Primary closure of infected spinal wounds

Although postoperative infections of spinal wounds are uncommon, when they occur, they cause considerable morbidity. The classic treatment for deep infected wounds of the spine involves opening the wound, packing it, and permitting secondary closure to occur through granulation. A combined total of 10 patients with infected postoperative spinal wounds (two cervical and eight lumbar) from the Lahey Clinic and the Cleveland Clinic were treated by primary closure. Infection was diagnosed, usually within 2 weeks of operation (average, 10.9 days), by increasing back pain, purulent drainage from the incision, cultures, and subfacial extension of the process. In one patient, an associated disk space infection was observed. Causative organisms were Staphylococcus aureus in five patients and Staphylococcus epidermidis in five patients. At the second operation, the wounds were opened and radically debrided, irrigated, and closed primarily over one or two large drains. Treatment with intravenously administered antibiotics was continued postoperatively; the duration of treatment varied from 10 days to 6 weeks, depending on the presence or absence of involvement of bone or disks. Complete resolution of the infections and primary healing of the wounds occurred in all patients. This technique offers advantages over the traditional technique of secondary wound closure by decreasing the amount of wound care and length of hospitalization and is recommended as the treatment of choice for patients with postoperative spinal wound infections.     

Studies in the management of the contaminated wound. VII. Susceptibility of surgical wounds to postoperative surface contamination

This study lends strong support to the thesis that wounds closed with tape are far more resistant to surface contamination than are wounds closed with percutaneous sutures. Immediate surface contamination with Staph aureus did not elicit an infection in any taped wound. Only 7.7 per cent of the taped wounds developed gross infection after contamination with E coli immediately after closure. Surface contamination with E coli two or more hours after closure did not result in infection in any taped wound.     

Delayed Staged Closure With Repeated Directional Suturing of Cutaneous Defects

BACKGROUND: Postsurgical wound management is traditionally a choice between intraoperative surgical repair or healing by secondary intention. We describe a technique that combines intraoperative and postoperative surgical repair with granulation. OBJECTIVE: Delayed closure with repeated directional suturing was evaluated as an alternative closure technique for large wounds. METHODS: Sixty patients had surgical defects partially closed intraoperatively with postoperative staged closures over 2 to 4 weeks. Only those wounds that could not be closed intraoperatively without vascular compromise or anatomic disfigurement were treated. RESULTS: All wounds were closed using skin from the same anatomic unit. Complications were minimal, and the results were acceptable to both the patients and the surgeon. CONCLUSION: Delayed closure with repeated directional suturing is a reasonable alternative when primary closure is not possible or when it would cause anatomic disfigurement.     

Delayed primary closure in colon operations.

Secondary closure of incisions by tape is a simple, safe procedure. In a retrospective series of 179 contaminated surgical wounds (incisions for colon operations) delayed wound closure resulted in a lower incidence of wound infection (5.8%) than did primary closure of similar wounds (11.8%). Although wounds left open do become infected, the acute swelling and systemic signs typical of an infection in a closed wound never develop. Delayed closure facilitated wound healing in hospital: only 3.8% of patients thus treated left hospital with open wounds, but 9.5% of patients whose wounds were closed primarily left hospital with wounds that were partially or completely open.     

Wound infections after transplant nephrectomy

Wound infections after transplant nephrectomy were analyzed retrospectively. When prophylactic antibiotics were not used, 20% of the closed nephrectomy wounds became infected. Eighty-one percent of the infections were due to staphylococcal organisms. Wounds containing a preexisting focus of infection or those reoperated on more than once within a month prior to nephrectomy are at such high risk for infection that these wounds should be left open for secondary healing. With the use of prophylactic cefazolin sodium, in the immediate preoperative and postoperative period, no wound infections have occurred in 18 closed transplant nephrectomy wounds.     

Prospective randomized trial of two wound management strategies for dirty abdominal wounds

OBJECTIVE: To determine the optimal method of wound closure for dirty abdominal wounds. SUMMARY BACKGROUND DATA: The rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. METHODS: Fifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. RESULTS: Two patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. CONCLUSION: A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.     

