J. Tracy Watson M.D. Professor Orthopaedic Surgery Chief, Orthopaedic Traumatology St. Louis University School of Medicine St.

Louis University Health Science Center St. Louis, MO

OTA
International Orthopaedic Trauma Care Forum

OPEN FRACTURES STATE OF THE ART: Timing Of Debridement, Antibiotics , Temp Wound Mamagement, Temporizing Measures, Definitive Coverage Options
PROBLEMS W ITH open Fxs Bone loss / fracture gap Soft tissue injury Zone of injury Vascular integrity Fracture gap CLASSIFICATION OF WOUNDS.Veliskakis et. al.. Gustilo and Anderson: Grade 1: < 1cm Grade 2: >1cm 10cm Grade 3: (a) high energy, gross contamination Grade 3: (b) soft tissue loss requiring graft/flap Grade 3: (c) vascular injury POOR INTEROBSERVER AGREEMENT BRUMBACK et.al. Interobserver agreement in classification of open fxs 125 randomized open fxs Respondents agreed on the classification type only 60% of the time trauma fellowship66% (range 40-100%) BUT, CORRELATES WITH INFECTION RATES: Grade 1: 0 2% Grade 2: 2 7% Grade 3: (a) 7% (b) 50% (c) 25 50%

ANTIBIOTICS IN OPEN FXS Why? Treat bacterial contamination in traumatized tissue, NOT prophylaxis. Majority of organisms found in open fractures: Aerobic gram-positive cocci

ANTIBIOTICS IN OPEN FXS W hen should they be given? ASAP Studies show significant reduction in incidence of infection if given early, irrespective of timing of debridement. 14% to 3% for all comers, if use abx. (Patzakis et al JBJS 56A;532, 1974) 4.5% if <3hrs, 7.5% if >3hrs (Patzakis et al CORR 243;36,1989) OLSON ICL 1997 Antibiotics duration: Grade 1 and 2 Grade 3 Subsequent intervention

72 HOURS 5 DAYS 72 HOURS

PATZAKIS, OLSON Antibiotics in Open Fractures Antibiotic Bead Pouches: Grade 2 fractures: Reduce infection rate from 15-20% to 3-4% Grade 3 fractures: Reduce infection rate from 20-44% to 4% TIMING OF DEBRIDEMENT No studies have shown a clear benefit to emergent debridement of open fractures TIMING OF INTRAVENOUS ANTIBIOTICS IS MORE IMPORTANT Timing of debridement No difference between emergent and early debridement REVIEW OF RECENT LITERATURE Keating et al; JOT 1996. Reamed Nailing of Open Tibia Fractures Using Bead Pouch Technique Grade III B Fractures 16% Infection Rate. W ith Bead Pouch 4% 7 Grade II with STSG? Henry et al for 11% and 2.7% REVIEW OF RECENT LITERATURE Gaebler et al JOT 2001 Closed and Open fractures treated with Unreamed IM nail Multicenter 467 cases 9mm nail used

Open IIIs 5.1% infection rate Locking Screw Failure rate 21.6% REVIEW OF RECENT LITERATURE Govender and BESTT Study Group rh BMP 2 for Treatment of Open Tibial Fractures. 450 patients JBJS 2002 Grade III A and III B Infection Rate 24% with rhBMP-2(1.50 mg/ml) Vs. 44% Control AGGRESSIVE TREATMENT OF 119 OPEN FRACTURE WOUNDS De Long W G , Born CT et al ; J Trauma, June 1999 42 Month Period 127 Patients with 163 Open Injuries 90 Patients with 119 Open Fractures Included Retrospective Analysis No GSW METHODS PRIMARY CLOSURE 22 of 25 Grade I ( 88%) 37 of 47 Grade II (86%) 24 of 35 Grade III A (75%) 4 of 12 Grade III B (33%) RESULTS Eight Fractures Complicated by Deep Infection (7%) (Published Range 5 2 0 %) Nineteen Developed Delayed or Nonunion(16%) (Published Range 15 20%) Revealed No Difference in Infection and Nonunion Rate Between Delayed and Primary Closure CONCLUSIONS Immediate Closure of W ounds After Thorough Debridement By an Experienced Fracture Surgeon Appears to Cause No Significant Increase in Infection or Need for Secondary Procedures CONCLUSIONS Early Closure May Decrease the Need for Subsequent Debridements and Soft Tissue Procedures Thereby Decreasing Surgical Morbidity This W ill Shorten Hospital Length of Stay and Decrease Cost This Treatment Seemed Safe to Study In a Prospective Randomized Fashion OTA MULTICENTER OPEN FRACTURE STUDY 387 patients completed the study 197 immediate closure

