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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 36-41

How long can secondary resurfacing surgery be delayed with continuous irrigation therapy for gustilo-anderson type iii fracture? A retrospective clinical study


Department of Plastic and Reconstructive Surgery, Nagasaki Medical Centre, National Hospital Organisation, Nagasaki, Japan

Date of Submission17-Mar-2021
Date of Decision16-Jun-2021
Date of Acceptance20-Jun-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Prof. Masaki Fujioka
Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, 1001-1 Kubara 2 Ohmura City, Nagasaki
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_4_21

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  Abstract 


Background: The resurfacing of Gustilo–Anderson (GA) IIIB and C fractures remains challenging. Immediate debridement and external stabilization of the fracture followed by early internal fixation along with wound closure using flaps are recommended. Although it requires early soft tissue reconstruction, it is not always possible. We considered that continuous wound irrigation might reduce the chance of infection and extend the delay period until the secondary surgery. Patients and Methods: A total of 19 patients with GA IIIB and C fractures who underwent debridement and external fixation were evaluated. Among them, 18 cases were examined, excluding one who received amputation. Ten underwent wound-resurfacing surgery within 10 days after injury, and the other 8 did so after 11 days. We examined the frequency of osteomyelitis development depending on the timing of wound closure and predicted how long secondary wound closure surgery could be delayed on the application of continuous irrigation therapy. Results: Eight patients developed osteomyelitis. The number of days until wound closure in the group that developed osteomyelitis was significantly greater than in those who did not develop osteomyelitis group (P < 0.05). Only one patient (10%) developed osteomyelitis in the early resurfacing group, while 7 (87%) did so in the late resurfacing group. There was a significant difference between the groups (P < 0.01). Conclusion: This study showed that that the continuous irrigation method could extend the delay time until the secondary surgery for GA III fractures. However, it suggested that the waiting should be limited to a maximum of 10 days.

Keywords: Fix and flap, Gustilo-Anderson III fracture, open fracture, osteomyelitis, soft tissue coverage, wound closure, wound irrigation


How to cite this article:
Fujioka M, Fukui K, Noguchi M. How long can secondary resurfacing surgery be delayed with continuous irrigation therapy for gustilo-anderson type iii fracture? A retrospective clinical study. J Orthop Dis Traumatol 2021;4:36-41

How to cite this URL:
Fujioka M, Fukui K, Noguchi M. How long can secondary resurfacing surgery be delayed with continuous irrigation therapy for gustilo-anderson type iii fracture? A retrospective clinical study. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 Oct 21];4:36-41. Available from: https://www.jodt.org/text.asp?2021/4/2/36/324598




  Introduction Top


Gustilo–Anderson (GA) Type III fracture is defined as open fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. Type IIIB is classified as open fracture with extensive soft tissue loss, and the severest open fracture, called Type IIIC, is fracture associated with an arterial injury requiring immediate repair.[1] The resurfacing of complex bone-exposing wounds associated with these fractures remains challenging.

“Fix and flap” is considered an ideal management for the treatment of GA IIIB and C bone-exposing injuries, involving radical debridement of the wound, skeletal stabilization, and early soft tissue coverage with a vascularized muscle flap.[2],[3] Debridement and stabilization of the fracture are invariably performed immediately. Urgent or early wound closure is recommended because the cause of perioperative infection in this type of open fracture is not initial contamination during injury or surgery but are acquired infection on the ward.[4],[5] Since Godina's study, it generally has been accepted that these open fractures require early (within 72 h) bony stabilization and soft tissue reconstruction.[6] Unfortunately, because these severe traumatic injuries are always treated emergently, soft tissue coverage is not always possible in an acute setting for some reasons. For example, treatment of other life-threatening serious trauma, such as brain injury or intra-abdominal hemorrhage, may be prioritized. In addition, the patient's general condition may be poor and he/she may not be able to tolerate long-term surgery or anesthesia.

We hypothesized that less frequent dressing changes using a continuous wound irrigation system might reduce the risk of infection and extend the delay period until the secondary “fix and flap” surgery and examined the results of GA IIIB and C fractures retrospectively.


