Wound Vacs versus Compressive Dressings for Skin Grafts

Increased Cost of Negative Pressure Dressings Is Not Justified for Split-Thickness Skin Grafting of Low-Risk Wounds

Kempton, Laurence B. MD*; Larson, Timothy B. MD*; Montijo, Harvey E. MD*; Seymour, Rachel B. PhD*; Getz, Stanely B. MD; Bosse, Michael J. MD*

July 2015 JOT

These authors should be congratulated for a nice study that shows us all that new technologies (in this case negative-pressure dressings (NPD)) are not always better than tried and true “old-fashioned” methods (compressive dressing).  This study is especially valuable because it also indicates that the substantial added expense of the new technology is not justified.  I agree with the invited comments of Dr.’s Sanders and Sagi that advantages of the compressive dressing protocol for STSG’s are limited if inpatient management is required.  Their proposed alternative, outpatient use of NPD, would certainly reduce costs associated with the inpatient stay but still have associated costs of the NPD device.  Our protocol is to use a compressive dressing and overlying splint that are removed in the outpatient setting 5-7 days after application.  Patients are not required to have an inpatient stay nor do they have the expense of a NPD.  The dressing is critical and consists of multiple layers: Xeroform; moist fluffed 4×4’s to fill all nooks and crannies; dry 4×4’s; ABD pad(s); Webril; then an ACE wrap.  A splint is then applied over this ACE.  We have been very pleased with the results of this protocol, however, a rigorous study would be required to substantiate virtually 100% take.

William M. Ricci, MD
Professor of Orthopaedic Surgery
Vice-Chair, Department of Orthopaedic Surgery
Chief, Orthopaedic Trauma Service
Director, Orthopaedic Clinical Operations
Washington University Orthopedics

August 2015 JOT Now Online

http://journals.lww.com/jorthotrauma/pages/currenttoc.aspx

The August issue of JOT is now online and in print.  The link above is to the table of contents on the JOT website.  Please feel free to submit posts and commentary to me at Hmirwvu@aol.com or directly on OsteoSynthesis.

Hassan R. Mir, MD, MBA, FACS

Editor | OsteoSynthesis – The JOT Online Discussion Forum

Tibial Plateau Fractures and Meniscal Tears

Stahl et al have published an article in the July 2015 JOT titled “Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients.”

The authors presented a series of patients with tibial plateau fractures and meniscal injuries. They found the rate of fractures with meniscal injuries requiring repair to be 30% and 45% with split depressed fractures. They felt this rate was lower than previously reported and that advanced imaging of tibial plateau fractures to overstate the true incidence of meniscal tears requiring intervention.
The information on the rate of meniscal injuries requiring repair at 30% and most often with split depressed fractures (45%) is more good information to maintain an index of suspicion for this injury.
What is not acknowledged as was noted in Gardner et al (J Orthop Trauma. 2005;19:79–84) was there can be medial meniscus injuries especially with significant depressed lateral fractures and the higher energy injuries. With a Schatzker IV essentially being a knee dislocation, there can be an expected incidence of soft tissue injury accompanying this. And often times a medial arthrotomy is not completed with fixation of IV, V, VI fractures so one must maintain a high index of suspicion or consider advanced imaging in appropriate, select cases.
I agree with the authors that direct visualization of the meniscus is useful to guide the treatment.

Lisa K. Cannada, MD
Associate Professor
Department of Orthopaedic Surgery
Saint Louis University

A Biomechanical Study of Posteromedial Tibial Plateau Fracture Stability: Do They All Require Fixation?

The biomechanical study in the July JOT evaluating posterior medial fragment stability in complex tibial plateau fractures emphasizes the importance of this fracture component when considering fixation strategies for the treatment of these intricate fracture patterns. The authors provide valuable data on the morphology of the critical posterior medial fragment size and at which point the fragment is likely displace with motion. The authors state ‘Certain sizes of posteromedial fragments may be inherently stable through a defined arc of motion and may not require direct surgical attention.” However, I would urge the readers to be very cautious if actually considering any non op management of these coronal plane components based on the authors results. The 10mm post medial fracture fragment evaluated was essentially an extra articular fragment. Contact pressure results largely demonstrated no significant differences between an intact condyle and the idealized 10-mm fracture fragment when tested in compression, internal rotation, and posterior shear loading.
These small coronal plane fractures are rare and occur infrequently in the clinical setting when treating these complex fracture patterns. The larger 20 mm fracture fragment specimens were thru the weight bearing portion of the medial condyle and displacement of this fragment increased progressively for all loading conditions, demonstrating the requirement for fragment stabilization. These larger fragments are the clinical norm. I would encourage clinicians to employ the column classification with transverse CT cuts to evaluate the size and overall morphology of these specific components with the realization that very few of these will be amenable to non op management.

J. Tracy Watson, MD

Professor and Chief of Orthopaedic Traumatology

Saint Louis University

July 2015 JOT

http://journals.lww.com/jorthotrauma/pages/currenttoc.aspx

The July issue of  JOT is now online and in print.  The link above is to the table of contents on the JOT website.  Please feel free to submit posts and commentary to me at Hmirwvu@aol.com or directly on OsteoSynthesis.

Hassan R. Mir, MD, MBA, FACS

Editor | OsteoSynthesis – The JOT Online Discussion Forum