Email updates

Keep up to date with the latest news and content from BMC Musculoskeletal Disorders and BioMed Central.

Open Access Research article

Fluid lavage in patients with open fracture wounds (FLOW): an international survey of 984 surgeons

Brad Petrisor1, Kyle Jeray2, Emil Schemitsch3, Beate Hanson4, Sheila Sprague5, David Sanders6, Mohit Bhandari15* and the FLOW Investigators

Author Affiliations

1 Department of Surgery, McMaster University, Hamilton, Ontario, Canada

2 Department of Surgery, Greenville Hospital System, Greenville, South Carolina, USA

3 Department of Surgery, University of Toronto, Toronto, Ontario, Canada

4 AO Foundation, Davos, Switzerland

5 Departments of Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

6 Department of Surgery, University of Western Ontario, London, Ontario, Canada

For all author emails, please log on.

BMC Musculoskeletal Disorders 2008, 9:7  doi:10.1186/1471-2474-9-7

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2474/9/7


Received:3 October 2007
Accepted:23 January 2008
Published:23 January 2008

© 2008 Petrisor et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Although surgeons acknowledge the importance of irrigating open fracture wounds, the choice of irrigating fluid and delivery pressure remains controversial. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds.

Methods

We used a cross-sectional survey and a sample-to-redundancy strategy to examine surgeons' preferences in the initial management of open fracture wounds. We mailed this survey to members of the Canadian Orthopaedic Association and delivered it to attendees of an international fracture course (AO, Davos, Switzerland).

Results

Of the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, the majority of surgeons surveyed, 676 (70.5%), favoured normal saline alone. Bacitracin solution was used routinely by only 161 surgeons (16.8%). The majority of surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound. There was, however considerable variation in what pressures constituted high versus low pressure lavage. The overwhelming majority of surgeons, 889 (94.2%), reported they would change their practice if a large randomized controlled trial showed a clear benefit of an irrigating solution – especially if it was different from the solution they used.

Conclusion

The majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds. However, opinions varied as regards the comparative efficacy of different solutions, the use of additives and high versus low pressure. Surgeons have expressed considerable support for a trial evaluating both irrigating solutions and pressures.

Background

Approximately 3–4% of all fractures are open fractures [1]. This translates to over 3,400 open fractures in Canada and an estimated 250,000 open fractures in the United States annually[1,2]. Reported rates of infection following severe open tibial fractures have ranged from 5% to 50% with infection potentially resulting in a significant number of repeat operations, delay in fracture healing and possible development of fracture nonunion [3-7]. Prevention of infection, stable fixation of the fractured bone and restoration of patient function remain paramount in the management of these complex injuries.

Meticulous debridement of contaminated soft tissues along with copious fluid irrigation is regarded as the most important initial step in the surgical wound management of open fractures [2,4,8-10]. While several authors have proposed techniques for irrigation, many issues remain unresolved including the irrigating pressures, the amount of irrigation, and the irrigating solution[2,11-14]. Identifying the optimal irrigating solution and pressure at which this solution should be delivered has global relevance. By 2020, disability from traffic accidents, the major cause of fractures is estimated to rank in the top 3 of all cause disability from disease. Accelerated urbanization and industrialization in India and China, which represent 40% of the world's population, have resulted in an alarming increase in traumatic injuries. A vehicular accident is reported every three minutes and a death every ten minutes on Indian roads. For every death, 3 patients survive and live with disability.

To explore current practice in the management of open wounds, we conducted an international survey of practicing orthopaedic surgeons in order to learn about their preferences for fluid irrigation of open fractures and to identify the need for future research in this area. We hypothesized that there was considerable variability in the operative treatment of open fracture wounds. Furthermore, we reasoned that the results of this survey may identify factors that influence a surgeon's preference for a particular treatment, serve to educate the orthopaedic community on issues regarding the treatment of open fractures, and allow for the development of future clinically related trials, which could help resolve the current controversy on optimal irrigation techniques among orthopaedic surgeons.

