Evaluating the Impact of Irrigation Solution on Deep Infection for Open Long Bone Fractures in Ethiopia

Purpose: Open fractures have an increased risk of complications and infection. Current guidelines to mitigate infection risk includes early antibiotic administration and operative irrigation and debridement. Bleach solutions have been considered as alternatives for irrigation in settings where there is limited access to normal saline. This study aims to determine the effectiveness of 3 irrigation solutions for the prevention of infection among open tibia and open femur fractures in Ethiopia.

Methods: This randomized controlled trial was conducted at Black Lion University Hospital and Hawassa University Hospital from March 2018 to December 2022. Colloidal silver solution, 0.025% bleach solution, and normal saline were compared for irrigation. The primary outcome was surgical site infection. Patients were assessed at multiple time points for up to 1 year. Descriptive, multivariate regression and time-to-event analysis were performed.

Results: A total of 218 patients were enrolled in this study. The mean age of our patient population was 33.1 years (standard deviation 13.1). The majority of fractures were classified as Gustilo-Anderson type IIIA (59.9%) and were treated with intramedullary nails (76.0%). At 12 months, there was 81.6% follow-up and 24.9% had developed an infection. There were 15 infections (25.4%) among the colloidal silver solution group, 12 (21.4%) among the bleach solution group, and 17 (27.4%) in the normal saline group (P = 0.762). In a multivariable model adjusting for other putative risk factors, surgical debridement after 24 hours (odds ratio [OR]: 2.2, 95% confidence interval [CI]:1.1-4.9, P = 0.040), and Type 3 Gustilo-Anderson open fracture (OR: 7.7, 95% CI:1.5-141.7, P = 0.046) were significantly associated with incidence of infection. Cox regression analysis demonstrated no statistically significant difference in time to infection between the 3 groups (hazard ratio [HR]: 0.84, 95%CI: 0.45-1.58, P = 0.594 and HR 0.62, 95% CI 0.31-1.21, P = 0.162, respectively).

Conclusion: There was no difference in the risk of infection associated with the irrigation solutions tested, suggesting that bleach solutions may be a reasonable and cost-effective. Our sample size may have not been adequate to discern modest reductions in infection rates between irrigation types. Time to debridement and injury severity were strong risk factors for infection. More research is necessary to determine whether low-cost alternatives to saline solution can mitigate the risk of infection in the setting of open fractures.