Is Operative Debridement Greater Than 24 Hours Post-admission Associated With Increased Likelihood of Post-operative Infection?

BACKGROUND: The historical "six-hour rule" as a golden hour for timing to debridement has been refuted in modern literature. Current standards prompt a timely debridement; however, in the setting of polytrauma, patients are often resuscitated for periods >24 h, with delayed orthopedic intervention. Therefore, we sought to determine the association between prolonged time to operative debridement (>24 h) and infection. METHODS: We conducted a retrospective review of patients with open fractures that underwent irrigation and debridement at a single institution from 2008 to 2016. Demographic, injury, and operative variables were collected. Infection was defined as the need for intravenous antibiotics and/or repeat irrigation and debridement. Chi-squared test and univariate logistic regression were performed. P < 0.05 was the cutoff for significance. RESULTS: Of 642 patients examined, 56 (8.7%) developed an infection. Prolonged time to debridement was not associated with increased infection rates (P = 1.00). Gustilo-Anderson classification was associated with increased risk of infection (type I: 2.1%, type II: 7.6%, and type III: 14.6%; P < 0.001). In univariate analysis, infection was associated with after-hours surgery (between 7 PM and 7 AM (odds ratio [OR] = 2.02; P < 0.02), definitive fixation more than 24 h post-admission (OR = 3.08; P < 0.001), wound closure more than 24 h post-admission (OR = 4.36; P < 0.001), and more than two operations performed post-admission (OR = 8.73; P < 0.001). Multivariate analysis of these factors found number of operations (OR = 7.13; P < 0.001) and time to definitive wound closure (OR = 4.04; P < 0.001) to be independent predictors of developing an infection. CONCLUSIONS: Our data suggests that there is no association between infection and prolonged time to debridement.

Enzymatic debridement as an effective treatment for combined flame and chemical burns caused by e-cigarettes.

Since its introduction on the market in 2007, the number of reports on injuries caused by the ignition or explosion of electronic nicotine delivery systems (ENDS) has increased significantly. Two male patients have been treated at our burn center, the for ENDS-related injuries. Their batteries came into contact with metal objects stored in their pants pockets, resulting in a short circuit and finally ignition. In both patients, the combined flame and chemical burn wounds were initially irrigated with water upon arrival at the emergency department, leading to increased levels of pain. In our burn center, the wounds were extensively cleansed which led to a subsequent drop in NRS-scores. Laser Doppler Imaging showed a clear indication for surgery as both patients suffered a partial-thickness burn, with one patient having a patch of full-thickness burn as well. We swiftly performed an enzymatic debridement in both patients, followed by conservative wound management. Although enzymatic debridement is not generally recommended in the treatment of chemical burns, we successfully made use of this treatment option. Different authors advocate the use of mineral oils to irrigate or cover alkali burns, as contact between the chemical compounds and water can set off an exothermic reaction, leading to further injury. We believe that a hypertonic rinsing solution could be recommended as well in an emergency setting and we want to stress the importance of rapid removal of the chemical compounds in suspected chemical burns as well as swift debridement.

Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank.

BACKGROUND: The morbidity and mortality associated with open long bone fractures have been greatly reduced due to antibiotics and early surgical washout and debridement. Guidelines recommend early washout and debridement within 6-8 h; however, newer studies have shown that delaying surgical washout and debridement up to 24 h can be done safely without an increase in surgical site infection, wound nonunion or sepsis. All studies thus far have looked at combined blunt and penetrating open long bone fractures, without distinguishing between mechanism or type of injury. Our study looked specifically at open long bone fractures of the lower extremity caused by a penetrating mechanism of injury. METHODS: We utilized the US National Trauma Data Bank and included patients who had diagnosis of lower extremity open long bone fracture from a penetrating mechanism and underwent irrigation and debridement (I&D) within 24 h of arriving to the hospital. RESULTS: A total of 1014 patients qualified for the study. Of those, 736 (72.6%) patients underwent an I&D within 8 h and 278 (27.4%) underwent an I&D between 8 and 24 h after hospital arrival. When examining the patient outcomes, there were few cases and no significant differences in the occurrence of surgical site infections, sepsis or wound disruptions between the two groups. CONCLUSION: The majority of the open long bone fractures were due to firearm injury. I&D of penetrating open long bone fracture can be performed within 24 h without any added infective morbidity.

Friction Injury Versus Deep Tissue Injury: Level of Tissue Involvement: A Comparison of 2 Cases.

