Initial Debridement Research Articles

71 Early Donor Site Harvesting in Burn Patients

Abstract Introduction Donor sites harvested for split-thickness skin grafts (STSG) are typically applied immediately to the intended recipient site. The size of a harvested donor site may delay discharge from the Burn Unit related donor site pain and healing. In September 2018, our burn center began to harvest donor sites early and banking the STSG for later use. In this paper, we evaluated the benefit and effectiveness of early donor site harvesting. Methods A retrospective review was performed to identify patients who underwent one homograft procedure followed by one autograft procedure that had donor sites harvested at the time of their homograft procedure and banked for later use (Group A). These patients were matched by TBSA and age to a patient that underwent a one homograft procedure followed by one autograft procedure that had a donor site harvested in their autograft procedure (Group B). TBSA, Total Length of Stay, and Length of Stay in terms of number of days per TBSA were reviewed for comparison. Results Since September 1, 2018, we have harvested STSG from 43 patients with their initial burn debridement and banked the STSG for their next surgery. The mean donor site size harvested early was 1520cm2. The average number of days the STSG was stored = 6.2 days. As seen in table 1, Group A has a larger mean TBSA and a shorter overall length of stay and lower number of days per TBSA. Both groups experienced graft loss in 2 patients that required regrafting. The graft loss in both groups was attributed to either poorly controlled diabetes or wound infection. The difference in length of stay is not statistically significant but is considered clinically and financially significant as the shorter length of stay is an average savings of $23662.80 in room and board charges. Conclusions Early harvesting of donor sites is successful and clinically effective. It is clinically safe to harvest and store STSG for delayed application. By harvesting donor sites early, patient discharge is not delayed due to an unhealed donor site which may be a financial savings for the patient and / or the institution. Applicability of Research to Practice Decreased of length of stay provides financial savings to the patient and the institution, as well as, decreasing possible complications.

856 A Pilot Study of a Point-of-care Wound Bed Assay to Predict Graft Take

Abstract Introduction Deciding when to graft a burn wound is instrumental in acute reconstruction. A technology capable of predicting autograft success would help optimize timing of initial debridement and grafting. In prior work, members of our team developed a point-of-care proteinase assay capable of predicting delayed wound healing in chronic wounds. In the work reported here, we seek to quantify these proteolytic enzymes in acute burn wounds in an effort to ultimately determine whether a quantitative assessment of proteinase activity in a burn wound might predict successful healing of autograft. Methods Eight burn patients were taken to the operating room for autografting. Tissue samples were obtained from unique sites, as well as swabs of wounds pre- and post-excision. A point-of-care proteinase assay determined initial rates of fluorescence, which correlates with the amount of proteolytic enzyme activity. Autograft sites were assessed after two weeks, with ≥50% take considered successful and < 50% take deemed unsuccessful. Initial rates of fluorescence were compared. These groups were analyzed using two-sided student’s t tests, with p< 0.05 identified as significant. Results The pre-excision group initial rate was significantly higher than the post-excision group (p=0.0006). The tissue group initial rate was also significantly higher than the post-excision group (p = 0.0028). We also compared pre-excision initial rates of enzymatic activity between successful autografts (n=10, 18.34±20.90 RFU/min) and unsuccessful autografts (n=5, 4.32±4.62 RFU/min) with p = 0.169. Conclusions Multiple findings indicate the potential of this assay to differentiate burn wounds based on proteinase activity. Pre-excision tissue beds contained significantly higher rates of proteinase activity compared to excised and debrided tissue beds (p = 0.0006). This is consistent with burn wound morphology, as proteolytic enzymes function to debride damaged tissue and promote angiogenesis in acute wounds. Interestingly, initial rates of proteolytic enzymatic activity in pre-excised wounds of successful autografts trended towards significance compared to unsuccessful autografts (p = 0.169), suggesting that these proteolytic enzymes reflect an overall healthy wound bed, the presence of which could portend a heightened chance for autograft success. Applicability of Research to Practice This pilot study confirms the presence of proteinase activity in acute burn wounds utilizing a point-of-care test. Future work will investigate whether this test can assist physicians in predicting amenability of burn wounds to autografting.

Surgical timing for open fractures

Controversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. However, the “six-hour rule” for initial open fracture debridement and revascularization has come into question. New evidence supports initial debridement within 24 hours with the appropriate surgical team. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis.

Association between baseline abundance of Peptoniphilus, a Gram-positive anaerobic coccus, and wound healing outcomes of DFUs.

