What are the recommended dressings for exposed surgical hardware?

Best Dressings for Exposed Surgical Hardware

For exposed surgical hardware, use sterile transparent semi-permeable dressings as the primary choice, changed weekly unless soiled or loose, or sterile gauze if the site is bleeding or oozing. 1, 2

Primary Dressing Recommendations

Standard Approach

• Sterile transparent semi-permeable polyurethane dressings are the preferred option for hardware exposure sites 1, 2

  • Allow continuous visual inspection of the site
  • Require less frequent changes (weekly) unless compromised
  • Provide barrier protection from microbial colonization

• Sterile gauze dressings should be used when:

  • Visible pus is exuding from the site
  • The site is actively bleeding or oozing
  • Replace every 2 days or sooner until resolved 1

Dressing Change Frequency

Change transparent dressings no more than once weekly unless the dressing becomes damp, loose, or visibly soiled 1, 2. This evidence comes from strong consensus (95.5% agreement) in ESPEN guidelines.

Advanced Dressing Options for Complex Hardware Exposure

Negative Pressure Wound Therapy (NPWT)

For high-risk surgical incisions with hardware (pilon, plateau, or calcaneus fractures), incisional NPWT is recommended to reduce deep surgical site infections 3. This carries a Strong recommendation from the 2023 AAOS guidelines.

However, there's an important caveat: After open fracture fixation, NPWT does not offer advantages over sealed dressings and does not decrease wound complications or amputations 3. The benefit is specifically for closed fracture fixations and high-risk incisions.

Combined NPWT with Dermal Substitutes

For hardware-exposed wounds where traditional closure isn't feasible, a staged approach using artificial dermal substitutes (MatriDerm) combined with NPWT before skin grafting has shown success in avoiding flap surgery 4. This involves:

• Surgical debridement and washouts
• Placement of dermal substitute
• NPWT application over the substitute
• Final closure with dermal-augmented skin grafting

Open fractures require significantly longer NPWT duration (mean 6.6 changes) compared to closed fractures (mean 2.5 changes) 4.

What NOT to Use

Silver-coated dressings are NOT recommended - they do not improve outcomes or decrease infections at hardware sites 3. This is a Moderate strength recommendation from AAOS 2023 guidelines.

Advanced dressings should NOT be routinely used for primarily closed surgical wounds over hardware, as there is no evidence they reduce surgical site infections compared to standard dressings 5.

Site Preparation Before Dressing

Before applying any dressing:

• Clean the site with chlorhexidine 2% in 70% isopropyl alcohol (preferred antiseptic) 6, 7
• Allow antiseptic to air dry for at least 3 minutes 8
• Use sterile technique with clean gloves
• Avoid touching exposed surfaces

Special Considerations

For Cardiac Surgery with Sternal Hardware

Standard dressings (dry sterile dressing for 24-48 hours) are typically sufficient 8. NPWT dressings may benefit high-risk cardiac surgery patients, though evidence shows no significant difference in overall surgical site infection rates between conventional gauze, absorbent foam, or NPWT in general cardiac surgery populations 9.

Well-Healed Sites

Once the hardware site is well-healed (approximately 3 weeks), dressings may not be required to prevent dislodgement 1. This is considered good practice, though the site should be monitored for any signs of compromise.

Common Pitfalls to Avoid

• Don't use sutures for catheter/hardware stabilization - use manufactured stabilization devices instead 7
• Don't apply topical antimicrobial ointments routinely 7
• Don't assume all hardware exposures require flap surgery - staged NPWT with dermal substitutes can be successful 4
• Don't continue NPWT after open fracture fixation expecting benefit - sealed dressings are equally effective 3