Open fracture wound care_Dr anglen

1,696 views

Published on

0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,696
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

Open fracture wound care_Dr anglen

  1. 1. Open Fracture Wound Care Jeff Anglen, MD Professor and Chairman Orthopaedics Indiana University
  2. 2. Baltimore, Maryland WWW.OTA.ORGOrthopaedic Trauma Association 26th Annual Meeting October 14 - 16, 2010
  3. 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. 4. Open Fracture Care: Timing #11 Open Fractures are Orthopaedic Emergencies!
  5. 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. 6. “Open Fractures must go the OR within 6 hours, to reduce the risk of infection” ?Based on animal studiesfrom 1898 by P. Friedrich
  7. 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. 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. 9. Enduring Principles Early administration of antibiotics Adequate debridement and wound care Early coverage or closure Appropriate skeletal stabilization
  10. 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. 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. 12. Debridement Initial procedure is most important Goals:  remove all foreign material  remove nonviable host tissue  decrease bacterial load  create clean, living wound
  13. 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. 14. Versajet
  15. 15. 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
  16. 16. Wound Irrigation Volume Delivery Method  high or low pressure  pulsatile or continuous Choice of Solution  Antiseptics  Antibiotics  detergents
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. A prospective randomizedcomparison of soap and antibioticirrigation in open lower extremity fracturesJournal of Bone and Joint Surgery 87-A(7):1415-1422, 2005
  21. 21. The study Prospective Randomized Sample Size: 200/group NO formal blinding 3 outcomes  Infection  Delayed or Nonunion  Failure of wound healing
  22. 22. 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
  23. 23. Outcomes - InfectionGroup B Group C18% 13% p=.2
  24. 24. Outcomes – Delayed/Nonunion Group B Group C 25% 23% p=.72
  25. 25. Outcomes – Wound Healing Group B Group C 9.5% 4% p=.03
  26. 26. Conclusion Level 1 evidenceAntibiotic solution offers no advantage over soap solution for irrigation of open fracture wounds, and may be detrimental to wound healing.
  27. 27. Recommendations Level 4 evidence  1st washout, highly contaminated Soap solution Subsequent washouts of clean wounds Saline Infected wounds Soap, then antibiotic
  28. 28. Dressings Temporary closures - rubber bands wet to dry dressings ( wet to wet) semi-permeable membranes antibiotic bead pouch VAC
  29. 29. Not FDA Approved - Off Label Use
  30. 30. VAC dressing Picture of wound vac here
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Stannard et alOTA 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
  36. 36. 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
  37. 37. 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
  38. 38. Thanks

×