Intraoperative Antiseptic Irrigation: Pertinent Considerations and a Case Series
More than 12.2 million emergency room visits per year in the United States occur due to issues with wound closure and wound management.1 Severe infections of surgical sites and wounds account for between 2.5% and 25% of these visits.2,3 Wound irrigation is one wound management intervention that aims to to decrease bacterial contamination, remove nonviable tissue and debris, and prepare the wound bed for healing.
The concept of wound irrigation dates back centuries, where basic water or wine were the injury cleansing agents of choice.4,5 The use of antiseptics in wound care gained prominence in the 19th century with the pioneering work of Joseph Lister, who introduced carbolic acid (phenol) to sterilize surgical instruments and clean wounds, drastically reducing postoperative infections.6
Throughout the 20th century, wound lavage evolved with the introduction of isotonic solutions (eg, normal saline) and the incorporation of antibiotics and antiseptics directly into irrigation fluids.5 Historically and today, the goals of wound irrigation have included reduction of bacterial load, removal of necrotic debris, and prevention of biofilm formation, particularly in complex or contaminated wounds. In the realm of podiatric surgery, especially with diabetic foot ulcers, osteomyelitis, and traumatic injuries, these techniques became crucial adjuncts to debridement and surgical intervention.
In our experience and opinion, the development of commercially prepared antiseptic-infused wound lavages marks a significant evolution in wound care—delivering standardized, evidence-based antisepsis while minimizing cytotoxicity to healthy tissue.
The irrigation agent discussed in the case series below (Irrisept, Irrimax Corporation) is a single-use, non-cytotoxic wound lavage system containing 0.05% chlorhexidine gluconate (CHG) in a sterile aqueous solution.7 This provides a broad-spectrum antisepsis effective against gram-positive and gram-negative bacteria, fungi, and some viruses.6,8 It is designed to mechanically and chemically cleanse wounds during clinical or surgical procedures. CHG disrupts microbial cell membranes and precipitates cellular contents.8 Unlike antibiotics, it does not induce resistance and retains residual antimicrobial activity on tissues.7
In foot and ankle surgery, particularly in high-risk populations (eg, patients with diabetes, vascular disease), infection prevention and biofilm control are paramount. In our experience, this irrigation agent is particularly beneficial in the following scenarios:
1. Infected Diabetic Foot Ulcers (DFUs) and Osteomyelitis
- Used intraoperatively during debridement to reduce surface bioburden.
- Effective against polymicrobial flora often present in chronic ulcers.9
- Helps disrupt early biofilm, which may not be reached with debridement alone.10
2. Post-Traumatic Wounds and Open Fractures
- In trauma cases involving soft tissue compromise or open fractures (eg, calcaneus, midfoot), 0.05% CHG in saline can reduce bacterial contamination at the time of initial washout.
- Provides a layer of protection without interfering with subsequent wound healing.
3. Surgical Site Irrigation in Hardware Placement/Exposure
- Used before closure in surgeries involving plates, screws, or joint replacements (eg, ankle arthrodesis, ORIF).
- Helps reduce risk of periprosthetic joint infections or implant colonization.11-13
- Particularly useful when a previous infection was present or in revision surgeries.
4. Amputations
- In amputations where infection or gangrene is present, 0.05% CHG in saline helps cleanse residual tissue and bone surfaces prior to closure or application of negative pressure wound therapy (NPWT).
- May reduce postoperative abscess formation or stump infection.14
5. Management of Surgical Wounds with Delayed Primary Closure
- After initial debridement and NPWT, 0.05% CHG in saline can be used just before delayed closure to ensure microbial control.
Discussing Historically Available Irrigation Options
So, why are some surgeons still adding antibiotics to their irrigation as opposed to using other modalities? In the past, there were only limited options for irrigation solutions. While dilute sodium hypochlorite solution and povidone-iodine were available, many surgeons thought they were too harsh.7,8,15 Adding antibiotics to irrigation was seen as a commonsense approach to the problem.
There is good evidence for pulse irrigation versus standard irrigation in decreasing rates of surgical site infections in cases lasting greater than 2 hours with pressures less than 15 psi.16 Nonetheless, we note there is still a lack of standardization when it comes to wound irrigation as a whole and more randomized controlled trials (RCTs) on larger patient samples are necessary for better quality results. This explains why why irrigation is not generally recommended in current guidelines.2
Irrigation can accomplish tissue hydration and allows for dilution of fluids, bacteria and cellular debris.2 Some studies show some bactericidal effects with either antibiotic or antiseptic irrigation, but due to low sample sizes and no standardization it is difficult to say how statistically effective these methods truly are.2
Intraoperative lavage, whether by way of gravity feed or pulse with saline is commonplace in cases involving infection. We contend that, from our experience, mechanical debridement with a solution such as that discussed here should be considered in many additional types of cases, to include open fractures, revisional surgeries following dehiscence or nonunions, or prior skin substitute applications.
