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Free flap transplantation combined with skin grafting and vacuum sealing drainage for repair of circumferential or sub-circumferential soft-tissue wounds of the lower leg
Abstract
Background
This study is aimed at evaluating the operation techniques and clinical significance of free flap transplantation combined with skin grafting and vacuum sealing drainage (VSD) in repairing severe traumatic extensive circumferential or semi-circumferential soft-tissue defects of the lower leg.
Material/Methods
Thirty patients with severe lower leg injuries were treated by free flap transplantation combined with skin grafting and VSD from January 2008 to June 2011. The size of the wounds ranged from 23×8 cm to 44×28 cm and all affected more 70% of the low leg circumferential area. Wounds were complicated by exposure, necrosis, or infection of deep tissues. The wounds were first debrided and covered by VSD. When the condition of the wound had improved (5 to 7 days later), free flaps were harvested to reconstruct damaged tissue and skin grafts and VSD was used to cover granulation tissues around the transplanted flap.
Results
Granulation tissues developed and the area requiring flap cover decreased in all 30 patients after debridement and VSD. In 28 of 30 cases, the transplanted flaps grew well without complication. Peripheral necrosis was observed in only 2 cases, which required a second debridement and skin graft. Ten wound areas covered by grafts were left with scattered peripheral wounds, which healed with the help of 1 more skin graft or dressing change. Morphological appearance and functional recovery were satisfactory in all 30 cases.
Conclusions
Initial debridement and the temporary VSD cover followed after several days by free flap transplantation combined with skin grafting and VSD protection is a reliable treatment regimen for traumatic large circumferential or sub-circumferential soft tissue wounds of the lower leg with deep tissue exposure.
... NPWT has also become a well-established method for improving outcomes after skin grafting, where the technique is used to prepare the wound surface for graft acceptance and to stabilize the graft to prevent shearing and removal [41][42][43]. ...
... Randomized controlled trials (RCTs), retrospective studies, and case series provide a substantial body of evidence that the use of either NPWT or closed incision management (CIM; Prevena™ Therapy [Kinetic Concepts, Inc., San Antonio, TX, USA]) ( Figure 1) may reduce the incidence of wound infections and other wound complications in a variety of post-surgical wound types (Table 1) [28,[42][43][44][45][46][47][48][49][50][51][52][53]. Orthopedic studies were included as well as cardiac surgery, because both are considered to be clean surgery [54]. ...
... Use of NPWT on closed incisions has been shown to reduce the risk of wound infection, wound dehiscence, and seroma in randomized, controlled studies of patients in orthopedic settings [47,51]. NPWT also enhances graft adherence and survival after skin and biomatrix grafting [43]. ...
Abstract Negative pressure wound therapy is a concept introduced initially to assist in the treatment of chronic open wounds. Recently, there has been growing interest in using the technique on closed incisions after surgery to prevent potentially severe surgical site infections and other wound complications in high-risk patients. Negative pressure wound therapy uses a negative pressure unit and specific dressings that help to hold the incision edges together, redistribute lateral tension, reduce edema, stimulate perfusion, and protect the surgical site from external infectious sources. Randomized, controlled studies of negative pressure wound therapy for closed incisions in orthopedic settings (which also is a clean surgical procedure in absence of an open fracture) have shown the technology can reduce the risk of wound infection, wound dehiscence, and seroma, and there is accumulating evidence that it also improves wound outcomes after cardiothoracic surgery. Identifying at-risk individuals for whom prophylactic use of negative pressure wound therapy would be most cost-effective remains a challenge; however, several risk-stratification systems have been proposed and should be evaluated more fully. The recent availability of a single-use, closed incision management system offers surgeons a convenient and practical means of delivering negative pressure wound therapy to their high-risk patients, with excellent wound outcomes reported to date. Although larger, randomized, controlled studies will help to clarify the precise role and benefits of such a system in cardiothoracic surgery, limited initial evidence from clinical studies and from the authors' own experiences appears promising. In light of the growing interest in this technology among cardiothoracic surgeons, a consensus meeting, which was attended by a group of international experts, was held to review existing evidence for negative pressure wound therapy in the prevention of wound complications after surgery and to provide recommendations on the optimal use of negative pressure wound therapy on closed median sternal incisions after cardiothoracic surgery.
... In a previous study, we adopted thoughly debridement and vacuum sealing drainage for the treatment of large wounds complicated with deep tissue exposure after severe trauma. Waiting until fresh granulation tissues of the wound grew well, we used free flap transplantation combined with simple skin graft to repair the wound and relatively high efficacy was achieved 7,8 . However, there are some disadvantages for this strategy. ...
... Broad-spectrum antibiotics were administered during the early stage to all of them. According to our previous methods 7,8,11,12 , early debridement was carried out to remove the foreign debris and ischemic inactivated tissues as much as possible. Simple internal or external fixation was performed to reconstruct the bone, with appropriate repair on the deep injured tissues (tendons, nerves, etc.). ...
Objective
To evaluate the clinical application and surgical efficacy of the chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap for the reconstruction of the large area of deep wound in foot and ankle.
Methods
Clinical data of 32 cases who underwent chimeric anterolateral thigh perforator flap to repair the large area of deep wound of the foot and ankle from January 2015 to December 2018 were retrospectively analyzed. The sizes of the defects ranged from 18 cm × 10 cm to 35 cm × 20 cm, with exposed tendon and bone and/or partial defects and necrosis, contaminations, accompanied by different degrees of infection. Following the radical debridement and VSD, chimeric anterolateral thigh perforator flap was employed to repair the deep wounds according to the position, site and deep-tissue injury of the soft-tissue defects. The skin flap and muscle flap were fanned out on the wound, and single- or two-staged split-thickness skin grafting was performed on the muscle flap. The operation time and blood loss were recorded. The survival and healing conditions of the operational site with chimeric anterolateral thigh perforator flap were evaluated post-operationally. Complications at both recipient site and donor site were carefully recorded.
Results
The mean time of the operation was 325.5 min and average blood loss was 424.8 mL. Among the 32 cases, two cases developed vascular crisis, which were alleviated with intensive investigation and treatment; Four cases suffered from partial necrosis of the flap or skin graft on the muscle flap or on the residual local wound, which were improved after treatment of further dressing change and skin grafting. Another four cases experienced post-traumatic osteomyelitis accompanied by bone defect were treated with simple bone grafting or Mesquelet bone grafting at 6–8 months after wound healing. Postoperatively, the wounds were properly healed, and the infection was effectively controlled without sinus tract forming. Overall, all 32 cases received satisfactory efficacy, without influencing subsequent functional reconstruction, and observed infection during the 12–36 months post-operational follow-up.
Conclusion
The chimeric perforator flap pedicled with the descending branch of the lateral circumflex femoral artery and the lateral thigh muscle flap provides an effective and relative safe procedure for the repair of a large area of deep wound in the foot and ankle, particularly with irregular defect or deep dead space.
... With the recent developments of surgical flap techniques, particularly perforator flap surgery, the damage to the donor site has been significantly reduced and the range of application has become wider. 7,8 Free flaps can be used not only to repair the wound and prevent deep tissues necrosis but also to mitigate local infection and enhance patients' comfort, providing an excellent soft tissue environment for subsequent surgery. Consequently, we prefer to use free flaps to repair the wounds following debridement during treatment of composite bone and soft tissue defects. ...
... In clinical practice, anterolateral thigh flaps, thoraco-umbilical flaps, and latissimus dorsi flaps are commonly adopted with respective advantages and disadvantages. 7 When choosing the flap for the donor site, we give priority to the flap that is most familiar to the surgeon. The anterolateral thigh flap has the most advantages 30 and is the most skillfully placed flap in our institution; thus, it is given high priority. ...
Objective:
To evaluate the clinical efficacy of free flap transplantation combined with Ilizarov bone transport in the treatment of severe composite tibial and soft tissue defects.
Methods:
We retrospectively analyzed the clinical data of 40 patients with severe composite tibial and soft tissue defects who underwent free flap transplantation combined with Ilizarov bone transport. The clinical efficacy was evaluated according to the following criteria: success rate of wound repair by free flap transplantation, incidence or recurrence rate of deep infection, healing rate of bone defects and external fixation index, incidence of complications, and functional score of affected extremities.
Results:
All infections were generally well controlled by radical debridement and negative-pressure therapy, and all 40 patients' wounds healed after repair and reconstruction of the tibia and soft tissues. Postoperative complications were alleviated by active treatment. The mean external fixation time was 12.83 ± 2.85 months, and the external fixation index was 1.55 m/cm. According to the Association for the Study and Application of Methods of Ilizarov (ASAMI) score, an excellent or good functional outcome was attained in 85% of patients.
Conclusion:
Free flap transplantation combined with Ilizarov bone transport is an effective treatment for severe composite tibial and soft tissue defects.
... Since its first description by Song et al. [1] in 1984, the anterolateral thigh flap has been considered to be an universal and preferential free flap [2,3] for the reconstruction of limb wounds, owing to its constant anatomical position of nutrient vessels, long vascular pedicle, thick vascular diameter, and relatively concealed donor site. Our group previously utilized the anterolateral thigh flap to reconstruct various types of wounds to achieve satisfactory outcomes [4,5]. However, repeated exudation and persistent infection surrounding the postoperative flaps in partial complex wounds occurred during the treatment process. ...
... According to the conditions of the wound contamination or infection prior to wound reconstruction, 56 cases were treated with debridement and VSD as previously described [4,5,13]. Following the wound cleaning, the chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery and lateral thigh muscle flap was applied to obliterate the deep dead space and reconstruct the wounds. ...
Background
Deep dead space may be thought as an independent risk factor of the poor infection control after flap reconstruction in complex limb wounds. But it can be easily neglected. The conventional skin flap and musculocutaneous flap are difficult to obliterate the deep dead space in irregular shape effectively. It was investigated that the clinical application of chimeric anterolateral thigh perforator flap in the treatment of complex wounds complicated with deep dead space of the extremities in the paper.
Methods
Fifty-six cases complicated with deep dead space wounds were registered in group. Following thorough debridement and treatment with VSD, the granulation tissues grew with well-controlled infection. And then the chimeric anterolateral thigh perforator flap was used to obliterate the deep dead space and repair the wounds. The postoperative flap survival and infection conditions were evaluated.
Results
Overall, the infection was effectively controlled, without persistent exudation or sinus tract formation after wound healing. While 5 cases lost to follow-up, the remaining 51 cases were followed up until 15 months on average. Generally, the affected extremities recovered satisfactorily with normal appearances and texture of the flaps, along with normal functions. Importantly, no recurrence of infection was observed.
Conclusion
During the grafting of chimeric perforator flap pedicled with lateral thigh muscle flap, the muscle flap is recommended to obliterate the deep dead space while the skin flap is being used to cover the wound. The combination of these two technologies performed well in the repair and reconstruction of the complex wounds of the extremities, possessing potential for broader clinical application.
