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

4. Open Fracture Care:
Timing
#11
Open
Fractures
are
Orthopaedic
Emergencies!

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

14. Versajet

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

26. Outcomes - Infection
Group B Group C
18% 13%
p=.2

27. Outcomes – Delayed/Nonunion
Group B Group C
25% 23%
p=.72

28. Outcomes – Wound Healing
Group B Group C
9.5% 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 contaminated
Soap solution
 Subsequent washouts of clean wounds
Saline
Infected wounds
Soap, 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

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 Δq480 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 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

43. Thanks