190 delayed OTA MULTICENTER OPEN FRACTURE STUDY Infection rate Immediate 8.6% Delayed 9.5% P = 0.77 OTA MULTICENTER OPEN FRACTURE STUDY Delayed or Nonunion rate Immediate 31% Delayed 27% OTA MULTICENTER OPEN FRACTURE STUDY Soft tissue reconstruction Immediate ( 2 stsg, 2 flaps ) Delayed ( 9 stsg, 2flaps ) P = 0.055 OTA MULTICENTER OPEN FRACTURE STUDY Because of low infection rate power analysis requires 5,000 enrollees to demonstrate infection rate difference Economic analysis requires only 700 OTA MULTICENTER OPEN FRACTURE STUDY Conclusion Infection rate seems similar ( power requires 5000 subjects ) Soft tissue reconstruction > with delayed treatment Immediate closure more cost effective WOUND MANAGEMENT Operating room Debridement muscle (3 cs) Debridement skin Debridement bone Most important part of treatment Irrigation with high volumes ( 9 liters ), pulse vs. bulb Consider regowning and changing gloves & drapes before fracture reduction a n d tx DEBRIDEMENT OF OPEN FXS What about Pulsatile Lavage? High Pressure (70 psi) Causes micro and macroscopic damage to bone/osteocyte Effective at removing adherent bacteria >6hrs

 Lo pressure (15 psi) No damaging effects to bone Not effective at removing adherent bacteria >6hrs (3hrs yes) (Bhandari et al JOT 13(8), 1999) IRRIGANT PRESSURE Increase in pressures remove increased debri and bacteria Higher pressures may damage bone / soft tissues.(air insufflation) Delay fx healing Increase infection risk Select system with variable settings Low or middle range IRRIGANT FREQUENTCY (PULSITILE) In theory.. Removal of surface debri by tissue elasticity not established.conjecture only Pulse lavage vs bulb irrigation using various irrigant solutions.. At 48 hrs, the bacterial levels in the pulsed lavage group rebounded to 94% 48% in the bulb syringe group.(p =0.048). No current recommendations as to (pulse) benefits (makes a nice squirt gun in your pool) HIGH VOLUME..LOW FLOW FOCUSED FLUID JET LAVAGE High pressure vacuum (variable) Draws non-viable tissue away from healthy Surgical ablation of non-viable tissue Controled focused volume of irrigant directed to site Venturi effect localized vacuum to target tissue Excision cutting head excision/aspiration angle dependent Contaminant removal ..vacuum and irrigation VJL vs HPPL IN OPEN FRACTURE DEBRIDEMENT OVERALL DECREASE IN: Surgical TIME Irrigant used Time to definitive closure Number of procedures ( W ebb et.al)

DEBRIDEMENT OF OPEN FXS What Irrigating Fluid? Benzalkonium chloride (BzC) ineffective vs. S. Aureus, excellent vs. P Aeruginosa Castile Soap excellent vs. S Aureus, ineffective vs. P. Aerug

