1. Open Fracture
Wound Care
Jeff Anglen, MD
Professor and Chairman
Orthopaedics
Indiana University
2. Baltimore, Maryland
WWW.OTA.ORG
Orthopaedic Trauma Association
26th Annual Meeting
October 14 - 16, 2010
3. Lecture Plan
Issues:
Timing of open fracture wound treatment – How
emergent is it?
What are the important principles that remain true?
What is new in –
Antibiotic coverage
Debridement techniques
Irrigation methods
Wound closure/coverage
5. Textbooks
“Open fractures are surgical emergencies.”
“Any delays…jeopardize limb survival…”
Skeletal Trauma, 1st edition, 1992
“Formal radical debridement and irrigation should be
accomplished within 6 hours (nationally recognized
standard).”
Miller’s Review of Orthopaedics, 4th edition, 2004
(italic emphasis added)
6. “Open Fractures must go the OR
within 6 hours, to reduce the risk of
infection”
?
Based on animal studies
from 1898 by P. Friedrich
7. Recent Literature
Khatod et al., Journal of Trauma 2003
Spencer et al. JRCS – England 2004
NO Difference
Charalambous et at. - 2005
Skaggs et al. JBJS 2005
Crowley et al – lit review of 40+ studies 2007
Retrospective
8. Conclusions
The “6 hour rule” is not supported
Timing of surgical treatment is not an important
factor in preventing infection (within limits)
Low grade open fractures can wait until morning
Some should probably still be treated emergently
Grade III
Gross contamination
9. Enduring Principles
Early administration of antibiotics
Adequate debridement and wound care
Early coverage or closure
Appropriate skeletal stabilization
10. IV Antibiotics – “Classic”
choice and duration by Gustilo grade
I, II - cephalosporin for 3 days
III - ceph + aminoglycoside for 5 days
Gram negative coverage
soil, farm - add penicillin
Clostridial coverage
re-cover for repeat visits to the OR
30+ year old data, poor study designs
Conclusions not supported by data
11. Antibiotic approach - EBM
Hauser CJ, Adams CA Jr., Eachempati SR.
Surgical Infection Society Guideline.
Surgical Infections 7(4):379-405, 2006
24-48 hours of 1st generation Cephalosporin
Begin as early as possible
NO need for specific gram negative coverage
NO need for clostridial coverage
No benefit for repeat courses with OR
We Need Better Studies!
12. Debridement
Initial procedure is most important
Goals:
remove all foreign material
remove nonviable host tissue
decrease bacterial load
create clean, living wound
13. Debridement
Principles
experienced surgeon
limit tourniquet
extend wound – carefully!
systematic, layer by layer
save skin in key areas
fat and fascia are expendable
dead muscle has to go
evolving situation
18. Pros & Cons
Adjustable power Learning curve
Small size Expensive
Gets into 3-D spaces Not well suited for large
and around contours well areas or high volumes
Eyelids, Fingers, web
spaces, lips and scalps
Ground in or fine
particulate surface dirt
on muscle
19. Wound Irrigation
Volume
Delivery Method
high or low pressure
pulsatile or continuous
Choice of Solution
Antiseptics
Antibiotics
detergents
20. Wound Irrigation
Volume “Copious”
More is better
Delivery Method
pulsatile or continuous GR 1: 3 liters
GR 2: 6 liters
high or low pressure
GR 3: 9 liters
Choice of Solution
Antiseptics
Antibiotics
detergents
21. Wound Irrigation
Volume
Delivery Method
pulsatile or continuous
high or low pressure
Choice of Solution
Antiseptics Higher pressure:
Antibiotics -Cleans bone better
detergents -Does not clean soft tissues
better, may be worse
-slows bone healing
22. Wound Irrigation
Volume
Delivery Method
pulsatile or continuous
high or low pressure
Choice of Solution
Antiseptics Toxic to host defense cells
Antibiotics NO proven benefit
detergents May remove bacteria and
contaminants better
23. A prospective randomized
comparison of soap and antibiotic
irrigation in open lower extremity
fractures
Journal of Bone and Joint Surgery 87-A(7):1415-1422, 2005
24. The study
Prospective
Randomized
Sample Size: 200/group
NO formal blinding
3 outcomes
Infection
Delayed or Nonunion
Failure of wound healing
25. The study protocols
Group B Group C
100,000 units of 80 cc. of
Bacitracin per liquid Castile Soap
3 Liter bag of NS per 3 liter bag of NS
400 patients
458 open fractures
29. Conclusion
Level 1 evidence
Antibiotic solution offers no
advantage over soap solution for
irrigation of open fracture
wounds, and may be detrimental
to wound healing.
36. Negative Pressure Wound
Therapy - NPWT
Mechanism of Action
Removal of interstitial fluid (edema)
Opens microcirculation
Removes enzymes that inhibit cell adhesion/migration
Mechanical tension on tissues
Deform cytoskeleton
Release of 2nd messengers
Angiogenesis
37. Comparison of NPWT to Wet-Dry
Dressings
Lalliss SJ, et al. OTA meeting 2007
Goat wounds contaminated with photon-
emitting Pseudomonas
VAC Δq480 vs W→D bid
VAC:
Fewer bacteria at all intervals
Less wound edema at all intervals
39. However….
Bhattacharyya T, et al. OTA 2007
38 pts with IIIB open tibias routinely Rx’d with
VAC
Risk of infection still related to delay to
definitive coverage within 7 days
12% vs. 54%, p<008
40. Stannard et al
OTA Basic Science Symposium 2008
PRCT
59 patients so far, >90% grade III
Saline wet-to-moist VS. NPWT
Total Infection rates
Saline WtM: 7/25 (5.4%)
NPWT: 2/37 (28%)
P=.03
41. To Close or Not to Close
Classic teaching – delayed closure of all open fx
New information:
Advances in open fracture care
irrig & debridement techniques
Improved antibiotic management
Better surgical stabilization methods
Most acute infections are hospital acquired organisms
Studies support primary closure in many cases
Weitz-Marshall and Bosse
J Am Acad Orthop Surg 2002;10:379-384
42. Contraindications to primary closure
Inadequate debridement
Gross contamination
Farm related or freshwater immersion injuries
Delay in treatment >12 hours
Delay in antibiotic administration
Compromised host or tissue viability