Need For Debridement Research Articles

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Introduction: The true incidence of blunt breast trauma is unknown due to a paucity of relevant literature. A retrospective chart review of 5,305 female blunt trauma victims reported an incidence of 2% of female blunt breast trauma (FBBT), which was most often following motor vehicle collisions (94%) and associated with long bone and rib fractures (45% and 44%, respectively). The vast majority of patients had simple hematomas that were managed expectantly. A small subset (6.5%) had expanding hematomas which required surgical evacuation (Saunders et al, 2011). Here, we describe a patient who presented in extremis with multiple injuries including a rapidly expanding breast hematoma necessitating urgent surgical intervention. This case highlights the importance of prompt recognition and treatment of FBBT in the trauma patient. A 51 year old female presented to the trauma resuscitation unit in extremis following a high-speed head-on motor vehicle collision with multiple injuries including grade II splenic laceration, right olecranon and patella fractures, bilateral ankle fractures, several rib fractures, bilateral pneumothoraces, and a rapidly expanding breast hematoma. Upon arrival, the patient was hypotensive and was urgently intubated. Despite the placement of bilateral chest tubes, her hypotension failed to resolve and her hemoglobin dropped from 9.1 to 5.7 g/dL. Clinically, there were signs of expansion of the hematoma in her left breast. Following resuscitation, the patient was taken urgently to the operating room for a left chest wall exploration and hematoma evacuation. A curvilinear incision was made in the upper portion of the left breast and the tissues were dissected down to the subcutaneous layer. A large hematoma was evacuated and the breast tissue was noted to be discolored, likely due to hematoma or direct injury. There was pulsatile hemorrhage from large branches supplying the pectoralis major muscle, which were ligated with 2-0 Vicryl ties. Other wounds were irrigated and packed tightly. The patient was transferred to the intensive care unit post-operatively, and orthopedic surgery managed the care of her multiple fractures. Three days following the initial procedure, the patient was brought back to the operating room for re-exploration of the left chest wall. At that time, there was no evidence of ongoing hemorrhage or any need for debridement. The pectoral muscle was closed with 2-0 Vicryl, a Jackson Pratt drain was placed deep in the wound, and the subcutaneous breast tissue was closed in multiple layers with 2-0 Vicryl. The skin was closed with a running 4-0 Monocryl subcuticular suture. The patient's post-operative course was uncomplicated and she was discharged to acute rehab approximately 2 weeks following admission. FBBT is an understudied entity; however, as the above case illustrates, breast hematomas can be the underlying cause of refractory hypotension and unchecked hemorrhage in the female blunt trauma patient. Concomitant injuries, particularly multiple fractures and pneumothoraces, as well as mechanism of injury, in this case a high speed motor collision, can raise the suspicion of FBBT in the trauma patient with visible signs of breast tissue damage who fails to appropriately respond to resuscitation and traditional interventions. Further research is needed to fully appreciate the incidence of FBBT and to aid in the establishment of guidelines in the management of breast hematomas. Many can be treated conservatively with close observation, but as in the case described, exploration, evacuation of the hematoma, and surgical control of hemorrhage may be required to prevent further decompensation of the patient.

Use of vacuum-assisted closure to maintain viability of a skin flap in a dog

A 4-year-old sexually intact male Labrador Retriever-Poodle mix was admitted to the hospital for treatment of a wound in the left thoracic region. The wound had been debrided and primary closure had been performed by the referring veterinarian 4 days previously. The dog had a 20-cm-long wound covered by a large flap of skin that extended caudally from the scapula over the left side of the thorax. A 3-cm defect was evident at the cranioventral aspect of the wound, from which purulent material was being discharged. The skin flap was necrotic, and the skin surrounding the flap was bruised. Signs of pain were elicited when the wound and surrounding region were palpated. Other findings, including those of thoracic radiography, were unremarkable. The wound was debrided, and vacuum-assisted closure (VAC) was initiated for 3 days until a healthy bed of granulation tissue developed. A reconstructive procedure was performed with a rotation flap 3 days after VAC dressing removal. The VAC process was reinitiated 2 days following reconstruction because of an apparent failing of the skin flap viability. After 5 days of VAC, the flap had markedly improved in color and consistency and VAC was discontinued. Successful healing of the flap occurred without the need for debridement or additional intervention. Use of VAC led to a good overall outcome for the dog, with complete healing achieved. Additional evaluation of this technique for salvaging failing skin flaps is warranted in dogs, particularly considering that no reliable method for flap salvage in veterinary species has been reported to date.