... Since its first description by Song et al. 1 in 1984, the anterolateral thigh flap has been considered to be a universal and preferential free flap 2, 3 for the reconstruction of limb wounds, owing to its constant anatomical position of nutrient vessels, long vascular pedicle, thick vascular diameter, as well as relatively concealed donor site. Our group previously utilized anterolateral thigh flap to reconstruct various types of wounds to achieve satisfactory outcomes 4,5 . However, repeated exudation and persistent infection surrounding the postoperative flaps in partial complex wounds occurred during the treatment process. ...
... 2.1 Preparation prior to wound reconstruction: According to the conditions of the wound contamination or infection prior to wound reconstruction, 56 patients were treated with debridement and vacuum sealing drainage as previously described 4,5,13 . Following the wound cleaning, the chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery and lateral thigh muscle flap was applied to obliterate the dead space and reconstruct the wounds. ...
Objective To investigate the clinical application of chimeric anterolateral thigh perforator flap in the treatment of complex wounds complicated with deep dead space of the extremities.
Methods From January 2014 to December 2018, 56 cases (38 males and 18 females) with wounds complicated with deep dead space received treatment of chimeric anterolateral thigh perforator flap. The average age was 33.4 years, ranged from 3 to 72 years. Causes of injury: 34 cases of vehicle or motorcycle bruise injuries, 12 cases of falling related injuries, and 10 cases of heavy objects crush injuries. All of these patients were experiencing severe limb injuries accompanied with varying levels of tissue necrosis, tissue infection and deep tissue exposure. Residual deep dead space was observed after debridement, including 41 cases of dead space caused by tendon and muscle exposure, 29 cases formed by bone and joint exposure, as well as 5 cases induced by exposure of internal fixators such as plates. The wound sized were from 8 cm×6 cm to 30 cm×15 cm. Forty-one cases were complicated with the ipsilateral fractures, and 21 cases were complicated with fractures in other bone parts or systematic injuries. Following thorough debridement and treatment with vacuum sealing drainage, the granulation tissues of the wound surface grew well with well-controlled infection, and then we used the chimeric anterolateral thigh perforator flap to obliterate the deep dead space and repair the wounds. The postoperative flap survival and infection condition were evaluated.
Results Among 56 patients, 2 cases developed vascular crisis, which was alleviated with timely vascular exploration. One case had excessive bleeding after flap grafting, which was resolved with surgical exploration. Three patients experienced partial necrosis of the flaps, leaving residual local wound, which were completely eliminated by secondary skin grafting in one case and by proactive dressing changes in the other 2 cases. Overall, the infection was effectively controlled, without persistent exudation or sinus tract formation after wound healing. While 5 cases lost to follow-up, the remaining 51 patients were followed up until 15 months, ranged from 9-24 months. Generally, the affected extremities recovered satisfactorily with normal appearances and texture of the flaps, along with normal functions. Importantly, no recurrence of infection was observed.
Conclusion During the grafting of chimeric perforator flap pedicled with descending branch of lateral circumflex femoral artery and lateral thigh muscle flap, the muscle flap is recommended to obliterate the deep dead space while the skin flap being used to cover the wound surface. The combination of these two methods performed well in the repair and reconstruction of the complex wounds of the extremities, possessing potential for broader clinical application.
... Emergency management was conducted by following the principle of "damage control." Wound debridement was performed before repair and reconstruction as previously described [25][26][27]. After debridement, VSD or KCI vacuum sponge was temporarily utilized to cover the wound. ...
... erefore, the flap should be fully utilized to repair the open wound of the deep bone, tendon, and nerve defects, thereby providing the maximum degree of tendon slip [9,17]. e preferred donor sites of the free flap are hidden locations with constant vascular pedicle, minimal influence on function, and large resection area, such as anterolateral thigh flap, thoracoumbilical flap, latissimus dorsi flap, and lateral thoracic flap [25,26,[39][40][41][42]. In this study, the appropriate donor site was selected according to the specific conditions of each patient, and no significant postoperative complications occurred on the donor site. ...
Objective. To evaluate the surgical efficacy of bone transport (Ilizarov technique) plus “shortening-lengthening,” “flap surgery,” and “open bone transport” as individualized treatments for traumatic composite tibial bone and soft tissue defects. Methods. We retrospectively analyzed sixty-eight cases (mean age: 35.69 years, (range, 16–65)) treated from July 2014 to June 2017, including 29 middle, 18 distal, and 21 proximal tibial bone defects (4–18 cm, mean: 7.97 cm) with soft tissue defects (2.5 cm × 4.0 cm to 30.0 cm × 35.0 cm after debridement). We adopted the bone transport external fixator to fix the fracture after debriding the defect parts. In the meantime, we adopted the “shortening-lengthening technique,” “flap surgery,” and “open bone transport” as individualized treatment based on the location, range, and severity of the composite tibial bone and soft tissue defects. Postoperative follow-up was carried out. Surgical efficacy was assessed based on (1) wound healing; (2) bone defect healing rate; (3) external fixation time and index; (4) incidence/recurrence of deep infection; (5) postoperative complications; and (6) Association for the Study and Application of the Methods of Ilizarov (ASAMI) score. Results. The mean duration from injury to reconstruction was 22 days (4–80 d), and the mean postoperative follow-up period was 30.8 months (18–54 m). After the repair and reconstruction, 2 open bone transport patients required infected bone removal first before continuing the bone transport treatment. No deep infection (osteomyelitis) occurred or recurred in the remaining patients, and no secondary debridement was required. Some patients had complications after surgery. All the postoperative complications, including flap venous crisis, nail channel reaction, bone nonunion, mechanical axis deviation, and refracture, were improved or alleviated. External fixation time was 12.5 ± 3.41 months, and the index was 1.63 ± 0.44. According to the ASAMI score, 76.47% of the outcomes were good/excellent. Conclusion. The Ilizarov technique yields satisfactory efficacy for composite tibial bone and soft tissue defects when combined with “shortening-lengthening technique,” “flap surgery,” and “open bone transport” with appropriate individualized treatment strategies.
1. Introduction
Stable fixation of fractures, early coverage of wounds, and effective prevention and treatment of infection are the fundamental management principles for severe open tibial fractures [1, 2]. Early coverage of the wound refers to covering the wound as soon as possible after the necrotic tissue is cleaned. It is difficult to estimate the vitality of the damaged tissue, especially for firearm injuries in the war, which brings more difficulties for treatment [3]. The importance of early, multiple, and thorough debridement is widely accepted. However, larger tibial and soft tissue defects are caused by debridement in some cases [4], which significantly increases the difficulty of subsequent repair and reconstruction. Nonetheless, great progress has been achieved in the treatment of severe composite tibial bone and soft tissue defects. The following methods can be combined or adopted alone in clinical practice: flap surgery, free vascularized bone graft (fibula [5, 6], ilium [7]), bone transport (Ilizarov technique) [8–22], Masquelet technique [11], simple bone graft after wound closure [23], and Papineau technique for open bone graft [24]. Among them, bone transport has become the primary method to treat large bone defects owing its success to improved external fixators, more precise surgical procedures, and new insights into “autologous bone tissue engineering technology” and “regenerative medicine.”
Discomfort exists at all stages of the bone transport process, which significantly impairs quality of life [10]. Reducing the time of the patients with an external fixator and improving the quality of their life, maximizing the advantages of the Ilizarov technique, and choosing the appropriate individualized treatment are critical. Multiple techniques should be combined and individualized treatment applied during each treatment step, such as early debridement, vacuum sealing drainage, and antibiotic carrier technology. During repair and reconstruction, the shortening-lengthening technique, flap surgery, and open bone transport can be selected in addition to bone transport according to the individual condition of the patient. In this investigation, clinical data from 68 cases of traumatic composite tibial bone and soft tissue defects undergoing bone transport from July 2014 to June 2017 were collected and retrospectively analyzed to evaluate the surgical efficacies of these individualized treatments.
2. Materials and Methods
2.1. Inclusion and Exclusion Criteria
Inclusion criteria were as follows: (1) age 16–65 years, (2) tibial defect >4 cm after traumatic debridement accompanied by soft tissue defects (i.e., the wound could not be directly sutured after debridement), and (3) an external fixator could be placed in the proximal lower extremity, distal lower extremity, or foot, and normal bone segments were available for osteotomy. Exclusion criteria were as follows: (1) loss to follow-up, (2) external fixator was changed to internal fixator, (3) no possibility of preserving the lower extremity due to local defects, and (4) patients unsuitable or unable to tolerate surgery.
2.2. Patients and Methods
According to the inclusion and exclusion criteria, 68 cases were retrospectively assessed (42 males and 26 females, age 16–65 years, average age: 35.69 years). Defects were located on the left side in 30 cases and the right side in 38 cases. Forty-four cases were traffic accident injuries, 14 falling injuries, and 10 crush injuries. Among them, 35 cases were transferred to our hospital after treatment in a local hospital. Injury site was the middle tibial bone in 29 cases, distal in 18 cases, and proximal in 21 cases. The length of the tibial bone defect ranged from 4 to 18 cm (7.97 cm on average), and soft tissue defects ranged in area from 2.5 cm × 4.0 cm to 30.0 cm × 35.0 cm after thorough debridement. Eighteen cases were complicated by ipsilateral extremity fractures, 20 cases with fractures at other sites, and 12 cases with other systemic injuries. The time from injury to repair and reconstruction ranged from 4 to 80 days (22 days on average).
2.3. Surgical Procedures
Broad-spectrum antibiotics were applied at the early stage of therapy. Individualized treatment was designed according to the severity of the injury and staged surgery was performed. Emergency management was conducted by following the principle of “damage control.” Wound debridement was performed before repair and reconstruction as previously described [25–27]. After debridement, VSD or KCI vacuum sponge was temporarily utilized to cover the wound. Each cycle of VSD or KCI was maintained for 4–7 days. Patients with severe contamination, unclear margins of necrotic tissues, or wound surface infection received repeated or enlarged debridement.
According to the fracture site and severity of defects, a unilateral or circular external fixator or unilateral-circular external fixator (OrthoFix Medical Inc., Italy or Tianjin Xinzhong Medical Devices Co., Ltd., China) was selected. The monoaxial fixator (LRS fixator) is a stable, easy-to-use, and very handy device; as a result, it is preferable to use [28]. The fixation method and needle insertion paths were based on the approaches of Nayagam [29]. Bilateral ends of the bone defects were repaired and leveled. Unhealthy tissues, such as those with inflammatory granulation, sinus tract, and unstable scar surrounding the bone defects, were thoroughly eliminated. The fibula was cut off at the middle or upper segments when necessary, and the lower leg was shortened. A proximal or distal tibial osteotomy was performed simultaneously or during the subsequent treatment stages. In addition to bone transport, we also applied the shortening-lengthening technique, flap surgery, and (or) open bone transport for wound repair. Among 68 enrolled patients, the wound area was reduced through limb shortening in 47 cases, while the remaining 21 cases did not undergo limb shortening. Specifically, 11 cases received subsequent direct suture, 25 cases received wound suture by local flap transfer, 19 cases underwent free flap transfer to repair the wound, and 13 cases received wound repair via bone transport.