Diabetic foot ulcers (DFUs) lead to nearly 100,000 lower limb amputations annually in the United States. DFUs are colonized by complex microbial communities, and infection is one of the most common reasons for diabetes-related hospitalizations and amputations. In this study, we examined how DFU microbiomes respond to initial sharp debridement and offloading and how the initial composition associates with 4 week healing outcomes. We employed 16S rRNA next generation sequencing to perform microbial profiling on 50 samples collected from 10 patients with vascularized neuropathic DFUs. Debrided wound samples were obtained at initial visit and after one week from two DFU locations, wound bed and wound edge. Samples of the foot skin outside of the wounds were also collected for comparison. We showed that DFU wound beds are colonized by a greater number of distinct bacterial phylotypes compared to the wound edge or skin outside the wound. However, no significant microbiome diversity changes occurred at the wound sites after one week of standard care. Finally, increased initial abundance of Gram-positive anaerobic cocci (GPAC), especially Peptoniphilus (p < 0.05; n = 5 subjects), was associated with impaired healing; thus, GPAC’s abundance could be a predictor of the wound-healing outcome.

Primary intramedullary nailing in compound Type 1 and 2 femur shaft fractures and their effect on functional outcome

Background: Femur shaft fractures are the most common long bone fractures encountered in orthopedic practice. Open fractures of the femur shaft are due to high-energy trauma; these patients are usually associated with other system injuries and vascular involvement. The initial management of open fractures includes antibiotics, debridement, and stabilization. If the initial debridement is believed to be adequate, definitive fixation of the femoral shaft can be performed usually with reamed intramedullary nailing. The present study was conducted to evaluate the functional outcome in open Type 1 and 2 femur shaft fractures managed with primary intramedullary nailing and the complications related to it. Materials and Methods: Twenty-two patients, having Grade 1 and 2 compound femur shaft fractures were admitted and included in the study from January 2016 to February 2019 after obtaining valid consent. All the patients were investigated with X-rays, and fractures were classified according to Gustilo–Anderson classification. All the patients were treated primarily with intramedullary nailing, and the functional outcome was assessed by using Harris Hip Score and Oxford Knee Score. Results: Thirteen (59.09%) patients had Type 1 open femur shaft fractures and nine (40.90%) patients had Type 2 fractures. Fracture union was observed in six patients (27.27%) at 3 months and in 16 (72.72%) at 3–6 months. Complications observed were superficial wound infections in two patients, deep infections in two patients, and nonunion in one patient. Thirteen (59.09%) patients got excellent outcome, four (18.18%) patients got good outcome, three (13.63%) patients got fair outcome, and two (09.09%) patients got poor outcome. Conclusion: Primary intramedullary nailing is an effective method of managing Type 1 and 2 open femur shaft fractures if thorough early and timely debridement can be done. It is associated with less complications, helps in early mobilisation and also avoids secondary procedures.

Resection Arthroplasty Using a Vastus Lateralis Muscle Flap in the treatment of patients with recurrent form of the hip prosthetic joint infection

To evaluate the efficacy of chronic recurrent hip periprosthetic joint infection (PJI) eradication after resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh. There were 38 patients with chronic recurrent hip PJI who underwent resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh in 2005-2016. The groups were compiled considering the absence or presence of recurrent infection in early postoperative period. Infection duration, number of operations, incidence of recurrent PJI, type of pathogen, laboratory parameters, bone defect size and presence of PJI remission within at least 2 years were investigated. Uneventful early postoperative period after resection arthroplasty with non-free transplantation of vastus lateralis muscle flap was noted in 81.6% of cases (n=31, group 1). Postoperative wound revision was required in 18.4% of cases (n=7, group 2). Stable remission of infection within 2-8 years (Me - 4 years) was achieved in 36 (94.7%) patients. Relative risk of recurrent PJI increased by more than 4 times (RR 4,364, 95% CI 0,581-32,787) in cases of polymicrobial infection involving Gram-negative bacteria and decreased in cases of monomicrobial infection (RR 0,256, 95% CI 0,034-1,916). Significantly longer duration of surgery and more pronounced laboratory changes were revealed in group 2. High efficacy of resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh was established in patients with chronic recurrent hip PJI. This procedure might be considered as a stage treatment with the possibility for revision arthroplasty in case of failed initial debridement surgery due to PJI pathogens that are difficult for eradication.