BACKGROUND: Friction injuries are postulated to be caused by acute or chronic abrasive/friction forces during sliding, scooting, or slouching behaviors prevalent in individuals with impaired mobility and particularly when transferring and repositioning. CASES: Patient histories for 2 cases were collected for determination of wound etiology. Outpatient wound clinic visits including photographic documentation for both cases were reviewed, compared, and contrasted for level of tissue involvement with each wound type/etiology. With serial sharp debridement of both wounds, differences were noted in level of tissue involvement/destruction. Healing progression and scarring were also different for both wounds. CONCLUSION: A comparison of 2 cases is presented to compare and contrast level of tissue involvement and destruction in an acute friction injury (top-down) versus a deep tissue injury (bottom-up). The importance of knowing a wound's history is critical for accurate diagnosis and coding.

Efficacy of Maggot Therapy on Staphylococcus aureus and Pseudomonas aeruginosa in Diabetic Foot Ulcers: A Randomized Controlled Trial.

PURPOSE: This study was conducted to evaluate the antimicrobial effects of medicinal maggots of Lucilia sericata on Staphylococcus aureus and Pseudomonas aeruginosa on diabetic foot ulcers (DFUs). DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: The sample comprised 50 adult patients from the clinic of the Academic Center for Education, Culture and Research of Tehran University of Medical Sciences, Iran. All participants who had at least 1 DFU present for at least 12 weeks, an arterial brachial index value of more than 0.6, and a hemoglobin A1c value of less than 8% were included in this study. METHODS: Subjects were randomly selected for the maggot-treated (treatment) or conventional treatment (control) group. Conventional treatments such as antibiotic therapy, debridement, and offloading were done for both groups, but maggot therapy (MT) was added to the protocol of the treatment group. Bacterial burden was monitored and compared for both groups using cultures collected using swab technique. Wound secretions were measured and compared in both groups. RESULTS: The number of infected cases with S aureus in the treatment group was significantly reduced after 48 hours in comparison with the control group (P = .047). The number of infected cases with P aeruginosa was significantly reduced after 96 hours (P = .002). We also found that wound secretions in the treatment group were significantly higher than in the control group (P < .00). CONCLUSIONS: Our findings indicate that MT is a safe and efficacious treatment of DFUs.

[Wound management with enzyme alginogels : Expert consensus]. / Wundbehandlung mit Enzym-Alginogelen : Expertenkonsens.

BACKGROUND: The challenges of modern wound management, such as the treatment of chronic wounds and their phase-specific handling, are demanding and require optimally adapted therapeutic measures. The principles of moist wound care as well as an adequate debridement have priority here. To support these necessary measures, different options are available, e.g., a new product group operating across several wound phases. OBJECTIVE: A new treatment principle in modern wound management based on an expert consensus is presented. METHODS: On the basis of clinical experience reports and published evidence, the current and new principles of wound treatment were discussed in a panel of experts and formulated as a consensus statement. RESULTS: Enzyme alginogels represent a combination of agents that allow phase-specific wound care. They exhibit autolytic, absorbent, and antimicrobial properties and simultaneously cover three components of wound management based on the TIME framework. Thus, according to the experts, they differ from other wound healing products and can be classified in a distinct product group. Clinical studies, as well as clinical experiences, provide evidence for the efficacy of enzyme alginogels. DISCUSSION: According to the experts, the potential of enzyme alginogels used considering the principles of moist wound care, comprises the three-fold effect (continuous and significantly simplified debridement, maintaining a moist wound environment and antimicrobial effect without cytotoxicity), the ease of use, and the flexible application. In addition, the flexibility of the product class regarding frequency of application, duration of treatment and combinability with secondary dressings, are of economic benefit in the health care sector.

Treatment of open fractures of the hand in the emergency department.

Current guidelines suggest early surgical treatment of open fractures. This rule in open hand fractures is not well supported and may be unpractical. Furthermore, desirable debridement and washout can be obtained in the emergency department (ED). The purpose of this study was to evaluate the relationship between the level of contamination, quality of washout in the emergency room, and the development of infection. Sixty-one patients with open fractures of the hand were retrospectively reviewed for demographic and fracture characteristics, and other complications. The infection rate was 14.8%. Contamination was present in 43 patients (70.5%). One thousand milliliters or more were used to obtain a grossly clean wound in 43 patients (70.5%). No significant relationship was found between fracture type, finger involved, hand dominance, comorbidities, and development of infection. The amount of fluid used for washout was significantly related to infection (P = 0.047), whereas wound contamination was not (P = 0.259). Type of oral antibiotic was significantly related to infection (P = 0.039). The level of contamination was not a significant factor in predicting infection, whereas the amount of fluid used for washout and the oral antibiotic type were significant factors in preventing infection. Since administration of intravenous antibiotics and thorough wound cleansing can be performed on open hand fractures in the ED under adequate anesthesia, most open fractures in the hand do not need to be treated early in the operating theater.

