Adequate debridement remains one the the most challenging and most important elements of the treatment of open fractures and FRI. The presence of a plastic surgeon capable of replacing non-vital tissue with healthy tissue (both for soft tissue and bone) makes the debridement easier and more effective. The best outcomes are probably being achieved when the debridement is performed in a orthoplastic collaboration and the surgeon who does debridement is encouraged to remove all devitalized tissue by a skilled plastic surgeon who can design her/his flap adapted to the size of the defect without compromising. Often a free flap is used in high income settings. However, significant soft tissue defects can be managed with large local flaps (both fasciocutaneus and muscle flaps) in experienced hands with acceptable donor side morbidity, if microsurgical techniques are lacking in resources-limited settings.

We experienced in many settings with limited availability of experienced and skilled plastic surgeons that soft tissue reconstruction is delayed because the wound is 'not ready yet' for soft tissue reconstruction. That means often that a more aggressive debridement is needed, preferably immediately followed with a more challenging local flap or free flap to assure soft tissue coverage. Only when the damage of the debridement cannot be effectively solved with a reconstruction or when the viability of the surrounding tissue is unclear, a more conservative approach is understandable. Because FRI patients confront surgeons with very complex technical challenges, it requires dedicated orthoplastic teamwork with from both specialties superspecialists to achieve the best outcomes. Plastic and orthopedic surgeons should be more specifically trained for these challenges globally.

Why and how to excise dead bone

Apart from the soft tissue debridement, excising dead (necrotic) bone is also essential in fracture-related infection to eliminate infection reservoirs, promote bone healing, and prevent chronic osteomyelitis. Necrotic bone lacks blood supply, making it a breeding ground for bacteria. Because it is non-vascularized, necrotic bone is also resistant to antibiotic treatment.

Removing necrotic bone enhances antibiotic effectiveness and allows healthy bone to regenerate. Additionally, excision facilitates reconstruction with bone grafts or other techniques, improving overall treatment outcomes.

Paprika sign: During excision, be alert for bleeding from small blood vessels in the cortex that occurs when drilling or sawing bone. This is called the ‘paprika sign’, and it indicates vital bone.

After debridement, we recommend to use the new FRI classification to make a personalized treatment plan together with the patient and relatives as explained in the next chapter.