Methods

Questionnaire Development

Item Generation

We developed a questionnaire using focus groups, key informants, and the previous literature. Orthopaedic surgeons in Canada and the United States participated in the development of the questionnaire.

The items generated from the focus group were improved by data from a MEDLINE search of articles published from 1966 to 2006 using text words "irrigation," "debridement," "infection," "open fractures," "pressure," "anti-bacterial agents," "detergents," "soaps," "solutions," "disinfection," and "bacitracin." Further items were generated with key informants. Surgeons specializing in orthopaedic trauma provided additional input into potential items for the questionnaire. We used a "sample to redundancy" approach by which we contracted new surgeons until no new items for the questionnaire emerged.

Pretesting and Validity Assessments

We pretested the questionnaire with an independent group of four orthopaedic surgeons to evaluate whether the questionnaire as a whole appeared to adequately address the question of current practice in treating open fractures (face validity); and whether the individual questions adequately reflected the four broad domains of surgeon training and experience, technical aspects of irrigation and debridement, and perioperative issues in open fractures (content validity). These surgeons also commented on the clarity and comprehensiveness of the questionnaire.

The final questionnaire framed the response options in one of two ways: five-point Likert scales or nominal scales. A previous report has shown that closed-ended questions resulted in fewer incomplete questionnaires than open-ended formats[15]. We obtained information regarding surgeon age, sex, number of open fractures treated per year, supervision of resident trainees, continent of practice, fellowship training in trauma, and type of practice (community or academic). Academic practice was defined as a formal affiliation with a university centre. In addition, we asked surgeons tochoose their preference for the following: time point for wound management, location of initial irrigation and debridement, time point to repeat debridement, type of irrigating solution, amount of irrigating solution, pressure (high vs. low) used, method of delivering irrigating solution, and definitions of high pressure and low pressure.

Questionnaire Administration

We surveyed all surgeons who were members of the Canadian Orthopaedic Association (COA) (active members, associate members, international members, senior members, honourary members, and emeritus members). Members of the COA each received a mailed package that included a copy of the survey, a personalized cover letter, and a return envelope. Surveys were not sent to non-responders, as repeat mailings were not necessary to obtain our required sample size. In addition, we surveyed orthopaedic surgeons attending an international trauma course (Davos, Switzerland). These surgeons each received a cover letter and copy of the survey to complete while attending the trauma course.

No monetary incentives or pre-notification telephone calls were used for this survey. Individual responses were kept confidential and questionnaire completion was voluntary. Individual responses were kept confidential and questionnaire completion was voluntary. This study was approved by our local ethics review board.

Sample Size

In order to determine the number of respondents needed to sufficiently power our analysis, we assumed, based on findings reported in the literature, that approximately 35% of surgeons surveyed used high pressure irrigation. In addition, we intended to use a 95% confidence interval, with a 95% confidence level. The calculation for appropriate sample size was performed according to the following formula:

N = (Zα/w)2p(1 - p)

Where:

Z = z value (1.96 for 95% confidence interval)

w = the confidence interval, expressed as decimal (0.05 = +/- 5)

p = percentage picking a choice, expressed in decimal (35% = 0.35)

According to our calculation, approximately 650 completed questionnaires facilitated meaningful analysis. Based on previous surveys of orthopaedic surgeons we anticipated a 70% response rate; therefore, a total of at least 930 questionnaires needed to be administered to obtain the desired number of completed surveys.

Statistical Analysis

We summarized categorical and dichotomous variables with percentages. Whenever the distribution of responses for a particular item in the questionnaire had multiple empty cells (cutpoints), we collapsed the categories in that particular item to achieve an even distribution of responses.

We performed univariable linear regression analysis to evaluate association between surgeon age, type of practice, fellowship training, trauma volume, amount of irrigation and type of irrigation used. Factors that were significantly associated with each dependent variable were combined in a multiple regression analysis. We plotted residuals from the regression analysis to ensure a normal distribution of the data points. We reported beta values and their 95% confidence intervals for each independent variable in the analysis.