Inferior turbinate reduction; coblation versus microdebrider - a prospective, randomised study.

OBJECTIVES: We prospectively evaluated and compared the safety, subjective and objective efficacy of the coblation and microde- brider for inferior turbinate reduction. METHODS: We designed a prospective randomized trial recruiting 70 patients with symptomatic enlarged inferior turbinates. Forty had coblation and 30 had microdebrider. Objectively, we scored each inferior turbinate size from 1 to 3 pre- and post-operatively. Subjectively, patients completed a visual analogue scale (VAS) evaluating their nasal symptoms, before and after surgery. RESULTS: Both techniques resulted in subjective significant improvement in the VAS for nasal obstruction, and other nasal symptoms. Comparing both groups, coblation showed significantly less pain than the microdebrider. Postoperative bleeding and mucosal tears were less frequent with coblation than with microdebrider but this was nonsignificant. Patient satisfaction significantly improved after both techniques. CONCLUSION: The submucous coblation is as effective as microdebrider for inferior turbinate reduction. It is easily performed with significantly less postoperative pain than the microdebrider. Both techniques produce significant reduction of the size of the turbinates and associated with a satisfactory improvement of the nasal obstruction, nasal secretion, crust formation, itching, sneezing and dryness. The side effects are minimal with both procedures with significant patient satisfaction postoperatively.

Debridement--is it time to revisit clinical practice?

Debridement is the removal of non-viable tissue from a wound bed. It is an essential procedure in order to achieve wound healing and symptom control. The clinical presentation of non-viable tissue varies in content, appearance, depth and level of hydration. There may be a risk of systemic infection if non-viable tissue is not removed in a timely fashion. There are various methods of debridement each with its own advantages and limitations. The competence of the practitioner undertaking the debridement is crucial and is a key consideration along with availability of the necessary equipment and the provision of the optimal environment. Client choice and involvement are vital to the debridement process. There should be no hierarchy of debridement methods and the chosen method should achieve timely optimal pain-free removal of non-viable tissue. There is a need to question the current situation in which the specialist nurse is highly skilled in the debridement process while the generalist nurse potentially carries a higher caseload of patients who require this procedure.

Initial extremity war wound debridement: a multidisciplinary consensus.

A joint meeting of the Limb Trauma and Wounds Working Groups resulted in the establishment of 29 consensus recommendations for the conduct of initial extremity war wound debridement. Pre-operative, operative and post-operative phases of debridement were considered along with wound irrigation and dressings. Wounds where a different surgical approach is required, such as superficial soft tissue wounds at one end of the spectrum and complex wounds sustained in close proximity to explosions at the other, were also discussed. The recommendations represent the consensus opinion of orthopaedic, vascular and plastic surgeons, as well as nursing officers, from across the Defence Medical Services and are intended to provide useful guidance to the deploying surgeon, regardless of their own personal experience.

An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis.

The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.

Safety of enzymatic debridement in extensive burns larger than 15% total body surface area.

OBJECTIVES: Bromelain-based enzymatic debridement has emerged as an alternative to surgical eschar removal. Indications include partial thickness, mixed pattern, and full-thickness burns. Enzymatic debridement has been approved by the European Medicines Agency for treating burn wounds affecting <15% total body surface area (TBSA). Data and evidence for the treatment of areas >15% TBSA in one session is scarce. The aim of this retrospective study was to retrospectively analyze off-label use of enzymatic debridement in a single burn center for large TBSA burns. METHODS: Between 01/2017 and 12/2018, 59 patients with partial- to full-thickness burns underwent enzymatic debridement in a single center study. Patients were categorized into two groups: the regular use group with a treated area less than 15% TBSA and the off-label group (OG) with larger TBSA debrided in one session. Treatment was evaluated for systemic inflammatory reaction, bleeding, hemodynamic instability and electrolyte shifts. RESULTS: In total, 49 patients were treated in the regular use group with a median application area of 6% (IQR 2.5-9.5) and 10 patients were treated in the off-label group with a median application area of 18% (IQR 15-19) TBSA. We found no significant differences regarding blood pressure, body temperature or hemodynamic stability during and after enzymatic debridement. No treatment-related serious adverse events were observed in either group. Catecholamine use was similar in both groups. No differences in leukocyte counts, CRP, PCT and lactate prior to application and during the following three days were observed. Sodium, potassium, chloride and phosphate levels did not differ. We found no evidence of an electrolyte shift. Survival was 49 of 49 patients (100%) in the RG and 7 of 10 patients (70%) in the OG (p = 0.004). CONCLUSION: Enzymatic debridement did not result in any expected or unexpected side effects in the patient groups investigated. These preliminary results indicate the potential safety of bromelain-based enzymatic debridementin the treatment of burns greater than 15% TBSA.