Postoperative management was conducted according to the classic Ilizarov method [21], with bone transport performed at 0.5–1 mm/day, 2–4 times per day starting one week postoperative. An X-ray examination was conducted on a regular basis. The speed of bone transport was adjusted according to the new callus. For patients treated with the shortening-lengthening technique, limb shortening was performed gradually according to the specific conditions after surgery to reduce the tension on soft tissues. Bone transport was completed toward bilateral ends, followed by lengthening to restore the normal span of the tibia. For patients undergoing flap surgery, careful observation and necessary braking were required. Anti-infection, antispasm, and anticoagulation therapies, as well as conventional microsurgical methods, were applied to preserve the blood supply of the flap. For those receiving open bone transport, it was necessary to provide more aggressive nursing of the wound. Specifically, the dressing was changed every 2-3 days, and Vaseline gauze or antibacterial gauze was used to keep the wound dry and clean after pulling until the wound was healed. Postoperative follow-up was conducted on a regular basis. According to the problems identified during postoperative follow-up, appropriate interventions were delivered, and repeated surgeries were considered when necessary.
2.4. Evaluation of Surgical Efficacy
Surgical efficacy was evaluated by the following parameters: (1) wound healing, (2) bone defect healing rate, (3) external fixation time and external fixation index (external fixation time/length of tibial bone defects), (4) incidence or recurrence rate of deep infection, (5) postoperative complications, and (6) Association for the Study and Application of the Methods of Ilizarov (ASAMI) Score of the lower extremity [15].
3. Results
Infections were effectively controlled in all 68 patients with tibial bone and soft tissue defects by debridement and 1–3 times VSD or KCI treatments. The time from injury to repair and reconstruction ranged from 4 to 80 days (mean: 22 days) and the duration of postoperative follow-up from 18 to 54 months (mean: 30.80 months). Twenty-five cases were treated with local flap transfer, and all demonstrated flap survival well and wound healing. Of the 19 cases who underwent free flap transplantation to repair the wound, vascular crisis appeared in 3 cases and small area necrosis occurred after vascular exploration. The wound was healed after debridement, skin grafting, or dressing change. In patients receiving open bone transport, soft tissue defects were repaired by skin traction, but bone scars were formed. Some patients suffered from local damage due to frequent skin itching and scratching. Among them, 2 cases experienced local skin necrosis after bone grafting due to postoperative nonunion of the bone fractures. These wounds healed after dressing change for approximately one month.
The bone defects of all 68 cases were eventually reconstructed. Twelve of these cases received autogenous ilium or allogeneic bone. The mean external fixation time was 12.5 ± 3.41 months, and the mean external fixation index was 1.63 ± 0.44. Two cases receiving open bone transport required repeated resection due to exposure and infection of the transported bone segments in the process of traction. This was followed by successful bone transport without the recurrence of infection. No deep infection (osteomyelitis) occurred or recurred in the remaining patients, and no further debridement was required.
In the process of bone transport, nail canal reactions of varying severity were observed. Most of these reactions were relieved after suspending or slowing down bone transport and by dressing change. Patients with mechanical axis deviation continued bone transport after outpatient adjustment. Cases with severe nail canal reactions or mechanical axis deviation were surgically adjusted. Overall, 80 postoperative complications were encountered (Table 1). The ASAMI functional score was excellent in 34 cases (50%), good in 18 (26.47%), moderate in 10 (14.7%), and low in 6 (8.82%). Thus, 76.47% of patients achieved excellent or good results (Table 2).
Complication
Number of cases (n = 80)
Management
Outcome
Flap crisis
3
Vascular exploration
Slight flap necrosis was healed after debridement, grafting, or dressing change
Recurrence of deep infection
2
Removal of infected bone
Improvement
Nonunion of bone defect
14
Autologous or allogeneic bone transplantation
Healing
Refracture
4
External fixation for another 6 months
Bone union
Severe nail tunnel reaction or mechanical axis deviation
19
Nail/needle replacement, mechanical axis adjustment
Improvement
Joint stiffness (knee joint stiffness, foot drop, claw toe)
13
Decompression surgery, foot ring
Improvement
Limb shortening (>3 cm)
2
None
None
Soft tissue folding affecting bone transport contact
5
Soft tissue repair
Improvement
Flap swelling
8
Flap repair
Improvement
Poor wound healing
10
Dressing change
Improvement
Note: the number of complications refers to the number of patients presenting with complications. One patient may successively or simultaneously have different complications, and one or more may be simultaneously treated during the surgical treatment. The functional score is obtained after these complications are treated.
... The soft tissue defects are commonly repaired by reconstructive skin flap surgery [1][2][3]. However, a considerable risk factor in reconstructive surgery is free or pedicle flap infection [4][5][6], which can reduce the quality of the flap or even lead to necrosis in part of the flap or in the entire graft [7,8]. Consequently, ensuring that the wound contains minimal bacterial load is key to proper primary wound closure and optimal skin flap transplantation outcome [9,10]. ...
... Several strategies have been employed to reduce or eliminate infections in physical trauma-induced open fractures. These include standard methods such as debridement and occlusive dressing [11,12] as well as more novel approaches such as dermal regeneration matrices [13] and preoperative irrigation and vacuum sealing drainage [PI-VSD] [8,[14][15][16][17], both of which may be accompanied by antibiotic prophylaxis, the application of antibiotic agents [10,12,14,18], photodynamic therapy [19,20], and the use of wound dressings that reduce biofilm formation [21]. PI-VSD comprises irrigation of the wound followed by the placement of a drainage container over the open wound and the passage of sterile fluid under conditions of negative pressure. ...
Objectives:
By observing the infection and soft tissue defect on the wound surface of the foot and ankle, this paper attempts to explore the effect of preoperative irrigation and vacuum sealing drainage with antibiotic-containing drainage fluid (abPI-VSD) on the bacterial quantity and the local inflammatory response at the flap, and further to provide a basis for applying this technique before a reconstructive skin flap surgery of foot and ankle wounds.
Methods:
Seventy-five patients were randomly divided into two groups, and all surgeries were done by one physician. The flap reconstructions were done to 31 cases with the abPI-VSD being used (group A); the flap reconstructions were done to the rest 44 cases after wound cleaning using antibiotic irrigation solution without the use of the abPI-VSD (group B). Quantitative bacteriology was made to group A before and after the use of abPI-VSD; quantitative bacteriology was made to group B before and after wound cleaning. Then, the reconstructive skin flap surgery was done. After the surgeries, the time of local inflammatory response at the flap in both groups were recorded. The measured bacterial quantity was evaluated in logarithm and by t test.
Results:
The bacterial quantity was 3.2 ± 1.9 × 107 cfu/g in group A before the use of abPI-VSD and 2.3 ± 2.0 × 107 in group B (P > 0.05) before debridement. The bacterial quantity was 1.2 ± 2.0 × 104 cfu/g in group A after abPI-VSD and was 2.9 ± 4.0 × 106 in group B after wound cleaning (P < 0.05). The time of postoperative inflammatory response in the flap was 8 ± 2.5 days in group A and 13 ± 3.4 days in group B (P < 0.05).
Conclusions:
abPI-VSD can distinctly reduce the bacterial quantity on the surface of the wound, provide a good condition of tissue bed for the flap reconstruction, and effectively control the local inflammatory response at the flap and hence improve the survival quality of the flap.
... Reportedly, a closed-incisional negative pressure therapy eases surgical site infections (SSIs) in spine surgery [17], and negative pressure wound therapy is arguably more effective against SSIs after vascular, abdominal, orthopaedical, and thoracic surgeries than conventional procedures [18]. Vacuum sealing drainage (VSD), a core technique of negative pressure wound therapy, demonstrably exerts therapeutic e cacies against SSIs following spinal surgeries and multiple wound infections [19][20][21]. However, the e cacy and outcome of VSD against SSIs after intracranial neurosurgery is still to be investigated fully. ...
Background: Surgical site infections (SSIs)are still a challenge to neurosurgeons. However, Vacuum Sealing Drainage (VSD), which has been used extensively in the treatment of various infections after surgery, looks a promising solution. This study examines the efficacy and outcome of VSD treatment of pyogenic SSIs following intracranial neurosurgery.
Methods: 20 patients with infections who underwent surgical intervention were treated retrospectively using VSD at the Zhongnan hospital of Wuhan University over the past five years. Primary surgery types, SSI types, VSD replacements, surgical procedures, pathogenic germs, antibiotic therapy and infection control were reviewed and discussed.
Results: Of the 20 infections, 13 (65%) were extradural, and 7 (35%) were extradural SSIs combined with intracranial infections (including 5 meningitis, 1 subdural abscess, and 1 brain abscess). All the patients consented to medical device implantation (including 5 titanium webs, 6 bone flap fixation devices and 12 dura-plasties), with most of the devices removed during debridement. The median duration from primary surgery to a SSI diagnosis was 19 days (range: 7 to 365 days). All the patients also agreed to debridement and VSD treatment; VSD was replaced 0 to 5 times (median, one time) every 4 to 7 days and retained for 4 to 35 days (median, 14 days). Seven (35%) patients had defined bacterial infections, with staphylococcus aureus the dominant infection. The deployed standard VSD and antibiotic treatment ensured full recovery from SSIs, including from intracranial infections: 14 (70%) patients were free of infection during follow-up, and no infection-associated death was registered; 6 (30%) patients died of severe primary affections.
Conclusion: VSD-assisted therapy is safe and effective against SSIs after intracranial neurosurgery.
... Studies have shown that flap, musculocutaneous flap, and greater omentum transplantation can effectively repair complex wounds and wound surfaces of lower limbs caused by various causes. 11,12 Among them, the flap is the most used clinically repairing lower limb soft tissue defect wound treatment, including the sural nerve nutritional flap, 13,14 sural artery femoral anterolateral flap perforators flap, 15 posterior tibial artery perforators flap, iliac groin flap, 16,17 etc., with the development of microscopy techniques, all kinds of skin flap design to get continuous improvement. The key to the treatment of patients with chronic osteomyelitis complicated with soft tissue defect is to select appropriate flaps, fascia flaps, muscle flaps, and bone flaps to fill the local soft tissue defect and cover the wound according to the location, scope, and type of the defect, which provides the possibility of permanent prosthesis implantation for these patients. ...
