Early versus delayed closure of open fractures

Injury, Int. J. Care Injured (2007) 38, 896—899

www.elsevier.com/locate/injury

DEBATE

Early versus delayed closure of open fractures L. Scott Levin * Duke University Medical Centre, Box 3945, Durham, NC 27710, United States Accepted 13 March 2007

KEYWORD Delayed wound closure

Summary Despite convincing data from Ljubljana, Yugoslavia 20 years ago, that emergency free tissue transfer for open fractures results in a low infection rate, shorter hospitalisation, decreased time for bone healing, and low incidence of flap failure, there are circumstances that preclude against immediate wound closure. The case for delayed wound closure is made based on several parameters that include: surgical team availability, the condition of a patient, and adequate informed consent. Delayed wound closure is the rule and emergency free tissue transfer is the exception, in major trauma centres around the world. There is a difference between immediate, delayed, and late coverage and these terms have yet to reach universal acceptance. The demographics of reconstructive surgery are changing in terms of surgeons having the skill sets, desires, and incentives to perform complex reconstruction for open fractures. This issue will perhaps be the most telling characteristic of what happens as we go forward into the future of trauma care and the timing of wound closure. # 2007 Elsevier Ltd. All rights reserved.

The controversy surrounding early versus delayed closure of open fractures has been an ongoing debate for at least 20 years, since Marco Godina published his landmark paper on the subject of emergency free flaps.12 The article was published posthumously and it described Godina’s experience with 134 consecutive open fractures. There was a 1.5% deep infection rate in this series, which were treated with emergency free tissue transfer. Godina tried to categorise emergency free tissue transfer, by defining it as the definitive coverage procedure performed at the time of the initial debridement. The patient would present to the emergency room with an open fracture. Fracture stabilisation and coverage would be done in the * Tel.: +1 919 684 2472; fax: +1 919 681 7340. E-mail addresses: [email protected], [email protected].

1st operative setting. In scrutinising the data, the patients that had emergency free tissue transfer, (that is a flap done at the first setting) compared with those who had a flap at 3 days, this did not show any difference in infection rates. It was emphasised that the surgeons lacking experience with debridement, and patients who had longstanding open wounds, did not do as well, in terms of infection rate and limb salvage after coverage.5 Furthermore, the longer coverage was delayed, the longer time was spent in hospital, either at outside referring institutions or even within Ljubljana. One would have thought that 20 years ago, that such convincing data, would have influenced orthopaedic surgeons and reconstructive microsurgeons, to change how open fractures are managed. In some centres this has been the case, but the fix and flap idea is still not mainstream thinking.

0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.03.011

Early versus delayed closure of open fractures Currently, the closure of open fractures and techniques associated with coverage are rarely in the hands of orthopaedic surgeons or traumatologists. Historically, many orthopaedic surgeons were involved with free tissue transfer. Many orthopaedic surgeons pioneered techniques in microvascular surgery, as they relate to replantation, vascularised bone transfers, and free tissue transfer. Limb salvage after trauma, tumour, and orthopaedic sepsis (osteomyelitis) were forever changed with the introduction of the operating microscope and development of autologous tissue transfer.9 Today microvascular free tissue transfer is available in most major trauma centres. However, a profound change has occurred over the last 25 years: fewer and fewer orthopaedic surgeons are capable or willing to perform free tissue transfer. Subsequently, microvascular free tissue transfer and sophisticated techniques such as fasciocutaneous flaps or perforator flaps (either rotational or free) have been relegated to ‘‘soft tissue surgeons’’ many of whom are reconstructive plastic surgeons. Furthermore, the interest of those that are keenly interested in reconstructive surgery or reconstructive microsurgery has diminished in plastic surgery, there are fewer and fewer surgeons who are willing to perform complex microsurgical extremity reconstruction. Even more frightening, is the suggestion that microsurgical techniques are ‘‘no longer needed’’, because alternatives such as dermal substitutes, wound VACS, and local rotational flaps will substitute or provide better coverage than free tissue transfer. I strongly disagree with this. While the wound VAC has taken its place in the armamentarium of lower extremity coverage for open fractures, in my estimation it has replaced wound temporisers and wound ‘‘bridging’’ that we used in the 80’s such as the bead pouch. Many authors have demonstrated that the wound Vac can treat a soft tissue defect associated with an open fracture to completion, by facilitating secondary intention healing, the VAC stimulates granulation tissue, that ultimately will epithealise, or support a skin graft, obviating the need for more complex reconstruction.3 To me this is a triumph of ‘‘technology over reason’’ and it is fraught with potential disasters. Bacterial colonisation and late infection of implants, bone, and plates and screws can lead to osteomyelitis, if the VAC is used for prolonged periods, especially when plates and bone are exposed. If one is to address the controversy of early versus delayed closure of open fractures, we should define what early versus delayed means. This has been debated for some time.2 Do we mean by early, at the same setting as primary debridement, within

