Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

Slobogean, Gerard P.; Sprague, Sheila; Wells, Jeffrey; Bhandari, Mohit; Harris, Anthony D.; Mullins, C. Daniel; Thabane, Lehana; Wood, Amber; Rocca, Gregory J. Della; Hebden, Joan N.; Jeray, Kyle J.; Marchand, Lucas S.; O’Hara, Lyndsay M.; Zura, Robert; Lee, Christopher; Patterson, Joseph T.; Gardner, Michael J.; Blasman, Jenna; Davies, Jonah; Liang, Stephen Y.; Taljaard, Monica; Devereaux, P.J.; Guyatt, Gordon; Heels‐Ansdell, Diane; Marvel, Debra; Palmer, Jana; Friedrich, Jeff; O’Hara, Nathan N.; Grissom, Frances; Gitajn, Ida Leah; Morshed, Saam; O’Toole, Robert V.; Petrisor, Bradley; Mossuto, Franca; Joshi, Manjari; D’Alleyrand, Jean-Claude G.; Fowler, Justin; Rivera, Jessica C.; Talbot, Max; Pogorzelski, David; Dodds, Shannon; Li, Silvia; Fabbro, Gina Del; Szasz, Olivia Paige; Bzovsky, Sofia; McKay, Paula; Minea, Alexandra; Murphy, Kevin D.; Howe, Andrea; Demyanovich, Haley; Hoskins, Wayne; Medeiros, Michelle; Polk, Genevieve; Kettering, Eric; Mahal, Nirmen; Eglseder, Andrew; Johnson, Aaron J.; Langhammer, Christopher G.; Lebrun, Christopher; Nascone, Jason W.; Pensy, Raymond A.; Pollak, Andrew N.; Sciadini, Marcus F.; Degani, Yasmin; Phipps, Heather; Hempen, Eric; Johal, Herman; Ristevski, Bill; Williams, Dale; Denkers, Matthew; Rajaratnam, Krishan; Al-Asiri, Jamal; Gallant, Jodi; Pusztai, Kaitlyn; MacRae, Sarah; Renaud, Sara; Adams, John D.; Beckish, Michael L.; Bray, Christopher C.; Brown, Timothy R.; Cross, Andrew W.; Dew, Timothy; Faucher, Gregory K.; Gurich, Richard W.; Lazarus, David E.; Millon, S. John; Moody, Marion; Palmer, M. Jason; Porter, Scott E.; Schaller, Thomas M.; Sridhar, Michael S.; Sanders, John; Rudisill, L. Edwin; Garitty, Michael J.; Poole, Andrew S.; Sims, Michael L.; Walker, Clark M.; Carlisle, Robert; Hofer, Erin Adams; Huggins, Brandon; Hunter, Michael D.; Marshall, W. A.; Ray, Shea B.; Smith, Cory; Altman, Kyle M.; Pichiotino, Erin R.; Quirion, Julia C.; Loeffler, Markus F.; Cole, Austin A.; Maltz, Ethan J.; Parker, Wesley; Ramsey, T. Bennett; Burnikel, Alex; Colello, Michael; Stewart, Russell J.; Wise, Jeremy; Anderson, Matthew J.; Eskew, Joshua; Judkins, Benjamin N.; Miller, James M.; Tanner, Stephanie L.; Snider, Rebecca G.; Townsend, Christine E.; Pham, Kayla H.; Martin, Abigail; Robertson, Emily; Bray, Emily; Sykes, J. Wilson; Yoder, Krystina; Conner, Kelsey; Abbott, Harper; Natoli, Roman M.; McKinley, Todd O.; Virkus, Walter W.; Sorkin, Anthony T.; Szatkowski, Jan P.; Mullis, Brian; Jang, Yohan; Lopas, Luke A.; Hill, Lauren C.; Fentz, Courteney L.; Diaz, Maricela M.; Brown, Krista; Garst, Katelyn M.; Denari, Emma W.; Osborn, Patrick M.; Pierrie, Sarah N.; Kessler, Bradley; Herrera, Maria; Miclau, Theodore; Marmor, Meir T.; Matityahu, Amir; McClellan, R. Trigg; Shearer, David; Toogood, Paul; Ding, Anthony; Murali, Jothi; Naga, Ashraf El; Tangtiphaiboontana, Jennifer; Belaye, Tigist; Berhaneselase, Eleni; Pokhvashchev, Dmitry; Obremskey, William T.; Jahangir, A. Alex; Sethi, Manish K.; Boyce, Robert; Stinner, Daniel J.; Mitchell, Phillip; Trochez, Karen; Rodriguez, Elsa; Pritchett, Charles; Hogan, Natalie; Moreno, A. Fidel; Hagen, Jennifer; Patrick, Matthew; Vlasak, Richard; Krupko, Thomas; Talerico, Michael; Horodyski, MaryBeth; Pazik, Marissa; Lossada-Soto, Elizabeth; Gary, Joshua L.; Warner, Stephen J.; Munz, John W.; Choo, Andrew M.; Achor, Timothy S.; Routt, Milton L; Kutzler, Michael; Boutte, Sterling; Warth, Ryan J.; Prayson, Michael J.; Venkatarayappa, Indresh; Horne, Brandon