  Patients and Methods Top


A total of 19 patients with GA III B (15 cases) and C (4 cases) open fracture were treated in our medical center in 2011 and 2019 [Table 1]. All patients had open fractures due to traffic accidents, and it was considered that there was early wound contamination. Thus, the first debridement is done within 6 h after injury. After debridement, they underwent open reduction, and external fixation on the day of injury. Six underwent immediate wound resurfacing with flaps, and others received wound treatment using continuous irrigation system [Figure 1]. All Grade IIIC injuries underwent immediate vascular reconstruction. Three were salvaged, but one patient underwent leg amputation due to the development of myonephropathic metabolic syndrome. The final rate of limb salvage was 95%, and they were all discharged walking on their feet. Seven patients underwent internal fixation secondary, the so-called “fix and flap” method. The remaining 11 were fixed externally.
Table 1: Patients with Gustilo–Anderson III leg fractures who underwent wound resurfacing surgery using flaps

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Figure 1: Schema of continuous irrigation system

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All patients with open wounds underwent continuous irrigation with 60–100 mL/h of saline for as long as possible from just after primary debridement until the secondary fix and flap surgery. However, if there were signs of infection such as local fever, swelling, redness, and pain, it was removed and a secondary debridement surgery was undergone. Regarding antibiotics, penicillin or cephalosporin and anaerobic coverage (clindamycin) were used together at first. The treatment was modified after Gram stains and culture reports became available. Eighteen cases were examined, excluding one patient with amputation. There were 10 cases of tibial and fibula fractures, 7 of tibial fractures only, and 1 of calcaneal fracture. Seven patients underwent conversion from external to internal fixation. Among these patients, 10 underwent wound resurfacing surgery within 10 days (0–10 days) after injury, and the other 8 did so after 11 days (20–180 days), often for critical reasons unrelated to the limb injury. All patients had no underlying disease, such as diabetes or cancer, that diminished their resistance to infection. We examined the frequency of osteomyelitis development depending on the timing of wound closure and predicted how long secondary wound closure surgery could be delayed with continuous irrigation therapy.

Statistical analysis was performed using Student's t-test, Wilcoxon signed-rank test, and Chi-square test. A P < 0.05 was determined as significant. The ethical committee of our medical center approved this study.

Case presentation

Case 1, a 22-year-old man had an open fracture of the left tibial fibula, a rupture of the gastrocnemius, soleus, and tibialis anterior muscles, and a defect in the tibialis anterior artery in a motorcycle accident [GA IIIB, [Figure 2] and [Figure 3]. Debridement and bone fixation using a Hoffman-type external fixator was performed. For the management of bone-exposing wounds, continuous wound irrigation was performed for 9 days [Figure 4]. Secondary-look “fix and flap surgery” was performed on the 9th day [Figure 5]. After fixing the tibia with an intramedullary nail and the fibula with a plate, the muscle/skin defect was reconstructed with a free flow-through type anterolateral thigh flap [Figure 6] and [Figure 7]. Five weeks after the surgery, he was walking at full load [Figure 8].
Figure 2: Case 1. The photographs showing wound immediately after injury

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Figure 3: Case 1. The photographs showing X-ray immediately after injury

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Figure 4: After debridement and external bone fixation, continuous wound irrigation was performed

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{Figure 4}
Figure 5: The photograph showing the wound just before the secondary-look Fix and Flap surgery. No infection is found

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Figure 6: The photographs showing a wound reconstructed with a free flow-through type anterolateral thigh flap immediately after fix and flap surgery

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Figure 7: Postoperative X ray after Flap surgery

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Figure 8: The patient could walk at full load 5 weeks after the surgery

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Case 2, a 74-year-old man had an open fracture of the right fibula and a crushed wound on the lateral malleolus in a motorcycle accident [GA IIIB, [Figure 9] and [Figure 10]. On the day of the injury, debridement and bone reduction were performed, bone fixation was performed using an Ilizanov external fixator, and continuous wound irrigation was performed on the exposed wound. On the 10th day after the injury, wound closure was performed by local flap and skin grafting [Figure 9], [Figure 10], [Figure 11]. He walks with bone fusion 6 months after surgery [Figure 12], [Figure 13], [Figure 14].
Figure 9: Case 2. The photographs showing wound immediately after injury

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Figure 10: Case 2. The photographs showing X-ray immediately after injury

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Figure 11: After debridement and external bone fixation, continuous wound irrigation was performed

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Figure 12: The photograph showing the wound just before the secondary-look wound resurface surgery. No infection is found

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Figure 13: The photographs showing a resurfaced right leg 6 months after surgery