Results

Characteristics of the respondents

Of the 1,764 surgeons who received the questionnaire, 984 (55.83%) responded. Of the 764 COA members, 328 (42.9%) completed the survey. Of 1,000 participants who received the survey at the trauma course, 656 responded by completion (65.6%). The typical respondent was a male over 30 with greater than 5 years of practice (Table 1). The majority [597 (61.2%)] worked in an academic centre and supervised trainees [587 (59.9%)] (Table 1). Two hundred and ninety-eight (37%) respondents had completed further orthopaedic trauma fellowship training with 344 (35.3%) of respondents spending >50% of their practice doing orthopaedic trauma (Table 1). Six hundred and three (63%) respondents see more than 10 open fractures per year and 107 (11.2%) see over 50 open fractures per year.

Table 1. Demographics

Management Preferences

Type of Fluid

When asked what type of irrigating solution was routinely used for open fracture wounds in their practice (Table 2), 676 (70.5%) respondents favoured normal saline alone. The most common additive to normal saline was bacitracin antibiotic solution chosen by 161 (16.8%) respondents. Fifty-five (6%) respondents used an iodine based solution and only 12 (1.3%) respondents used a soap, or detergent, when irrigating open wounds. Over half the surgeons believed that neither bacitracin nor soap solution provided additional efficacy over saline alone [453 (50.1%) and 489 (55.1%), respectively] (Table 3). Alternatively, the majority of surgeons believed iodine and chlorhexidine were more effective than saline alone [398 (44%) and 413 (46.3%), respectively] (Table 3). Surgeons who used only normal saline solution were significantly more likely to operate on more open fractures yearly (odds ratio = 1.1, p = 0.048), worked in an academic hospital setting (Odds ratio = 1.3, p = 0.04) and believed that bacitracin was no more effective than saline alone (Odds ratio = 2.9, p < 0.001)

Table 2. Type of Irrigation Solution Routinely Used

Table 3. Effectiveness of Solutions Relative to Normal Saline in Reducing Infection Risk

Amount of irrigating solution

For Type 1 open injuries the majority of surgeons, 609 (63.9%), preferred 3 litres or less of irrigating solution. For Type II open wounds, 475 surgeons preferred between 3 and 6 litres of irrigating fluid (50.1%). In Type III open wounds, the most commonly endorsed volume by 386 (41.3%) surgeons remained between 3 and 6 litres of irrigating fluid, surprisingly not 9 or more liters. However, the respondents were 8-fold more likely to use more than 9 litres of irrigating solution as the Gustilo Type increased from Type I to Type III (p < 0.01) (Table 4).

Table 4. Amount of Irrigation Solution Routinely Used

Irrigating Pressure

Six hundred and ninety-five surgeons (71%) preferred the delivery of irrigating fluid at low pressure. The majority of whom [317 surgeons (32.2%)] did so with a bulb syringe (Table 5). However, there was some discrepancy in defining both high and low pressure lavage (Table 6). Surgeons definitions about high pressure lavage varied considerably, while the majority [609 (73.1%) surgeons] agreed that low pressure represented pressures less than 20 p.s.i. (Table 6). Regression analysis suggested that younger surgeon age (Odds ratio = 1.7, p = 0.049) and the belief that high pressure irrigation on fractures may delay fracture healing (Odds ratio = 2.1, p < 0.001) were significantly associated with surgeon preferences favoring lower pressure irrigation.