Inpatient Management of Diabetic Foot Disorders: A Clinical Guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Available options for debridement

A clear understanding of the need for debridement and available options is necessary for the clinician to make the best choice.

The treatment of diabetic foot infections: focus on ertapenem

Clinically, 3 distinct stages of diabetic foot infection may be recognized: localized infection, spreading infection and severe infection. Each of these presentations may be complicated by osteomyelitis. Infection can be caused by Gram-positive aerobic, and Gram-negative aerobic and anaerobic bacteria, singly or in combination. The underlying principles are to diagnose infection, culture the bacteria responsible and treat aggressively with antibiotic therapy. Localized infections with limited cellulitis can generally be treated with oral antibiotics on an outpatient basis. Spreading infection should be treated with systemic antibiotics. Severe deep infections need urgent admission to hospital for wide-spectrum intravenous antibiotics. Clinical and microbiological response rates have been similar in trials of various antibiotics and no single agent or combination has emerged as most effective. Recently, clinical and microbiological outcomes for patients treated with ertapenem were equivalent to those for patients treated with piperacillin/tazobactam. It is also important to judge the need for debridement and surgery, to assess the arterial supply to the foot and consider revascularization either by angioplasty or bypass if the foot is ischemic. It is also important to achieve metabolic control. Thus infection in the diabetic foot needs full multidisciplinary treatment.

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients

ABSTRACTTo compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Techniques in Soft Tissue Coverage Around the Knee

Abstract: Delayed wound healing may have potentially devastating consequences to the final outcomes of surgical procedures around the knee. Issues with necrosis of the skin and subsequent infection may threaten bony healing or prosthesis retention and could lead to the eventual need for debridement or hardware removal. One of the most important aspects in the management of these difficult situations is to obtain stable soft tissue coverage over the defect. The use of musculocutaneous or fasciocutaneous flaps has been very effective in achieving this goal. Recruiting tissue from a remote source not only successfully provides closure of the knee joint or coverage of exposed critical structures around the knee but also aids in the clearing of infections by improving the vascularity in the area. Several techniques, including skin grafts, local skin flaps, rotational muscle flaps, and free flaps, have been used both prophylactically and for salvage procedures for complications that occur after knee surgery. The gastrocnemius muscle flap has proven to be a dependable method of providing knee coverage; however, for those patients in whom the integrity of the muscle or its blood supply has been compromised, other techniques must be considered. In this paper, new advances in soft tissue reconstructive techniques will be discussed. A review of the results and complications will be presented, along with possible future advances.

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients.

To compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Debridement and Closed Packing for Sterile or Infected Necrotizing Pancreatitis

To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis. Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described. Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality. The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02). Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement.

Severity scoring for prognostication in patients with severe acute pancreatitis: comparative analysis of the Ranson score and the APACHE III score.

Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis. The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP. Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM. Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration. The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.