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Figure 14: The photographs showing a resurfaced right leg X-ray 6 months after surgery

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  Results Top


Eight patients developed osteomyelitis and four developed wire infection on external fixation. The timing of wound closure in the groups that did and did not develop osteomyelitis is shown in [Figure 15]. The days wound closure in the group that developed osteomyelitis ranged from 0 to 180 days (average, 51.5 ± 57.4 days) and that in the group not developing osteomyelitis ranged from 0 to 46 days (average, 7.2 ± 14.2 days). There was a significant difference between the groups (P < 0.05 Wilcoxon signed-rank test). Seven patients who underwent secondary fix and flap surgery to replace the intramedullary nails at a later date did not develop wire infection on external fixation. However, 4 of 11 patients who continued to undergo external fixation developed wire infection.
Figure 15: The timing of wound closure in the groups that did and did not develop osteomyelitis

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Differences in the tendency of osteomyelitis in early (within 10 days after injury) and late (after 10 days) wound resurfacing are shown in [Figure 16]. Only one patient (10%) developed osteomyelitis in the early resurfacing group, while 7 (87%) did so in the late resurfacing group. There was a significant difference between the groups (P < 0.01 Chi-square test).
Figure 16: Differences in the tendency of osteomyelitis in early and late wound resurfacing

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  Discussion Top


A radical protocol that includes debridement, immediate bony stabilization, and early soft tissue coverage using a muscle flap is called “fix and flap,” and it has markedly improved outcomes in patients with open tibial fractures.[2],[7] The sooner the wound is closed, the lower the risk of wound infection; thus, “single-stage emergent fix and flap” should provide better results by preventing infection.[8] The treatment of these very severe injuries should be performed by a combined orthopedic and plastic surgical approach; however, it is difficult to convene orthopedic and plastic surgeons in a timely manner or to prepare appropriate intramedullary nails immediately after injury. As shown in our study, long-term external fixation was associated with chronic pin-track infections; thus, we believe that initial debridement and temporary external fixation followed by conversion to internal fixation along with wound closure using flaps (secondary “fix and flap” surgery) as early as possible is the safest procedure.[2]

Regarding wound infection, the current evidence indicates that infections of open fractures are not caused by initial contaminating organisms but are acquired in the hospital.[4] In addition, severe trauma may reduce the immune system and make it more susceptible to infection. Thus, it generally has been accepted that these open fractures require early (within 72 h) soft tissue reconstruction.[6] However, even secondary soft tissue coverage is not always possible within 72 h after injury in a clinical setting. Rymer et al. investigated 78 patients with open fractures of the lower limb and receiving definitive soft tissue coverage after their initial debridement within 24 h, and 56.4% received coverage within 72 h. The main reasons for delayed secondary resurfacing surgery were transfer from other hospitals, plastic surgeons not present at the initial operation, and intervening critical illness.[9] Fernandez et al. evaluated the course of 48 patients with Gustilo Type IIIB and IIIC leg fractures and reported that the 72-h secondary soft tissue coverage target was still only met in 54%. They concluded that achieving early coverage presents a considerable challenge, particularly in those with the most severe injuries.[10]

These reports show that ideal soft tissue closure surgery within 72 h was performed in only about half of the cases. This tendency is the same in our medical center. If the secondary resurfacing surgery is expected to take more than 72 h, what is the best way to manage the wound to prevent infection?

Because infections of open fractures were acquired after initial debridement in the hospital, fewer dressing changes might reduce the risk of wound infections. Some investigators suggested that negative pressure wound therapy dressings in open tibial fractures resulted in fewer infections compared with gauze dressings in the acute phase.[11],[12] Schlatterer et al. reported an association between decreased infection rates with negative pressure wound therapy compared with gauze dressings. They reported that Grade IIIB tibial fracture patients with negative pressure wound therapy did not show increasing infection rates beyond 72 h.[13]

Wound irrigation to remove debris and reduce bacterial contamination is an essential component of open fracture care. Continuous wound irrigation aims to remove or decrease bacteria and has shown promise in animal models of the complex-contaminated musculoskeletal wounds.[14] Bahrs et al. reported in an in vitro study that wound irrigation is an effective technique to reduce bacteria on contaminated surfaces.[15] Wound irrigation to remove debris and reduce bacterial contamination is an essential component of open fracture care.[14] On the one hand, surgical debridement combined with wound irrigation with a lavage system is still the basic treatment for osteomyelitis once it has developed.[16] Therefore, for fresh open fractures that have not yet been infected, continuous wound irrigation after the initial debridement may prevent infection and delay the acceptable time until secondary wound-covering surgery.

