intraoperative injection of vitamin C has been reported to be able to promote tendon healing, we speculate that vitamin C supplementation may also work for graft healing enhancement in ACL reconstruction. The purpose of this study is to formulate a vitamin C-supplemented saline for intraoperative irrigation, in order to promote biological healing in ACL reconstruction. The study hypothesis was tested using 114 rats. During ACL reconstruction, the knee joint of the rats were irrigated with either normal saline, or saline supplemented with 3 mg/mL, 10 mg/mL, or 30 mg/mL vitamin C. Inflammatory response was measured by serum C-reactive protein enzyme-linked immunosorbent assay at Day 1, Day 4, and Day 7 postoperation. Functional recovery was evaluated by gait analysis at preinjury, and Week 4 and Week 6 postoperation. Knee samples were harvested at Week 6 postoperation for anterior–posterior (A–P) knee laxity test and graft pull-out test. Histology was performed at Day 1, Day 4, Day 7, and Day 42 for scoring. Vitamin C supplementation at all doses significantly reduced serum C-reactive protein level as compared to saline control at Day 1 ( p = 0.029) postoperation. At 6 weeks postoperation, ACL reconstruction with 3 mg/mL vitamin C irrigation led to a better restoration of A–P knee laxity as compared to saline irrigation ( p = 0.032), whereas no positive effect was observed in the groups with 10 mg/mL and 30 mg/mL vitamin C irrigation. Vitamin C irrigation did not affect ultimate load of the graft complex. Histological analysis revealed that at Week 6 postoperation, graft deterioration was significantly reduced in 3 mg/mL and 10 mg/mL vitamin C groups, but no significant difference was observed in graft incorporation among different groups at Day 42 postoperation. Although no significant difference was detected in the gait parameters among experimental groups, increased percentage of rats with asymmetric walking gait (with limb idleness index > 1.3) was found in the groups of 10 mg/mL or 30 mg/mL vitamin C irrigation. The results showed that intraoperative supplementation of low dose (3 mg/mL) vitamin C effectively reduced graft deterioration and improved restoration of A–P knee laxity at 6 weeks postoperation, but higher doses of vitamin C irrigation may have side effects that lead to a higher chance of gait asymmetry. This study reveals the potential use of surgical irrigation saline as a delivery method for bioactive agents to promote healing, which might be a cost-effective and translatable approach for biological modulation for orthopaedic surgeries.