R.; Jerele, Jennifer; Clark, Linda; Boulton, Christina; Lowe, Jason; Ruth, John T.; Askam, Brad; Seach, Andrea; Cruz, Álejandro; Featherston, Breanna; Carlson, Robin; Romero, Iliana; Zarif, Isaac; Dehghan, Niloofar; McKee, Michael D.; Jones, Clifford B.; Sietsema, Debra L.; Williams, Alyse; Dykes, Tayler; Guerra-Farfán, Ernesto; Tomàs-Hernández, Jordi; Teixidor-Serra, Jordi; Molero-García, Vicente; Selga-Marsà, Jordi; Porcel-Vazquez, Juan Antonio; Andrés-Peiró, José Vicente; Esteban-Feliu, Ignacio; Vidal-Tarrason, Nuria; Serracanta, Jordi Franch; Núñez, Jorge H.; Villar-Casares, Maria del Mar; Mestre-Torres, Jaume; Lalueza-Broto, Pilar; Moreira-Borim, Felipe; Garcia-Sanchez, Yaiza; Marcano-Fernández, Francesc; Martínez-Carreres, Laia; Martí-Garín, David; Serrano-Sanz, Jorge; Sánchez-Fernández, Joel; Sanz-Molero, Matsuyama; Carballo, Alejandro; Pelfort, Xavier; Acerboni-Flores, Francesc; Alavedra-Massana, Anna; Anglada-Torres, Neus; Berenguer, Alexandre; Cámara-Cabrera, Jaume; Caparros-García, Ariadna; Fillat-Gomà, Ferràn; Fuentes-López, Ruben; Garcia-Rodriguez, Ramona; Gimeno-Calavia, Nuria; Martínez-Álvarez, Marta; Martínez-Grau, Patricia; Pellejero-García, Raúl; Ràfols-Perramon, Ona; Peñalver, Juan Manuel; Domènech, Mònica Salomó; Soler-Cano, Albert; Velasco-Barrera, Aldo; Yela-Verdú, Christian; Bueno-Ruiz, Mercedes; Sánchez-Palomino, Estrella; Andriola, Vito; Molina‐Corbacho, Matilde; Maldonado-Sotoca, Yeray; Gasset-Teixidor, Alfons; Blasco-Moreu, Jorge; Fernández-Poch, Núria; Rodoreda-Puigdemasa, Josep; Verdaguer-Figuerola, Arnau; Cueva-Sevieri, Heber Enrique; Garcia-Gimenez, Santiago; Viskontas, Darius; Apostle, Kelly; Boyer, Dory; Moola, Farhad; Perey, Bertrand H.; Stone, Trevor; Lemke, H. Michael; Spicer, Ella; Payne, Kyrsten; Hymes, Robert A.; Schwartzbach, Cary C.; Schulman, Jeff E.; Malekzadeh, Arjan; Holzman, Michael; Gaski, Greg E.; Wills, Jonathan; Pilson, Holly; Carroll, Eben A.; Halvorson, Jason J.; Babcock, Sharon; Goodman, J. Brett; Holden, Martha B.; Williams, Wendy R.; Hill, Taylor; Brotherton, Ariel; Romeo, Nicholas M.; Vallier, Heather A.; Vergon, Anna; Higgins, Thomas F.; Haller, Justin M.; Rothberg, David L.; Olsen, Zachary M.; McGowan, Abby V.; Hill, Sophia; Dauk, Morgan K.; Bergin, Patrick F.; Russell, George V.; Graves, Matthew; Morellato, John; McGee, Sheketha L.; Bhanat, Eldrin; Yener, Ugur; Khanna, Rajinder; Nehete, Priyanka; Potter, David A.; VanDemark, Robert; Seabold, Kyle; Staudenmier, Nicholas; Coe, Marcus P.; Dwyer, Kevin P.; Mullin, Devin S.; Chockbengboun, Theresa A.; DePalo, Peter; Phelps, Kevin D.; Bosse, Michael J.; Karunakar, Madhav A.; Kempton, Laurence B.; Sims, Stephen H.; Hsu, Joseph R.; Seymour, Rachel B.; Churchill, Christine; Mayfield, Ada; Sweeney, Juliette; Jaeblon, Todd; Beer, Robert; Bauer, Brent A.; Meredith, Sean J.; Talwar, Sneh; Domes, Christopher M.; Gage, Mark J.; Reilly, Rachel M.; Paniagua, Ariana; Dupree, JaNell; Weaver, Michael J.; Keudell, Arvind G. von; Sagona, Abigail E.; Mehta, Samir; Donegan, Derek J.; Horan, Annamarie D.; Dooley, Mary; Heng, Marilyn; Harris, Mitchel B.; Lhowe, David W.; Esposito, John G.; Alnasser, Ahmad; Shannon, Steven F.; Scott, Alesha N.; Clinch, Bobbi; Weber, Becky; Beltran, Michael J.; Archdeacon, Michael T.; Sagi, Henry Claude; Wyrick, John D.; Le, Theodore T.; Laughlin, Richard T.; Thomson, Cameron G.; Hasselfeld, Kimberly; Lin, Carol A.; Vrahas, Mark; Moon, Charles N.; Little, Milton T. M.; Marecek, Geoffrey S.; Dubuclet, Denice M.; Scolaro, John A.; Learned, James; Lim, Philip K.; Demas, Susan; Amirhekmat, Arya; Cruz, Yan Marco Dela