NS alone yields high persistent cultures Greatest reduction was seen with castile soap, which lowered the photon count to 1 3 % This was followed by benzalkonium chloride, bacitracin, and saline solution at 18%, 22%, and 29% The highest rebound was measured in the castile soap group, which rebounded to 120% of the pretreatment level Normal saline solution lowest rebound at (68%) Bacitracin ineffective vs. S. Aureus, mod vs. P Aeruginosa Volume of irrigant Gd 1 fx 3 LITERS Gd 2 fx.6 LITERS Gd 3 fx.9 LITERS WOUND CULTURES Pre-op cultures generally unrelable (no value) i Infected cases predebridement cultures grew infecting organism only 22% of time POST IRRIGATION AND DEBRIDEMENT CULTURES AS TREATMENT GUIDELINE Timing Of Wound Closure Infected cases .post debridement cultures grew infecting organism 42% of time Used as guideline for timing of secondary wound closure..(W atson, Lenarz, et.al.JBJS Aug 2010) Sequential I and D with post cultures obtained Wounds closed at time of negative wound cultures Overall deep infection rate was 4.3%. Gd II fxs (4%) and Gd III Fxs (5.7%

WOUND MANAGEMENT Operating room W hat do you do now? Pack it open Close primarily Second look washout DEAD SPACE MANAGEMENT Basic Science Edema fluid and its contents inhibit proliferation of kertinocytes, fibroblasts, and vascular endothelial cells Cells responed to controled distraction with increased rate of mitiosis, new vessel formation, and recruitment of adjacent tissue via viscoelastic flow

VACUUM-ASSISTED CLOSURE (V.A.C.) Changes in W ound Environment Blood Flow Peak flow four time baseline 125 mmHg subatmospheric pressure 5-minutes-on/2-minutes-off cycle VACUUM-ASSISTED CLOSURE (V.A.C.) Bacterial Clearance W ounds with 108 organisms/gram of tissue Infection>105 organisms/gram of tissue V.A.C. wounds < 105 organisms/gram of tissue at 5 days of treatment, control group at 11 days Patients treated with NPWT were only one-fifth as likely to have an infection compared with patients randomized to the control group. Stannard et.al. FLAP CLOSURE Burns et.al. J Orthop Trauma 2010;24:697703 67 Type III B tibia fractures were treated with Rotational or free flap coverage.There was a significantly lower amputation and reoperation rate for patients treated with rotational coverage. LEAP STUDY W ebb et.al. JBJS 2007 IIIB open tibial shaft Fx IM nail /ex fix with rotational flap similar functional outcomes Ex fix pts requiring flap coverage worse functional outcome compared to IM nial pts also requiring flaps
Specifically, it appears that the timing of wound dbridement (within six hours after the injury as compared with six to twenty-four hours after the injury), the timing of soft-tissue coverage (three days or less after the injury as compared with more than three days after the injury), and the timing of bone grafting procedures (less than three months after the injury as compared with three months or more after the injury) did not impact the infection or union rates and had no effect on functional outcome. Quote from article

WOUND MANAGEMENT Considerations Close primarily for gr I, II and IIIA if not a farm equivalent injury and only if complete and thorough debridement provided CONCLUSIONS Open Fractures Require Thorough Debridement Antibiotics Play Important Role. W HAT IS DEFINED, HOWEVER, IS THE EARLIER THE BETTER

Any Questionable Wound Goes Back to the ORrepeated debridements Farm Equivalent Injuries Should be Treated Open Primary closure may help decrease cost and morbidity of multiple procedures and exclude hospital bacterial flora CONCLUSIONS Limited Experience Suggests that Grade II and III A W ounds Can be Safely Closed III B W ounds Seem to Do Better W hen Covered ( flap etc.) ASAP by literature reports SUMMARY Timing Of Intravenous Antibiotics Matters Most Timing Of Debridement Matters Less Liberal Use Of Antibiotic Bead Pouches And Other Methods Of Dead Space ManagementVAC etc Immediate W ound Closure Appears to Be Reasonable If a Thorough Debridement Was Performed Duration Of I.V. Antibiotics Should Probably Continue To Be At Least 72 Hours The Quality Of The Debridement Probably Matters