A revolutionary advance in skin closure compared to current methods

Six pigs were used to evaluate the influence of three separate modalities on contaminated wounds. Full-thickness skin wounds on the abdomen were contaminated with 10(4) or 10(5) Staphylococcus aureus and then closed with one of three methods. The three closure modalities included (1) a new absorbable staple (Insorb) placed in the subcuticular tissue, (2) a braided Vicryl suture, and (3) percutaneous metal staples. Any foreign body material implanted in tissue increases the risk of infection at that site. Wound closure always involves the use of a foreign body. Historically, sutures have been the primary material used to close tissue. The newer synthetic sutures are significangly more biodegradable and cause less infection than sutures composed of protein, such as silk and catgut. Metal staples are also associated with a low risk of infection. Recently, Incisive Surgical, Inc. (Plymouth, Minnesota) has developed an absorbable polymer staple specifically for subcuticular skin closure. The purpose of this study was to compare the new Insorb staple to both an absorbable polymer suture and a metal staple. Wound infection was assessed 7 days after closure by clinical signs and quantitative bacterial swabs. The results demonstrated that wounds closed with Insorb staples had the lowest incidence (33%) of infection, followed by percutaneous metal staples (44%). All wounds (100%) closed with Vicryl suture became infected. The incidence of wound infection directly correlated with the level of quantitative bacterial count at analysis. The Insorb staple was associated with significantly reduced closure time, less inflammation and infection, and better aesthetic result compared to Vicryl. Compared to metal staples, the Insorb subcuticular staplers demonstrated comparable closure time without the need for later staple removal. In conclusion, the closure of contaminated wounds with the Insorb staples is a superior choice to Vicryl suture because they have a significantly (p = 0.009) lower incidence of infection. The Insorb staple is a revolutionary advance in subcuticular skin stapling.     

Primary closure of wounds in burned tissue: experimental and clinical study

Penetrating wounds in burn tissue may become infected, therefore primary closure of such wounds has only been recommended for lacerations of the face. To determine if wounds in burned areas can be closed primarily if seen early, we created partial- or full-thickness thermal burns in guinea pigs (n = 54) and made incisions through the burned tissue. One side was closed primarily at variable time intervals postburn. Infectious complications were determined by observation and the quantitative bacterial smear technique. All wounds closed primarily at 24 hours or longer postburn became infected. Wounds closed primarily at 4 hours postburn had fewer infectious complications than wounds left open (p less than 0.05). We also reviewed our experience with 23 multiply injured burn patients over an 11-year period who had peritoneal lavage or exploratory laparotomy. There were no wound infections in 12 patients with incisions closed primarily in unburned areas or in 11 patients with wounds through burned tissue. We conclude that lacerations or surgical incisions in burned tissues seen early (less than 12 hrs) postburn should be treated as wounds in unburned patients. Wounds in burned tissue seen late (greater than 24 hrs) postburn should be considered contaminated.     

Efficacy of treatment with Repithel and Jelonet in comparison to treatment with Jelonet alone - a randomized clinical trial in patients receiving meshed skin grafts

Moist wound treatment is a well recognized method for the treatment of aseptic acute and chronic wounds. While the moist environment is beneficial to the woundhealing process, it also increases the risk of bacterial superinfection. We here report on the results of a clinical phase-III-study in which we tested the effect of a new PVP-iodine liposomal hydrogel (Repithel) on split-thickness skin grafts. This formulation optimizes moist wound treatment by improving the cell proliferation rate while preventing wound infection. AIM: The aim of this phase-III-study was to analyse the efficacy and tolerance of Repithel in patients receiving meshed skin grafts. METHODS: 167 patients with transplantation wounds were either treated with lipid gauze alone (control group) or with lipid gauze and Repithel. In both groups the extent of neoepithelization, the frequency and severity of graft losses and the time until complete wound closure was achieved were determined. Analysis of the re-epithelization was achieved by photoplanimetry. Impedance measurements gave additional information on the regeneration of the epidermal barrier. RESULTS: Wounds receiving Repithel showed a significantly faster neoepithelisation than wounds which were treated with lipid gauze alone. Treatment with Repithel significantly reduced both the number of graft losses and the size of area lost. The time until wounds were closed completely was significantly shorter in patients receiving Repithel than in controls. The positive effects of Repithel on wound healing were especially observed in smokers, patients with chronic wounds, burns or infected wounds. CONCLUSIONS: Repithel supports healing of meshgraft transplants and reduces the risk of graft loss. Patients who heal poorly benefit particularly from the Repithel treatment.     

