Muscle Viability Revisited: Are We Removing Normal Muscle? A Critical Evaluation of Dogmatic Debridement.
OBJECTIVE
Determination of muscle viability during debridement is a subjective process with significant consequences. Evaluating muscle color, consistency, contractility, and capacity to bleed (the 4 Cs) was established by a study performed half a century ago. This work reinvestigates the utility of the 4 Cs using current histopathologic techniques.


METHODS
After institutional review board approval, 36 biopsies were prospectively collected at a level-1 trauma center from 20 patients undergoing a debridement for open fracture (81%), compartment syndrome (11%), infection (5%), or crush injury (3%). Surgeons graded the biopsies using the 4 Cs, and provided their overall impression as healthy, borderline, or dead. Blinded pathological analysis was performed on each specimen. A correlation between the 4 Cs and surgeon impression with histopathological diagnosis was sought through a univariate statistical analysis.


RESULTS
The surgeon's impression was dead muscle in 25 specimens, borderline in 10, and healthy in 1. Pathological analysis of the 35 specimens considered as dead or borderline muscle by the surgeon demonstrated normal muscle or mild interstitial inflammation in 21 specimens (60%). Color (P = 0.07), consistency (P = 0.12), contractility (P = 0.51), capacity to bleed (P = 0.07), and surgeon impression (P = 0.50) were unable to predict histologic appearance.


CONCLUSIONS
Neither the 4 Cs nor the surgeon's impression correlate with histological findings regarding muscle viability. In 72% of specimens, the treating surgeon's gross assessment differed from the histopathologic appearance. Although the fate of the debrided muscle remains unclear if left in situ, these results raise questions regarding current practices, including the possibility that surgeons are debriding potentially viable muscle.


METHODS
Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Departments of *Orthopaedic Surgery, and†Surgical Pathology, Orlando Regional Medical Center, Orlando, FL.
Adam
A
Sassoon
John
J
Riehl
Amy
A
Rich
Joshua
J
Langford
George
G
Haidukewych
Gary
G
Pearl
Kenneth J
KJ
Koval
D000465:Algorithms; D003646:Debridement / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D018482:Muscle, Skeletal / Q000473:pathology* / Q000601:surgery*; D019637:Orthopedic Procedures / Q000379:methods*; D014022:Tissue Survival; D016896:Treatment Outcome; D019564:Unnecessary Procedures