Table 5. Types of Pressure – High versus Low

Table 6. Definitions of High and Low Pressure

Need for Further Research

There was considerable support among respondents for a clinical trial evaluating outcomes following both the use of different irrigating solutions as well as irrigating pressures [803 (84.8%) and 730 (77.6%) respectively] (Tables 7 and 8). The overwhelming majority of surgeons [889 (94.2%)] reported they would change their practice if a large randomized controlled trial showed a clear benefit of an irrigating solution – especially if it was different from the solution they used. Table 8 demonstrates the relative risk reduction of infection, in percent, needed to change the surgeons current practice pattern. And 19.3%, the largest group, considered changing their practice for any reduction in infection. However, the majority of surgeons [765 (80.6%)] believed that a particular irrigating solution would need to reduce the risk of infection compared to a standard by at least 25%.

Table 7. Need for Further Research

Table 8. Clinical Importance and Interest in Participating in Study

Discussion

Key Findings

The results of this survey demonstrated four key findings: 1) Most surgeons preferred the use of normal saline alone when irrigating open fracture wounds, 2) Surgeons felt that additives such as bacitracin and soap were either equivalent to or more effective than normal saline alone, 3) Surgeons were fairly uniform at defining low pressure but were less so when defining high pressure irrigation, and 4) most surgeons felt there was a need for further clinical trials on types of irrigating solutions as well as the pressure of irrigating solutions and would consider participating in a multi-centre randomized trial.

Strengths and Limitations

The strengths of our study include: 1) the use of a rigorous process for the development of the questionnaire items with active surgeon participation, 2) a comprehensive sampling of surgeons of North America and Europe as well as academic and non-academic centres, and 3) an acceptable survey response rate of approximately 56% that helps to limit, but not eliminate, non-responder bias [16,17]. Our response rate of over 900 surgeons provided a robust data set for the general purposes of our study, and it exceeded the level for our anticipated study precision. Nevertheless, future studies that are aimed at more rigorously evaluating potential non-responder bias will need to institute a strategy to: 1) define non-responders by a temporal cut-off, and 2) re-administer the survey one more or more times in an attempt to achieve a sufficient level of non-responder compliance for statistical evaluation. Similar strategies have been employed in survey studies of orthopaedic surgeons' behaviors/practices on topics where responder bias would seem highly likely [18] compared to those that would seem, similar to the present study, unlikely [19].

Irrigating Pressures

Experimental data suggests that high pressure lavage may be more effective than low pressure lavage for removing debris and bacteria from contaminated open wounds[12,13,20]. However, the efficacy in removing debris and bacteria may come at the expense of damage to bone as well as bacterial propagation into the intramedullary canal[21,22]. Cellular effects relating to the use of high pressure lavage have also been reported with an observed reduction and promotion of stem cell differentiation toward the adipocyte cell type rather than osteoblast cell type [20,23,24]. These cellular level effects have been seen to translate into a significant reduction in fracture callus strength[25]. Indeed, when undergoing mechanical testing, callus in rat femurs which had undergone high pressure irrigation of bone ends showed a significantly lower peak bending force and stiffness when compared to the control and bulb syringe (low pressure) groups (p < 0.05)[25]. The use of high pressure irrigation resulted in a 37% lower bending force compared to the low pressure irrigation and control groups[25]. However, conflicting results have been described by other investigators. While Dirschl et al., have found similar results and early detriment to fracture healing with high-pressure pulsatile lavage (HPPL), others have reported that HPPL has a similar effect on bone damage when compared with low-pressure irrigation and does not drive the bacteria further into the surrounding tissues [14,21,26].

Irrigating Solutions

Experimental studies have evaluated several irrigation additives including antiseptics, antibiotics, and surfactants. Antiseptics have been shown to exhibit toxicity to the host cells [2,27-30]. Although antibiotics (such as bacitracin) and surfactants (such as castile soap) are routinely used for open wound irrigation, their relative effects on clinically important outcomes remain unknown. Other experimental evidence suggests that soap solution may be more effective for removing bacteria than normal saline, with a greater efficacy for removing some organisms over others [3,12,27,31,32].

