Commentary - (2021) Volume 0, Issue 0
The informal use of acetic acid within Orthopaedics is a well-established, but poorly reviewed practice. Its aseptic properties [1] have lent it to be used in cases of soft tissue injury, post-operative scar reduction, biofilm eradication and debridement [2-4]. Current literature, however, has only superficially begun to evaluate the clinical effectiveness of AA in its multifaceted orthopaedic use [3,5,6]. Owing to its status as an off-license agent stems controversy within the specialty regarding its utilisation in clinical practice, with ambiguous guidance and lacking evidence on the topic proving discouraging to some. Looking specifically at the use of acetic acid as a tool within debridement and biofilm eradication, it is the growing redundancy of standard agents that has catalysed the popularity of acetic acid use, such as in the case of per prosthetic joint infections [7,8]. Although scarce, the literature still lends support to the use of acetic acid where standard antimicrobials have been ineffective [2]. Details regarding therapeutic use are absent, such as that on the varying effect on differing bacterial species, most effective concentration of acetic acid, soak durations and long-term surgical outcomes; thus, investigation into these aspects and guideline outlining is required to facilitate widespread use, with practitioner confidence, in the future. Another interesting aspect of acetic acid utilisation is Acetic Acid Iontophoresis (AAI), where ionized molecules penetrate tissue, facilitated by current application [9]. Acetic acid use in this way is effective in managing ossifying conditions, where application causes a regression of the hydroxyapatite crystals usually responsible for ossification. Inexpensive and simple, AAI has been used in calcifying tendonitis of the shoulder and ankle, Achilles tendon calcification, rotator cuff pathologies and others, as highlighted in the original article [10-13]. Interestingly, efficacy may be further augmented when use is combined with therapeutic ultrasound [12,14], suggesting prospects for use as an adjunctive or combined treatment modality.
Finally, looking at the documented use of acetic acid within scar reduction, again this is poorly reviewed. In patients with premature plateau in total active range of after occupational therapy, acetic acid treatment was administered, increasing the total active range of motion with statistical significance [15]. This study, like many from which acetic acid support has been drawn, was limited by sample size, and other issues with study design. Furthermore, unlike the use of acetic acid in other purposes, there is a lack of unified understanding of the mechanism of action of acetic acid in post-operative scarring. If we are unable to understand the mechanism action effectively, how can we use acetic acid as a targeted treatment or optimise its use within patient cohorts?. Ultimately, despite its widespread use, there have been no MHRA-specified guidelines regarding acetic acid use. Therefore, the ‘off license’ use of acetic acid is in accordance with each surgeon’s own clinical judgement. Although there are many benefits to acetic acid use, most notably its antimicrobial properties in cases resistant to standard treatments and cost-effectiveness, future high-quality research is required. Optimal therapeutic concentrations, the effect of patient-specific factors on acetic acid effectiveness, and differential considerations with AA-use across varying procedures must be investigated before standardised guidelines regarding use can be made.
The authors have no conflicts of interest to declare.
No funding received.
Anam Jawaid was responsible for the drafting this editorial; Yousuf Hashmi, Andrew Kailin Zhou and Matija Krkovic were responsible for reviewing it critically for important intellectual content.
Citation: Jawaid A, et al. Acetic Acid: A Versatile Agent in the Orthopaedic Toolkit. Med Rep Case Stud, 2021, 06(S4), 013
Received: 01-Sep-2021 Published: 06-Oct-2021, DOI: 10.35248/2572-5130.21.s4.013
Copyright: © 2021 Jawaid A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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