SLR - November 2021 - Stephanie E. Dal Porto-Kujanpaa

Randomized Controlled Trial Comparing Silver-Impregnated Fibrous Hydrocolloid Dressings With Silver Sulfadiazine Cream Dressings for Treatment of Fracture Blisters to Determine Time to Surgical Readiness

Reference: Wiese KR, van Heukelum M, Lombard CJ, Ferreira N, Burger MC. Randomized Controlled Trial Comparing Silver-Impregnated Fibrous Hydrocolloid Dressings With Silver Sulfadiazine Cream Dressings for the Treatment of Fracture Blisters to Determine Time to Surgical Readiness. J Orthop Trauma. 2021 Aug 1;35(8):442-447.

Level of Evidence: Therapeutic Level I

Scientific Literature Review

Reviewed By: Stephanie E. Dal Porto-Kujanpaa, DPM
Residency Program: Scripps Mercy Hospital – San Diego, CA

Podiatric Relevance: Following a traumatic injury, the development of fracture blisters can be problematic, especially when surgical intervention is warranted. They are often associated with delays to surgery, suboptimal surgical approaches, wound complications, and increased costs. While various forms of fracture blister treatments exist, we lack a clear standard of care. This study compares silver sulfadiazine dressings (SS), the most commonly used modality, versus the use of silver-impregnated fibrous hydrocolloid dressings (SFH) in terms of time to surgical readiness and cost.

Methods: This study was a single-blind randomized controlled trial. Patients were included if they were >18 years of age, had one or more fracture blisters overlying fractures, and required surgical intervention. Patients were evenly allocated into the SS group or SFH group and were blinded to their assignment. The principal investigator performed the daily wound evaluation and treatment. All blisters were initially prepped with povidone-iodine solution and deroofed using an 18-gauge needle. The assigned treatment method was then applied followed by sterile dressings. Both groups had daily wound inspections, but the SS group had new applications of cream daily while the SFH group retained the same dressing, which was only removed once re-epithelialization was observed.  Full re-epithelialization of the blister wound was deemed ready for surgery. The primary outcome measured was time to surgical readiness, measured in days. Secondarily, they calculated the direct treatment cost for each group based on the hospital stay and dressings used until surgical readiness was determined.

Results: A total of 70 patients participated with each group containing 35 patients. Fracture types predominantly observed in this study occurred in the lower limbs with the ankle or tibial shaft most often being affected. A significant difference of four days was seen for the mean time to surgical readiness where it took a shorter period of time to achieve full epithelialization in the SFH group (5.3 days) compared to the SS group (9.3 days). No difference was observed for time to surgical procedure or total length of hospital stay. In terms of the total cost of the dressings and hospital stay until deemed ready for surgery, the SFH group (375.24 USD) on average cost significantly less than the SS group (656.86 USD).

Conclusions: This study demonstrates that the silver-impregnated fibrous hydrocolloid dressing is superior to the more commonly used product, silver sulfadiazine cream, for the management of fracture blisters as it significantly reduces the time to surgical readiness and is more cost-effective. The 43 percent reduction in time to full re-epithelialization is quite notable. In fact, it’s worth pointing out that 128 patients were initially enrolled in the study; however, the trial was stopped for efficacy after 70 patients based on an interim analysis of the primary outcome, showing evident inferiority of the SS cream. While this study undoubtedly demonstrates the superiority of SFH dressings, their conclusions would have been further strengthened if the study had been double-blind to eliminate potential bias and possible if they had compared the total surface area of the blisters in each group.

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