To investigate the clinical application value of different flap transfer and repair techniques in adult patients with chronic osteomyelitis of limbs complicated with soft tissue defects. According to the characteristics and defects of 21 cases, different plastic surgery was applied, including debridement, negative pressure device, and tissue flap to cover wound. Among 21 cases of chronic osteomyelitis complicated with local soft tissue defect, 15 patients were repaired with sural neurotrophic musculocutaneous flap transfer, 2 patients were repaired with medial plantar skin flap transfer, 2 patients were repaired with ilioinguinal skin flap transfer, 1 patient was repaired with z-forming wound, and 1 patient was repaired with soleus muscle flap combined with full-thickness skin graft. All the 21 patients underwent bone cement implantation after dead bone osteotomy. Among them, 19 patients underwent bone cement replacement with 3D prosthesis within 6 months to 1 year after surgery, and 2 patients carried bone cement for a long time. Early intervention, thorough debridement, removal of necrotic or infection, and then selecting the appropriate wound skin flap coverage are important means of guarantee slow osteomyelitis wound healing and for providing a possible way to permanent prosthesis implantation subsequently.
... The use of VSD after first-stage debridement not only facilitates quick, simple, and effective treatment of the wound but also reduces the traumatic effect on the child, decreases the chance of infection, and reduces complications. As such, VSD provides an optimal environment that guarantees successful subsequent free flap grafting (9). ...
Background:
To investigate the clinical experience and discuss the use of vacuum sealing drainage (VSD) combined with free anterolateral femoral flap grafting to treat pediatric foot and ankle soft tissue traumas.
Methods:
This was a retrospective analysis of 16 pediatric patients with foot and ankle soft tissue traumas treated with free anterolateral femoral flap grafting from January 2015 to January 2018. After successful debridement and VSD, the clinical efficacy of the procedure was evaluated by observing parameters such as the color, shape, and texture of the flap on the receptor site.
Results:
All patients were followed up for 23-32 months after surgery. Of the 16 patients, six had a flat flap appearance, while the remaining ten patients required flap repair surgery 6-9 months after the procedure. Eight of these ten patients had a satisfactory repair, and the remaining two patients had further repair surgery 9-10 months after the flap grafting. The postoperative results of all patients were satisfactory; no local infection, good flap survival, soft texture, glossy elasticity, and flat appearance. Statistical results showed only one case of local necrosis at the distal end of the flap, and the wound healed at stage II after redebridement and dressing change.
Conclusions:
VSD combined with free anterolateral femoral flap grafting is an easy and reliable operation with a good prognosis and excellent clinical utility and feasibility for treating pediatric patients with foot and ankle soft tissue traumas.
... Removal of lower extremity osteomyelitis lesions The site and extent of the infected lesions were evaluated, and tissue samples were collected for bacteriological culture. As described in our previous methods [14][15][16][17], infected and inactivated tissues in the lesions were thoroughly eradicated; the patency of the medullary cavity was restored; dead and slerotic bones were removed until blood oozed from the bone surface (red pepper sign); and the infected periosteum and surrounding inflammatory soft tissues were removed. Depending on the eradication of infection, relatively healthy bone was retained in the FVFG group, while bilateral ends of the bone defects were trimmed in the IBT group. ...
Abstract Objective The objective was to explore the relative indications of free vascularized fibular graft (FVFG) and Ilizarov bone transport (IBT) in the treatment of infected bone defects of lower extremities via comparative analysis on the clinical characteristics and efficacies. Methods The clinical data of 66 cases with post-traumatic infected bone defects of the lower extremities who underwent FVFG (n = 23) or IBT (n = 43) from July 2014 to June 2018 were retrieved and retrospectively analyzed. Clinical characteristics, operation time, and intraoperative blood loss were statistically compared between two groups. Specifically, the clinical efficacies of two methods were statistically evaluated according to the external fixation time/index, recurrence rate of deep infection, incidence of complications, the times of reoperation, and final functional score of the affected extremities. Results Gender, age, cause of injury, Gustilo grade of initial injury, proportion of complicated injuries in other parts of the affected extremities, and numbers of femoral/tibial defect cases did not differ significantly between treatment groups, while infection site distribution after debridement (shaft/metaphysis) differed moderately, with metaphysis infection little more frequent in the FVFG group (P = 0.068). Femoral/tibial defect length was longer in the FVFG group (9.96 ± 2.27 vs. 8.74 ± 2.52 cm, P = 0.014). More patients in the FVFG group presented with moderate or complex wounds with soft-tissue defects. FVFG treatment required a longer surgical time (6.60 ± 1.34 vs. 3.12 ± 0.99 h) and resulted in greater intraoperative blood loss (873.91 ± 183.94 vs. 386.08 ± 131.98 ml; both P
... As rectal blood supply (rectal, middle and lower arteries) is rich, ischemic necrosis rarely occurs [4]. Traumatic large soft tissue avulsion injuries are classified as complete or incomplete, are often accompanied by extensive necrosis and severe contamination, which can damage the skin veins and capillaries as well as severely infect the blood supply and venous return, and can involve the muscles, nerves, bone and joints [22]. In patients with traumatic perianal avulsion injuries, the authors believe that rectal and visceral injuries should be excluded first [3]. ...
Background
Traumatic avulsion injuries to the anus, although uncommon, can result in serious complications and even death. Management of anal avulsion injuries remains controversial and challenging. This study aimed to investigate the clinical effects of treating large skin and subcutaneous tissue avulsion injuries in the perianal, sacral, and perineal regions with island flaps or skin graft combined with vacuum assisted closure.
Methods
Island flaps or skin graft combined with vacuum assisted closure, diverting ileostomy, the rectum packed with double-lumen tubes around Vaseline gauze, negative pressure drainage with continuous distal washing, wounds with skin grafting as well as specialized treatment were performed.
Results
The injuries healed in all patients. Six cases had incomplete perianal avulsion without wound infection. Wound infection was seen in four cases with annular perianal avulsion and was controlled, and the separated prowl lacuna was closed. The survival rate in 10 patients who underwent skin grafting was higher than 90%. No anal stenosis was observed after surgery, and ileostomy closure was performed at 3 months (six cases) and 6 months (four cases) after surgery, respectively.
Conclusions
Covering a wound with an island flap or skin graft combined with vacuum assisted closure is successful in solving technical problems, protects the function of the anus and rapidly seals the wound at the same time.
... Tissue edema, especially secondary to renal disease, can be exacerbated in extremity surgery, secondary to the inflammation of the injury itself, restricted motion, lymphatic disruption or radiation therapy, and tourniquet use [4][5][6][7] . Unfortunately, these factors can predate the surgery, and in fact represent a contribution to the primary disease state and extremity wound. ...
Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure.
Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated.
Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group.
Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.
... The inhibitory effects on bacteria reproduction could largely result from the negative pressure of VSD, which creates a relatively anoxic environment on the wound surface, without affecting the surrounding healthy tissues. Owing to these merits of VSD, surgeons have broadly accepted VSD for treatment of soft tissue trauma (1,5,6) and boneexposed wounds (7)(8)(9). Nonetheless, few comprehensive analyses have investigated the effectiveness and inherent mechanism of VSD treatment for bone-exposed wounds. ...
This study was designed to assess the efficacy of vacuum sealing drainage (VSD) on skull exposure wounds in rabbits and to investigate the underlying mechanism of the process. Full-thickness excisional circular wounds 2×2 cm with or without periosteum involvement were created in 88 New Zealand white rabbits (mean body weight: 3.0±0.65 kg). Animals were randomly divided into 4 groups: periosteum-intact wounds treated with traditional dressing (p+control), periosteum-intact wounds treated with VSD (p+VSD), periosteum-lacking wounds treated with traditional dressing (p–control) and periosteum-lacking wounds treated with VSD (p–VSD). The wounds treated with traditional dressing were covered with Vaseline gauze, while VSD treatment was accompanied with continuous –120 mmHg pressure. Finally, wound tissues were harvested for analysis of hydroxyproline content and histologic detection. VSD hastened the wound healing process significantly (P<0.05) compared to the corresponding control groups. VSD alleviated the inflammation reaction, accelerated re-epithelialization and facilitated the organization of collagen fibers into neat rows. During the wound healing process, the hydroxyproline content increased overtime [i.e., postoperative days (POD) 7, POD 10 and POD 15] in all four groups, and it peaked in the p+VSD group. VSD also promoted angiogenesis via increasing number and quality of collagen. We concluded that VSD can promote healing in bone-exposed wounds via increasing hydroxyproline content and vessel density, reducing inflammatory responses and generating ordered collagen arrangement.
... The continued vacuum increases blood flow to the area that needs to be treated and draws out fluid from the wound into an exudate container. In the microsurgery department of Wuhan University Zhongnan Hospital, we use Vacuum-sealing drainage (VSD; Wuhan Weisidi Inc, Hubei, China), a dressing commonly adopted as therapeutic material for treatment of severe injuries as well as long-standing non healing wounds [14,15]. ...
Background:
Perforator flap techniques with conventional wound dressing have being extensively used in the management of soft-tissue defects. However; the flap's survival rate is not always guaranteed and the wound healing time always long. The aim of this study was to investigate the clinical effectiveness use of a freshly transplanted perforator flap in conjunction with Vacuum-assisted closure (VAC) for better clinical outcomes.
Methods:
A prospective, randomized, effectiveness study comparing the clinical outcomes of VAC versus traditional wrap and bandages for the treatment of open wounds that required hospital admission and operative debridement using perforator flaps, was carried out from March 1, 2014 to March 31, 2016 at Wuhan University Zhongnan Hospital. Fifty-one eligible patients were randomized into two groups; study group (perforator flaps covered by VAC) and control group (perforator flaps covered by traditional wrap and bandages). The measured clinical endpoints included the time of the first post-operative dressing change, pain visual analogical scale, perforator flap infection rate, 95% perforator flap healing time and percentage of survived perforator flap.
Results:
There was no statistically significant difference in the demographic profiles in the two cohorts. There were statistically significant differences in the clinical endpoints in the two groups (p < 0.001; p < 0.05, Table 2).
Conclusions:
In summary, VAC combining with perforator flap technique, can diminish accumulated exudation of the transferring flap, protect against postoperative infection, prolong the interval between perforator flap relocation and first postoperative dressing change, decrease pain during removal of dressing, increase perforator flap survival rate, and shorten wound healing time, with a good aesthetic outcome, a good mobility and a satisfactory therapeutic result.
... On the first stage, an extensive debridement for the osteomyelitic lesion were undertaken, leaving only viable tissue, then followed by vacuum sealing drainage (VSD) treatment and continuous irrigated with 1-2 liters solution per day for 5-7days, which the volume fraction of 0.9% sodium chloride solution containing 8-16W units gentamicin per liter. Debridement for the infected lesion was conducted according to the methods described previously 18,19 . The internal fixation of the infected bone segments was performed as follows: two patients with localized and short-term infections were preserved; three patients with implant duration more than 3 weeks were removed and replaced by external fixation. ...
Purpose:
The present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur.
Methods:
Twelve patients (aged 15-58 years) with infected bone defects of the femur (between 6.0 and 18.0cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1-2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site.
Results:
Mean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7-15cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9-72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%.
Conclusions:
Free vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.
... Their usage is considered the "gold standard" for many years and it has been associated with minimal rate of complications. However, recently some data about the same effectiveness of free fasciocutaneous flap in patients with open fractures and chronic osteomyelitis have been published [11,22]. Better esthetic appearance of limb, development of full thickness coverage (skin and subcutaneous fat) over the zone of injury, better stability of flap tissue for the second operation are the advantages of free fasciocutaneous flaps usage. ...