In an in-vitro calvarial cell culture model, 1% soap solution has been shown to have preserved both alkaline phosphatase activity and bone nodule formation to the greatest extent when compared to other solutions (p < 0.05)[12]. Moreover, soap solution preserved osteoclast numbers to the greatest extent. In contrast, proviodine and chlorhexidine solutions resulted in the greatest decline in bone nodule formation, alkaline phosphatase activity, and osteoclast numbers (p < 0.001) [12]. We were surprised that over 40% surgeons believed proviodine was superior to normal saline given a complete lack of evidence that such antiseptics have any benefit and experimental evidence suggesting they may actually cause harm at the cellular level [12].

Limited Clinical Evidence

There is a paucity of clinical trials evaluating open fracture wounds. Museru et al., conducted a randomized controlled trial comparing isotonic saline, distilled water and boiled water in the irrigation of open fracture wounds[33]. They reported an infection rate of 35% in the isotonic saline group, 17% in the distilled water group and 29% in the boiled water group. While statistical testing was limited, they suggested that the rates of infection were not influenced by the type of irrigating solution used[33]. Recently, Anglen conducted a large randomized trial of 400 patients with 458 open fractures has been conducted which compared castile soap and bacitracin as additives to normal saline solution[11]. The results suggested that there was no significant difference between these irrigating solutions (infection risk with soap versus bacitracin: 13% vs 18%, p = 0.2, respectively)[11]. Even though 95% confidence interval was wide (risk reduction = 28%, 95%CI: -26%–55%) the point estimate of the treatment effect displayed a trend towards the use of soap solution in reducing the risk of infection compared to antibiotic solution (28% reduction in infection risk)[11]. This lack of significance however may have been associated with the overall power of the study.

No further clinical trials have been completed comparing either normal saline alone or normal saline with soap additive in a prospective randomized fashion.

Need for Further Clinical Trials

We have shown that there are varied opinions from surgeons on the management of open fracture wounds as regards initial irrigation and debridement. While recent clinical evidence suggests a trend towards decreased infection rates with soap solution, larger trials are needed to definitely resolve whether soap is a better alternative. Secondly, there is as yet no clinical trial on the efficacy of different irrigating pressures on outcomes such as infection rates, union rates or functional outcomes.

Planning Another Trial

Our survey findings have aided in the planning of a pilot study. A randomized controlled trial is currently underway in pilot phase and is titled F.L.O.W (

    F
luid
    L
avage in Patients with
    O
pen Fracture
    W
ounds). This study is a 2 × 2 factorial design with randomization into one of 4 groups: 1) Normal saline, low pressure irrigation, 2) Normal saline, high pressure irrigation, 3) normal saline/soap solution, low pressure irrigation and 4) normal saline/soap solution, high pressure irrigation. Randomization is underway in select pilot centers in both Canada, the United States and Europe, with active recruitment of centers for a large scale multicenter trial. Sample size calculations for the large trial have been based on an estimate of 20% infection in the saline control group[4]. This was calculated for a desired power of 0.80 and α = 0.05, estimating 13% and 20% rates of infection (35% Relative risk reduction) in the treatment and control groups, respectively, which represents a clinically important difference[11]. The final adjusted sample size was 536 per group, or a total of 1072 patients. Given that over 1000 patients are needed for the large trial, feasibility issues necessitate this be done in a multicenter fashion. The first 100 patients serving in the pilot study will be used to assess estimates of treatment effect and issues surrounding the sample size needed for a large trial. If infection rates are significantly lower than suggested from previous trials, the sample size will increase significantly. If we identify a gradient of effect between High and Low pressure lavage, we will also consider adding a third arm (very low pressure, bulb syringe), further increasing the study sample size to over 1500 patients.

Conclusion

Overall, the majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds. However, opinions varied as regards the comparative efficacy of different solutions, the use of additives and high versus low pressure. Surgeons have expressed considerable support for a trial evaluating both irrigating solutions and pressures.

