b. It should be performed after complete surgical debridement.
c. Normal saline is the most commonly used irrigant with poor support for other adjuvants to the solution.
d. Irrigant may be administered in a low-pressure manner by saline bags passing through cystoscopy tubing by gravity.
e. High-pressure irrigation is an alternative form with increased irrigant velocity thought to enhance debridement. Potential disadvantages outlined in basic science studies suggest an additional insult to bone and soft tissue, and concern for propulsion of bacteria deeper into tissues.
f. FLOW study: level 1 multicenter study comparing irrigation types in open fractures.
i. No clinical difference in reoperation rates between high-pressure, low-pressure, and gravity-rate irrigation.
ii. Higher reoperation rates in patients randomized to soap irrigation compared to saline.
C. Fracture stabilization
1. External fixation:
a. It provides preliminary temporary skeletal stabilization in an expeditious manner or it can be used as definitive fixation. This is important not only to stabilize the bone but may also help in stabilizing the soft-tissue injury.
b. Soft-tissue injury can make pin placement difficult. Pins can be placed either at a distance from the wound or directly in the wound depending on size and morphology.
c. Consider for severe trauma/polytrauma, associated vascular injury, and highly contaminated open injuries that may require multiple surgical debridements.
d. External fixation is often advantageous in these situations as it is easy to obtain full access to the wound by displacing the bones which is more difficult to do once internal fixation is in place.
2. Internal fixation:
a. Performed after debridement and irrigation is complete.
b. May be performed in the same surgical setting after debridement for open fractures that have a low likelihood for persistent contamination and infection.
c. Many surgeons prefer to limit the time between definitive fixation and flap coverage, and recent data supports that longer times (7 days or more) between fixation and flap coverage are associated with higher infection rates.
d. Temporary internal fixation, known as “damage-control plating,” has recently been described as an effective means to stabilize open fractures prior to repeat surgical debridement with significantly lower costs (25%) incurred.
D. Infection prevention: local antibiotic delivery
1. Antibiotic bead placement:
a. This serves as an easily retrievable method for high-dose local antibiotic delivery to prevent infection although there is little data looking at their use (▶Fig. 2.2).
Fig. 2.2 An example of an open distal tibia fracture with bone loss and gross contamination being treated with antibiotic beads fabricated by polymethylmethacrylate combined with antibiotic powder.
b. Antibiotic powder is combined with polymethylmethacrylate cement and shaped into beads.
c. Vancomycin and tobramycin are commonly used although other heatstable options exist.
d. Capable of delivering very high local antibiotic concentrations and avoid the potential systemic antibiotic side effects.
e. Beads are typically strung onto wire or suture to keep them localized in the wound and are often removed at the time of final wound closure.
2. Antibiotic spacer placement:
a. Composition similar to that of antibiotic beads.
b. Administered in the form of a cement block.
c. In addition to providing high concentrations of local antibiotic delivery, this technique, when placed into a bone void can provide additional skeletal stability.
3. Antimicrobial implants:
a. Antibiotic cement may be used to coat orthopaedic implants when infection risk is high. Some implants exist with antimicrobial coatings but their clinical impact is unknown.
E. Indications for serial debridement
1. Intraoperative findings during the initial debridement dictate the need for subsequent debridement.
2. High levels of contamination and tissue nonviability will necessitate repeat surgical debridements (▶Fig. 2.3) as these wounds often evolve and more necrotic tissue will be observed at subsequent debridements.
Fig. 2.3 Large open and grossly contaminated wounds typically require multiple surgical debridements.
V. Soft Tissue Management in Extremity Injuries
A. Negative pressure wound therapy
1. Negative pressure applied creates unique environment encouraging for wound healing (▶Fig. 2.4).
2. Ideal for soft tissue defects that will heal through secondary intention or require skin grafting.
3. Helpful in the prevention of wound desiccation, reduction of microbial contamination that may occur with dressing changes, and aid in facilitation of wound drainage.
4. Effective way to downscale the complexity of soft tissue reconstruction by promoting granulation tissue.
5. Avoid direct contact with blood vessels, nerves, exposed bone, or tendon without paratenon as it may desiccate or damage these tissues.
6. It will not remove contaminated tissue by itself and basic science data shows it does not lower bacterial counts as much as antibiotic beads.
B. Primary wound closures and skin grafting
1. Open fractures are frequently associated with significant soft-tissue injury and subsequent edema making primary wound closure challenging.
2. Closure should be performed with techniques to preserve the soft tissue integrity and viability.
3. Relaxing incisions adjacent to the wound can be utilized to prevent excessive tension on wound edges when attempting primary closure.
4. Skin grafting is a coverage option for wounds that cannot be closed primarily and have a healthy underlying wound bed of muscle, paratenon, or subcutaneous tissue.
C. Soft tissue flap coverage
Flaps are dictated by the location and size of the soft tissue defect when primary closure is no longer possible. They are indicated for coverage of exposed vital structures including bone, artery, nerve, or tendon without paratenon.
1. Rotational flap coverage:
a. Mobilization of local tissue with its vascular pedicle to an area in need of soft tissue coverage (▶Fig. 2.5).
b. This is a commonly needed option when addressing soft tissue loss in the leg. The local flap of choice is dictated by the defect location.
c. Flap tissue cannot be from an already devitalized area involved in the initial zone of injury.
2.