Reduction of infection rates in abdominal incisions by delayed wound closure techniques.

A low incidence of infection in abdominal wounds after contaminated, infected, and selected clean-contaminated operations was achieved after delayed wound closure of the skin and subcutaneous tissue. An effective method of delayed primary closure is described. Four days of open wound management with Xeroform gauze between the skin and subcutaneous tissue is followed on the 5th day be removal of the Xerform and skin approximation with Steri-Strips. Proper use of this technique is based upon appropriate assessment of wound contamination and infection risk factors. All contaminated and infected wounds are best managed with delayed primary closure and, when not possible, with healing by secondary intention. Delayed primary closure should be applied to clean-contaminated wounds if the patients are older than 60 years or have associated diabetes mellitus, malnutrition, or obesity.     

Complications of colostomy closure

The records of 83 patients with 85 colostomy closures at Charity Hospital, New Orleans from January 1976 through June 1981 were reviewed. There were 47 complications in 30 patients (36 percent) with no deaths. The material used for anastomosis and fascial closure, the precipitating or underlying disease, the site of colostomy, and the length of operation did not influence the complication rate. The major factor affecting the complication rate was the interval of time from creation of the colostomy to its closure. Those patients who underwent closure after a 90 day interval had a lower overall complication rate than comparison groups with less than a 30 day interval and 30 to 90 day intervals (p less than 0.05). Other factors that appeared to influence the complication rate were as follows: loop colostomies had a lower suture line complication rate than divided colostomies, patients who underwent relaparotomy and closure had a higher complication rate than those whose closures were confined to the colostomy site, and wounds left open or that underwent delayed primary closure had a lower infection rate than wounds closed primarily. Thus, loop colostomies appear to have fewer complications at the time of closure than divided stomas. This is most likely related to the necessity for relaparotomy in some of the patients with divided stomas and the need for minimal mesenteric dissection required for most loop colostomy patients. Divided stomas should still be created if indicated, but when a choice exists, loop colostomies are preferable. Contaminated wounds are best managed with secondary closure or delayed primary closure. Because of the significant difference in complication rates between intervals from formation to closure of a colostomy, all patients should have their colostomies closed only after a minimum of 90 days has elapsed.     

The treatment of chronic hematogenous osteomyelitis

Eighty-five patients with a total of 103 foci of chronic hematogenous osteomyelitis were treated in the period from 1965-1982. Only patients who had been followed for two or more years of treatment were included in the series for evaluation. All foci were treated surgically with thorough debridement. According to the management of the wounds, patients were divided into three groups: wound healing by secondary intention in cases where skin closure was impossible; primary closure of wound with or without pedicle muscle transfer in cases of a small debrided cavity or in cases where a nearby skeletal muscle is available; and closed irrigation and suction drainage of the wound cavity. After a long-term follow-up period, satisfactory results to varying degrees were obtained in each group. Closed intermittent irrigation and suction drainage with high concentrations of antibiotic solutions gave the best results. In instances of failure, the causes may be due to inadequate removal of infected sclerotic bone and sequestra, obstruction of drainage tubes, resistance to antibiotics, or inadequate systemic antibiotic treatment. The use of myocutaneous flap transference to close the postoperative wound of chronic osteomyelitis was introduced, and preliminary results are encouraging.     

Small tissue bites and wound strength: an experimental study

HYPOTHESIS: Placing stitches close to the cut wound edge does not produce low wound bursting strength in midline laparotomy incisions closed with a suture length:wound length ratio of 4. DESIGN: Experimental study in rats. METHODS: Midline incisions were closed with a running suture in 51 Sprague-Dawley rats. A suture length:wound length ratio of 4 was used and stitches were placed at a distance of 3, 6, or 10 mm from the wound edge. Wound bursting strength was studied immediately after and 4 days after wound closure. RESULTS: Immediately after wound closure, bursting pressure was higher with stitches placed 10 mm from the wound edge than those at a distance of 3 mm. After 4 days, bursting pressure and bursting volume were lower with stitches placed 10 mm from the wound edge than those at a distance of 3 or 6 mm. The abdominal wall ruptured outside the suture line in 14 of 17 wounds closed with 21 stitches, in 11 of 17 wounds closed with 16 stitches, and in 6 of 17 wounds closed with 11 stitches (P=.02). CONCLUSIONS: Four days after closure of midline laparotomy incisions using a suture length-wound length ratio of 4, wound bursting strength is higher with stitches placed 3 to 6 mm from the wound edge than those at a distance of 10 mm. Wound bursting strength increases with the number of stitches used.     