doi:10.1016/s0140-6736(22)01652-x

The Lancet

2022

DOI: 10.1016/s0140-6736(22)01652-x

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Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

Gerard P. Slobogean¹,

Sheila Sprague²,

Jeffrey Wells³

et al.

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Cited by 5 publications

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“…These solutions have been used to prevent bacterial growth after joint arthroplasty and within contaminated wounds in the setting of open fractures. 9 , 20 , 21 Although several studies have demonstrated that chlorhexidine gluconate (CHG) solutions can result in catastrophic chondrolysis of articular cartilage, 7 , 24 CHG irrigation is still used by some surgeons as a disinfectant during joint surgery in the presence of intact articular cartilage. CHG can come into contact with native articular cartilage if used in such procedures as partial joint replacement, including hip and shoulder hemiarthroplasty, as well as unicompartmental knee arthroplasty and periarticular fracture fixation.…”

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confidence: 99%

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Moslehyazdi,

Bielajew,

Schlechter

et al. 2024

Am J Sports Med

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Background: Chlorhexidine gluconate (CHG) solution is commonly used as an antiseptic irrigation for bacterial decontamination during orthopaedic surgery. Although the chondrotoxicity of CHG on articular cartilage has been reported, the full extent of CHG-related chondrotoxicity and its effects on the extracellular matrix and mechanical properties are unknown. Purpose: To investigate the in vitro effects of a single 1-minute CHG exposure on the viability, biochemical content, and mechanics of native articular cartilage explants. Study Design: Controlled laboratory study. Methods: Articular cartilage explants (6 per group) were harvested from femoral condyles of the porcine stifle and sectioned at tidemark. Explants were bathed in CHG solution (0.05% CHG in sterile water) at varying concentrations (0% control, 0.01% CHG, and 0.05% CHG) for 1 minute, followed by complete phosphate-buffered saline wash and culture in chondrogenic medium. At 7 days after CHG exposure, cell viability, matrix content (collagen and glycosaminoglycan [GAG]), and compressive mechanical properties (creep indentation testing) were assessed. Results: One-minute CHG exposure was chondrotoxic to explants, with both 0.05% CHG (2.6% ± 4.1%) and 0.01% CHG (76.3% ± 8.6%) causing a decrease in chondrocyte viability compared with controls (97.5% ± 0.6%; P < .001 for both). CHG exposure at either concentration had no significant effect on collagen content, while 0.05% CHG exposure led to a significant decrease in mean GAG per wet weight compared with the control group (2.6% ± 1.7% vs 5.2% ± 1.9%; P = .029). There was a corresponding weakening of mechanical properties in explants treated with 0.05% CHG compared with controls, with decreases in mean aggregate modulus (177.8 ± 90.1 kPa vs 280.8 ± 19.8 kPa; P < .029) and shear modulus (102.6 ± 56.5 kPa vs 167.9 ± 16.2 kPa; P < .020). Conclusion: One-minute exposure to CHG for articular cartilage explants led to dose-dependent decreases in chondrocyte viability, GAG content, and compressive mechanical properties. This raises concern for the risk of mechanical failure of the cartilage tissue after CHG exposure. Clinical Relevance: Clinicians should be judicious regarding the use of CHG irrigation at these concentrations in the presence of native articular cartilage.

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confidence: 99%

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Moslehyazdi,

Bielajew,

Schlechter

et al. 2024

Am J Sports Med

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Large-scale, pragmatic randomized trials in the era of big data, precision medicine and machine learning. Valid and necessary, or outdated and a waste of resources?

Stengel

Augat

Giannoudis

2023

Injury

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What is the best pre-surgical scrub for skin antisepsis in fracture surgery?

Ryan,

Birk,

Buckley

2024

Injury

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Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

Cited by 5 publications

References 30 publications

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Detrimental Effects of Chlorhexidine on Articular Cartilage Viability, Matrix, and Mechanics

Large-scale, pragmatic randomized trials in the era of big data, precision medicine and machine learning. Valid and necessary, or outdated and a waste of resources?

What is the best pre-surgical scrub for skin antisepsis in fracture surgery?

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