Although secondary wound closure in GA IIIB and C fractures has been recommended within 72 h, our findings suggest that the continuous irrigation method may help delay the permissible waiting time until the secondary surgery. Osteomyelitis did not develop in 90% of cases of wound closure within 10 days after injury, but the incidence of infection significantly increased in cases of wound closure after 11 days, even if the wound was managed with continuous irrigation. It is suggested that a delay of secondary wound closure of more than 10 days should be avoided. Furthermore, negative pressure wound therapy with instillation (NPWTi) and dwell time, which is an adjunctive treatment modality for selected complex wounds, were most appropriate for complex wounds such as patients with severe traumatic wounds. When NPWTi is added to continuous irrigation in severe open fracture cases, it may provide better overall clinical outcomes than continuous irrigation alone.[17]


  Conclusion Top


Secondary wound coverage within 72 h has become the golden standard for the treatment of GA IIIB and C fractures, but this has not been possible in many cases due to various reasons associated with severe trauma in reality. This study suggests that the continuous irrigation method may delay the acceptable waiting time until the secondary surgery. However, the incidence of infection significantly increased after 11 days, even if the wound was managed with continuous irrigation. However, it also suggested that 10 days is the limit for delaying secondary wound closure surgery.

Ethical considerations

The procedures followed were in accordance with the ethical standards of our institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.  Back to cited text no. 1
    
2.
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959-66.  Back to cited text no. 2
    
3.
Soni A, Tzafetta K, Knight S, Giannoudis PV. Gustilo IIIC fractures in the lower limb: Our 15-year experience. J Bone Joint Surg Br 2012;94:698-703.  Back to cited text no. 3
    
4.
Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg 2002;10:379-84.  Back to cited text no. 4
    
5.
Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2007;127:131-6.  Back to cited text no. 5
    
6.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92.  Back to cited text no. 6
    
7.
Mehta S, Williams W. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2001;83:773-4.  Back to cited text no. 7
    
8.
Singh J, Dhillon MS, Dhatt SS. Single-stage “fix and flap” gives good outcomes in Grade 3B/C open tibial fractures: A prospective study. Malays Orthop J 2020;14:61-73.  Back to cited text no. 8
    
9.
Rymer B, Dimovska EO, Chou DT, Choa R, Davis B, Huq S. A representative assessment of the management of open fractures of the lower limb within UK orthoplastic centres: A two-centre audit of compliance with national standards. Injury 2017;48:2266-9.  Back to cited text no. 9
    
10.
Fernandez MA, Wallis K, Venus M, Skillman J, Young J, Costa ML. The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures. Ann R Coll Surg Engl 2015;97:456-9.  Back to cited text no. 10
    
11.
Blum ML, Esser M, Richardson M, Paul E, Rosenfeldt FL. Negative pressure wound therapy reduces deep infection rate in open tibial fractures. J Orthop Trauma 2012;26:499-505.  Back to cited text no. 11
    
12.
Stannard JP, Volgas DA, Stewart R, McGwin G Jr., Alonso JE. Negative pressure wound therapy after severe open fractures: A prospective randomized study. J Orthop Trauma 2009;23:552-7.  Back to cited text no. 12
    
13.
Schlatterer DR, Hirschfeld AG, Webb LX. Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures? Clin Orthop Relat Res 2015;473:1802-11.  Back to cited text no. 13
    
14.
Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001;9:219-26.  Back to cited text no. 14
    
15.
Bahrs C, Schnabel M, Frank T, Zapf C, Mutters R, von Garrel T. Lavage of contaminated surfaces: An in vitro evaluation of the effectiveness of different systems. J Surg Res 2003;112:26-30.  Back to cited text no. 15
    
16.
Tiemann AH, Hofmann GO. Wound irrigation within the surgical treatment of osteomyelitis. GMS Interdiscip Plast Reconstr Surg DGPW 2012;1:Doc08.  Back to cited text no. 16
    
17.
Kim PJ, Attinger CE, Crist BD, Gabriel A, Galiano RD, Gupta S, et al. Negative pressure wound therapy with instillation: Review of evidence and recommendations. Wounds 2015;27:S2-19.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
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