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Page 4 of 11 Artiaco et al. Plast Aesthet Res 2023;10:57 https://dx.doi.org/10.20517/2347-9264.2022.145

It must also be considered that worldwide antibiotic resistance is quite variable; therefore, referring to local
[6,9]
institutional guidelines for proper therapy is necessary when they are available .
Debridement
Debridement is a crucial step for success in the treatment of infected hand STL. During debridement
procedure, a systematic approach is recommended, evaluating the wound area from the margins to the
[10]
center and from the surface to the deeper layers [Figure 2] . Surgery should commence with a thorough
and extensive removal of all nonviable and infected tissues. Vessels, nerves, and tendons should be carefully
examined and spared. In this phase, a tourniquet may be inflated in order to facilitate the identification of
anatomical structures. After tourniquet removal, all residual nonviable tissues should be excised
[Figure 3] [10,11] . Determination of muscle tissue viability is based on subjective intraoperative parameters
summarized in the "4 C rule": color, consistency, contractility, and capacity to bleed. Nevertheless, a recent
histological study questioned the "4 C rule" ability to identify muscle tissue vitality correctly .
[12]
Simultaneously, multiple tissue samples should be retrieved for microbiological examination. Microbiologic
cultures are essential in established infection, but in acute open fracture and wound, there is no need to take
samples because the correlation between tissue culture obtained at the time of debridement, and subsequent
infection has not been proved .
[13]
Once debridement is complete, abundant irrigation with saline or antiseptic solution is performed, and the
wound is left open or approximated. Irrigation with saline or antiseptic solution aims to reduce the bacterial
load and remove debris from the wound. In wounds that may be infected, recent guidelines recommend at
least three liters of sterile saline solution in low-pressure irrigation because high-pressure washing may
transport bacteria and debris into the deeper layers . Whether this effect is relevant in the clinical setting
[12]
needs further investigation [14,15] . In complex, highly contaminated wounds and/or severe infections, serial
debridement is often necessary to remove all infected and nonviable tissue and prepare the site for
subsequent reconstruction. In these cases, after primary debridement, strict clinical observation and prompt
surgical revision are always mandatory.

Skeletal stabilization in open fractures contaminated and potentially infected
In post-traumatic infected STL of the hand associated with fractures, skeletal stabilization is essential to
promote tissue healing and facilitate medications and dressings. External fixation and/or stabilization with
Kirschner wires should be preferred because internal fixation devices can be easily contaminated by biofilm-
[16]
forming bacteria . In some cases, fixation is not possible because of bone loss, and a staged reconstruction
should be considered. A temporary custom-made cement spacer may represent a useful instrument waiting
for secondary bone reconstruction. Bone loss can be treated in secondary procedures with different
techniques. As a general rule, minor bone loss (less than 2-3 cm) that is commonly observed at the hand is
usually reconstructed with a non-vascularized bone graft from the iliac crest. Major bone loss
(more than 2-3 cm) is not common at the hand and represents a surgical challenge. In these rare cases, bone
reconstruction can be attempted by means of vascularized bone graft or induced membrane technique
[17]
according to the concepts developed by Masquelet .

Wound closure
Once debridement of infected soft tissues and the treatment of associated skeletal injuries is completed, the
wound can be loosely sutured to allow drainage of blood and fluid. Temporary sterile absorbent dressing
can be used in the first days after operation to keep the wound bed hydrated and promote tissue healing.
Alternatively, a temporary NPWT can be directly applied and used for a short period of time, enabling the
assessment of the evolution of the healing process. Postoperative monitoring is essential because after
primary debridement, local infection may persist, and in serious cases, sepsis may worsen, extending along