Appendix 1: FLOW investigative Team

Steering Committee (Pilot Study)

Mohit Bhandari, MD (Hamilton, ON); Gordon Guyatt MD (Hamilton, ON); Brad Petrisor, MD (Hamilton, ON); Kyle Jeray, MD (Greenville, SC); Emil Schemitsch, MD (Toronto, ON); Stephen Walter, PhD (Hamilton, ON).

Adjudication Committee (Pilot Study)

Mohit Bhandari MD (Hamilton, ON), Brad Petrisor MD(Hamilton, ON), Emil Schemitsch MD (Toronto, ON), and Kyle Jeray MD(Greenville, SC).

Investigators (Pilot Study)

Dennis Beck, MD (Evansville, IN); Mohit Bhandari, MD (Hamilton, ON); Chad Coles, MD (Halifax, NS); Cory Collinge, MD (Fort Worth, TX); Joseph Conflitti, MD (Tyler, TX); Gregory Della Rocca, MD (Columbia, MO); Paul Duffy, MD (Calgary, AB); Edward Harvey, MD, (Montreal, QC); Kyle Jeray, MD (Greenville, SC); Alan Jones, MD (Dallas, TX); Sumito Kawamura, MD (Hokkaido, Japan); Kenneth Koval, MD (Lebanon, NH); Hans Kreder, MD (Toronto, ON); Yves Laflamme, MD (Montreal, QC); Theodore Miclau, MD (San Francisco, CA); Silas Motsitsi, MD (Pretoria, South Africa); Peter O'Brien, MD, (Vancouver, BC); Steve Papp, MD, (Ottawa, ON); Brad Petrisor, MD (Hamilton, ON); Laura Phieffer, MD (Columbus, OH); Robert Probe (Temple, TX); George Russell, MD (Jackson, MS); Claude Sagi, MD (Tampa, FL); Parag Sancheti, MD (Pune, India); David Sanders, MD London, ON); Emil Schemitsch, MD (Toronto, ON); Dan Schlatterer, MD (Atlanta, GA); Trevor Stone, MD (New Westminster, BC); and Bob Zura, MD (Durham, NC).

Research Coordinators (Pilot Study)

Natalie Ansell (Hamilton, ON); Kate Babusiak (Durham, NC); Tigist Belaye (San Francisco, CA); Leah Briggs (Columbia, MO); Naomi Crnko (Toronto, ON); Carole Ehleben (Atlanta, GA); Kristy Genuario (Lebanon, NH); Chris Herrick (Temple, TX); Susie Howell (Tyler, TX); Raman Johal (Vancouver, BC); Skye Macalester (Columbus, OH); Caterina Marrazza (Montreal, QC); Tashay Mignott (Hamilton, ON); Zhen Qin (Jackson, MS); Laura Quigley (Hamilton, ON); Marie-France Poirier (Montreal, QC); Steve Rocha (Pune, India); Stephanie Tanner, MSc (Greenville, SC); Milena Santos (Toronto, ON); Christina Tieszer (London, ON); Kelly Trask (Halifax, NS); Liisa Vexler, (Ottawa, ON); and Mauri Zomar (New Westminster, BC).

Coordinating Center (McMaster University, Hamilton, Ontario)

Natalie Ansell; Lisa Buckingham, BSc; Diane Heels-Ansdell, MSc; Christina Lacchetti, MSc; Tashay Mignott; Laura Quigley; and Sheila Sprague, MSc.

Authors' contributions

Study Concept and Design: MB, BP. Study Coordination: SS. Data Analysis: MB, BP, SS. Drafting Manuscript: BP, MB, KJ, DS, BH, SS. Revision Manuscript: BP, MB, KJ, DS, BH, SS.

Acknowledgements

Funding for this project was received in part from the Physicians' Services Incorporated and the Orthopaedic Trauma Association. Dr. Bhandari is funded, in part, by a Canada Research Chair, McMaster University.

We are grateful to Christina Lacchetti, MSc, Natalie Ansell, Tashay Mignott, and Laura Quigley for their assistance with questionnaire administration and collation.

