Primäres Weichteilmanagement bei offenen Frakturen

Abstract

Objective: Debridement of soft tissue and bone in an open fracture situation to minimize infection risk and achieve primary skin closure, or to provide conditions for early soft tissue coverage. Indications: Indications are Gustilo–Anderson grade I-III A-C open fractures. Contraindications: Contraindications are injuries requiring amputation, burns, and life-threatening injuries which make appropriate treatment temporarily impossible. Surgical technique: Removal of gross contamination and macroscopic contaminants; debridement of the wound; complete resection of contaminated and dirty tissue; sparse step-by-step resection of contaminated or non-vital wound and bone margins until vital, bleeding tissue begins; low-pressure irrigation with isotonic irrigation fluid; diagnostic biopsies for microbiological testing; reduction of dead space by interpositioning of muscle or cement spacers loaded with local antibiotics; primary wound closure if tension-free closure possible; otherwise, if resources and knowhow permit and satisfactory clean debridement was achieved, local flap; if flap impossible, debridement not satisfactory, secondary tissue necrosis likely, potential remaining contamination or contamination with fecal matter, then vacuum-assisted closure therapy. Postoperative management: Wound inspection on the second postoperative day, generous indication for second-look surgery after 36–48 h, wound inspection on the second postoperative day, wound inspection every other day, primary antibiotic prophylaxis with a first- or second-generation cephalosporin (e. g., cefuroxime), and adaptation of antibiotic therapy according to susceptibility screening. Results: Infection rates of 2–4.7% are reported for immediate primary wound closure in Gustilo–Anderson grade I, II, and III A open fractures. For Gustilo–Anderson grade III B, good wound healing, bony consolidation, and no need for secondary surgery was reported in 86.7% when primary wound closure was achieved.