(1)
Departememt of Surgery, Montpellier Regional University Hospital, Montpellier, France
33.1 Introduction
33.2.1 Debridement
33.2.2 NPWTi
33.2.3 Hardware Removal
33.2.4 Soft-Tissue Reconstruction
33.2.5 Alternatives to Flap Cover
33.1 Introduction
Skin necrosis is a frequent complication in the management of traumatized extremity, particularly in the case of open fracture.
The treatment of open fracture is not the purpose of this article and will not be discussed here.
A prolonged period of hardware exposure ultimately leads to contamination, and then the goal of treatment is to prevent infection of hardware and underlying bone.
The traditional management of soft-tissue defects and exposed hardware includes irrigation and debridement, intravenous antibiotics, and likely removal of the hardware. Obviously, preservation of the hardware would be the optimal goal to maintain stability and optimal reduction [1].
Skin necrosis covering osteosynthetic material can be divided into two groups: on one hand that which happened early after the surgery because of soft-tissue injury (contused or crushed) or too tensile strength in stitched and on the other hand that when a deep infection induces skin necrosis, early or later after the surgery.
In all cases, skin necrosis had to be removed, and bone and hardware had to be covered with soft tissue.
33.2 Postoperative Skin Necrosis
In this case, skin necrosis is initially a soft-tissue complication but can lead to a bone infection.
This is often seen in lower limb trauma with open or closed fracture. Skin necrosis appears because of a combination of soft-tissue injuries (direct contusion, soft-tissue degloving, displaced fracture fragments, articular dislocation, compartment syndrome), vascular injuries (hematoma, ischemia), early infection, and surgery (strength stitches, skin undermining, surgical approach).
33.2.1 Debridement
Those wounds require aggressive irrigation and debridement. This involves excision of all necrotic, devitalized, and contaminated tissue and bone as well as incisions for additional exposure and drainage [2] and had to be repeated every 24–48 h to ensure all necrotic and devitalized tissue had been removed.
The aim of debridement is to prevent the risk of bacterial proliferation and to remove debris and necrotic tissue.
Many different techniques are available. Mechanical methods include ware-jet dissection (Versajet hydrosurgery system [3]) or coblation technology (ArthroCare). Consensus on irrigation technique and additives (bacitracin, antiseptics, surfactants, or non-sterile soap) still remains to be determined. Other additions to wound care including the use of silver dressings [4] and NPWT (negative-pressure wound therapy) have proven successful in helping reduce infection rates. The use of NPWT has decreased the need for further debridements to every 48–72 h.
33.2.2 NPWTi
A modification of the NPWT system that adds automated intermittent wound irrigations was introduced nearly a decade ago. Instillation with normal saline can speed up wound fill with higher-quality granulation tissue composed of increased collagen compared with traditional NPWT [5]. The instillation of an antimicrobial solution (antiseptic or antibiotic) into an infected wound can help decrease the bioburden and create a more favorable environment for wound healing [6]. In addition, analgesics may be mixed with some solutions to treat the pain that may be associated with NPWT therapy [7].
NPWT with instillation is particularly indicated to manage patients with infected orthopedic wounds (open fractures, osteomyelitis). Debridement of the infected and devitalized tissue and bone is important prior to the initiation of the NPWTi especially for chronic infections where the presence of a biofilm may make penetration of antibiotics tissues and bones into and treatment of chronic infection more difficult.
The types of wound commonly treated from NPWTi are listed in Table 33.1.
Table 33.1
Indications for NPWT with instillation
Wounds with persistent infection, especially after a trial of traditional negative-pressure wound therapy (NPWT) |
Infected wounds with a foreign body in place (orthopedic hardware and total joint arthroplasty)
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