References

  1. Court-Brown Charles, McQueen Margaret, Tornetta Paul III: Trauma. 1st edition. Philadelphia, Lippincott Williams and Wilkins; 2006. OpenURL

  2. Anglen JO: Wound irrigation in musculoskeletal injury.

    J Am Acad Orthop Surg 2001, 9:219-226. PubMed Abstract | Publisher Full Text OpenURL

  3. Anglen JO, Gainor BJ, Simpson WA, Christensen G: The use of detergent irrigation for musculoskeletal wounds.

    Int Orthop 2003, 27:40-46. PubMed Abstract | Publisher Full Text OpenURL

  4. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH: Treatment of open fractures of the shaft of the tibia.

    J Bone Joint Surg Br 2001, 83:62-68. PubMed Abstract | Publisher Full Text OpenURL

  5. Bhandari M, Tornetta P III, Sprague S, Najibi S, Petrisor B, Griffith L, Guyatt GH: Predictors of reoperation following operative management of fractures of the tibial shaft.

    J Orthop Trauma 2003, 17:353-361. PubMed Abstract | Publisher Full Text OpenURL

  6. Petrisor B, Anderson S, Court-Brown CM: Infection after reamed intramedullary nailing of the tibia: a case series review.

    J Orthop Trauma 2005, 19:437-441. PubMed Abstract | Publisher Full Text OpenURL

  7. Valenziano CP, Chattar-Cora D, O'Neill A, Hubli EH, Cudjoe EA: Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?

    Arch Orthop Trauma Surg 2002, 122:259-261. PubMed Abstract | Publisher Full Text OpenURL

  8. Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH: Outcomes in open tibia fractures: relationship between delay in treatment and infection.

    J Trauma 2003, 55:949-954. PubMed Abstract | Publisher Full Text OpenURL

  9. Spencer J, Smith A, Woods D: The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital.

    Annals of the Royal College of Surgeons of England 2004, 86:108-112. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  10. Tsukayam DT, Schmidt AH: Open fractures.

    Current Treatment Options in Infectious Disease 2001, 3:301-307. OpenURL

  11. Anglen JO: Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study.

    J Bone Joint Surg Am 2005, 87:1415-1422. PubMed Abstract | Publisher Full Text OpenURL

  12. Bhandari M, Adili A, Schemitsch EH: The efficacy of low-pressure lavage with different irrigating solutions to remove adherent bacteria from bone.

    J Bone Joint Surg Am 2001, 83-A:412-419. PubMed Abstract | Publisher Full Text OpenURL

  13. Bhandari M, Thompson K, Adili A, Shaughnessy SG: High and low pressure irrigation in contaminated wounds with exposed bone.

    Int J Surg Investig 2000, 2:179-182. PubMed Abstract OpenURL

  14. Caprise PA Jr, Miclau T, Dahners LE, Dirschl DR: High-pressure pulsatile lavage irrigation of contaminated fractures: effects on fracture healing.

    J Orthop Res 2002, 20:1205-1209. PubMed Abstract | Publisher Full Text OpenURL

  15. Griffith L, Cook DJ, Guyatt GH, Charles CA: Comparison of open and closed questionnaire formats in obtaining demographic information from Canadian general internists.

    Journal of Clinical Epidemiology 1999, 997-1005. PubMed Abstract | Publisher Full Text OpenURL

  16. Armstrong D, Ashworth M: When questionnaire response rates do matter: a survey of general practitioners and their views of NHS changes.

    British Journal of General Practice 2000, 479-480. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  17. Templeton L, Deehan A, Taylor C, Drummond C, Strang J: Surveying general practitioners: does a low response rate matter?

    British Journal of General Practice 1997, 47:91-94. PubMed Abstract | PubMed Central Full Text OpenURL

  18. Skedros , et al.: Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture.

    J Bone and Joint Surgery (American) 2006, 88:18-24. Publisher Full Text OpenURL

  19. Skedros Hunt KJ, JG , Pitts TC: Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians.

    BMC Musculoskelet Disorders 2007, 6(8):63. BioMed Central Full Text OpenURL

  20. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG: High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage.