897 3 days, within 1 week, within 2 weeks, or more? Delayed coverage may be defined as anytime after the initial debridement; the delay may last weeks or months. While I believe in the principles that Marco Godina published in his thesis, and recognise him to be a brilliant contributor to modern concepts in wound closure and microvascular surgery, the days of Godina’s team in Ljubljana are different from what exists today in healthcare systems around the world. Marco Godina had a tireless crew of dedicated reconstructive surgeons and reconstructive microsurgeons who worked around the clock in teams, to provide expert and highly successful microvascular tissue transfers. Part of the rationale was that there was so much work to be done, that these cases would have to be done urgently, because more cases would be presenting later on. When there is a replant or microvascular team available in an institution around the clock, there is no reason why early or even emergency free tissue transfer cannot be performed. The reality is, that this is not practical in most centres around the world and certainly not in North America, due to the diminished interest in microsurgery by orthopaedic and plastic surgeons. Open fractures often present during the hours of 10 p.m.—7 a.m., therefore, delayed closure of open fractures has become the rule. This does not mean the delay is for weeks or months, but as Godina stated in his paper, up to 3 days will provide a good outcome. In our institution, our microvascular team will examine the patient at time of the initial debridement, and perhaps during the placement of external fixation, with plans to immediately return the patient to the operating room for a ‘‘second look’’ sometimes after 24 or usually 48 h.8 At that time, provided the first debridement is radical, there may be a second requirement or second touch up debridement and then the patient will be closed at that sitting. Closure does not always involve microvascular free tissue transfer. There can be secondary intention wound healing, application of a wound vac with granulation tissue that is allowed to epithealise, application of a wound VAC to create a bed suitable for split thickness skin graft, skin grafting in and of itself, local rotational flaps or free tissue transfer.7 A BOA BAPS combined report published in 1997 reviews modern principles of management for open tibial fractures.13 Furthermore, as Godina taught us 20 years ago, it does not matter if a wound is closed within 24 or 72 h, the results in terms of infection are the same. In ‘delayed cases’, which is defined as dehiscence following emergency treatment, there are several factors to be covered. If there is infected hardware,

898 this must be removed. Often different fracture stabilisation must be chosen such as external fixation. Often in IIIB and IIIC injuries particularly, with vascular injury, it may be prudent to wait 1,2 or 3 days to see how successful the vascular bypass is, and whether additional muscle groups may go on to infarction.11 For example, a large intercalary zone of injury, that requires a femoral distal tibial bypass into the distal posterior tibial artery, may revascularise the foot and ankle, but the intercalary bone, soft tissue, and skin segments may become necrotic. Providing an emergency free flap around this or attaching the flap to the vascular bypass, would not render this tissue viable. Lots of energy would have been wasted at the initial setting, resulting in a disaster, with a live free flap and foot but a dead leg. One must also decide whether or not the trauma team will pursue reconstruction or amputation.10 Patients and families, particularly patients, may need a few days to sort this out. You will need to obtain informed consent and have discussions among the team of physicians, psychiatrists, therapists, orthopaedic surgeons, and plastic surgeons. It is an advantage to wait in that case, so that the patients and families can rationally, to the best of their ability, decide whether or not they want to pursue limb salvage. This supports delayed coverage, and such a decision usually takes only a few days to be reached. Another rationale for ‘delayed closure’ is that extremities may be too swollen. Tissues are declaring themselves. Bacterial colonisation may be too high, and despite what we would consider a perfect debridement, it may be rational to wait a few days until the wound and the patient are prepared. Furthermore it is also important to have the proper team in place, with the proper amount of OR time. It does not make sense to try to perform an emergency free flap, without trained nursing staff in the middle of the night. Residents or support staff may be unfamiliar with the tempo of the microvascular procedure. In my opinion, this is a recipe for disaster. Perhaps the surgeon who is capable of doing this may be going out of town or unavailable on a certain day. Certainly doing a flap would be fine, assuming there are people that can cover, if a microvascular thrombosis occurs. I make it a policy to be available for several days in case a flap has a thrombosis after surgery. Although this usually occurs in the first 24 h, we have had vascular compromise for a variety of reasons, on the arterial venous side, as late as 3 and 4 days. Timing is important for the surgeon, operative team, and the patient. Delayed closure is often appropriate even with the circumstances of an ideal debridement. Muscles may be contused that in 48 h can declare themselves. Vascular bypass reconstructions may be open or thrombose, and these may

