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The field of patient safety in surgery has seen dramatic improvements in the new millennium [1]. Ongoing global initiatives keep a focus on assuring timely access to appropriate care for disparities while avoiding “low value” surgical care with the goal of optimizing long-term patient outcomes [2, 3]. The widespread implementation of fast-track surgery through evidence-based “enhanced recovery after surgery” (ERAS) programs has improved key outcome metrics on a global scale, including shorter hospital length of stay, reduction of opiate use for perioperative pain control, increased patient experience scores and improved outcomes [4]. In addition, the widespread implementation of standardized sepsis intervention bundles for early recognition and treatment of patients at risk of adverse outcomes from sepsis has led to a dramatic decrease of mortality and morbidity in highly vulnerable patient populations [5]. Notwithstanding the impressive achievements by proven best practices and modern evidence-based approaches for surgical care, complications related to postoperative wound healing remain unresolved conundrum in the twenty-first century [6–10]. From a historic perspective, there have been multiple landmark achievements in the arena of aseptic surgical technique [11]. The revolutionary “germ theory”, postulated by Louis Pasteur in the 1850s, was followed by pivotal improvements in the field of antiseptic techniques, such as the use of phenol as a disinfectant spray (Lister in 1865), steam sterilization (Bergmann in 1891), rubber gloves (Halstead 1890), and surgical masks (MickuliczRadecki 1897) [12, 13]. The subsequent groundbreaking discovery of penicillin by Sir Alexander Fleming in 1928 further laid the foundation for the administration of perioperative antibiotic prophylaxis and represented a foremost contribution to the development of safe surgical techniques [14]. The implementation of antiseptic surgical techniques also opened the door for the development of surgical implants, which was pioneered by grand entrepreneurs, such as Carl Hansmann (1886), Albin Lambotte (1909), Gerhard Küntscher (1940), and Robert Danis (1949) [15–17]. In 1958, the Arbeitsgemeinschaft für Osteosynthesefragen (AO) was founded and provided an umbrella for research, outcome documentation, education, development of implants and instrumentation [18]. As the learning curve has continued over the last decades, the surgical community has developed an improved understanding of appropriate soft tissue management. Thus, it has been realized that in patients with musculoskeletal injuries, successful management of the traumatized surrounding soft tissues plays a key role in achieving favorable surgical outcomes [19]. Although we have made rapid progress in improving surgical outcomes in patients with musculoskeletal injuries, we still have a long way to go. Despite the availability of appropriate antiseptic techniques, modern technology, and an improved understanding of soft tissue management, the risk of surgical site complications leaves significant room for improvement. As of today, the risk of surgical site infection in patients with high-risk lower extremity fractures, such as high-energy fractures of the tibial plateau, tibial plafond, and calcaneus, may be as high as 15% [20]. This rate may even be higher in elderly patients and patients with medical co-morbidities [6]. Surgical site infections continue to represent a significant healthcare and socioeconomic problem as they frequently result in hospital re-admissions, need for secondary surgeries, need for * Correspondence: zelle@uthscsa.edu; Philip.Stahel@gmail.com Department of Orthopaedics, University of Texas Health, 7703 Floyd Curl Dr.,MC-7774, San Antonio, TX 78229, USA Rocky Vista University, College of Osteopathic Medicine, Parker, CO 80134, USA

Lessons learned for postoperative wound healing: respect the past and embrace the future