Clinical and pathological changes in the knee after accidental chlorhexidine irrigation during arthroscopy

Abstract

We describe six knees in five patients, referred to us after accidental irrigation with chlorhexidine 1% in aqueous solution during arthroscopy.All six knees developed persisting pain, swelling and crepitus with loss of range of movement. Radiographs showed loss of joint space in all three compartments due to extensive chondrolysis, with many loose bodies and synovitis. Histological examination showed partial necrosis of the cartilage, with slight non-specific inflammation and fibrosis of synovial specimens.Care is needed in checking irrigation fluids, and these should have a distinctive colour.J Bone Joint Surg [Br] 1998;80-B:437-40. Received 4 November 1997; Accepted 27 November 1997 Arthroscopy is now very common, and involves the use of an irrigating solution. Articular cartilage is a complex and active tissue which depends on diffusion from the synovial fluid for its nutrition and metabolism. The effect of different irrigating fluids on cartilage metabolism has previously been investigated in vitro and in animal studies; these have shown that those used most commonly have an inhibiting effect. 1,2Chlorhexidine is not normally used in arthroscopy, but is a common irrigating fluid for surgical wounds, and has been shown to help to prevent infection with Staphylococcus aureus.3 Chlorhexidine 4% was shown to have no deleterious effect on the histological appearance of wound healing of the skin in guinea-pigs. 4 Other data on the toxicity of chlorhexidine have been generally favourable, although, to our knowledge, no experiments on articular cartilage have been reported. 5We describe the macroscopic and microscopic effect of the accidental use of chlorhexidine solution during arthroscopy in six knees in five patients. Case reportsThree of the five patients were referred to us after the proven but accidental irrigation of the knee with 1% aqueous chlorhexidine during arthroscopy. There was no proof of the use of chlorhexidine in the other two patients, but the history and findings were similar. Case 1. A 26-year-old man had an arthroscopy for a lesion of the lateral meniscus in his left knee. After the operation it was discovered that aqueous chlorhexidine 1% had been used for irrigation instead of normal saline.Two months later he was referred to us with increasing pain, swelling and crepitus in the knee. He had severe loss of movement and atrophy of the quadriceps. Radiographs already showed loss of joint space in all compartments of the knee. Open debridement and synovectomy were performed, with biopsies taken for histology. The knee showed extensive chondrolysis and proliferative synovitis, but the procedure produced no improvement. After another two months arthroscopic arthrolysis and manipulation under anaesthesia also failed and progressive radiological degeneration was seen.Three years after the initial arthroscopy a further open debridement with removal of loose bodies and periarticular calcification led to spontaneous fusion of the joint in 10° of flexion. Case 2. A 21-year-old man had diagnostic ar...

The effect of different irrigation solutions on fracture healing in a rat femur fracture model

“…It has a broad spectrum for gram-positive and gram-negative bacteria, fungi and prokaryotic cell membrane with low toxicity to mammalian tissue. [14] Interestingly, CHG, which has a wide range of use in modern practice with low toxicity and with effective antiseptic activity, has not been investigated as an irrigation solution in clinical or animal experimental open fracture model. Despite this lack of evidence, some surgeons advise the use of this solution in surgical field instead of normal saline.…”

Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate

“…Mechanisms underlying this phenomenon include alteration in actin cytoskeleton assembly, disruption of mitochondrial membrane potential, and generation of reactive oxygen species [14]. Though there are reported cases of chondrolysis following accidental CG irrigation during arthroscopy, there has yet to be in vitro experimentation to determine CG's local and systemic effects during arthroplasty or to determine the dose and exposure time required to reproduce these effects [15].…”

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

“…Two to 3 months after surgery, all these patients had pain, swelling, loss of function, and crepitus, and postoperative radiographs revealed loss of joint space and loose bodies due to extensive chondrolysis. 7 In contrast, Best et al 3 showed that a 1-minute exposure to 0.05% CHG did not have adverse effects on nonosteoarthritic cartilage, while decreases in metabolic activity were only observed in osteoarthritic cartilage. Similarly, in a rat…”

“…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 car-tilage. 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.…”

“…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. A case report and review conducted by Douw et al 7 examined the effects of CHG irrigation during arthroscopy. In this review, 5 young patients underwent irrigation of the knee with 1% aqueous chlorhexidine during arthroscopy.…”