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Open Fracture Wound Care

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Timing of open fracture wound treatment How emergent is it? ... 100,000 units of Bacitracin per. 3 Liter bag of NS. Group C. 80 cc. of. liquid Castile Soap ... – PowerPoint PPT presentation

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Title: Open Fracture Wound Care


1
Open Fracture Wound Care
Jeff Anglen, MD Professor and Chairman Orthopaedic
s Indiana University
2
WWW.OTA.ORG
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

4
Open Fracture Care Timing
5
Textbooks
  • Open fractures are surgical emergencies.Any
    delaysjeopardize limb survival
  • Skeletal Trauma, 1st edition, 1992
  • Formal radical debridement and irrigation should
    be accomplished within 6 hours (nationally
    recognized standard).
  • Millers 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
NO Difference
  • Khatod et al., Journal of Trauma 2003
  • Spencer et al. JRCS England 2004
  • 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

14
Versajet
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Pros Cons
  • Adjustable power
  • Small size
  • Gets into 3-D spaces and around contours well
  • Eyelids, Fingers, web spaces, lips and scalps
  • Ground in or fine particulate surface dirt on
    muscle
  • Learning curve
  • Expensive
  • Not well suited for large areas or high volumes

19
Wound Irrigation
  • Volume
  • Delivery Method
  • high or low pressure
  • pulsatile or continuous
  • Choice of Solution
  • Antiseptics
  • Antibiotics
  • detergents

20
Wound Irrigation
  • Volume
  • Delivery Method
  • pulsatile or continuous
  • high or low pressure
  • Choice of Solution
  • Antiseptics
  • Antibiotics
  • detergents

21
Wound Irrigation
  • Volume
  • Delivery Method
  • pulsatile or continuous
  • high or low pressure
  • Choice of Solution
  • Antiseptics
  • Antibiotics
  • detergents

22
Wound Irrigation
  • Volume
  • Delivery Method
  • pulsatile or continuous
  • high or low pressure
  • Choice of Solution
  • Antiseptics
  • Antibiotics
  • detergents

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
  • 100,000 units of Bacitracin per3 Liter bag of NS
  • Group C
  • 80 cc. ofliquid Castile Soap per 3 liter bag of
    NS

400 patients 458 open fractures
26
Outcomes - Infection
  • Group B
  • 18
  • Group C
  • 13

p.2
27
Outcomes Delayed/Nonunion
  • Group B
  • 25
  • Group C
  • 23

p.72
28
Outcomes Wound Healing
  • Group B
  • 9.5
  • Group C
  • 4

p.03
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.

30
Recommendations
Level 4 evidence
  • 1st washout, highly contaminatedSoap solution
  • Subsequent washouts of clean woundsSaline
  • Infected woundsSoap, then antibiotic

31
Dressings
  • Temporary closures - rubber bands
  • wet to dry dressings ( wet to wet)
  • semi-permeable membranes
  • antibiotic bead pouch
  • VAC

32
Not FDA Approved - Off Label Use
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35
VAC dressing
Picture of wound vac here
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 ?q480 vs W?D bid
  • VAC
  • Fewer bacteria at all intervals
  • Less wound edema at all intervals

38
Parrett et al. Plast Reconst Surg 2006
  • Open IIIB tibia fxs
  • 92-95 42 free flaps
  • 96-99 26 free flaps
  • 2000-03 11 free flaps
  • Infection rate unchanged
  • Local flaps unchanged

39
However.
  • Bhattacharyya T, et al. OTA 2007
  • 38 pts with IIIB open tibias routinely Rxd with
    VAC
  • Risk of infection still related to delay to
    definitive coverage within 7 days
  • 12 vs. 54, plt008

40
Stannard et alOTA Basic Science Symposium 2008
  • PRCT
  • 59 patients so far, gt90 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
200210379-384
42
Contraindications to primary closure
  • Inadequate debridement
  • Gross contamination
  • Farm related or freshwater immersion injuries
  • Delay in treatment gt12 hours
  • Delay in antibiotic administration
  • Compromised host or tissue viability

43
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