L.S. Levin require a revision or Fogerty embolectomy. What appears to initially be a patient in need of a complex closure, with time, oedema resolution, and circulation stability, the wound can be closed with an alternative method such as a simple closure or skin graft. In patients that have co-morbidities such as peripheral vascular disease, diabetes, or other issues like HIV, early closure is still indicated provided that these metabolic conditions are adequately controlled such as having cardiology clearance of a patient with a low ejection fraction as long as the appropriate consultants optimised the patient, then one should proceed with early closure independent of these factors. The only indication in my opinion, for emergency free tissue transfer is the concept of the emergency fillet flap where part is amputated and could be used to provide limb salvage and coverage. This is by definition an open fracture and this is a true indication for emergency free tissue transfer.4 Another alternative for immediate closure is when major limb replantation is performed. The goal is to repair all structures in the first setting. However, in digital replantation or hand replantation, wounds are partially left open, either for venous egress or just to allow egress of blood and serum that may accumulate. Another reason not do immediate closure is that many polytrauma patients may have systemic problems (ARDS, acute renal failure and cardiac contusion) that need to be resolved before they are subjected to long operative procedures assuming the microvascular free tissue transfer has to occur. Another rationale for ‘delayed closure’ is that mutilating injuries in the extremities often take up to a year to recover, and often require secondary procedures such as tendon transfers, or bone grafts.6 What difference does a few days make? Procedures can be done to provide provisional coverage on the night of injury, such as use of a wound VAC bead pouch, or pigskin; this does not close the wound but covers the wound preventing desiccation of tissues that are exposed. The VAC can be used as a temporary bridge and some have used it for definitive coverage. There are case reports that indicate that the VAC can contribute to erosion into a major artery causing haemorrhaging. Finally, it all comes down to personnel, dialogue, and communication between the traumatologist, vascular surgeons, orthopaedic surgeons, nurses, PA’s, and plastic surgeons. The question remains–— who is available, when can they do it, are they willing to do it, and if they do it, can they do it with a degree of certainty that will assure complete and ‘‘living coverage’’, once coverage is provided? In those circumstances, it is better to delay coverage or even transfer a patient to another centre, than have an

Early versus delayed closure of open fractures inexperienced team of personnel try to provide coverage with an unsuccessful outcome. The latter certainly creates terrible morbidity, increases hospitalisation costs, and generates emotional trauma to patients. In the polytrauma patient with open fractures, particularly in the extremities, coverage is just one part of total care that includes haemodynamic stabilisation, fracture stabilisation, definitive fixation, perhaps provisional coverage, definitive coverage, and then reconstruction down the line of missing bone segments, motor tendon units, or peripheral nerves. I am an advocate for aggressive use of microsurgical free tissue transfer procedures and I am an advocate for using fasciocutaneous flaps such as the sural flap for small defects that can be effectively managed.1 I am an advocate for very early wound closure, but this does not have to be immediate. If we define early versus delayed wound closure as basically emergency free flaps compared to ‘‘everything else’’, then I am on the side of everything else with the exception of emergency free flaps, emergency free fillet flaps, or replantation.

References 1. Erdmann DE, Gottlieb N, Humphrey JS, et al. Sural flap delay procedure: a preliminary report. Ann Plastic Surg 2005;54(5): 562—5.

899 2. Gupta A, Shatford RA, Wolf TW, Tsai TM, Scheker LR, Levin LS. Treatment of the severely injured upper extremity. Instr Course Lect 2000;49:377—96. 3. Horch RE, Gerngross H, Lang W, et al. Indications and safety aspects of vacuum-assisted wound closure. MMW Fortschr Med 2005;147(Suppl. 1):1—5. April 7, German. 4. Kuntscher M, Erdmann D, Homann H, et al. The concept of fillet flaps: classification, indications, and analysis of their clinical value. Plast Reconstruct Surg 2001;108(4): 885. 5. Levin LS, Erdmann DE. Primary and secondary microvascular reconstruction of the upper extremity. Hand Clinics 2001;17(3):447—55. 6. Levin LS, Goldner RD, Urbaniak JR, et al. Management of severe musculoskeletal injuries of the upper extremity. J Orthopaed Trauma 1990;4(4):432—40. 7. Levin LS, Heller L. Lower extremity microsurgical reconstruction. Plast Reconstruct Surg 2001;108(4):1029. 8. Levin LS. Debridement Techniques in Orthopaedics, vol. 10(2). Lippincott-Raven; 1995. pp. 88—93. 9. Levin LS. Microsurgical autologous tissue transplantation for orthopaedic reconstruction Techniques in orthopaedics, vol. 10(2). Lippincott-Raven Press; 1995 . pp. 134— 44. 10. Levin LS. Combined free tissue transplantation and Illisarov for lower extremity salvage. Young microsurgeon’s perspective newsletter. American Society for Reconstructive Microsurgery; 1996. 11. Lin CH, Levin LS. The functional outcome of lower extremity fractures with vascular injury. J Trauma 1999;43(3): 480—5. 12. Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg 1988;13A:22—8. 13. Membership of the BOA/BAPS Working Party: A Report by the BOA/BAPS Working Party on The Management of Open Tibial Factures; 1997.