Perforating wounds of the colon and rectum

In summary, in this last group of ninety-five cases there were thirty-six double barrel spur colostomies, fifty-five loop colostomies and four cecostomies. No instance of spreading peritonitis was seen after closure of the loop colostomy even though all were replaced in the free peritoneal cavity. No complications were associated with the clamping of the spur in the thirty-six double barrel spur colostomies. No patient required a secondary cecostomy following the closure of his colostomy, although in several patients with a loop colostomy on the left side, it was four to five days following closure before they were able to pass gas by rectum.Eleven patients in this group were evacuated to the United States with their colostomies not closed. Seven of these patients had rectal wounds which were not healed five to six weeks following their injury. The other four were evacuated early because of an especial need for hospital beds at the time, and each had associated injuries or complications which made closure of their colostomies a secondary matter.There were no fatalities in the first group of patients. In the second group there were four fatalities. One patient died suddenly shortly after admission from an exsanguinating hemorrhage due to a divided gastroduodenal artery which had been overlooked at the time the perforation in his duodenum had been repaired and the perforation in his hepatic flexure of the colon exteriorized. A second died seven weeks following his original injury from generalized peritonitis arising from a series of abscesses secondary to a retracted cecostomy. Two large abscesses in the right lumbar gutter were drained but a third gave rise to peritonitis from which he failed to recover. The third patient died from a pulmonary embolus following laparotomy for an intestinal obstruction ten days after his colostomy had been closed. The fourth patient died several weeks after his original injury from persistent suppuration in the retroperitoneal tissues. He failed to respond to penicillin, chemotherapy and drainage of the infected area.     

毁损性骨外露坏死的整形修复

目的：采用4种方法修复各部位毁损性损伤及骨外露坏死创面,依据不同部位损伤大小、深度和形态探索最佳的整形治疗方案。方法：①骨面植皮裸露骨钻洞培养肉芽后皮片移植,毁损的死骨咬除到板障层或裸露软骨面皮片移植;②传统皮瓣、皮管移植修复骨外露;③筋膜瓣覆盖骨外露创面后皮片移植;④早、晚期头皮扩张囊扩张皮瓣带毛发移植修复颅骨外露坏死及毛发缺失创面。结果：86例毁损性骨外露创面,Ⅰ期手术修复58例,Ⅱ期修复24例,4例创面感染和死骨残余未清除彻底而失败,经换药控制感染后再次手术修复成功。结论：依据各部位的毁损性骨外露创面程度,形态及全身情况,选择相应的修复方法,不但创面得以覆盖,也能取得良好的外观整形效果。     

Efficacy of debridement and primary closure of contaminated wounds: a comparison of methods

Proper management of highly contaminated traumatic wounds frequently requires delayed primary closure of healing by secondary intention to prevent subsequent infection. This animal study compares the efficacy of various wound debridement methodologies to prevent infection following primary closure of treated contaminated wounds. Forty-four Sprague-Dawley rats with uniform, paravertebral incisions were studied. Each wound was inoculated with a standard amount of Staphylococcus aureus bacteria and allowed to remain open for two hours. Each wound was treated before wound closure by one of four debridement methods: (1) surgical scrubbing, (2) high-pressure irrigation, (3) ultrasonication, or (4) soaking. The control animals' wounds were closed without debridement. At 7 days, each animal was evaluated for the presence of gross infection and wound induration. Ultrasound, with a 25% incidence of gross infection, compared with irrigation (75%), scrubbing (82%), and soaking (89%) provided significant protection from subsequent abscess formation. The control group uniformly developed infection (100%). The average amount of induration after ultrasonication (1.35 +/- 0.56 cm) was also significantly less than irrigation (2.07 +/- 0.75 cm), scrubbing (1.95 +/- 0.34 cm), and soaking (1.73 +/- 0.22 cm). Our data demonstrate that ultrasonic wound debridement has exciting potential as a new debridement technique for contaminated traumatic wounds.     

