Tactical use of irrigants in open orthopaedic procedures: 'what to use & when'.

Musculoskeletal infections (MSIs) pose formidable challenges to healthcare resources. Surgical wound irrigation is a crucial step in reducing microbial bioburden in open orthopaedic procedures, yet there remains ambiguity regarding optimal use of lavage agents. For tactical selection of irrigants, orthopaedic wounds can be classified into three major categories (aseptic, acute septic and chronic septic) based upon microbial bioload and presence or absence of biofilm upon implanted hardware and/or musculoskeletal tissues. Irrigant products can be stratified based upon their modes of action: single modal (dilutional), dual modal (dilutional and chemical) and multi-modal (dilutional with multiple mechanisms). Host toxicity is commensurate with increased complexity of an irrigant product. A tailored, stepwise strategy of irrigant selection aligned with wound type is recommended, escalating from simple low toxicity dilutional lavage for low microbial bioloads to potent multi-modal chemical agents for biofilm-laden chronic infections. The method of irrigant delivery and selected volume are integral to wound lavage. The difference between methods is the impact pressure to host tissues and the depth of fluid penetration. Higher impact pressures clear adherent bacteria and foreign debris albeit the cost of host tissue damage.