Bone fractures involve damage not only to the bone but also to the surrounding soft tissue, e.g. the skin, subcutaneous fatty tissue, muscles and tendons.
A fracture that breaks the skin immediately exposes the bone to outside influences, allowing germs on the skin and bacteria (dirt) from “off the street” to penetrate the wound and potentially trigger inflammation. Besides affecting the soft tissue, this type of inflammation can in worst-case scenarios also attack the broken bones. The term we use for cases of this kind is “osteomyelitis”, i.e. bone inflammation. Osteomyelitis is usually difficult to treat, since it can be very stubborn and flare up again later on. As a rule, the larger the wound inflicted by an open fracture and the more extensive the soft tissue damage, the greater the risk of developing inflammation of the bone or soft tissue . The thinner the layer of skin and muscle around the open fracture, the greater the risk of recurrent bone inflammation
Certain treatment guidelines must be followed if osteomyelitis sets in after an accident. When treating a fresh open fracture, the first step is to ensure that it is adequately stabilised. The goal is to use as few “foreign materials” (metal parts) as possible, since the bacteria that cause osteomyelitis like to adhere to these metal parts and form a layer of mucus that is difficult to remove. This is why fractures are often stabilised using external fixators with bone pins and (transverse) rods, since this means that relatively few metal parts are required to fix the bone.
Repeated surgical procedures and adjuvant treatment with antibiotics are required when treating the osteomyelitis and cleaning the inflamed area. Regular surgical cleaning is necessary to reduce the quantity of mucus coating (a so-called “biofilm”) formed by the bacteria so that bacteriostatic medication (antibiotics) can work more effectively.
At the end of the 1990s, Morykwas and Argenta introduced an innovative negative pressure dressing technique for treating infected (defect) wounds . Along with surgical wound cleaning, this technique was based on the use of special sponges in combination with a sealing foil and a suction pump, with which an infected wound was converted into a semi-closed system. This was an innovative form of treatment, since infected wounds had previously usually been bandaged using “open” dressings. The advantage of this new dressing technique was that it enabled wound infections to be treated more efficiently. Fleischmann and Jukema  developed this system further by adding a phase in which the sponges are actively rinsed using a disinfectant solution. This special negative pressure wound therapy together with the so-called instillation or rinsing technique was first used for the successful treatment of bone inflammation. It turned out that this negative pressure instillation technique combined with repeated operations to cleanse the wound and inflamed bone could be used very effectively to treat osteomyelitis. Besides successfully reducing the length of time required to treat the osteomyelitis, it can also minimise the risk of the infection recurring and requiring treatment later on.
The Department of Traumatology at Zurich University Hospital is still researching and developing this special negative pressure instillation technique and using it successfully to treat patients with osteomyelitis.
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University Hospital Zurich
Department of Traumatology