Introduction:
Tactic of emergency closing of soft tissue defect allows to significantly improve the treatment results concerning patients with severe open fractures. However, a number of certain factors make the implementation of this tactic rather difficult. Injured people’s unstable conditions are mong these crucial factors which include, polytrauma in lots of cases, absence of exact recommendations for recovery terms, choice of definite tissue flaps and a type of circulation.
The Aim of Study:
is to develop exact, usable and in practice algorithm of emergency reconstruction of leg soft tissues in patients with severe open tibia fractures, based on the usage of the most foolproof and simple methods.
Data (Patients) and Methods:
85 patients with open tibia fractures complicated by soft tissue defects were included in our study. Patients were divided into two groups. The control group consisted of 56 patients. Soft tissue reconstruction in this group was provided without an exact algorithm, after continuous attempts on local healing. After analyzing the treatment process and the treatment results we have developed the algorithm of emergency soft tissue reconstruction. It was used in 29 patients (the study group). This algorithm allows choosing optimal timing for tissue reconstruction and appropriate method to be applied, depending on the patient’s condition, the mechanism of soft tissue defect formation, and its square and localization.
Results:
We observed a statistical decrease in deep wound infection frequency, partial tibia necrosis frequency, chronic osteomyelitis frequency, duration of hospitalization in patients with severe open tibia fractures because of using our algorithm.
... It has been found to be useful in the treatment of various types of wound surfaces. [4][5][6][7] Recently, Wu et al 8 of extensive polyacrylamide hydrogel (PAAG) migration after breast augmentation. The mechanism of VSD for prompting granulation growth and accelerating wound healing has been proven at the cellular level. ...
Vacuum sealing is a therapeutic concept to achieve secure and rapid wound healing in traumatic soft tissue damage. Its application and effect in the treatment of severe buttocks and perianal infection are unclear.
We describe a case of buttocks and perianal infection using the vacuum sealing drainage (VSD) technique. A 58-year-old man was admitted with buttocks and perianal severe infection, which was caused by injection. The size of the wounds was 40 × 30 cm. Colostomy was applied prior to the prompt surgical debridement to prevent defecation and keep the perianal region clean. Emergency debridement was then conducted. After the wounds were thoroughly washed with conventional disinfection solution, they were then covered by VSD system.
The infection was controlled 9 days after the first surgery by prompt surgical debridement, the application of VSD treatment, and the use of narrow-spectrum antibiotics based on susceptibility result. After 3 applications of VSD treatment, skin grafting harvested from the left leg was conducted. All free skin grafts survived at 8 weeks. Colon was placed back into the abdominal cavity finally.
Initial colostomy and debridement, the temporary VSD cover followed after several days by skin grafting is a reliable treatment regimen for severe buttocks and perianal infection.
... Moreover, subsequent hypothermia, systemic infection, metabolic abnormalities, and decreased resistance may delay or even prevent healing (Hu et al., 2010;Byard et al., 2011;Dahl, 2011). Thus, vacuum-assisted closure (VAC) technology was proposed as a new therapy for wound healing, and its application was first reported by the German Dr. Fleischmann (Li et al., 2013). In recent years this technique has experienced rapid development and has been widely used to treat various acute and chronic wounds with excellent outcomes (Gabriel et al., 2009;Witkowski et al., 2009;Palm et al., 2011;Wood and Molnar, 2011;Masden et al., 2012;Ogawa, 2012). ...
The therapeutic effect of vacuum-assisted closure (VAC) has been confirmed in many types of complex wounds, but there are few relevant reports regarding seawater-immersed wounds. The aim of this study was to determine the effect of VAC on seawater-immersed wound healing under different negative pressures and explore the optimal negative pressure value. Four purebred miniature pigs were used as the experimental animal models. Four acute, symmetrical wounds were made on each side of the spine and designated as the experimental group (wounds with 2 h of seawater immersion) and the control group (wounds without seawater immersion). Wounds were divided into a conventional dressing group and 3 further groups with different VAC therapies (negative pressure at either 120, 180, or 240 mmHg). The extent of wound healing, and speed of granulation growth and re-epithelialization were measured. Bacterial flora distribution in the wounds was observed, and fibronectin levels in the exudate of the wounds were tested. Results showed that seawater immersion aggravated wound injury and that VAC therapy with 180 mmHg negative pressure induced the fastest epidermis migration, obvious edema elimination, significant capillary proliferation, and the highest level of fibronectin, and that in wounds, the proportion of Gram-negative bacteria tended to decrease and that of Gram-positive bacteria tended to increase. Our results show that VAC promotes seawater-immersed wound healing and that 180 mmHg negative pressure may be optimal for wound healing.
... The mechanism of VSD is as follows: It increases the blood flow to the wound, promotes angiogenesis, reduces the surface area of the wound, adjusts and inhibits the fluid flow in the wound, induces cell proliferation, reduces oedema and increases bacterial clearance (7,8). Recently, VSD application ...
The aims of this study were to observe the effects of vacuum sealing drainage (VSD) with three different negative pressures on the wound healing rate, macrophage count and the expression of hyaluronic acid (HA) as well as its receptor CD44 in seawater-immersed blast-injury wounds (SIBIW) and to determine the optimal negative pressure value. In a minipig SIBIW model, different suction pressures and routine dressing were applied. Histological and immunohistochemical comparisons as well as molecular biology methods were performed to compare the wound healing conditions, macrophage count and the levels of HA and CD44. The wound healing rate of the VSD group was significantly higher than that of the control group, with the -120 mmHg group exhibiting the best effects. The macrophage count of the VSD group was higher than that of the control group. The HA level fluctuation was higher in the VSD group, with the -120 mmHg and the -180 mmHg groups showing the most significant fluctuation (P < 0·05). CD44 was expressed in the full-thickness wound-limbic tissues and was higher in the treatment group than that in the control group, with the -120 mmHg group having the most obvious expression. VSD significantly improved the healing ability and increased the macrophage count and the HA content. It also promoted CD44 expression. -120 mmHg is the optimal negative pressure value.
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... This has been documented for its use in wound coverage until definitive therapy is decided or indicated [5], as well as helping to reduce the size of wound, allowing free flap reconstruction of the massive lower limb wound [96,97], or the passage down the reconstructive ladder to the point of foregoing the need of even a local flap, something improving investigations and surgical technique is also allowing [98]. ...
The lower extremities of the human body are more commonly known as the human legs, incorporating: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region.
The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs’ primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage.
This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb.
A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.
The purposes for performing negative pressure wound therapy (NPWT) in severe burns are diverse, but few reports comprehensively discussing its indications and methods have been published. We included patients with a ≥30% total burn area. There were 4 patients, and a total of 9 NPWT were performed. The therapy sites were the upper extremity (n = 2), the elbow (n = 1), the dorsum of the hand (n = 5), and the knee (n = 1). The purposes of the therapy were bridge-to-skin grafting (n = 5), dressing the artificial dermis (n = 1), therapy for bolstering the autograft (n = 1), bridge-to-flap surgery (n = 1), and covering the flap (n = 1). The devices used were bedside wall suction (n = 5) and dedicated device (n = 3). Therapy was converted to wall aspiration after use of the dedicated device in 1 case. NPWT is an effective option in severe burn treatment. For each purpose, it is necessary to consider the device used, negative pressure setting, starting date, frequency of dressing changes, and period of therapy. NPWT in severe burns also has the advantage of prioritizing life-prolonging treatment. If strict control of negative pressure is required, a dedicated device should be used rather than wall suction.
The development of hydrogels that support vascularization to improve the survival of skin flaps, yet establishing homogeneous angiogenic niches without compromising the ease of use in surgical settings remains a challenge. Here, pressure-driven spreadable hydrogels were developed utilizing beta-sheet rich silk nanofiber materials. These silk nanofiber-based hydrogels exhibited excellent spreading under mild pressure to form a thin coating to cover all the regions of the skin flaps. Deferoxamine (DFO) was loaded onto the silk nanofibers to support vascularization and these DFO-laden hydrogels were implanted under skin flaps in rats to fill the interface between the wound bed and the flap using the applied pressure. The thickness of the spread hydrogels was below 200 μm, minimizing the physical barrier effects from the hydrogels. The distribution of the hydrogels provided homogeneous angiogenic stimulation, accelerating rapid blood vessel network formation and significantly improving the survival of the skin flaps. The hydrogels also modulated the immune reactions, further facilitating the regeneration of the skin flaps. Considering the homogeneous distribution at the wound sites, improved vascularization, reduced barrier effects and low inflammation, these hydrogels appear to be promising candidates for use in tissue repair where a high blood supply is in demand. The pressure-driven spreading properties should simplify the use of the hydrogels in surgical settings to facilitate clinical translation.
Severe trauma to the soft tissue and/or underlying structures needs specialized wound care. Local debridement of devitalized tissue, wound irrigation, local and systemic antibiotics, as well as vacuum-assisted dressing is the mainstays of initial therapy. The secondary strategy after achieving clean structures often consists in using skin grafts or local or distant flaps. Early diagnosis of a compartment syndrome is essential in order to avoid severe complications. Degloving injuries, as well as soft tissue injuries of the face or the extremities, impose difficult problems and might need specialized care.
Background The timing of soft tissue reconstruction for soft-tissue defect in patients with open fractures in the lower extremity is known to be critical for successful outcomes. However, medical advances, including development of dressing materials and refinement in the microsurgical techniques, might have undergone modifications in this “critical period.” There have been no studies on the role of timing on reconstructive outcomes. Thus, we have analyzed the effect of reconstruction timing on optimal surgical outcomes and complication rates in a single type of lower extremity injury.
Methods Data of patients who underwent microvascular free tissue transfer with an open fracture in the lower extremity from 2014 through 2016 were retrospectively reviewed (n = 103). Surgical outcomes, including flap complication rate, flap revision rate, and long-term bony complications, were analyzed serially in accordance with time interval until coverage using the receiver operating characteristic (ROC) curve analysis. Significant factors with a p < 0.05 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors.
Results A total of 46 patients (33 males and 13 females) were finally included in the study. Based on the association between surgical timing and flap-related complication rate, the best cutoff period for surgery was 33 days, with an area under the curve of 0.658 (p = 0.040). Further, in the revision rate, the cutoff period was identified as 10 days (p = 0.016). Regarding the incidence of bony complications, ROC curve showed that the maximal period until operation was 91 days with no influence on the occurrence of bony complications (p = 0.029).
Conclusion Although the best method is an early reconstruction, many modalities such as negative pressure wound therapy play a role as a temporary measure. Our study suggests that the acute or early period for successful reconstruction might be extended compared with previous studies.
