Salvage of Infected Orthopedic Hardware With Intraoperative and Postoperative Hypochlorous Acid Instillations

Eric Clayman, MD; Zackery Beauchamp, BS; Jared Troy, MD

Abstract

Background. Orthopedic hardware infections often require hardware removal or replacement. In some situations, hardware removal is not possible or would require amputation. Thus, a method of in-situ hardware salvage could significantly improve patient outcomes. Hypochlorous acid is a broad-spectrum antimicrobial solution with rapid effectiveness in biofilm impairment. 

Methods. This article presents 2 patients with orthopedic hardware infection. Patient A had recurrent draining sinuses from an intramedullary nail in the femur. The orthopedic surgery team recommended above-knee amputation if hardware salvage was not possible. Patient B had a degloving injury of the right upper extremity with radius and ulna fractures that required revascularization and free flap coverage; when hardware infection developed, hardware removal would have required external fixator placement. In both patients, hypochlorous acid was used intraoperatively during debridement to soak the hardware for 5 minutes. Closed suction drains were placed along the hardware, and postoperative instillations of hypochlorous acid were placed through the drains for 5 minutes 1 to 2 times a day for 4 days for Patient A and 7 days for Patient

Results. On follow-up at 10 months for Patient A and at 9 months for Patient B, there was no evidence of recurrent hardware infection. Hardware was successfully salvaged in both patients.

Conclusions. Hypochlorous acid is an effective and safe topical antimicrobial agent for recurrent infections due to hardware-associated biofilm. Postoperative instillations of 0.025% hypochlorous acid through closed suctions drains may improve hardware salvage rates and optimize

Keywords PhaseOne Hypochlorous Acid Hardware Salvage Infected Hardware Biofilm

Kick-Starting Wound Healing: A Review of Pro-Healing Drugs

Bethany L. Patenall , Kristyn A. Carter and Matthew R. Ramsey *

Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。 (K.A.C.)

* Correspondence: 该Email地址已收到反垃圾邮件插件保护。要显示它您需要在浏览器中启用JavaScript。; Tel.: +1-(617)-525-5775

Abstract: Cutaneous wound healing consists of four stages: hemostasis, inflammation, proliferation/repair, and remodeling. While healthy wounds normally heal in four to six weeks, a variety of underlying medical conditions can impair the progression through the stages of wound healing, resulting in the development of chronic, non-healing wounds. Great progress has been made in developing wound dressings and improving surgical techniques, yet challenges remain in finding effective therapeutics that directly promote healing. This review examines the current understanding of the pro-healing effects of targeted pharmaceuticals, re-purposed drugs, natural products, and cell-based therapies on the various cell types present in normal and chronic wounds. Overall, despite several promising studies, there remains only one therapeutic approved by the United States Food and Drug Administration (FDA), Becaplermin, shown to significantly improve wound closure in the clinic. This highlights the need for new approaches aimed at understanding and targeting the underlying mechanisms impeding wound closure and moving the field from the management of chronic wounds towards resolving wounds.

Keywords: chronic wounds; diabetes; wound healing; epithelization; macrophages; biomaterials

Comparative assessment of commercially available wound gels in ex vivo human skin reveals major differences in immune response‑modulatory effects

S.Seiser¹ , D. Cerbu¹ , A. Gallhofer¹ , J. Matiasek² & A. Elbe‑Bürger^1*

Effect of Stabilized Hypochlorous Acid on Re-epithelialization and Bacterial Bioburden in Acute Wounds: A Randomized Controlled Trial in Healthy Volunteers

Ewa A. BURIAN¹, Lubna SABAH¹, Klaus KIRKETERP-MØLLER¹, Glenn GUNDERSEN² and Magnus S. ÅGREN^1,3,4

¹Department of Dermatology and Copenhagen Wound Healing Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark, ²SoftOx Solutions AS, Oslo, Norway, ³Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, and ⁴Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Topical hypochlorous acid (HOCl) blocks inflammatory gene expression and tumorigenic progression in UV-exposed SKH-1 high risk mouse skin

Jana Jandova ^a,b , Jeremy Snell ^a,b , Anh Hua ^a,b , Sally Dickinson ^b , Jocelyn Fimbres ^a,b , Georg T. Wondrak ^a,b,*

^aDepartment of Pharmacology and Toxicology, College of Pharmacy and UA Cancer Center, University of Arizona, Tucson, AZ, USA

