Open fractures. Reto Babst MD, Prof. of Surg. Head of Trauma Surgery Clinic for Orthopedics and Trauma Luzerner Kantonsspital 6002 Luzern
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1 Open fractures Reto Babst MD, Prof. of Surg. Head of Trauma Surgery Clinic for Orthopedics and Trauma Luzerner Kantonsspital 6002 Luzern
2 Outline Problem list Emercency room treatment + assessment Debridement Stabilization bone Soft tissue coverage Case exampels
3 Problems with open fractures Disruption of soft tissue integrity bacterial contamination/colonisation (time?) Prophylaxis of infection Stabiliziation of soft tissue + bone Soft tissue closure Bone healing Functional restoration or amputation
4 Local assessment + first actions Trauma mechanism Clinical assessment Wound (soft tissue grading) floating extremity vascularity (Doppler) neurology Rx: CT (polytrauma), ap/lateral, distal/prox. joint (monotrauma) Fotodocumentation and sterile coverage (1 time inspection) Prophylaxis of infection! Splinting AB prophylaxis (therapy)
5 Assessment wound (Gustillo-Anderson) Type Wound Contamination Soft-tissue damage 1 1 cm - Clean Minimal 2 1 cm + Moderate Moderate, some muscle Bone injury Simple, minimal comminution Moderate comminution 3A. 10 cm + High 3B. 10 cm + High 3C. 10 cm + High Severe with crushing Severe loss of cover Vascular injury requires repair Soft-tissue cover possible Requires reconstructive surgery Requires reconstructive surgery
6 Prognosis & Gustilo-Anderson Classification Fracture healing: IM NAIL TIBIA GRADE I GRADE II GRADE IIIA GRADE IIIB HEALING WKS WKS WKS WKS Infection rate and Amputation: GRADE I II IIIA INFECTION 0-2% 2-7% AMPUTATION 10-25% IIIB 10-50% IIIC 25-50% 50% Gustilo, J.Trauma 1984
7 Gustillo-Anderson classification - Focus on tibia - Focus on skin lesion (caviation in gun shot wounds?) - Moderate interobserver reliabiltiy (60%) - Vascular lesions are not differenciated ü Prognosis correlates with soft tissue damage
8 Open fractures and 6 h rule Metaanalysis of 7 studies n= 610; Level II-III P: open tibia fractures Gustillo-Anderson I-III A-C I: debridment < 6 C: debridment > 6h O: Infection raten, on union rate.. taking into account the limitations of this study, our results suggest that there is no obvious difference in the overal deep infection and non union rate between open tibial fractures debrided < 6 hours vs > 6 h Prodromidis AD et al JOT 2017 ahead of publication
9 Antibiotics Open fractures 1st and 2nd degree 2nd generation Cephalosporin 2 g i.v. at ER Repeat after 12 h in total 3 x 2 g Open fractures 3rd degree same than preemptive therapy for 5 days with Coamoxicillin i.v. 3x2 g/day Prophylaxis for tetanus
10 Stabilization of soft tissue and bone Irrigation Debridment Assessment Plan redebridment (24-48h) Soft tissue cover Not a science, but an art! Experience with time Sequential Beware low blood pressure and tourniquet!
11 Irrigation Saline or low pressure? Avoid Implosion of foreign material Hydrodissection of tissue Insufflation of tissue Amount of liquid? Dilution is the solution to pollution (10 l) Solution?