Chronic wounds are a challenge for clinicians. Treating chronic wounds in elderly patients is difficult due to comorbidities and poor immunity, tissue renewal, and regeneration. This study shared the therapeutic experiences of 40 patients with super long-term difficult-to-heal wounds and to describe the effects of negative pressure wound therapy (NPWT)-assisted debridement and autologous scalp grafting. Elderly patients with chronic wounds for more than 60 years who underwent NPWT-assisted debridement and autologous scalp grafting between 2015 and 2017 were retrospectively analyzed. Forty patients were identified and analyzed. Among all patients, the average wound area was 56 (interquartile range 30-90) cm2. The wound infection rate was 82.1%, and that before the first autologous scalp grafting was 51.3%. The average total number of surgeries was 3, and the number of times the NPWT device was replaced was once. A total of 97.4% of patients had one autologous scalp grafting performed. The transplanted scalp survived completely in 97.4% of patients. One hundred percent of patients had no postoperative complications and healed. The average wound healing time was 34.5 ± 10.1 days. This study showed that NPWT-assisted debridement and autologous scalp grafting have the advantages of high survival rate of the skin and decreased wound recurrence and may be a suitable treatment for super long-term difficult-to-heal wounds in elderly patients.
To investigate the effectiveness of adipose tissue-derived stem cells sheet combined with atelocollagen matrix on a mouse model of radiation-induced skin injury, adipose tissue-derived stem cells were harvested from the bilateral groin of mice and were screened out by fluorescence-activated cell sorting. Cell sheets were created on a temperature-responsive cell culture surface. The wound recovery rate was detected by measuring the injury area and the recovery shapes of wound were monitored by hematoxylin–eosin, Masson’s trichrome, and immunohistochemical staining. Quantitative reverse transcription polymerase chain reaction and Western blot analysis were conducted to detect relative mRNA expression level of interleukin-1β and protein expression level of vascular endothelial growth factor, respectively. As results, the three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix treatment promoted wound healing significantly compared to other treatments. More collagen, higher vessel density, and milder inflammation were observed in the group of three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix compared with other treatments. Moreover, both mRNA expression level of interleukin-1β and protein expression level of vascular endothelial growth factor were drastically decreased in that group. In conclusion, three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix could promote wound healing synergistically, providing a substantial advance in cell-based tissue engineering and wound healing.
Background:
In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.
Methods:
The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.
Results:
The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb.
Conclusion:
Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.
Level of evidence:
Systematic review of predominantly level II studies, level II.
Background:
Severe open tibia fractures are disastrous injuries associated with a high incidence of complications. Negative pressure wound therapy (NPWT) is a novel treatment for open tibia fractures; however, its efficacy remains unclear. This is a systematic review and meta-analysis performed to evaluate the effect of NPWT on decreasing the infection rate, amputation rate, nonunion rate, and flap-related complications in open tibia fractures.
Methods:
The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched. Complications were evaluated in terms of the rates of infection, amputation, nonunion, and flap-related complications.
Results:
Twelve studies were included. In the meta-analysis, NPWT showed significantly lower soft-tissue infection rate (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.34-0.68, P < 0.0001), nonunion rate (OR 0.61, 95% CI 0.39-0.95, P = 0.03), flap necrosis rate (OR 0.37, 95% CI 0.21-0.63, P = 0.0003), and flap revision rate (OR 0.44, 95% CI 0.22-0.89, P = 0.02) than conventional wound management. However, no significant difference was found in osteomyelitis rate (OR 0.54, 95% CI 0.09-3.28, P = 0.50) and amputation rate (OR 0.89, 95% CI 0.36-2.22, P = 0.80) between the 2 groups.
Conclusion:
Lower rates of soft-tissue infection, nonunion, flap necrosis, and flap revision were observed in the NPWT group than in the conventional dressing group. However, additional high-quality studies are warranted to verify the efficacy of NPWT in the treatment of severe open tibia fractures. We could not make a definitive conclusion about the comparative efficacy of the 2 methods in terms of complications because of insufficient data.
Backround: Marko Godina suggested in 1986 that soft tissue coverage of traumatic extremity wounds within 72 h of injury optimizes outcomes. Decades later, these recommendations remain controversial.
Methods: We performed systematic review of the literature using keywords ‘free flap coverage’ OR ‘soft-tissue reconstruction’ AND ‘lower extremity trauma’ OR ‘tibial or fibular fractures’. Patients receiving free flap or local muscle or fascia flaps were included. Patients were divided into two groups, one receiving coverage within 72 h of injury (<72 h) and one after 72 h (>72 h). Primary outcome measures were partial and total flap loss, as well as infection. Use of negative pressure wound therapy (NPWT) was noted. Descriptive statistics were performed.
Results: Twenty-one publications from 1986 to 2015 were included. The <72 h group had 295 patients and the >72 h group 972 patient. Total flap failure rate was 1.4% if coverage was performed <72 h after injury and 8.8% if >72 h after injury. Partial flap failure rate was 0.4% if coverage was performed <72 h after injury and 1.8% if >72 h after injury. Infection rate was 7.7% if coverage was performed <72 h after injury and 11.6% if >72 h after injury. Among the 182 patients in the >72 h group receiving NPWT, total flap failure rate was 3.6% and total infection rate 7.3%.
Conclusions: Total and partial flap loss rates, as well as infection rates, were lower when coverage was performed within 72 h of injury. Supporting Godina’s recommendation, early soft tissue coverage may be beneficial when circumstances permit. NPWT may be useful when reconstruction is not feasible within 72 h.
Reduction of surgical site infection (SSI) rates after (cardiac) surgery remains an important topic for all involved in the surgical domain. These infections lead to a higher risk for mortality and an increased morbidity in the individual patient. Despite many advances in perioperative care, however, the percentage of SSI has not declined. On a macrolevel, the costs associated with SSI are enormous, and all possible interventions to reduce SSI should be investigated. A possible new intervention is negative topical pressure therapy on clean, closed surgical wounds. In this chapter the theory behind this technique is explored, advice on patient selection is given, and treatment duration is discussed.
Background: Patients with composite bone non-union and soft tissue defects are difficult to treat. Vacuum-assisted closure (VAC) combined with open bone grafting is one of the most effective treatments at present. The aim of the present study was to preliminarily investigate the effect and mechanism of VAC combined with open bone grafting to promote rabbit bone graft vascularization, and to propose a theoretical basis for clinical work. Material/Methods: Twenty-four New Zealand white rabbits were randomly divided into an experimental and a control group. Allogeneic bones were grafted and banded with the proximal femur with a suture. The experimental group had VAC whereas the control group had normal wound closure. The bone vascularization rate was compared based on X-ray imaging, fluorescent bone labeling (labeled tetracycline hydrochloride and calcein), calcium content in the callus, and expression of fibroblast growth factor-2 (FGF-2) in bone allografts by Western blot analysis at the 4th, 8th, and 12th week after surgery. Results: At the 4th, 8th, and 12th week after surgery, the results of the tests demonstrated that the callus was larger, contained more calcium (p<0.05), and expressed FGF-2 at higher levels (p<0.05) in the experimental group than in the control group. Fluorescent bone labeling showed the distance between the two fluorescent ribbons was significantly shorter in the control group than in the experimental group at the 8th and 12th week after surgery. Conclusions: VAC combined with open bone grafting promoted rabbit bone graft vascularization.
Background: Vacuum-sealing drainage in wound skin grafting can close wound, reduce the leakage, promote granulation hyperplasia and improve skin new speed. Objective: To compare the clinical effects of two kinds of wound surface dressings used in wound skin grafting. Methods: Eighty patients who needed skin grafting for trauma were retrospectively studied and chosen from September 2010 to March 2012. They were divided into two groups: biomaterial group (dressings mainly made of luffa fibers) and synthetics group (seaweed polyvinyl alcohol foam). The vacuum-sealing drainage device and wound dressing were removed after 1 week treatment. The skin grafting coverage and wound healing time were recorded. Results And Conclusion: All patients of two groups got effective skin grafting coverage rate, and no patient appeared with infection and nonunion. The skin grafting coverage and wound healing time of the biomaterial group significantly differed from the synthetics group (P < 0.05). These findings indicate that compared to the synthetic material group, the biomaterial group can be better for effective drainage, good circulation, bacteria inhibition and fast repair.
BACKGROUND: The treatment of osteomyelitis is a worldwide problem, how to improve the cures rate of osteomyelitis is a current research emphasis. OBJECTIVE: To explore the effective treatment of traumatic osteomyelitis of the distal humerus by a combination therapy of external fixator, vacuum sealing drainage and pediculated latissimus dorsi myocutaneous flap transplantation. METHODS: During May 2006 to September 2013, 36 patients with distal humeral traumatic osteomyelitis were enrolled in this study, and were treated with a combined treatment, including external fixator, vacuum sealing drainage and the pedicle latissimus dorsi myocutaneous flap. Mayo elbow scoring system was applied to evaluate elbow joint function preoperatively and postoperatively. We adopted follow-up with outpatient service, telephone tracked and family visited. RESULTS AND CONCLUSION: All the involved 36 cases were followed up for 8 months to 6 years 8 months, average 4 years 3 months. The pedicle latissimus dorsi myocutaneous flaps were all survived, the biggest one was 40 cm × 13 cm and the least was 15 cm × 6 cm. 21 cases were treated using Orthofix external fixator, 11 cases with combined external fixator and 4 cases with Ilizarov circular external fixator. The fracture healing time was respectively 6-14 months, 10-16 months and 8-20 months. The average time of removing external fixator was 8 months. The postoperative elbow joint function was excellent in 3 cases, good in 19 cases, mild in 11 cases and poor in 3 cases. Among them, two cases recurred infection. At postoperative 3 months, 1 case appeared sinus again and was healed by debridement and iliac graft. One case with radial and median nerve injury had an elbow flexion of 100° and active extension active range of 20°, the wrist and fingers drop deformity was observed, fingers flexion contracted and stiffed, radial dorsal and flex sides of forearm were insensitive and subsided. Among the four cases, different degrees of tract exudation was visible in one or two pins, which cured after debridement and dressing. Small area skin defect in one case was healed after skin transplantation. Other cases were healed well, no iatrogenic nerve and vascular injury was observed. The combination therapy of external fixator, vacuum sealing drainage and pediculated latissimus dorsi myocutaneous flap transplantation is an effective treatment of traumatic osteomyelitis of the distal humerus. © 2014, Journal of Clinical Rehabilitative Tissue Engineering Research. All rights reserved.
Objectives:
To investigate the effect of vacuum sealing drainage in the patients with osteofascial compartment syndrome in comparison to conventional treatment.
Methods:
Fifty-two patients diagnosed with osteofascial compartment syndrome were enrolled in this study. They were randomly divided into two groups based on treatments: vacuum sealing drainage and conventional treatment. After operation, the length of hospital stay and antibiotics administration were recorded in the two groups, as well as swelling elimination and wound closure.