^bUA Cancer Center, University of Arizona, Tucson, AZ, USA

ABSTRACT

Hypochlorous acid (HOCl) is the active oxidizing principle underlying drinking water disinfection, also delivered by numerous skin disinfectants and released by standard swimming pool chemicals used on a global scale, a topic of particular relevance in the context of the ongoing COVID-19 pandemic. However, the cutaneous consequences of human exposure to HOCl remain largely unknown, posing a major public health concern. Here, for the first time, we have profiled the HOCl-induced stress response in reconstructed human epidermis and SKH-1 hairless mouse skin. In addition, we have investigated the molecular consequences of solar simulated ultraviolet (UV) radiation and HOCl combinations, a procedure mimicking co-exposure experienced for example by recreational swimmers exposed to both HOCl (pool disinfectant) and UV (solar radiation). First, gene expression elicited by acute topical HOCl exposure was profiled in organotypic human reconstructed epidermis. Next, co-exposure studies (combining topical HOCl and UV) performed in SKH-1 hairless mouse skin revealed that the HOCl-induced cutaneous stress response blocks redox and inflammatory gene expression elicited by subsequent acute UV exposure (Nos2, Ptgs2, Hmox1, Srxn1), a finding consistent with emerging clinical evidence in support of a therapeutic role of topical HOCl formulations for the suppression of inflammatory skin conditions (e.g. atopic dermatitis, psoriasis). Likewise, in AP-1 transgenic SKH-1 luciferase-reporter mice, topical HOCl suppressed UV-induced inflammatory signaling assessed by bioluminescent imaging and gene expression analysis. In the SKH-1 high-risk mouse model of UV-induced human keratinocytic skin cancer, topical HOCl blocked tumorigenic progression and inflammatory gene expression (Ptgs2, Il19, Tlr4), confirmed by immunohisto-chemical analysis including 3-chloro-tyrosine-epitopes. These data illuminate the molecular consequences of HOCl-exposure in cutaneous organotypic and murine models assessing inflammatory gene expression and modulation of UV-induced carcinogenesis. If translatable to human skin these observations provide novel insights on molecular consequences of chlorination stress relevant to environmental exposure and therapeutic.

Keywords:

Pathway-focused gene expression profiling Hypochlorous acid Skin cancer Solar UV radiation Inflammation Oxidative stress

Antimicrobial Hypochlorous Wound Irrigation Solutions Demonstrate Lower Anti-biofilm Efficacy Against Bacterial Biofilm in a Complex in-vitro Human Plasma Biofilm Model (hpBIOM) Than Common Wound Antimicrobials

Julian-Dario Rembe^{1 *†} , Lioba Huelsboemer^2† , Isabell Plattfaut² , Manuela Besser² and Ewa K. Stuermer³

¹Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany, ²Chair for Translational Wound Research, Centre for Biomedical Education and Research, Witten/Herdecke University, Witten, Germany, ³ Department of Vascular Medicine, University Heart and Vascular Center Hamburg, Translational Wound Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Biofilms pose a relevant factor for wound healing impairment in chronic wounds. With 78% of all chronic wounds being affected by biofilms, research in this area is of high priority, especially since data for evidence-based selection of appropriate antimicrobials and antiseptics is scarce. Therefore, the objective of this study was to evaluate the anti-biofilm efficacy of commercially available hypochlorous wound irrigation solutions compared to established antimicrobials. Using an innovative complex in-vitro human plasma biofilm model (hpBIOM), quantitative reduction of Pseudomonas aeruginosa, Staphylococcus aureus, and Methicillin-resistant S. aureus (MRSA) biofilms by three hypochlorous irrigation solutions [two <0.08% and one 0.2% sodium hypochlorite (NaClO)] was compared to a 0.04% polyhexanide (PHMB) irrigation solution and 0.1% octenidine-dihydrochloride/phenoxyethanol (OCT/PE). Efficacy was compared to a non-challenged planktonic approach, as well as with increased substance volume over a prolonged exposure (up to 72 h). Qualitative visualization of biofilms was performed by scanning electron microscopy (SEM). Both reference agents (OCT/PE and PHMB) induced significant biofilm reductions within 72 h, whereby high volume OCT/PE even managed complete eradication of P. aeruginosa and MRSA biofilms after 72 h. The tested hypochlorous wound irrigation solutions achieved no relevant penetration and eradication of biofilms despite increased volume and exposure. Only 0.2% NaClO managed a low reduction under prolonged exposure. The results demonstrate that low-dosed hypochlorous wound irrigation solutions are significantly less effective than PHMB-based irrigation solution and OCT/PE, thus unsuitable for biofilm eradication on their own. The used complex hpBIOM thereby mimics the highly challenging clinical wound micro-environment, providing a more profound base for future clinical translation.

Keywords: wound infection, biofilm, antimicrobial, antiseptic, hypochlorous acid, human plasma biofilm model, wound irrigation, chronic wound