Open Fractures: Understanding When To Wait, When To Fix, When to - PowerPoint PPT Presentation

Open Fractures: Understanding When To Wait, When To Fix, When to Wash Out Mani Kahn MD

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Open fractures are often high energy injuries Short term Long term • Contamination • Wound healing Compromised soft tissue • Infection • 5-50% envelope • Delayed union • Compromised host • Nonunion 7-60% • Nerve injuries • Loss of function • Vascular injuries • Amputation

Open fractures are often high energy injuries Short term Long term • Contamination • Wound healing • Compromised soft tissue • Infection 5-50% envelope • Delayed union • Compromised host • Nonunion 7-60% • Nerve injuries • Loss of function • Vascular injuries • Amputation

Management • Recognize the soft tissue injury • Thorough debridement in the OR • Temporizing (damage control) fixation • Appropriate operative planning

Augment treatment… • Appropriate early antibiotics • High volume irrigation • Effective wound care

Principles of debridement • Exploration/extension of wounds • Careful inspection of surfaces • Preservation of critical tissue • Thorough removal of foreign material and dead tissue

Surgical Urgency • All open wounds are considered to be contaminated • Whether infection occurs is determined by 3 variables: – Presence of bacteria – Presence of inert surfaces – Viability of host cells and tissues

Surgical Urgency • systemic antibiotics may not be able to effectively penetrate the site of infection to deliver antibiotic levels above the minimum inhibitory concentration

Timing of debridement “The 6 Hour Rule” Friedrich 1898 Robson et al 1973

Obstacles to effective early debridement • Multiply injured and under-resuscitated patients • Protracted transport times • OR availability • Suboptimal conditions • Trauma surgeon availability

National trends in timing of treatment of open tibia fractures • 42 % delay > 6 hrs • 24 % delay > 24 hrs Male gender, older age • Head or thoracic Injury AIS> 2 • Presentation between 6 pm and 2 am • • Level 1 university hospital setting Namdari et al 2011

Delays >6 hrs do not appear to increase infection risk Retrospective, prospective and meta-analysis studies Pollak et al 2010 Schenker et al 2012 Weber et al 2014 No increased infection for open tibia fractures debrided >24 and >48 hours Duyos et al 2017

Infection risk factors • Increasing Gustilo grade • Lower extremity fractures Harley et al 2002

Wound care/coverage Bead pouch • • Wound vac • Delayed primary closure Skin grafting • • Rotational flaps • Free tissue transfer

Wound Closure • Stable tissue viability after multiple debridements • Low energy wounds that have been adequately debrided and cleaned can be closed Recent level II evidence supports primary closure • of all clean I, II, and IIIA fractures without increased risk of infection or nonunion Scharfenberger et al 2017

Provisional fixation: Damage control orthopedics • Provisional fixation of fractures to allow for improved physiology • Provide stability and minimal soft tissue damage with little surgical bleeding • Avoid “second hit” of major orthopedic procedure until patient is resuscitated

Indications for definitive fixation • Adequate resuscitation – lactate <2.5-4.0, base excess ≥ -2 to -5, pH ≥ 7.3, UOP>30cc/kg/hr – Coagulopathy corrected • Soft tissues permit • Definitive coverage planned

Does Timing of Fixation and Wound Coverage Matter? • 105 free flaps in 103 patients monitored for infection Liu et al Injury 2011

When to consider immediate ORIF • Open upper extremity fractures Radoicˇic ́ et al 2014 Harley et al 2002

When to consider immediate ORIF • Periarticular fractures • Distal femur fractures with bone loss • Axial injuries – Early fixation in multiply injured patients • Shorter ICU stays • Fewer complications Dugan et al 2013 Vallier et al 2013

Ex-fix or IMN for open tibia fractures? • 143 tibia GI to GIIIb open tibia fractures treated with unreamed IMN at time of debridement with 3% infection rate Kakar 2007 • Staged ex-fix then IMN with higher infection and nonunion rates compared with immediate IMN Duyos 2017

References • Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-Wve open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453–458 • Schenker ML, Yannascoli S, Baldwin KD, et al. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94A:1057–1064. • Friedrich PL. Die aseptische Versorgung frischer Wunden, unter Mittheilung von Thier-Versuchen uber die Auskeimungszeit von Infectionserregern in frischen Wunden. Archiv fur Klinsche Chirugie. 1898:288-310. • Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30. • Namdari S, Baldwin KD, Matuszewski P, Esterhai JL, Mehta S. Delay in surgical de ́ bridement of open tibia fractures: an analysis of national practice trends. J Orthop Trauma. 2011;25:140-4. • Hauser CJ, Adams CA, Eachempati SR, et al. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence- based guideline. Surg Infect. 2006;7:379–405. • Scharfenberger et al Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection. J Orthop Trauma Volume 31, Number 3, March 2017 • Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma. 2002;16:484-90. • Radoicˇic ́ et al. Does timing of surgery affect the outcome of open articular distal humerus fractures Eur J Orthop Surg Traumatol (2014) 24:777–782 Dugan et al Open supracondylar femur fractures with bone loss in the polytraumatized patient – Timing is • everything! Injury, Int. J. Care Injured 44 (2013) 1826–1831 • Vallier et al. Do Patients With Multiple System Injury Benefit From Early Fixation of Unstable Axial Fractures? The Effects of Timing of Surgery on Initial Hospital Course

Benefits of early debridement • Early limb triage • Reduction in bacterial load/removal of nonviable tissue • Shorten treatment course

Treatment Arm Time period Patients Infection rate (Type III) Retrospective 1955-1968 670 open 12% (44%) fractures Prospective 1969-1973 352 open 2.5% (9%) fractures

How far have we come? • Infection Rate 4-63% Schenker et al 2012

Indications for operative debridement All wounds associated • with – Fractures – traumatic arthrotomy – penetrating the fascia, pleura, peritoneum, and vascular structures

Antibiotics: Timing counts! Hauser et al 2006 Lack et al 2015

Nonunion risk factors • Increasing Gustilo grade Presence of infection • Harley et al 2002

Antibiotics • Type I and Type II • First generation cephalosporin • Type III • Add aminoglycoside • High-risk anaerobic (barnyard), vascular • Add PCN injury (low O 2)

Irrigation • High volume, low pressure saline +/- pulsatile +/- antiseptic Type 1 – 3L Type 2 – 6L Type 3- 9L