Title: Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds
Authors: Anglen, JO
Source: The Journal of Bone & Joint Surgery 2005; 87-A(7): 1415-1422.
PODIATRIC RELEVANCE:
This large prospective study compares the efficacy of two irrigants – castile soap and bacitracin – for irrigating open fractures of the lower extremity. Foot and ankle fractures comprised 31% of the fractures in this study.
METHODS:
This is a randomized, prospective study conducted from 1995 – 2002 in 400 adult patients (458 fractures) presenting to the emergency room with lower extremity open fracture(s). The patients were randomized to two treatment groups – castile soap (C) or bacitracin (B). Fractures were stratified by severity according to the Gustilo-Anderson system with grade I and II fractures randomized separately from grade III fractures. The amount of solution for irrigation was determined by the Gustilo-Anderson fracture grade: 3 L for grade I fractures, 6 L for grade II fractures and 9 L for grade III fractures. In cases of multiple open fractures on the same patient, the patient was randomized once using the most severe injury and the same solution was used to irrigate each fracture site. For each 3 L of normal saline, 80 ml of castile soap (16 packets) or 100,000 units of bacitracin was added.
Fixation of fractures and wound closure technique was determined by the attending physician. Post-operative antibiotic prophylaxis was a three-day course of a cephalosporin for grade I and II fractures and a five day course of a cephalosporin and an aminoglycoside for grade III fractures. The primary outcomes included nonunion, delayed union, wound infection (deep or superficial) and failure of soft tissue to heal. Exclusion criteria included: prisoner status, lack of informed consent, use of immunosuppressive drugs, previous or pre-existing infection at the fracture site or allergy to any study irrigant or antibiotic.
RESULTS:
There were no significant differences in gender, grade of Gustilo-Anderson fracture, time-to-irrigation after injury, or tobacco, alcohol or illegal drug use between groups B and C. There were significant differences between the groups in age (mean age group B = 38 years, group C = 42 years), mean duration of follow-up (group B = 560 days, group C = 444 days), and post-operative intravenous antibiotic treatment (group B = 11 days, group C = 9 days). Patients were followed for infection, delayed or nonunion and failure of wound healing. There were no significant statistical differences between the groups for infection (group B = 18%, group C = 13%), delayed/nonunion (group B = 25%, group C = 23%). There was a significant difference in failure of wound healing between the two groups (group B = 9.5%, group C = 4%).
COMMENTS:
Irrigation of open fractures is crucial to removing foreign material, necrotic tissue and bone and bacterial contaminants from the wound. It has been shown that irrigation of a metallic surface coated with a layer of glycocalyx producing Staphylococcus epidermidis with soap solution removed more bacteria than irrigation with antibiotic solution. This study finds that non-sterile castile soap and bacitracin are statistically the same in every aspect compared except wound healing, where there were fewer complications in the castile soap group.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.