title: [Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies].
abstract: The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain "decontamination" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.
authors.affiliation: Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum Rekonstruktion von Defektwunden, Exzellenz-Zentrum zur Versorgung von Verwundeten aus Kriegs- und Krisengebieten, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland. christianwilly@bundeswehr.org.
authors.forename: C
authors.initials: C
authors.lastname: Willy
authors.affiliation: Sektion Gefäß- und Thoraxchirurgie der Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland.
authors.forename: M
authors.initials: M
authors.lastname: Stichling
authors.affiliation: Abteilung I/Laborgruppe Med. Mikrobiologie, Zentrales Institut des Sanitätsdienstes, der Bundeswehr Kiel/Berlin, Berlin, Deutschland.
authors.forename: M
authors.initials: M
authors.lastname: Müller
authors.affiliation: Abteilung I/Laborgruppe Med. Mikrobiologie, Zentrales Institut des Sanitätsdienstes, der Bundeswehr Kiel/Berlin, Berlin, Deutschland.
authors.forename: R
authors.initials: R
authors.lastname: Gatzer
authors.affiliation: Institut für Hygiene und Umweltmedizin, Universitätsmedizin Greifswald, Greifswald, Deutschland.
authors.forename: A
authors.initials: A
authors.lastname: Kramer
authors.affiliation: Abteilung Allgemein- und Viszeralchirurgie, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland.
authors.forename: D A
authors.initials: DA
authors.lastname: Back
authors.affiliation: Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum Rekonstruktion von Defektwunden, Exzellenz-Zentrum zur Versorgung von Verwundeten aus Kriegs- und Krisengebieten, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland.
authors.forename: D
authors.initials: D
authors.lastname: Vogt
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy / Q000379:methods; D003646:Debridement / Q000379:methods*; D006801:Humans; D007869:Leg Injuries / Q000628:therapy*; D054843:Negative-Pressure Wound Therapy / Q000379:methods*; D016879:Salvage Therapy / Q000379:methods*; D013530:Surgical Wound Infection / Q000517:prevention & control*; D007507:Therapeutic Irrigation / Q000379:methods*
chemical_list: D000900:Anti-Bacterial Agents
keywords: Biofilms; Negative pressure wound therapy; Open fractures; Therapeutic irrigation; Vacuum instillation therapy; Wound infection