06-nwosa_open-fxs

8/17/2019 06-Nwosa_Open-Fxs

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Chinedu Nwosa, M.D.

Iowa Ortho

Mercy Medical Center Trauma

Des Moines, Iowa

Review Historical Basis for Management ofOpen Fractures

Review Accepted Practices of Open FractureTreatment

Examine Current Controversies andMethodology of Treatment of Open Fractures

Pierre Desault (1731-1795)

Promoted deepening ofincisions to explore wounds,remove nonviable tissue,allow a path for drainage

Coined the term“debridement”

Stated the soonerdebridement performed, theless likely an infection woulddevelop


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Joseph Trueta (1897-1977)

The Principles and Practiceof War Surgery

1.)Enlargement of the woundto permit adequatevisualization

2.)Assessment of injuredtissue for viability

3.)Excision of allcontaminants and all nonviable tissue

4.)Stabilization of fracture

5.)Establishment ofappropriate Drainage

World War II

Penicillin becomesreadily available by theend of the war

Widespread use in thetreatment of woundsfrom open fractureswith good results

ATLS Guidelines / ABC’s Immobilize and apply sterile dressing to

injured extremity Early IV Antibiotics

Early operative irrigation and debridement withskeletal stabilization Repeated irrigation and debridement as

necessary

Thorough rehabilitation


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Gustilo Type I◦

Low Energy◦ Minimal soft tissue

damage

◦ Minimal contamination

◦ Usually inside-outinjuries

Gustilo Type II◦ Low-Moderate energy

◦ Moderate soft tissueinjury

◦ Moderatecontamination

◦ Moderate comminution

◦ “Tricked out”skateboarder!!

Gustilo Type III

Originally defined as :◦ “Either an open

segmental fracture, anopen fracture withextensive soft-tissuedamage, or a traumaticamputation ”

◦ Special categories: GSW,farm injury, openfracture requiringvascular repair


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Gustilo found Type III to be increasing inincidence and the category to be too inclusive

Significantly higher infection rates noted inGustilo Type III fractures

Gustilo et al JOT 1984, subdivision of Type IIIfractures into three subtypes in order ofworsening prognosis

Gustilo Type IIIA◦ High Energy

◦ Severe, crushing softtissue injury

◦ High degree ofcontamination

◦ Moderate-severecomminution

Gustilo Type IIIB◦ High Energy

◦ Severe loss of softtissue coverage

◦ Typically requiring asoft-tissue flap forcoverage of the wound

◦ High degree ofcontamination

◦ Moderate-severecomminution


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Gustilo Type IIIC◦ High Energy◦ Arterial Injury requiring

repair◦ Requires Skeletal

Fixation to protect therepair

◦ High Degree ofcontamination

◦ Mod-severeComminution

Size of the wound, softtissue damage can bedifficult to judge oninitial assessment

Many factors affect thefinal classification

Classify in operatingroom

Brumback et al JBJS 1994

◦ 245 Orthopaedicsurgeons showed 12

videotapes of openfractures, includingintraop footage

◦ Asked to assign Gustilo-Anderson classification

◦ Overall agreement ~60%


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Important in directing treating surgeon topresence and extent of injury variables

Only classify during surgery, during woundexploration and debridement

All open fracture wounds are contaminateddue to exposure to outside environment

Bacterial colonization

Presence of dead space and devitalizedtissues

Soft tissue damage


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Objectives of SurgicalTreatment

Prevent Sepsis

Achieve Union

Restore Function

NOT PROPHYLACTIC…THERAPEUTIC

Patzakis and Wilkins study of 1104 openfractures CORR 1989◦ ABX given < 3 hrs from time of injury

17/364 developed infection (4.7%)

◦ ABX given > 3 hrs from time of injury 49/661 developed infection (7.4%)

Antibiotic therapy to be initiated as soon aspossible following injury

Seventy two hour duration


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First Generation Cephalosporin