12 Reoperation Reoperation Bandari M et al. N Engl J Med 373; December 31, 2015
13 Debridment soft tissue Skin and subcutaneus tissue Longitudinal inzisions Trimm edges 1-2 mm to create clean wound edges Cut fat back to punctuate bleeding Fascia Muscles Colour Consistency Contractility Capillary bleeding
14 Debridment Bone Shaft: remove all fragments without soft tissue attachments Necrotic cortical bone: 50% increase in infection rate * Articulation: preserve segments of articular surface which are important for joint salvage Dead space: Gentamycin spacer * Edwards CC CORR 1988
15 Stabilization bone External fixator Temporary: damage control surgery early switch to IM nail or plate IM Nail? Plate (fix and flap)
16 Stabilization bone Primary Nail vs Ex fix Open Tibia I-III B IM Nail equal or better results Bone healing, weight bearing secondary procedures Infection rate assoc. with pin tract infection Malunion Tornetta P JBJS Br 1994 Schandelmaier Clin Orthop 1997 Alberts KA Injury 1999 Yokohama K et al Indian J of Orthop 2008
17 Stabilization bone Staged Procedure Ex Fix to IM Nail damage control fixation planned switch dependent on general and local conditions short period < 14 (-21) days pin tract infection is a contraindication to a one step procedure from ex fix to nail Blachut PA JBJS 1990 Siebenrock KA Arch Orthop Trauma Surg 1997 Maurer DJ JBJS 1989 Nowotarski PJ JBJS Am 2000
18 Soft tissue closure Primary closure: I ev. II; no tension!!! Delayed closure: Sterile dressing artificial skin Vac skin graft if amputation Fix and Flap (one stage) Local flaps vascularized flaps
19 Soft tissue closure Immediate flap less complications better Severe results open fractures Grade III (A) B and C Secondary Aggressive procedures debridement and stabilization Fracture Temporary healing soft tissue closure Infection Wound not rate be closed < 72 (<7) d by NPWT Only in stable conditions (Monotrauma) Transfer to a an institution with reconstructive surgery < 72 h lower infection rate < 7 d + NPWT Godina M Plast Reconstr Surg 1986 Hertel R Arch Orthop Trauma 1999 Sinclair JS Injury 1997, Gopal S JBJS BR 2000 Bhattacharyya T et al AAOS 2008
20 Reconstruction ladder Use the least complicated method of softtissue coverage that can reasonably provide durable coverage Free tissue transfer Local tissue transfer Skin grafts (NPWT) Delayed primary closure (NPWT)
21 Impact of Vac infection + timing P: III open fractures I: NPWT C: Sterile dressing O: acute and delayed infection N = 37 N = 25 p Acute infection 0 2 Delayed infection Standard JP et al AAOS 2008 NPWT should not delay wound closure beyond 7d Bhatacharyya T et al Plast Recon Surg 2008
22 Complications after severe open fractures Compartment syndrome Infection deep/superficial Delayed union Hardware failure Malunion
23 Functional restoration or amputation? MESS Score Decisonal help Score > 7 may be predictive for amputation* Skeletal + soft tissue injury Limb ischemia Schock Helfet et al. Clin Orthop 1990 Johansen et al. J Trauma 1991 Sharma et al Injury 2003 Age
24 Limb salvage? Intraoperative decision after revasularisation and debridment If reconstruction: Clarifiy expectations Functional outcomes similar Patients and their family must be to be involved in decision making Risk factors? More hospitalisations Severe disability > 50% Patients prefer
25 Salvage: Is it worth? F.C. m 33 y MVA, Gustilo III C; MESS 8
26 Salvage: Is it worth? 6 interventions Numbness sensation, orthopedic shoe Walking distance % office worker Married Still prefers limb preservation 4 m p op 5th op 6th op 2 y post op
27 History l l O. J. 42j, forest ranger Stone avalange
28 OP start 19:35
29 What would you do? ISS 32, hypovolemic, responder Right lower leg MESS: 8 points? angio? revascularisation, shunt? amputate? Right forearm MESS: 7 points? angio? ev. Revaskularisation shunt? amputate?
30 venous bypass rigth lower leg end-zu End anastomosis Radial A fix ex right Humerus right Forearm rigth Tibia left Femur Wound débridments compartment release right lower leg and left femur End of Operation: 22:55h (3.20 ) Doppler: all pulses present
31
32 18 days after acc: Gracilis flap 10 days after acc 10 days after acc 14 days after acc: ICU 19 days Latissimus dorsi flap Hospitalisation 36 days Reha 4 Mth
33 1st Rehospitalisation: 6 weeks after discharge: Cancelous bone graft right forearm + right Tibia
34 4 Mte post op Dynamisation 2nd Rehospitalisation 10 Mth after accident:delayed union. Infected nonunion (Staph. epidermidis), debridement, staged nailing +CBG
35 3 years after acc: 90% working capacity as forest ranger slightly reduced load capacity. Some nocturnal spasm in right lower extremitiy and left femur
36 Take home message Emergency assessment + treatment ATLS Prevention of infection! Antibiotics, Tetanus Irrigatrion, debridment, re-debridment Stabilization Ex fix. switch early IM equal or better (GA I-IIIB) Plate fix and flap in one stage
37 Take home message Soft tissue coverage: early < 72h, NPWT < 7 d NPWT less infection vs sterile dressing Salvage/Amputation: Scores Guidlines Bone healing: Delayed, Malunion Functional recovery with limitations
38 38
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