The contaminated high-energy open fracture: a protocol to prevent and treat inflammatory mediator storm-induced soft-tissue compartment syndrome (IMSICS).

The treatment modalities currently used in surgical débridement leave the traumatic wound with viable but tenuous tissue and a variable level of microcontaminants potentially laden with bacteria. In high-energy contaminated wounds, retention of these contaminants within the tenuous tissue of the so-called zone of stasis can result in further tissue necrosis and the development of infection. A novel protocol for managing the high-energy contaminated open fracture involves two new techniques. First, Bernoulli's principle is used to facilitate a systematic excision of contaminants, as well as the wound surface to which they are adsorbed, by means of a high-velocity fluid stream. Second, topical negative pressure is established as a means to resuscitate the remaining edema-laden wound tissue to help avoid embarrassment to microcirculatory blood flow.

Does Screw Configuration or Fibular Osteotomy Decrease Healing Time in Exchange Tibial Nailing?

OBJECTIVES: This multicenter study was designed to evaluate whether tibia fracture nonunions treated with exchange nailing proceed to union faster with dynamically- versus statically-locked nails, or with fibular osteotomy versus no fibular osteotomy. DESIGN: Retrospective, chart-review, multicenter study. SETTING: Multicenter review of 6 level 1 trauma centers. PATIENTS/PARTICIPANTS: Patients who had a tibia fracture treated with an intramedullary nail that progressed to nonunion, and were subsequently treated with exchange nailing, were identified. All patients that met inclusion criteria and subsequently progressed to union were included in the study. INTERVENTION: Patients underwent tibial exchange nailing to repair nonunions, with screws in either a dynamically- or statically-locked configuration with or without fibular osteotomy. MAIN OUTCOME MEASURES: The primary outcome measure was a comparison of time to healing of tibial nonunion comparing different screw configurations and fibular osteotomy. RESULTS: Fifty-two patients underwent an exchange nail procedure and their outcomes were used for the primary analysis. Patients with dynamically-locked nails proceeded to union 7.9 months after revision surgery compared with 7.3 months for those with statically-locked nails, but this was not statistically significant (P = 0.68). Patients with fibular osteotomy proceeded to union 2.9 months faster than those without fibular osteotomy, and this trended toward significance (P = 0.067). Obese patients healed on average 8.8 months after surgery compared with 6.8 months for nonobese patients (P = 0.27). Closed fractures healed after 6.4 months compared with 7.7 months for open fractures (P = 0.40). CONCLUSIONS: There was no significant difference in time to union between patients who had a dynamic screw configuration compared with a static screw configuration for their exchange nail. Patients who underwent fibular osteotomy proceeded to union faster than those without an osteotomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.