Results:
No significant difference was observed in terms of the baseline characteristics between the two groups. There are no obvious local or systemic complications in all cases. In contrast to conventional treatment group, the time of swelling elimination, wound closure, hospital stay and antibiotics application were reduced significantly in vacuum sealing drainage group. No allergic reactions or other side effects were observed after the application of vacuum sealing drainage material, indicating its safety.
Conclusion:
Vacuum sealing drainage is effective in treating osteofascial compartment syndrome with better clinical outcomes than conventional therapy.
BACKGROUND: Foot soft tissue defect can be repaired by skin flap transplantation technology. Vacuum sealing drainage technology can support a good tissue bed for skin flap transplantation, thereby to speed up the local growth of granulation tissue. OBJECTIVE: To further verify the application value of vacuum sealing drainage combined with flap transplantation in foot soft tissue repair. METHODS: A retrospective analysis was performed on the clinical data of 23 cases of foot soft tissue defects, and these 23 cases were divided into observation group (vacuum sealing drainage combined with flap transplantation; n=12) and control group (flap transplantation with no vacuum sealing drainage; n=11) according to the repair scheme. RESULTS AND CONCLUSION: The overall therapeutic excellent rate and survival rate of the flap in the observation group were significantly higher than those in the control group (both P < 0.05). All the 23 patients were followed up for 6 months, and the follow-up rate was 100%. In the observation group, the flaps survived well with red and yellow color, which were soft and had no distinct difference from the surrounding normal skin tissues. The therapeutic effect in the observation group was better than that in the control group. These findings indicate that vacuum sealing drainage combined with flap transplantation in foot soft tissue repair can achieve better effects in the repair of foot soft tissue defects and has certain value in clinical application. © 2015, Journal of Clinical Rehabilitative Tissue Engineering Research. All rights reserved.
Background
Patients with composite bone non-union and soft tissue defects are difficult to treat. Vacuum-assisted closure (VAC) combined with open bone grafting is one of the most effective treatments at present. The aim of the present study was to preliminarily investigate the effect and mechanism of VAC combined with open bone grafting to promote rabbit bone graft vascularization, and to propose a theoretical basis for clinical work.
Grade IIIB open tibia fractures are devastating injuries. Some clinicians advocate wound closure or stable muscle flap coverage within 72 hours to limit complications such as infection. Negative pressure wound therapy was approved by the FDA in 1997 and has become an adjunct for many surgeons in treating these fractures. Opinions vary regarding the extent to which negative pressure wound therapy contributes to limb salvage. Evidence-based practice guidelines are limited for use of negative pressure wound therapy in Grade IIIB tibia fractures. This systematic literature review of negative pressure wound therapy in Grade IIIB tibia fractures may substantiate current use and guide future studies.
We sought to answer the following: (1) Does the use of negative pressure would therapy compared with gauze dressings lead to fewer infections? (2) Does it allow flap procedures to be performed safely beyond 72 hours without increased infection rates? (3) Is it associated with fewer local or free flap procedures?
We conducted a systematic review of six large databases (through September 1, 2013) for studies reporting use of negative pressure wound therapy in Grade IIIB open tibia fractures, including information regarding infection rates and soft tissue reconstruction. The systematic review identified one randomized controlled trial and 12 retrospective studies: four studies compared infection rates between negative pressure wound therapy and gauze dressings, 10 addressed infection rates with extended use, and six reported on flap coverage rates in relation to negative pressure wound therapy use beyond 72 hours. None of the 13 studies was eliminated owing to lack of study quality.
Negative pressure wound therapy showed a decrease in infection rates over rates for gauze dressings in two of four studies (5.4% [two of 35] versus 28% [seven of 25], and 8.4% [14 of 166] versus 20.6% [13 of 63]), an equivalent infection rate in one study (15% [eight of 53] versus 14% [five of 16]), and an increased infection rate in the fourth study (29.5% [23 of 78] versus 8% [two of 25]). In terms of the second question regarding infection rates with negative pressure wound therapy beyond 72 hours, eight of 10 studies concluded there was no increase in infection rates, whereas two of 10 reported an increase in infection rates associated with negative pressure wound therapy use beyond 72 hours. Infection rates varied from 0% to 57% in these 10 studies. Five studies reported low infection rates of 0% to 7% and five reported rates of 27% to 57%. The third question (addressed by six studies) regarded the potential decreased use of a soft tissue flap in patients treated with extended negative pressure wound therapy. Flap rates were reduced by 13% to 60% respectively compared with those of historical controls. Grade IIIB tibia fractures by definition required soft tissue procedures. The patients in these six studies had Grade IIIB tibia fractures after the first débridement. However, after extended negative pressure wound therapy, fewer patients required flaps than grading at the first débridement would have predicted.
There is an increasing body of data supporting negative pressure wound therapy as an adjunctive modality at all stages of treatment for Grade IIIB tibia fractures. There is an association between decreased infection rates with negative pressure wound therapy compared with gauze dressings. There is evidence to support negative pressure wound therapy beyond 72 hours without increased infection rates and to support a reduction in flap rates with negative pressure wound therapy. However, negative pressure wound therapy use for Grade IIIB tibia fractures requires extensive additional study.
Level III, therapeutic study.
Microskin autografts with conventional wrap and compression are used extensively in the treatment of skin and tissue defects. This comparative study aimed at investigation of the clinical application of negative pressure wound therapy (NPWT) in combination with microskin autografts for repair of acute and chronic wounds.
A prospective case-control study was performed from December 1, 2010-December 31, 2013 in Changhai Hospital, Shanghai. We compared a study group of patients received microskin autografting covered by NPWT with that of a control group of patients received microskin autografting covered by a conventional gauze.
A total of 81 patients were in this study, 27 patients were allocated to the study group and 54 patients to the control group. The study group exhibited significant low infection rate and pain score during removal of inner layer at first dressing change after skin grafting compared with those of the control group (P < 0.05). The time interval between skin grafting and first postoperative change was longer in the study group than that in the control group (P < 0.01), the study group showed a significant shorter 95% wound healing time (P < 0.05), and survival rate of microskin autografts in the study group was higher than that in the control group (P < 0.05).
NPWT is beneficial for wound closure after microskin autografts, which prolongs the interval between skin transplantation and first postoperative dressing change, reduces pain during removal of inner layer dressing, increases skin graft survival rate, and shortens wound healing time. Therefore, NPWT can be recommended for repair of acute and chronic wounds with microskin autografts.
Copyright © 2015 Elsevier Inc. All rights reserved.
1. To determine whether negative pressure dressings (NPD) are superior to conventional compressive dressings (CD) for split-thickness skin grafts (STSG) placed on healthy, low-risk wounds. 2. To determine cost difference of NPD versus CD.
Retrospective SETTING:: Level I Trauma Center PATIENTS/PARTICIPANTS:: 195 traumatic wounds treated with STSG.
Patients were assigned outcomes based on postoperative documentation: completely healed, incompletely healed (small areas of graft necrosis), failed, or lost to follow-up. The costs associated with the each dressing type were documented.
35 of 195 STSG were lost to follow-up, leaving N=120 STSG-NPD, N=40 STSG-CD. Of the remaining 120 STSG treated with NPD, 91 completely healed, 23 incompletely healed, and 6 failed. Of the 40 STSG treated with a compressive dressing, 37 completely healed, 1 incompletely healed, and 2 failed. Patients treated with compressive dressings had higher likelihood of healing relative to the NPD (p = 0.018). Analyzing the outcomes as failed versus "not failed" revealed no significant difference between the groups (p = 1.00). There were more smokers in the compression dressing group (p=0.022). In this series, the mean cost associated with NPD compared to compressive dressing was $2,370 more per patient.
There is a high rate of successful healing of split-thickness skin grafts for traumatic extremity wounds regardless of dressing used. The increased cost of NPD is not justified in wounds that are at low risk for STSG failure.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
This study was set to explore a new strategy for repairing skin wounds, co-transplantation of mesenchymal stem cells from Wharton's Jelly of the human umbilical cord (hUC-Wharton's jelly-MSCs) and microparticles. A mixture of hUC-Wharton's jelly-MSCs and microparticles was co-transplanted to 10-mm diameter, full-thickness, mid-dorsal, excisional skin wounds of mice. After 7, 14, and 21 days, the tissue sections were sampled for reconstruction analysis and histological examination. Our results showed that hUC-Wharton's jelly-MSCs possess the potentials for multi-directional differentiation. After co-transplantation, there was remarkable development of newborn skin and its appendages. Newly generated layers of epidermis, sebaceous glands, hair follicle, and sweat glands were observed. This promising innovative strategy could significantly increase the quality of repair and regeneration of skin after injuries.
Abstract Purpose: To investigate the influence of vacuum sealing drainage on sciatic nerve repair after injury in rabbits. Materials and Methods: 24 New Zealand white rabbits were randomly divided into experimental group and control group. About 1cm sciatic nerve was transected and sutured it back in sute. The experimental group had vacuum sealing drainage assisted wound closure whereas the control group had normal wound closure. The nerve repair rate was compared based on nerve conduction velocity, lower leg triceps wet weight recovery rate, histology, immunohistochemical of brain-derived neurotrophic factor and ultrastructure observation of regenerated nerve by electron microscopy at the 4th and 8th week after surgery. Results: At the 1-2 week after surgery, irritation and ulcers was observed on the surgical side in both experimental group and control group. At the 4th and 8th week after surgery, electrical nerve conduction velocity in the experimental group was faster than control group (p < 0.05), triceps muscle calf wet weight recovery rate in the experimental group was higher than the control group, (p < 0.05). Brain-derived neurotrophic factor immunohistochemical staining intensity in experimental group was higher than control group (p < 0.05) and toluidine blue staining and electron microscopic observation showed that the nerve regeneration and repair was more pronounced in experimental group compared to control group. Myelinated nerve fibers in experimental group were more than the control group at the 4th weeks and the 8th week after surgery. Conclusion: Vacuum sealing drainage facilitates repair of peripheral nerve injury.
Introduction:
Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients.
Materials and methods:
Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups.
Results:
A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p<0.001).
Conclusion:
Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.
In this study, we aimed to evaluate the vascular structures of the lower limb with multidetector computed tomography (CT) angiography and to reveal the importance of this method in preoperative planning of microsurgical transplantation. In 24 patients, lower-limb arteries were bilaterally evaluated with 16-detector spiral CT scanner in terms of patency, stenosis, or occlusion; maximal and minimal external diameters through their traces; and variations as well as length of the peroneal artery. The peroneal artery was absent unilaterally in two patients (4.3%). The mean maximal and minimal diameters were as 2.77 and 1.63, 2.92 and 1.75, and 2.72 and 1.50 mm for anterior and posterior tibial and peroneal arteries, respectively. The ranges of lengths of peroneal arteries were 50 to 117 mm. This valuable tool can provide detailed information about vascular and the remaining anatomic structures by means of its high-resolution characteristics before planning free flap surgery.
To evaluate the effect of vacuum-assisted closure (VAC) therapy on wound management by measuring the graft take, wound healing time, need for any re-grafting and duration of hospitalization.
