Evolution of Technology

Negative Pressure Wound Therapy (NPWT)

Negative pressure wound therapy (NPWT) is a method of soft-tissue injury treatment in which an impervious dressing is applied to skin or soft tissue, and then connected to a vacuum-generating device. Research has demonstrated decreased rates of infection, increased rates of healing, and fewer subsequent surgeries when NPWT is used in the setting of open fractures, infection, or extensive soft-tissue loss. Traditionally, NPWT required the use of large, immobile vacuum-generating devices, which often could not leave the hospital. This leads to increased cost to patients, and often served as a barrier to discharge or de-escalation of care-level.

Amputation sites following necrotizing soft tissue infections are often left open, or loosely closed, for eventual definitive closure. Uncertainty of extent of infection, profound local edema and soft tissue swelling, and impaired patient healing factors are all factors which often lead surgeons to delay primary closure. Negative pressure wound therapy (NPWT) has become the mainstay of treatment when delayed primary closure is utilized. Research has demonstrated a proven effect on NPWT’s ability to decrease local swelling and edema, decrease spread of infection, and promote healing factor migration to local areas. Owing to the fact that most patients with NSTIs spend prolonged periods of time in the hospital, portability of NPWT is not of paramount important. Rather, strength of suction and dressing availably moves to the forefront as the most important variables.

Evolution of Procedure

Irrigation and Debridement

Operative irrigation and debridement is the gold standard surgical procedure by which open fractures are initially managed. While timing for definitive osseous fixation varies depending on fracture severity and location, it is widely accepted that time to operative debridement should be no more than 6-8 hours. Effective operative debridement includes removal of foreign bodies, copious irrigation of the injury site, extension of soft tissue injury to fully visualize the field of injury, possible local infiltration of antibiotic, and primary or delayed soft-tissue closure.

Evolution of Diagnosis

Open Fracture

Open fractures can be a catastrophic injury. Often associated with high-energy injury mechanisms, with substantial morbidity and mortality, these fractures are among the most serious treated by orthopaedic surgeons. While open fractures of the fingers are the most common, open fractures of weight-bearing long bones (i.e. tibia or radius) often require multiple surgeries or meticulous soft-tissue management to appropriately treat. Infection rates are high, and infection in the setting of open fracture can have drastic implications.

The mainstay of treatment for open fractures is based around a few tenets: prevention of infection, repair of osseous injury, and treatment of associated soft-tissue injuries. While early administration of antibiotics is the first step in preventing infection, operative irrigation and debridement is the gold standard method through which risk of infection is minimized.