Utilizing Pure Hypochlorous Acid (pHA) Preserved Wound Cleanser and Bioresorbable Silver Matrix to Preserve Orthopedic Hardware in Patients with a Non-Infected Surgical Wound Dehiscence

Hi. My name is Amanda Murray. I'm a nurse practitioner in Great Falls, Montana, and I work primarily in a hospital outpatient department. I've been involved with some kind of wound care for probably the last 15 years, three years as a nurse practitioner, and I think everybody in the wound care world can agree that managing wounds with exposed hardware is a difficult task, a tedious task. I think most of our providers assume that once hardware is exposed in a wound that it's infected and it needs to be removed right away. However, there's some patients hardware removal isn't an option and we need to care for those patients. So today I'm going to be describing two cases, one in which hardware removal was an option and the other case was not. And sometimes hardware removal is not an option because the bone's not healed around the hardware or it's in a difficult place such as the spine, maybe sternal wires after open heart surgery, those patients have a 50% mortality rate.

And so I want to do more research in this department and prove maybe that we can leave primary orthopedic hardware in place if it's not infected and if it's stable. So the first case was a young lady, a 29-year-old female that sustained a tibial plateau fracture after a four-wheeling accident. She came to me four weeks after her initial surgery. She had two surgeries, and about that time it had been about couple weeks since her external fixator was removed, and she had a wound dehiscence on both the medial and lateral side of the right knee. The lateral wound was more concerning because it did have orthopedic hardware directly under necrotic tissue. Once the necrotic tissue was removed to reduce the bioburden over that hardware, I appreciated that screw in the base of that wound right away. And I think if we can manage and prevent biofilm formation in wounds, we can also do that in wounds with exposed hardware and we can do it really well.

Technology and products have come a long way. I used in that case, pure hypochlorous acid, which is non-cytotoxic, so it's killing bacteria without killing key cells, and also an extended antimicrobial under negative pressure, which was a microparticle silver dressing. And so it provides extended, like I said, antimicrobial coverage in the wound. As I said, it's important to pick products that are not cytotoxic, and there's a lot of articles that don't prove the effectiveness of silver. However, a microparticle silver that dissolves in the wound base and you can place right over hardware under negative pressure is optimal because of the small particles. It's non-cytotoxic. It will give you a clean wound instead of a clean dressing, if you will. So a lot of silver dressings pull drainage up into the dressing and that's where the antimicrobial action happens, and this happens right in the wound base, which is optimal for this situation.

The patient had a 98% reduction in wound size before she did decide to have her hardware removed because of reduced range of motion and pain. So I did give her the option of keeping the hardware in place intact, which is important to give our patients that option if we can. The second case was a patient who underwent a lapiplasty. She was in her 70s. She had a lapiplasty with hardware in the dorsal foot, so she had a plate exposed in the dorsal foot. You don't have a lot of tissue, even in the first case over the head of the fibula. You sure don't have a lot of tissue over the dorsum of the foot. So a podiatrist came to me and said, "Amanda, is there anything we can do? I can't remove the hardware at this time. Her bone is not healed around it." And so I use the same protocol in this case, and it took several weeks, but we eventually closed that wound.

I was able to use the nanoparticle silver dressing under my primary closure, so I would embed it in the wound, it dissolves, and then I'm able to primarily close and there's no other dressing like that, that exists. So I appreciate so many aspects of that dressing as well as a non-cytotoxic cleanser for these patients. She did achieve full wound closure and she's back in a shoe, and I was able to discharge her and haven't heard anything for the past probably four or five weeks, so I assume she's doing well. I look forward to further research in the way of preserving orthopedic hardware. As long as it's stable in the bone, I think we can really move forward in advance this option for patients.