Retroperitoneoscopic debridement and internal fixation for the treatment of lumbar tuberculosis.

ABSTRACT: To describe the retroperitoneoscopic debridement technique and evaluate the clinical outcome of internal fixation for the treatment of lumbar tuberculosis.Twenty-eight patients were performed conventional laparoendoscopic technique (n = 17) or laparoendoscopic single-site technique (n = 11). Antituberculosis chemotherapy and thoracolumbosacral orthosis were given to all patients. The clinical outcomes were evaluated with preoperative and postoperative Visual Analog Scale, and radiographs with respect to sagittal angle and fusion status.Average time of the 28 procedures was 220.6 ±â€Š50.9 min (180-365 min). The average intraoperative blood loss was 108.6 ±â€Š95.3 mL (50-400 mL). All patients showed significant improvement of their Visual Analog Scale back pain score at follow-up and were classified as having a radiographic fusion in this study. The mean sagittal angle was 11.2 ±â€Š3.6° before operation, significantly improved to 3.7 ±â€Š2.4° after operation. There were no recurrent infections during the follow-up period. Complications included loosening of anterior fixation and temporary deficit of the sympathetic nerve.Retroperitoneal laparoscopic approach with CO2 insufflation technique is a challenging but safe and effective procedure for lumbar spine tuberculosis. Retroperitoneal laparoendoscopic single-site can be used for anterior lumbar spine surgery, offer exposure for L1 through L5.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell Time: An Overview.

SUMMARY: The use of negative-pressure wound therapy (NPWT) has become an established therapy for wound management. There have been many advancements in the technology of NPWT including NPWT with instillation and dwell (NPWTi-d). NPWTi-d promotes wound healing by wound cleansing, irrigation, and nonexcisional debridement. NPWTi-d has been shown in comparative clinical studies to decrease the time to definitive wound healing and length of hospitalization. NPWTi-d-using a reticulated open-cell foam dressing with "through" holes (ROCF-CC)-has been postulated to facilitate solubilization, detachment, and elimination of infectious materials, such as slough and thick exudate, before or after operative debridement, and in cases where surgical debridement is not an option. The authors provide an overview on the use of NPWTi-d by reviewing the components of the system, proposed mechanism of action, clinical outcomes, and current consensus guidelines for its utilization.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell in Breast Reconstruction.

SUMMARY: The use of negative-pressure wound therapy (NPWT) has expanded over the last 3 decades, paralleled and documented by an increase in research. This article discusses the evolution and current applications of NPWT in modern breast reconstruction. Negative-pressure wound therapy with instillation and dwell (NPWTi-d) technology can be used to remove infectious material, facilitate salvaging compromised tissue, and stabilize the soft-tissue environment. Published consensus NPWTi-d guidelines can aid in treatment selection and implementation of this new technology. The therapeutic approach of simultaneously removing infectious material and actively improving mastectomy flap perfusion and thickness is a burgeoning concept, and illustrative cases are presented. NPWTi-d preliminary use has led to reconstruction salvage with reproducible early experience and outcomes, and it is hoped that it will raise interest and awareness of this promising application of the technology to improve breast reconstruction outcomes.

Assessment of arthroscopic shavers: a comparison test of resection performance and quality.

