8.1.1 Historical background of wound management

“Successful reconstructive surgery is measured in terms of safe defect coverage with simultaneous restoration of form and function and avoidance of donor site deformity” [1].

The history and evolution of wound management is closely related to the development of civilization and especially to warfare. The nature of war wounds has changed considerably from ancient times to present day in accordance with the technical progress of the weapons used. These changes constantly challenge all players involved in the treatment of casualties. They have led to improved techniques in both military and civilian surgical care and were the starting point of surgical specialties such as plastic and reconstructive surgery. In ancient Greek and Roman times, the options for managing wounds caused by arrows, spears or swords were sparse, and the mortality rate was high. This did not seem to change until the 16th century, when better patient selection (triage) (chapter 6), early surgical repair, the technique of vessel ligation, as well as the use of a tourniquet were introduced. This reduced the mortality rate of war wounds to extremities considerably. The treatment, of course, mainly consisted in amputation [2]. The fact that even by the end of the 19th century, infection and pus were considered an inevitable consequence of surgery indicates that undergoing an operation was still a hazard. While initially gunpowder was held responsible for any infection, the introduction of antiseptic and aseptic techniques, and the new theory that germs are responsible for infections were further milestones. Beside advances in imaging, improved surgical techniques, and higher respect for the soft parts, the introduction of antibiotics dramatically changed the outcome of surgery. Finally, the advances in reanimation and anesthesia spurred progress in wound management and decision making (chapter 6.2). While only a few decades ago the immediate and definitive stabilization of fractures as well as primary wound closure were the goal of treatment, today′s trend is towards multistage procedures with repeated debridement and delayed wound closure, which appear to reduce wound-healing complications. This has opened the door for the salvage of complex extremity trauma that previously had to be subjected to amputation. Substantial improvements in fracture-fixation techniques in the second half of the 20th century were accompanied by the development of the soft-tissue reconstruction principles that are outlined in this book.

Currently, most wounds observed in orthopaedic and plastic surgery are either acute—by blunt (chapter 3.1) or penetrating (chapter 3.2) trauma—or chronic in nature such as in diabetic, neuropathic, or vasculopathic patients. Various environmental exposures, such as thermal and/or electrical insults, compression forces, radiation, or animal bites cause specific types of wounds that usually require special treatment and attention. A multitude of different dressing options exists, ranging from simple saline-soaked or paraffin-embedded gauzes to antimicrobial, fibrinolytic, or growth-factor-enhanced devices (chapter 9.1). Negative-pressure wound therapy is also a rather recent and promising treatment option that is enjoying wide-spread application (chapter 9.3). However, scientific evidence is still lacking for most of these treatment modalities and their respective indications. Nevertheless, many of these possibilities can positively enhance wound healing, but they cannot replace the need for sound knowledge of the basic principles of wound management.

8.1.2 Analysis of patient and wound

Most surgical and many traumatic wounds are considered “clean”, allowing for primary wound closure with or without excision of the wound margins. This is described in chapter 10.1. Then again, a considerable part of the practice of plastic surgery deals with the reconstruction of defects. The armamentarium for the surgical techniques varies from simple procedures such as tissue advancement (chapter 10.1) or skin grafting (chapter 10.2) to sophisticated tissue transplantation (chapter 10.3 to 10.6). Regardless of the technical skills of the surgeon, it is paramount to include the patient and, possibly, even his or her relatives in the decision-making process. Therefore, the analysis of the patient and especially of the wound and/or defect as well as the evaluation of local and systemic parameters run in parallel and are inseparable processes.

The overall assessment of the patient needs to be based on a detailed medical history, including professional occupation, personal interests, and expectations. The compliance of the patient and his or her mental capacity to understand and follow complex reconstructive procedures must be evaluated. Furthermore, systemic factors that potentially influence wound healing (chapter 4.4) such as peripheral artery occlusive disease, diabetes mellitus, neuropathies, malnutrition, smoking, or steroid or drug intake have to be acknowledged and included within the decision-making process.

The medical history inquires into the etiology, the mechanism and energy of the injury as well as the age of the lesion, its location, size and any loss of function. Depending on the nature of the lesion, exposed and missing structures, the presence of foreign material, ischemic or necrotic tissue, fibrin and granulation tissue, quality and quantity of exudation, as well as signs of inflammation and infection have to be assessed. The viability of tissues can also change following radiotherapy, in the presence of a neoplasm, such as a Marjolin ulcer in a chronic unstable scar, or in the case of vasculitis.

After compiling the different findings necessary for decision making, the complex interdependence of all these factors is analyzed, pros and cons are balanced against each other and brought into relation with the therapeutic goals. The proposals can range from a conservative, nonoperative proposal to a complex multistage surgical reconstruction. Whereas in some situations the indication and the advantages for a patient are obvious, there is a gray zone where either a conservative or surgical, a simple or complex approach could eventually be successful and benefit the patient.

With regard to the safety of a procedure, ie, the success of wound closure, it is a commonly held misbelief that a simple procedure is a safe procedure. Wound-edge advancement and closure under tension is simple but will frequently result in delayed wound healing or wound breakdown. The success of a skin graft depends on multiple factors and cannot always be guaranteed. Thus, time to complete healing can be long, as reoperations and prolonged immobilization may be necessary. On the other hand, free tissue transfer is comparatively safe with a success rate of > 95% in most centers treating complex limb trauma on a regular basis, provided precise anatomical knowledge and technical skills in microsurgery are available (chapter 10.6). However, the loss of a split-thickness skin graft does not have such a catastrophic effect as the failure of a free flap.

In summary, decision making in plastic and reconstructive surgery is a very individual process that needs to consider a wide range of factors. The optimized preparation of both the patient and wound is necessary in order to obtain conditions for successful wound closure or coverage by a surgical intervention. Preoperative modification of the local and systemic factors that negatively influence wound healing can make a big difference.

A prerequisite for optimal patient management is that the decision-making process, the therapeutic approach, and follow-up are a multidisciplinary endeavor from beginning to end (chapter 6.2). The joint establishment of a treatment plan will substantially decrease the rate of morbidity, reduce the number of operations, shorten hospital stay and outpatient visits, improve patient satisfaction, and, last but not least, reduce costs.