Examining Representative Wound Irrigation Cases
Case 1: Partial Fifth Ray Amputation Dehiscence. The patient was a 66-year-old male with a past medical history remarkable for type 2 diabetes mellitus, severe lymphedema, morbid obesity, factor V Leiden mutation, and peripheral artery disease. He underwent a partial fifth ray amputation of the left foot. Postoperatively, he walked on his foot in a surgical shoe without any rest and the wound dehisced (Figure 1A). The patient was a farmer and continued to work outside and around farm animals in the immediate postoperative period—regularly presenting to the clinic with wet and soiled dressings. Cultures taken in the clinic demonstrated multiple drug-resistant bacteria to include Bacteroides fragilis, Citrobacter koseri, Escherichia coli, Pseudomonas aeruginosa, and multiple species of Klebsiella, Morganella, Enterobacter and Serratia. Following multiple wound debridements in clinic, the patient underwent wound irrigation utilizing 0.05% CHG in sterile saline via handheld jet lavage. The mechanical action of the jet lavage was used in combination with the CHG solution to remove bacteria and any other foreign particulate without damaging the surrounding soft tissue. The patient demonstrated complete closure of the left foot surgical wound within 3 months from initiation of the CHG irrigation with wound debridement and local wound care including offloading, topical povidone-iodine, and a multilayer compression dressing (Figure 1B). The patient’s wound remained epithelialized following secondary closure of the surgical wound, which we carefully monitored in the year following treatment.
Case 2: First Tarsometatarsal Joint Arthrodesis Dehiscence. The patient was a 67-year-old female without any significant past medical history who underwent a left first tarsometatarsal joint arthrodesis. She presented 1 week postoperatively with wound dehiscence down to the level of bone and hardware (Figure 2A). The patient began intravenous antibiotics. She subsequently underwent operative debridement 3 times, including wound irrigation utilizing 0.05% CHG in sterile saline in preparation for skin substitute application. It was applied four times. She was able to heal within 12 weeks from the date of surgery without further complications or additional surgery (Figure 2B).
Case 3: Open Trimalleolar Ankle Fracture. The patient was an 80-year-old female who sustained an open trimalleolar fracture after a ground level fall. She initially presented to the emergency department following injury with a more than 10cm laceration overlying the medial malleolus and anterior ankle (Figure 3). There was intermingled debris in this area. She underwent an open reduction with external fixation due to the contamination. During surgery, we utilized irrigation with 0.05% CHG in sterile saline. Her course included oral antibiotics prescribed for 2 weeks. After the wound and soft tissue envelope healed, she went on to an open reduction with internal fixation. She did not develop cellulitis or bone infection during this time.
Case 4: Achilles Tendon Rupture/Infection. The patient was a 76-year-old female with a past medical history of peripheral arterial disease that presented for a wound dehiscence after end-to-end Achilles tendon repair. After surgery, the wound underwent 2 months of treatment with debridement and local wound care. She presented for a second opinion. Clinical examination of the surgical site demonstrated 2 areas with full-thickness dehiscence compounded by evidence of a superimposed infection (Figure 4A). The underlying tendon was discolored and mushy. Magnetic resonance imaging (MRI) demonstrated a full-thickness re-tear of the distal insertional Achilles tendon and proximal retraction of the torn tendon fibers up to 5 cm with adjacent inflammation. After taking the patient to surgery, we noted that the Achilles tendon had indeed re-ruptured with a large portion of the central tendon appearing necrotic/infected. Because of this, it was necessary to resect approximately one-third of the Achilles tendon. Due to the infection, we used 0.05% CHG in sterile saline to irrigate the surgical site. Additionally, she underwent a period of oral antibiotics including 10 days of levofloxacin. She subsequently underwent flexor hallucis longus tendon transfer 16 days later with application of a skin substitute to cover a 5 square centimeter soft tissue defect superficially. We used the 0.05% CHG in sterile saline again at this time. The wound epithelialized within 12 weeks from the initial revisional surgery without further complications (Figure 4B).
In Conclusion
Surgical site infections can result in prolonged hospital stays, increased overall costs and lead to increased morbidity and mortality rates.17 From a podiatric surgical perspective, we feel that 0.05% CHG in sterile saline represents a major advancement in intraoperative and bedside wound care. In our experience, its balance of antimicrobial efficacy and low cytotoxicity makes it ideal for complex foot and ankle wounds, especially in high-risk patients prone to infection.8,18 Compared to traditional lavages, 0.05% CHG in sterile saline offers consistent, targeted antisepsis without the risks associated with systemic antibiotics or harsh antiseptics.7 We find that incorporating it into surgical protocols can improve outcomes and reduce complications such as infection, hardware failure, or reoperation. These case discussions above provide examples of complicated patient scenarios where we observed that adding this modality aided in healing.
Dr. McEneaney is the Owner/CEO of Northern Illinois Foot & Ankle Specialists and a Diplomate of the American Board of Foot & Ankle Surgery.He is a Past President of the Illinois Podiatric Medical Association and Co-Director of the Northwest Illinois Foot & Ankle Foundation Fellowship. He discloses that he is a consultant for Irrisept.
Dr. Bichler is an Associate of the American College of Foot and Ankle Surgeons and practices at Northern Illinois Foot & Ankle Specialists.
Dr. Statkus is a Fellow of the American College of Foot and Ankle Surgeons and practices at Northern Illinois Foot & Ankle Specialists.
Drs. Kolyesnykov and Patel are Associates of the American College of Foot and Ankle Surgeons and is a Fellow at the Northwest Illinois Foot and Ankle Foundation Fellowship.
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