Book Review

Master Cases: Orthpaedic Trauma. Clayton R. Perry and Charles M. Court-Brown, Thieme, New York, NY, U.S.A., 1999 The purpose of this book was to present a case-based approach to orthopaedic traumatology. The authors employ a collection of case presentations to provide an interactive format to examine critical issues surrounding trauma in both the upper and lower extremities. The use of a clinical case-based teaching format to illustrate basic principles and controversies in orthopaedic traumatology stands in marked contrast to conventional orthopaedic trauma textbooks. The authors carefully detail a representative cross-section of orthopaedic trauma experience. The material examined ranges from simple to complex, but is not all-inclusive. The book is organized in two principle sections. Section I examines upper extremity fractures (25 cases) and section II lower extremity injuries (39 cases). Each chapter is organized as if a patient were presenting to an emergency room: history and physical examination, radiographic findings, diagnosis, surgical management, and postoperative management. Three sections follow each case presentation: discussion, alternative methods of management, and complications. Each alternative management of a given fracture is displayed in a table format highlighting its advantages and disadvantages and a brief comment about each technique. Last, the authors provide suggested readings for each clinical scenario. This format challenges the reader to think critically about each patient's case and problem in a sequential fashion. The reader is presented with the history and clinical findings and has the opportunity to interpret the radiographs. The reader can formulate a potential treatment plan, and as the discussion unfolds, the reader will learn if it is one of the methods proposed by the authors. The authors often provide clinical pearls and pitfalls based on their voluminous experience as internationally known traumatologists. The authors do not emphasize particular instrumentation choices but examine the key anatomic, technical, and fundamental patient management issues. Decision points are emphasized. Is the distal humerus fracture intra-articular? Does one need to use an olecranon osteotomy or two-incision approach? What features shape these decisions? These are representative issues that are addressed. Throughout the text, the authors emphasize the need to look not only at the osseous injuries, but to consider the complete management of the patient's injury patterns. The author's stress the importance of the soft tissue injury, need for debridements, timing of interventions, and consideration of ultimate patient function. Naturally, criticism of case-based textbooks will stem from the author's lack of coverage of particular injury patterns or those not covered in enough detail. The lack of coverage of acetabular fractures and sole case of a pelvic injury represent a shortcoming of this text. Acetabular fracture management seems uniquely suited to this type of format. These fractures often confuse orthopaedic surgery residents and the general orthopaedist. Other injury patterns that merit more attention are knee dislocations or fracture/dislocations. In summary, this text is a valuable addition to the libraries of most orthopaedic residents and general orthopaedists. It will provide a useful starting ground to stimulate further discussion of the numerous controversies that surround orthopaedic trauma management. However, the more experienced reader will want to supplement this text with more recent, comprehensive and in depth studies and reviews of the respective injury types. This book, however, represents a refreshing case based format to examine the complex field of orthopaedic traumatology.

Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements.

Twenty-nine patients with necrotizing fasciitis were treated from 1980 to 1988. This study evaluates how the addition of hyperbaric oxygen (HBO) therapy to surgical treatment has affected mortality and the number of debridements required to achieve wound control in these patients. Two groups of patients were viewed: group 1 (n = 12) received surgical debridement and antibiotics only; group 2 (n = 17) received HBO (90 minutes at 2.5 atm, average 7.4 treatments) in addition to surgery and antibiotics. Both groups were similar in age, race, sex, wound bacteriology, and antimicrobial therapy. Body surface area affected was similar, however, perineal involvement was more common in group 2 (53%) than in group 1 (12%). The admitting conditions of patients in group 1 (non-HBO) were diabetic, 33%; white blood cell count more than 12,000, 50%; and shock, 8%. The admitting conditions of patients in group 2 (HBO) were diabetic, 47%; white blood cell count more than 12,000, 59%; and shock, 29%. Although group 2 patients receiving HBO were more seriously ill on admission, mortality was significantly lower (23%) compared to group 1 (66%) (p less than 0.02). In addition, only 1.2 debridements per group 2 patient were required to achieve wound control versus 3.3 debridements per group 1 patient (p less than 0.03). The addition of HBO therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity (number of debridements) in this study, especially among nonclostridial infections. We conclude that HBO should be used routinely in the treatment of necrotizing fasciitis.