+/- Aminoglycoside

+/- Pen G or Clindamycin if Pen allergic

No Cipro alone Patzakis MJ, J Orthop Trauma Nov 2000

24-72hr course

Antibiotic Beads◦ Ostermann et al JBJS Br 1993◦ 1,085 open fractures◦ Group 1

240 fractures treated withPO abx only

Resulted in 12% infectionrate

◦ Group 2 845 fractures treated with

PO abx + abx beads Resulted in 3.7% infection

rate **Fractures treated with

local abx more likely toundergo early woundclosure

Aminoglycoside-impregnated PMMA Used in more severe fractures

Placed inside bony defects and covered with a liner

Much greater local concentrations of ABX without as

many systemic side effects Wound sealed from external environment


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Bone Defects: Bead Pouch

PMMA –aminoglycoside +/- vancomycin

Bead pouch

Solid spacer


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Goals◦

Extension of thetraumatized wound toallow identification ofthe zone of injury

Allow for superficialand deep explorationof the wound

Allows for bestclassification of thefracture

Goals◦ Removal of debris and

non-viable tissue

◦ Begin irrigation

◦ Asess 3C’s of muscle

“THE

SOLUTIONTOPOLLUTIONIS DILUTION”


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Volume◦ Ideal volume not clearly defined

Gustilo-Anderson Originally described use of 10-15 Liters for irrigation of

all wounds

◦ Commonly used guidelines

Type I: 3-6 Liters

Type II: 6-9 Liters

Type III: 9 Liters

Saline +/- surfactants (soap) Anglen J, Removal ofsurface bacteria by irrigation. J Orthop Res 1996

Pressure – avoid high pressure / pulse

lavage Polzin B, Removal of surface bacteria by irrigation. J Orthop Res 1996

Timing > 6 hrs Crowley DJ, Debridement and wound closureof open fractures: The impact of the time factor on infection rates.

Injury 2007

Large Fragments: What todo?

• Infection Rates with retained - 21%• Infection Rates with removed- 9%

Edwards CC Severe open tibial fractures. Results treating 202

injuries with external fixation.

RR

1998

• Use to assist in determining length,rotation and alignment


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Definitive coverage should be performed within 7-10

days if possible

Most type 1 wounds will heal by secondary intent or

can be closed primarily Hohmann E, Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop

Trauma Surg 2007

Delayed primary closure usually feasible for type 2

and type 3a fractures

Careful planning of skin incisions

Longitudinal incisions / “Z” plasty

Essential to fully explore wound as even Type 1fractures can pull dirt/debris back into wound and onfracture ends

All foreign material, necrotic muscle, unattached bonefragments, exposed fat and fascia are debrided

After initial evaluationwound covered withsterile dressing and legsplinted

Appropriate tetanus

prophylaxis andantibiotics begun

Thorough debridementand irrigation undertakenin OR within 6 hours if

possible

Photo documentation


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Wound extensions

can be closedprimarily

When feasible,primary woundsshould be closedunder minimaltension

Allgower –DonatiSuture Technique

Relative Contraindications to wound closure◦ Grossly contaminated wound

◦ Delay in Antibiotic initiation beyond 12 hours frominjury

◦ Questionable tissue viability at the time ofdebridement

Infection, sepsis, chronic osteomyelitis

Nonunion, malunion

Loss of function (muscle loss, nerve injury,unrecognized compartment syndrome)

SIRS, ARDS, multi-system organ failure


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Open Fractures present a challenging situationto even the most experienced Orthopaedic

surgeon

Treatment should be prompt and antibioticsgiven therapeutically and aimed at appropriatecontaminants

Classification of open fractures is a consistentlyevolving process and is best done in theoperating room after debridement andexploration

All open fractures should be thoroughlyirrigated and debrided

Wound closure and coverage should becompleted as soon as possible to preventnosocomial infection

Some aspects of the ideal management ofopen fractures are yet to be elucidated

06-nwosa_open-fxs

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