Dura versus Gore-Tex as an abdominal wall prosthesis in an open and closed infected model

Occasionally, it is necessary to use prosthetic material to close large abdominal wall defects in infected, potentially infected, or open wounds. We compared the effectiveness of Gore-Tex (PTFE, W.L. Gore & Associates, Flagstaff, AZ) and dura for closing large, full thickness abdominal wall defects in terms of resistance to infection, patch separation, and intraperitoneal adhesion formation. Ninety guinea pigs had full thickness, 2 cm2, abdominal defects patched with either PTFE or dura. The skin was (A) left open (B) closed over the patch under aseptic conditions, or (C) closed after wound contamination with 10(5) CFU of staphylococcus aureus. Wounds were examined daily and the wound and peritoneal cavity examined at necropsy (day 45). Patch separation, patch retention, and adhesions were similar in both open (A), and clean closed (B) wounds patched with PTFE or dura. In the infected closed wounds (C) of the PTFE animals, the incision remained intact significantly longer, the time of patch separation and overall patch retention were significantly increased, and bowel adhesions were significantly reduced compared to dura animals.     

Studies in the management of the contaminated wound. IX. Quantitation of the Evans blue dye content of open and primarily closed surgical wounds

The purpose of the present study was to quantitate the changes in the vascular permeability of open and primarily closed wounds after bacterial contamination. Alterations in vascular permeability in tissue were indicated by measuring the content of Evans blue dye in open and primarily closed wounds at different intervals after wounding and contamination. Evans blue dye forms a stable complex with circulating plasma albumin and extravasates through the walls of vessels as they become increasingly permeable.One hour after wounding, the tissue in the clean open wound exhibited a marked increase in dye content when compared with primarily closed wounds not subjected to bacterial contamination. The elevated dye content in the open wound persisted at least seventy-two hours after wounding. Contamination of the open wound with Staph aureus resulted in minimal changes in the content of dye when compared with open wounds not subjected to contamination. In contrast, topical application of Staph aureus to the surface of a wound undergoing primary closure elicited a marked increase in the Evans blue dye content of the primarily closed wound.It is postulated that the increase in Evans blue dye in the clean open wound is a reflection of extravasation into the wound of plasma proteins that form a serous exudate. This accumulation of blood proteins in the open wound may account for its resistance to infection by providing either local lymphatic blockades to bacterial invasion, wound drainage for removal of foreign bodies, antibacterial activity that renders the wound free of bacteria, or all of these factors.     

Treatment of open fractures: a prospective study

A double-blind prospective study was done to assess the benefit of delaying closure of the wounds associated with open fractures. An additional double-blind study compared the effectiveness of clindamycin versus cefazolin for prophylactic antibiotic coverage. Quantitative cultures of the wounds were accomplished at the time of debridement and again at the time of closure if the wound was not closed initially. Almost half of the wounds were contaminated (46%) at the time of debridement, although the incidence of wound infection was low (6.5%). Gram-negative organisms resistant to the prophylactic antibiotic were recovered initially only eight times, but four of these (50%) became infected. The contaminating organisms in each case were present in high concentration (greater than 10(5) CFU/gm of tissue) at initial culture. The time of wound closure, cefazolin versus clindamycin, and internal fixation of the fracture were not followed by significant differences in the development of clinical infection in this series.     

The effect of 5-fluorouracil on abdominal wound healing in rats.

We carried out experiments to test the hypothesis that 5-Fluorouracil would retard wound healing when administration was started on the day of operation. Abdominal wounds were made in rats and closed again, and some of the animals were given daily 5-FU, the rest acting as controls. Test animals were killed three, five, seven and 10 days after operation, and the strength of their wounds was measured. At five and seven days the control wounds were 10 times stronger than those of the treated animals, and at 10 days they were four times stronger. We speculated that the difference in strength might be largely due to the observed fact that the muscle layer in the treated animals was considerably weaker than in the controls. We concluded that it would be unsafe to start giving 5-FU to patients immediately after operation.