Date Published: September 27, 2018
Publisher: Public Library of Science
Author(s): Jason S. Radowsky, Romon Neely, Jonathan A. Forsberg, Felipe A. Lisboa, Christopher J. Dente, Eric A. Elster, Nicole J. Crane, Ahmed Ibrahim.
The complexity and severity of traumatic wounds in military and civilian trauma demands improved wound assessment, before, during, and after treatment. Here, we explore the potential of 3 charge-coupled device (3CCD) imaging values to distinguish between traumatic wounds that heal following closure and those that fail. Previous studies demonstrate that normalized 3CCD imaging values exhibit a high correlation with oxygen saturation and allow for comparison of values between diverse clinical settings, including utilizing different equipment and lighting.
We screened 119 patients at Walter Reed National Military Medical Center and at Grady Memorial Hospital with at least one traumatic extremity wound of ≥ 75 cm2. We collected images of each wound during each débridement surgery for a total of 66 patients. An in-house written computer application selected a region of interest in the images, separated the pixel color values, calculated relative values, and normalized them. We followed patients until the enrolled wounds were surgically closed, quantifying the number of wounds that dehisced (defined as wound failure or infection requiring return to the operating room after closure) or healed.
Wound failure occurred in 20% (19 of 96) of traumatic wounds. Normalized intensity values for patients with wounds that healed successfully were, on average, significantly different from values for patients with wounds that failed (p ≤ 0.05). Simple thresholding models and partial least squares discriminant analysis models performed poorly. However, a hierarchical cluster analysis model created with 17 variables including 3CCD data, wound surface area, and time from injury predicts wound failure with 76.9% sensitivity, 76.5% specificity, 76.6% accuracy, and a diagnostic odds ratio of 10.8 (95% confidence interval: 2.6–45.9).
Imaging using 3CCD technology may provide a non-invasive and cost-effective method of aiding surgeons in deciding if wounds are ready for closure and could potentially decrease the number of required débridements and hospital days. The process may be automated to provide real-time feedback in the operating room and clinic. The low cost and small size of the cameras makes this technology attractive for austere and shipboard environments where space and weight are at a premium.
Despite many recent advances in wound care techniques, decisions to primarily close open wounds having undergone surgical débridement are still based on principles that have not changed for the past century. Called the four ‘C’s’, these include contractility of muscle when stimulated, color, consistency, and capacity to bleed. However, while successful in a majority of cases, approximately 20% of wounds during the recent wars in Afghanistan and Iraq failed following primary closure.[2–4] This represents a significant expenditure in resources both in terms of consumable wound care supplies as well as increasing operating room utilization and hospital length of stay, not to mention prolonged patient discomfort and delay of rehabilitation therapies.
Non-invasive 3CCD imaging, combined with multivariate statistical analysis, provides the means to distinguish healed and dehisced wounds with greater than 75% sensitivity, specificity, and accuracy. This study may lead to novel strategies for clinical decision-making in the future. Not only would models based on these differences be beneficial for deciding whether or not to close wounds, but may also provide information as to whether or not a certain therapy was working from one débridement to the next by revealing the trajectory of 3CCD values. This possibility is clearly illustrated with contrast enhanced 3CCD images in Figs 1 and 2. To the naked eye, there is very little difference between the image from the first and the final débridements for the healed wound (Fig 1). However, the dehisced wound (Fig 2) demonstrates noticeably lower contrast enhanced values in the area of the wound for the final débridement compared to the healed wound.