Delayed reconstruction for olecranon fracture with extensive soft tissue injury and bone loss: A case report

Delayed surgery for intraarticular fractures of the elbow is usually avoided, especially to prevent complications such as stiffness. We described an interesting case of a young patient who presented with open fracture of right olecranon, with extensive soft tissue injury and bony loss. He was treated with a 3-stage surgical procedure, prioritising on the soft tissue healing first before undergoing a delayed, definitive fixation of the olecranon, which was done 4 weeks after the trauma. The 3 stages include initial debridement and temporary skeletal stabilisation using Kirschner wires and external fixator, second look debridement with shoelace (dermato-traction) technique of delayed wound closure, and a definitive, reconstructive surgery using tricortical iliac bone graft with anatomical locking plate. The subsequent radiographs showed restored articular congruency of the elbow joint, before the olecranon eventually achieved bony union. He recovered well with excellent outcomes, as the elbow range of motion achieved almost full flexion at 120° and the extension lag at 10° and the Disabilities of the Arm, Shoulder and Hand (DASH) score of 3.3 was recorded. Delayed reconstructive surgery for olecranon fracture with extensive soft tissue and bone loss is a viable option to avoid complications, including infection and non-union. A judicious consideration by prioritising soft tissue management over expeditious bony surgery is important to achieve excellent outcomes.

Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. Retrospective comparative cohort study over a 2-year period. Level 1 trauma center. A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. Time to initial debridement and definitive management. Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Computed tomography-guided thoracoscopic debridement for multiple loculated organizing empyema: a case report

BackgroundVideo-assisted thoracoscopic surgery (VATS) for organizing empyema is challenging because fibrous septa and peel within the cavity are thickened and hardened. Some patients have multiple isolated empyema cavities that require debridement individually because firm intrathoracic adhesion was developed during this phase. If the debridement was incomplete as a result of worrying about an accidental injury of the surrounding organ, additional interventions may be required due to the persistent empyema cavity or insufficient expansion of the ipsilateral lung. We here describe a representative case with multiple loculated organizing empyema that could safely and reliably perform VATS debridement under C-arm cone-beam computed tomography (CBCT).Case presentationA 67-year-old woman was admitted to our department for the treatment of right empyema. Chest computed tomography showed fluid collection in three independent spaces within the right thoracic cavity. It was assumed that a firm adhesion between the lung and chest wall was developed because about 7 weeks passed since the onset. Therefore, we decided to use CBCT to completely debride three empyema cavities separately by VATS. One cavity was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage. By clicking any intended anatomical structures on CBCT images, the position was readily depicted by lase projection on the body surface, which helped to place the best skin incision. Moreover, in other cavities, CBCT after initial debridement showed insufficiently dissected cavity. Additional debridement resulted in a successful shrinkage of the empyema cavity.ConclusionWe believe that VATS debridement under CBCT guidance is one of the useful treatment options for multiple loculated organizing empyema.

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial.

The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation. The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses. This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392-1401.

Anterior urethral erosion: report of a malfunctioned and infected artificial urinary sphincter

Background: Since its introduction in less than a century, artificial urinary sphincter (AUS) remains the gold standard in the treatment of severe male sphincter weakness incontinence. It is an extremely reliable prosthesis and patient's satisfaction rate is high after successful implantation. However, complications can occur following implantation and one of the most feared complications is anterior urethral erosion from sphincter malfunction and failure. As patients embark on medical tourism, Urologists in our environment may be challenged with complications resulting from various interventions not readily available in our environment.Case Summary: A 15 year old male student presented to our facility with fever of one week duration and painful scrotal swelling which ruptured spontaneously discharging purulent foulsmelling fluid two (2) months following successful implantation of AUS at a hospital in India. He was febrile with temperature of 38.70C, respiratory rate 32 cycles/minute, pulse rate 110 beat per minutes and blood pressure of 100/60mmHg. His packed cell volume was 34 % other laboratory parameters were not remarkable. He was managed for urosepsis with intravenous infusion, parenteral antibiotics, and initial wound debridement and subsequent AUS ex-plantation and perineal urethrostomy. Patient did well and he is awaiting urethroplasty and AUS placement.Conclusion: Artificial urinary sphincter removal and perineal urethrostomy is a viable option for the emergency management of anterior urethral erosion due to malfunctioned infected artificial sphincter.Keywords: Anterior urethral erosion, artificial urinary sphincter, Urosepsis, perineal urethrostomy, urethroplastySavannah Journal of Medical Research and Practice 2018;7(1):23-27

Wound healing of open fractures: comparison of vaccum assisted dressing versus traditonal dressing

