In a follow-up to the last Q&A column on preventing post-op wounds (see page 16, January issue), our expert panelists have reconvened to discuss the treatment of post-op wounds. They explore treatment approaches to a variety of wounds, ranging from the post-op dehiscence and infected wounds to exposed internal fixation and fracture blisters. Without further delay, here are their thoughts.
Q: How do you typically manage the post-op wound dehiscence? What types of wound products do you suggest?
A: Ronald G. Ray, DPM, PT, says you should first remove any loose suture material and debride the wound as needed. Luke D. Cicchinelli, DPM, immobilizes the area if motion is part of the problem and employs saline wet to dry dressings. Sometimes, he will use hydrogels in order to maintain a moist wound environment and control any edema. Dr. Cicchinelli will either proceed to perform any debridements and delayed secondary closures if necessary or allow healing by secondary intention if possible.
For a small, simple post-op wound dehiscence, Lawrence G. Karlock, DPM, will traditionally employ standard light packing of the wound with saline-moistened Nu-Gauze dressings and try to perform these changes bid for the first few days. He also orders flushing of the wound twice a day during the dressing changes. In most cases with a wound dehiscence, Dr. Ray says “appropriate wound care and immobilization are all that is needed.”
Dr. Cicchinelli says it’s important to know the difference between a wound dehiscence and a post-op infection. He says the dehisced wound can “look angry and irritated but not necessarily be infected.”
If one determines that a wound is infected (via signs of significant erythema, increased skin temperature, purulence, malodor and tissue necrosis or liquefaction), Dr. Ray says you should start appropriate empiric antibiotic coverage (until you get the culture results) and initiate dressing changes.
When it comes to large and deep wounds with a limb-threatening infection and a high amount of drainage, Dr. Karlock institutes VAC therapy, which he says has been shown to be useful in some of these situations.
When treating contaminated wounds, Dr. Ray says you should thoroughly cleanse the wound with a mild surgical soap, flush with saline and dress it. If the wound is cavitating, he recommends gently packing it open with alginates or cadexomer iodine to absorb excess fluids. If there is minimal fluid, Dr. Ray says he will pack the wound with 1/4 to 1/2 inch plain packing gauze moistened with an amorphous hydrogel and/or Regranex.
Dr. Ray points out that papain/urea debriding agents are extremely effective in removing wound debris and promoting the formulation of granulation tissue. He also notes that he has used unilayered and bilayered skin equivalents to provide a “biologic covering” while promoting granulation tissue. Dr. Ray adds that one can use VAC therapy in isolation or in conjunction with human skin equivalents to facilitate wound closure.
Q: How would you handle exposed internal fixation in the postoperative wound?
A: Dr. Karlock refers the patient to a reconstructive limb salvage plastic surgeon, who typically will perform appropriate flap and/or graft coverage to cover the internal fixation. In general, if the fixation is performing the job and is not obviously infected and loose, he maintains the fixation.
To deal with exposed internal fixation, Dr. Ray uses rotational or advancement-type flaps to acquire full-thickness coverage of the implant.
Dr. Cicchinelli removes the internal fixation and converts it to an external fixator that bridges the incision in case stability is an issue. He notes the high probability that retained internal fixation is harboring bacteria due to avascularity. He emphasizes addressing any potential infection first and subsequently optimizing wound closure. Doing so reduces the risk of the patient developing deep infections or osteomyelitis, notes Dr. Cicchinelli. He adds that one may have to subsequently deal with a residual deformity or do a second procedure if necessary.
Q: Any thoughts about operating in the face of fracture blisters?
A: Dr. Ray says he prefers not operating through bullae, especially if they are hemorrhagic. Instead, he immobilizes the site to prevent further soft tissue trauma. He elevates and cools the limb, saying ice or a cooling unit can prevent swelling. Employing a sequential compression device will facilitate removal of edema from the limb and you can unroof the bullae, according to Dr. Ray. Then you would manage the wound to promote epithelialization.
Dr. Cicchinelli concurs. When treating fracture blister patients, he says you can put the “vast majority” of them in splints and Jones compression dressings. Then he suggests scheduling them for a follow-up visit 10 days to two weeks later and continuing to optimize the skin/wound environment.
Dr. Cicchinelli says he will only operate if the patient has an open fracture or neurovascular compromise, and the risk of infection is equal or greater to the possibility of wound compromise from the fracture blisters.
Q: What other suggestions do you have on using VAC therapy for postoperative wound problems?
A: While he has limited experience in using VAC therapy for post-op wounds, Dr. Karlock says the adjunctive modality has a role for the draining, well vascularized postoperative wound. He says he would avoid using this modality in a partially ischemic wound that is fragile and prone to pressure breakdown.
Dr. Cicchinelli has a private practice at Eastern Carolina Foot and Ankle Specialists, Inc. in Greenville, N.C., and is a faculty member of the Podiatry Institute.
Dr. Ray has a private practice at the Foot and Ankle Clinic of Montana in Great Falls, Mt., and is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.