    J Orthop Trauma 1999, 13:526-533. PubMed Abstract | Publisher Full Text OpenURL

  21. Lee EW, Dirschl DR, Duff G, Dahners LE, Miclau T: High-pressure pulsatile lavage irrigation of fresh intraarticular fractures: effectiveness at removing particulate matter from bone.

    J Orthop Trauma 2002, 16:162-165. PubMed Abstract | Publisher Full Text OpenURL

  22. Polzin B, Ellis T, Dirschl DR: Effects of varying pulsatile lavage pressure on cancellous bone structure and fracture healing.

    J Orthop Trauma 2006, 20:261-266. PubMed Abstract | Publisher Full Text OpenURL

  23. Bhandari M, Adili A, Lachowski RJ: High pressure pulsatile lavage of contaminated human tibiae: an in vitro study.

    J Orthop Trauma 1998, 12:479-484. PubMed Abstract | Publisher Full Text OpenURL

  24. Bhandari M, Schemitsch EH: High-pressure irrigation increases adipocyte-like cells at the expense of osteoblasts in vitro.

    J Bone Joint Surg Br 2002, 84:1054-1061. PubMed Abstract | Publisher Full Text OpenURL

  25. Adili A, Bhandari M, Schemitsch EH: The biomechanical effect of high-pressure irrigation on diaphyseal fracture healing in vivo.

    J Orthop Trauma 2002, 16:413-417. PubMed Abstract | Publisher Full Text OpenURL

  26. Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T: High pressure pulsatile lavage irrigation of intraarticular fractures: effects on fracture healing.

    J Orthop Trauma 1998, 12:460-463. PubMed Abstract | Publisher Full Text OpenURL

  27. Conroy BP, Anglen JO, Simpson WA, Christensen G, Phaup G, Yeager R, Gainor BJ: Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopaedic wounds.

    J Orthop Trauma 1999, 13:332-337. PubMed Abstract | Publisher Full Text OpenURL

  28. Gainor BJ, Hockman DE, Anglen JO, Christensen G, Simpson WA: Benzalkonium chloride: a potential disinfecting irrigation solution.

    J Orthop Trauma 1997, 11:121-125. PubMed Abstract | Publisher Full Text OpenURL

  29. Moussa FW, Gainor BJ, Anglen JO, Christensen G, Simpson WA: Disinfecting agents for removing adherent bacteria from orthopaedic hardware.

    Clin Orthop Relat Res 1996, 255-262. PubMed Abstract | Publisher Full Text OpenURL

  30. Tarbox BB, Conroy BP, Malicky ES, Moussa FW, Hockman DE, Anglen JO, Simpson WA, Adelstein EH, Christensen G, Gainor BJ: Benzalkonium chloride. A potential disinfecting irrigation solution for orthopaedic wounds.

    Clin Orthop Relat Res 1998, 255-261. PubMed Abstract | Publisher Full Text OpenURL

  31. Anglen J, Apostoles PS, Christensen G, Gainor B, Lane J: Removal of surface bacteria by irrigation.

    J Orthop Res 1996, 14:251-254. PubMed Abstract | Publisher Full Text OpenURL

  32. Marberry KM, Kazmier P, Simpson WA, Christensen GD, Phaup JG, Hendricks KJ, Anglen JO, Gainor BJ: Surfactant wound irrigation for the treatment of staphylococcal clinical isolates.

    Clin Orthop Relat Res 2002, 73-79. PubMed Abstract | Publisher Full Text OpenURL

  33. Museru LM, Kumar A, Ickler P: Comparison of isotonic saline, distilled water and boiled water in irrigation of open fractures.

    International Orthopaedics (SICOT) 1989, 13:179-180. Publisher Full Text OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2474/9/7/prepub