PurposeFor permanent wound coverage of compound fractures, the wound surface should have 100% granulation tissue without any discharge or necrotic slough. Negative pressure wound therapy (NPWT) is a well known modality in the management of open fractures, and post-operative wound problems. This study was conducted to compare the outcome of NPWT and traditional dressing in wound healing of open fractures. Material and methodsA prospective study of 100 cases was conducted to compare the wound healing outcomes of open fracture following vacuum assisted closure (VAC) dressing (50 cases) and traditional wound dressing (50 cases). Patients included in the study underwent initial debridement to remove necrotic slough and tissue when indicated. Foam dressings were used to cover the wounds using aseptic conditions in the VAC group. Dressings were changed daily for patients in traditional dressing group using hydrogen peroxide, normal saline and povidone iodine in a sequential manner and every 3–4 days in the VAC dressing group. Patients were evaluated clinically for appearance of granulation tissue, duration of hospital stay and reduction in wound surface area using appropriate statistical methods. ResultThere was a significant difference between the rate of wound healing in the group NPWT/VAC group compared to the traditional wound dressings group in terms of appearance of granulation tissue, reduction in wound surface area and duration of hospital stay. ConclusionVacuum assisted dressing is more effective than traditional wound dressing in wound healing of open fractures.

Oral Antibiotic Management of Acute Osteomyelitis of the Hand: Outcomes and Cost Comparison to Standard Intravenous Regimen.

Background: Acute, direct inoculation osteomyelitis of the hand has traditionally been managed by intravenous antibiotics. With proven high levels of bone and joint penetration, specific oral antimicrobials may deliver clinical efficacy but at substantially lower cost. Methods: Sixty-nine adult patients with surgically proven acute, direct inoculation osteomyelitis of the hand were evaluated for clinical response on a 6-week postdebridement regimen of susceptibility-matched oral antibiotics. Inclusion required gross purulence and bone loss demonstrated at the initial debridement and radiographic evidence of bone loss. Excluded were 2 patients with extreme medical comorbidities. There were 53 men and 16 women with a mean age of 46 years. Mean follow-up was 16 weeks (±10). The cost model for the outpatient oral antibiotic treatment was intentionally maximized using Walgreen's undiscounted cash price. The cost model for the traditional intravenous treatment regimen was intentionally minimized using the fully discounted Medicare fee schedule. Results: All patients achieved resolution of osteomyelitis by clinical and radiographic criteria. In addition, 7 patients underwent successful subsequent osteosynthesis procedures at the previously affected site without reactivation. The mean postdebridement direct cost of care per patient in the study cohort was $482.85, the cost of the antibiotic alone. The postdebridement direct cost of care per patient on a regimen of vancomycin 1.5 g every 12 hours via peripherally inserted central catheter line was $21 646.90. Conclusions: Acute, direct inoculation osteomyelitis of the hand can be successfully managed on oral antibiotic agents with substantial direct and indirect cost savings.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic.

With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure. In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group. In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002-1008.

Open reduction and internal fixation of Gustilo type-I and type-II open pilon fractures using a lateral approach.

Traditional anteromedial incision for pilon fractures would further increase the damage to the subcutaneous tissues anterior and medial to tibia. In this study, we retrospectively evaluated the method and the outcomes of lateral approach for surgical treatment of Gustilo type-I and type-II open pilon fractures with medial soft tissue injuries. From May 2014 to September 2017, 35 patients with Gustilo type-I and type-II open pilon fractures were treated with standard protocol using a lateral approach. The initial wound debridement and application of a spanning external fixator or traction of calcaneal tubercle were performed within 24 h and a definitive fixation was performed when the wound was healed. The mean time from primary surgery to definite surgery was 11.8 (range: 8-16) days. Postoperative radiographs, complications, bone union, and American Orthopedic Foot and Ankle Society (AOFAS) ankle/hind foot score were recorded. The mean follow-up period was 17 months (range: 13-23). The average time to bone union was 22 weeks (range: 18-25). In 35 patients, 2 patients had a superficial wound infection and another 1 patient showed limitation of ankle joint motion. No cases of deep infection, skin necrosis, and symptomatic implant reported. The mean AOFAS score was 89.8 (range: 84-95). On final outcome, 25 patients come under excellent and 10 patients had good result. From the results of this study, we can conclude that the lateral approach to treat Gustilo type-I and type-II open pilon fractures was a safe option with a low complication rate. On the other hand, it provides sufficient exposure to restore anatomic articulation, which is worthy of clinical recommendation.

Risk Factors for Infection After Intramedullary Nailing of Open Tibial Shaft Fractures in Low- and Middle-Income Countries.