BACKGROUND: Arthroscopic shavers play an indispensable role in arthroscopic debridement. They have exquisite structures and similar designs. The purpose of this study was to establish a reproducible testing protocol to compare the resection performance and the quality (tensile strength, torsional strength, and corrosion resistance) of different arthroscopic shavers with comparable designs. We hypothesized that there could be little difference in resection performance and quality between these shavers. METHODS: Incisor Plus Blade (IPB; Smith & Nephew, Andover, MA) and Double Serrated Plus Blade (DSPB; BJKMC, Shanghai, China) were selected for resection performance and quality test. For resection performance testing, the resection torque, which is the minimum torque required to cut off silicone blocks with the same cross-sectional area, was measured to evaluate the resection performance of shaver blades when the other factors remain the same. For quality testing, tensile and torsion tests of the shavers' joint part were performed, and ultimate failure load and maximum torque were measured and compared. The corrosion resistance of these blades was assessed by the boiling water test based on the ISO13402. RESULTS: No significant difference existed in the resection torque between the shaver blades of IPB and DSPB (P = 0.54). To the failure load of shavers' joint parts, IPB was significantly higher than DSPB, both in the outer and inner blades (P < 0.0001). The maximum torque of the joint part had no significant difference between IPB and DSPB (for inner blades P = 0.60 and outer blades P = 0.94). The failure load (for both IPB and DSPB P < 0.0001) and maximum torque (for IPB P = 0.0475 and DSPB P = 0.015) of the inner blades were higher than those of the outer blades. No blemishes were observed on the surface of the blades after corrosion resistance tests. CONCLUSIONS: This study provided some new methods to evaluate the resection performance and quality of different shavers. The resection performance, the torsional strength of the joint part, and the corrosion resistance of IPB and DSPB may show comparable properties, whereas the tensile strength of the shavers' joint part showed some level of difference.

[Mid-term effectiveness of manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement for primary frozen shoulder].

OBJECTIVE: To evaluate mid-term effectiveness of manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement for primary frozen shoulder. METHODS: Between January 2013 and December 2017, 33 patients of primary frozen shoulder were treated with manipulation under anesthesia combined with 360° arthroscopic capsular release and subacromial debridement. There were 10 males and 23 females, aged from 37 to 65 years, with a mean age of 50.9 years. The affected shoulder on left side in 17 cases and on right side in 16 cases. The disease duration was 6-13 months (mean, 8.4 months). Before and after operation, the visual analogue scale (VAS) score was used to evaluate the shoulder joint pain, Constant score was used to evaluate the shoulder joint function, and the flexion, abduction, and external rotation of shoulder joint were recorded. The internal rotation function was assessed based on the vertebral plane that the thumb could reach after internal rotation of the affected shoulder joint (the rank of internal rotation vertebra). X-ray film was taken to measure the distance of the subacromial space. RESULTS: There was no fracture or labrum tear in all patients, and all the incisions healed by first intention. All the 33 patients were followed up 20-31 months, with an average of 24.1 months. During the follow-up, there was no complication such as wound infection and nerve injury. At last follow-up, the range of motion of shoulder flexion, abduction, and external rotation, the rank of internal rotation vertebra, the VAS score, Constant score, and subacromial space were significantly improved when compared with preoperative ones ( P<0.05). CONCLUSION: Manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement can achieve a good mid-term effectiveness without complication for primary frozen shoulder.

Evaluation of a joint distractor to facilitate arthroscopy of the canine stifle.

OBJECTIVES: To assess a novel technique for arthroscopic evaluation of the canine stifle avoiding the need for fat pad debridement. STUDY DESIGN: Prospective study. SAMPLE POPULATION: Cadaveric canine stifles (n=10); Client-owned dogs (15). METHODS: In cadaveric stifles, the femoropatellar space was assessed before placement of a joint distractor and examination of the femorotibial joint. Time to complete evaluation of the femoropatellar space, to observe the cruciate ligaments, and to completion of examination of the femorotibial joint were recorded. Distractor-assisted arthroscopy was then performed in 15 consecutive clinical cases. Clinical information, time to complete joint evaluation, and ability to perform any additional arthroscopic surgery were recorded. RESULTS: Observation and palpation of intra-articular structures were possible in all cadaveric stifles. Mean time to evaluate the femoropatellar space was 3.2 minutes (range, 2-4 minutes); to observe the cruciate ligaments, 5.8 minutes (range, 3-8 minutes); and to completion of joint inspection, 9.1 minutes (range 6-13 minutes). In the clinical cases, observation of intra-articular structures was also possible in all stifles. Mean time to complete joint inspection was 21 minutes (range, 10-40 minutes). Partial meniscectomy was performed successfully in 5 stifles. CONCLUSIONS: Use of a joint distractor allowed arthroscopic observation of all relevant structures. Partial meniscectomy was readily performed. CLINICAL RELEVANCE: Use of a joint distractor may simplify arthroscopic assessment of the canine stifle and avoid potential morbidity associated with fat pad debridement.