(1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. Prospective cohort study using an international online database. Multiple hospitals in LMICs worldwide. A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Initial Debridement of Dorsal Hand Abscesses in the Operating Room Does Not Improve Outcomes.

Background: Hand infections frequently involve the dorsal aspect of the hand and often develop secondary to some traumatic mechanism. Although Staphylococcus aureus is most commonly isolated, anaerobic and polymicrobial infections are not uncommon. To date, treatment is largely anecdotal, with some surgeons preferring a formal debridement in the operating room, while others opt for an initial debridement at the bedside. The goals of this study were to compare outcomes between treatment modalities and to identify the most common causative organisms. Methods: A 10-year retrospective chart review was conducted to identify adult patients who presented with a dorsal hand infection to a single, level 1, urban trauma center. Demographic data were collected as well as the abscess size, location, duration of symptoms, treatment administered, number of formal debridements, length of hospital stay, and complications. Results: The number of formal debridements was significantly less in the initial bedside debridement group (P < .01), as was the hospital length of stay (P < .01). There was no significant difference in hospital readmissions, complications, or infection due to methicillin-resistant Staphylococcus aureus. There was also no significant difference in abscess size, duration of symptoms, or demographic data including age, sex, comorbidities, intravenous drug use status, and immunocompromised status. Conclusions: An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room. This decreases number of formal debridements and days in the hospital, without any increase in complications. This permits safe, expeditious, and cost-effective treatment for this common condition.

Microdeformational wound therapy: A novel option to salvage complex wounds associated with the Nuss procedure

BackgroundComplex wounds associated with the Nuss procedure are a resource intensive complication that may lead to significant morbidity with potential removal of the implanted device and abandonment of the repair. We report our management technique of this complication utilizing microdeformational wound therapy (MDWT) that is safe, is efficacious and allows for salvage of the repair. Operative techniqueWe defined a complex wound as a wound that became suppurative and drained in the postoperative period and failed to resolve with a trial of conventional wound management and antibiotics. Upon recognition of a complex wound, we recommend an initial operative wound debridement. This allows wound cultures, wound assessment and precise initiation of MDWT. It is not uncommon to have exposed hardware in the wound early in the course of therapy. Metal allergy must be excluded. The patient is transitioned to oral antibiotics following resolution of the acute process. MDWT is performed until the wounds are completely epithelialized with no clinical signs of drainage or infection. The average length of MDWT in our patients was 39 days. Following complete wound healing the patients are maintained on antibiotics until implant removal. ConclusionsThe use of microdeformational wound therapy in complex wounds associated with the Nuss procedure is a safe and effective modality. The technique may reduce the likelihood of implant removal with potential recurrent pectus excavatum. Type of studyOperative technique. Level of evidenceLevel IV, case series with no comparison group

Prevalence and patterns of traumatic bone loss following open long bone fractures at Mulago Hospital.

Introduction:Significant traumatic bone loss in developed countries occurs in a high proportion of open fractures ranging from 11.4% to 40%. However, literature from developing countries such as Uganda scarcely documents the prevalence and patterns of traumatic bone loss. Direct trauma and iatrogenic factors have been associated with traumatic bone loss as possible etiologies.Objective:The study was aimed at establishing the prevalence and patterns of traumatic bone loss following open long bone fractures, and identifying factors associated with traumatic bone loss among patients presenting to Mulago Hospital within 24 hours of sustaining the injury up to completion of the initial fracture debridement, reduction, and fixation.Methodology:It was a prospective cohort study conducted at Mulago Hospital. A total of 136 open long bone fractures were registered and physically examined for traumatic bone loss. Patients who consented were recruited consecutively to participate in the study. Data on the patients’ sociodemographics and fracture patterns were collected using pretested questionnaires and analyzed using Stata version 12.Results:From 123 patients, a total of 136 open long bone fractures were registered. The prevalence of traumatic bone loss following open long bone fractures was 26.5%. Of the 36 open long bone fractures with traumatic bone loss, the more common pattern (61.1%) was significant traumatic bone loss (≥ 2.5 cm long). Commercial motorcycle riders (22.0%) and traders (20.3%) were the most common occupations associated with open long bone fractures. Gunshot injuries were the leading cause of traumatic bone loss in open long bone fractures.Conclusion:Our setting has a high prevalence of traumatic bone loss among open long bone fractures with the majority occurring in Gustilo type IIIB injuries of the tibia. The likelihood of traumatic bone loss is higher in open fractures caused by gunshots.