Single blinded randomized controlled trial.
This study was carried out in the Department of Plastic and Reconstructive Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from October 2007 to December 2009.
A total of 100 adult patients of either gender with acute traumatic wounds were included. Patients who needed flap coverage as the primary intervention, and those with Diabetes, malignancy, bleeding diathesis were excluded. Half of the patients were randomly assigned to the intervention group and the rest to the control group with lottery method. All wounds were initially subjected to thorough excision. Wound bed preparation for STSG (split thickness skin graft) was achieved using 10 days pre-treatment with VAC dressings in the intervention group while employing normal saline gauzes in the control group. All patients were subsequently treated with STSG. The primary outcome measure was graft take while the secondary outcome measures included wound healing time, need for any re-grafting and duration of hospital stay. Results were compared in both groups using chi-square test.
Marked differences were found in favour of the VAC therapy group with respect to the various wound management outcome measures studied. i.e. graft take (greater than 95% graft take in 90% of VAC therapy group vs. 18% of controls), wound healing time (2 weeks postgrafting in 90% of VAC therapy group vs. 18% of controls), need for regrafting (none among VAC therapy group vs. 8% of controls) and duration of hospital stay (less than 3 weeks in 90% of VAC therapy group vs. 18% of controls).
VAC therapy should be employed in the pre-treatment of wounds planned to be reconstructed with STSG, since it has marked advantages in the wound bed preparation compared with the traditional normal saline gauze dressings.
So far this article has been Cited by the following articles:
1) Peinemann F, Sauerland S. Negative pressure wound therapy. Systematic review of RCTs. Dtsch Arztebl Int 2011;108(22):381-9.
2) Christopher W, David C, Michael C, Steven D, Lucy L, Sarah P. Does treatment of split-thickness skin grafts with negative-pressure wound therapy improve tissue markers of wound healing in a porcine experimental model? Journal of Trauma and Acute Care Surgery 2012;73(2): 447–51
3) Vacuum Assisted Wound Therapy in the Outpatient Setting.www.empireblue.com/medicalpolicies/policies/mp_pw_a050281.htm
4) Landsman, A., Blume, P.A., Jordan Jr., D.A., Vayser, D., Gutierrez, A. An open-label, three-arm pilot study of the safety and efficacy of topical microcyn Rx wound care versus oral levofloxacin versus combined therapy for mild diabetic foot infections. (2011) Journal of the American Podiatric Medical Association
5) Scala, M., Spagnolo, F., Trapasso, M., Strada, P., Moresco, L., Santi, P. Association of vacuum-assisted closure and platelet gel for the definitive surgical repair of an enterocutaneous fistula: A case report (2012) In Vivo
6) Mrs. Chandan Sylvia D’souzaa. Study to assess the effectiveness of structured teaching programme on vacuum assisted closure therapy among staff nurses working in selected hospitals at Bangalore. Rajiv Gandhi University of Health Sciences. Bangalore, Karnataka
7) 何东红， 郑光辉， 骆丽君， 姜亮， 徐琳， 郭琳玲… - 齐齐哈尔医学院 …, 2012 - 万方数据资源系统
8) Muhammad Saaiq. VAC Therapy: A Valuable Adjunct to Wound Care Armamentarium. Ann Pak Inst Med Sci 2012;8(2):
9) EA Azzopardi, DE Boyce, WA Dickson… - Annals of plastic …, 2013 - journals.lww.com. Application of topical negative pressure (VAC) to split thickness skin grafts: A structured eveidence based review.
Use of topical negative pressure over difficult-to-heal wounds has been studied. The objective of this study was to analyze the effects from negative pressure in the treatment of complex wounds.
Case series developed at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo.
Twenty-nine patients with complex wounds were treated with the vacuum system and then underwent a surgical procedure to close the wound.
85% of the skin grafts took well, and 87.5% of the local flaps were successful, thus demonstrating adequate wound preparation. The wounds were closed within shorter times than observed using other conventional treatments In two cases, the vacuum system was also used to stabilize the skin grafts over the wounds.
Use of the vacuum method is safe and efficient for preparing wounds for surgical closure. It allows for an improvement of local wound conditions, and healthy granulation tissue develops with control over local infection.
To explore the surgical technique and clinical value of treatment for posttraumatic large circular soft tissue defect in the lower extremities using a combination of posterior tibial vascular bridge flap in the unaffected leg and skin graft covered by vacuum sealing drainage (VSD).
From January 2008 to June 2010, 11 cases with posttraumatic large circular soft tissue defects with deep tissue exposed or partial necrosis in the lower extremities were treated by bridge flaps and combined with free skin graft covered by VSD. There are 7 males and 4 females, with an average age of 32.5 years (range from 15 to 52 years). The size of wound varied from 24 cm × 13 cm to 45 cm × 24 cm. After the wound were completely debrided, the external fixation or internal fixation was conducted for the patients with unstable fracture. Then VSD were used to covered the wound for 1-2 times with a period of 5 to 7 days according to the wound condition. After granulation tissue grew, bridge flap transplantation was performed to repair tissue defect and cover the exposed bone, which combined with skin graft covered by VSD was used to cover the residual wound. Survival rate and quality healing of the flaps were followed up postoperatively.
The granulation growth of 11 cases with large circular soft tissue defect in the lower extremities associated tissue exposure was good after the application of VSD. All the cases were covered by free flap transplantation and skin grafting except for 6 cases due to large defect. The wound was covered by skin re-grafting in 4 cases and frequently dressing change in 2 cases. All the flaps were successful with good infection control and no sinus. The average period of follow-up was 10.6 months (5 - 24 months). All the patients were satisfied with the good outline and good function of the affected limb.
Patients with posttraumatic large circular soft tissue defect in the lower extremities can be effectively treated with a combination of bridge flaps and free skin graft covered by VSD, which can shorten the course of treatment, and restore the function of affected extremities as much as possible.
Negative pressure (wound) therapy, synonymous with topical negative pressure or vacuum therapy mainly cited as branded VAC® (vacuum-assisted closure) therapy, is a mode of therapy used to encourage wound healing. It is used both as primary treatment of chronic and complex wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. The device has come into wide and successful use, although the physiological basis of its effect is not yet fully understood, and with a delay, increasingly evidence-based data become available. A meta-analysis was made of peer-reviewed publications (PubMed-Medline) chosen on the basis of inclusion of the terms randomized clinical trial, vacuum-assisted closure, and topical negative pressure. Scientific data were evaluated from experimental animal studies, randomized clinical trials, observations of clinical applications, and case reports on all known effects of VAC therapy. Systematic analysis of the data shows efficacy concerning induction of wound healing mechanisms, especially in the early stage. Increased perfusion can be considered proven. Data analysis shows positive efficacy for treatment of infection. Although this therapy appears effective and its superiority to conventional techniques has been demonstrated, there are still some critical votes concerning efficacy. Because its mechanisms of action remain unclear, and because there is still some gap between evidence-based data and the excellent clinical results, further prospective, randomized, blinded studies are needed. Even so, we conclude that vacuum therapy, used when indicated and especially by experienced surgeons, is an excellent tool to support wound healing.
The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others.
Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application.
From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded.
The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage.
The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.
The effects of negative pressure wound therapy (NPWT) on wound edge microvascular blood flow are not clear. The aim of the present study was therefore to further elucidate the effects of NPWT on periwound blood flow in a porcine peripheral wound model using different blood flow measurement techniques. NPWT at -20, -40, -80, and -125 mmHg was applied to a peripheral porcine wound (n = 8). Thermodiffusion, transcutaneous, and invasive laser Doppler velocimetry were used to measure the blood perfusion 0.5, 1.0, and 2.5 cm from the wound edge. Thermodiffusion (an invasive measurement technique) generally showed a decrease in perfusion close to the wound edge (0.5 cm), and an increase further from the edge (2.5 cm). Invasive laser Doppler velocimetry showed a similar response pattern, with a decrease in blood flow 0.5 cm from the wound edge and an increase further away. However, 1.0 cm from the wound edge blood flow decreased with high pressure levels and increased with low pressure levels. A different response pattern was seen with transcutaneous laser Doppler velocimetry, showing an increase in blood flow regardless of the distance from the wound edge (0.5, 1.0, and 2.5 cm). During NPWT, both increases and decreases in blood flow can be seen in the periwound tissue depending on the distance from the wound edge and the pressure level. The pattern of response depends partly on the measurement technique used. The combination of hypoperfusion and hyperperfusion caused by NPWT may accelerate wound healing.
The aim of the study is to evaluate the surgical technique and clinical significance of the sequential therapy of vacuum sealing drainage (VSD) and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities.
Twenty-two children (aged from 3 to 10 years) received sequential therapy of VSD and free-flap transplantation. All cases suffered from extensive area soft-tissue defects and exposure or partial defects of bones, tendons and other deep tissues. The wound sizes varied from 10 cm × 6 cm to 30 cm × 22 cm. Amongst 22 cases, 12 cases had fresh wounds and the remaining 10 children had necrotising infection. After complete debridement, the wounds were covered by VSD. External fixation or Kirschner-wire fixation should be performed for the cases complicated by unsteady fractures. After the removal of negative pressure VSD devices, free-flap transplantations were performed in 8 cases after debridement, and 14 cases received combined therapy of free-flap transplantation and skin grafting depending upon the severity of soft-tissue and deep-tissue defects. The flap survival and wound healing were followed up postoperatively.
After VSD treatment, the infection of deep-tissue exposure was effectively prevented, and granulation tissues surrounding the exposed areas of tendons and bones grew well. All patients who received free-flap transplantation at the second stage survived without the occurrence of vascular crisis, infection or sinus formation. During follow-up ranging from 6 to 24 months, all the patients were satisfied with the morphological appearance and functional recovery of the affected limbs.
Sequential therapy of VSD and free-flap transplantation can serve as a reliable option for children with extensive soft-tissue defects below the knee in the extremities and exposed deep tissues, after complete debridement, which significantly shortens remedy period, enhances success rate for surgery and achieves maximal restoration of limb function.
Several randomized controlled trials comparing negative-pressure therapy to standard wound care for chronic wounds have been published. Although these studies suggest a benefit for negative-pressure therapy, the majority of the review articles on the topic conclude that the studies are inconclusive. The authors conducted a quantitative meta-analysis of the effectiveness of negative-pressure therapy for the management of chronic wounds.
The MEDLINE, EMBASE, and Cochrane databases were searched from 1993 to March of 2010 for randomized controlled trials comparing negative-pressure therapy to standard wound care for chronic wounds. Measures of wound size and time to healing, along with the corresponding p values, were extracted from the randomized controlled trials. Relative change ratios of wound size and ratios of median time to healing were combined using a random effects model for meta-analysis.
Ten trials of negative-pressure therapy versus standard wound care were found. In the negative-pressure therapy group, wound size had decreased significantly more than in the standard wound care group (relative change ratio, 0.77; 95 percent confidence interval, 0.63 to 0.96). Time to healing was significantly shorter in the negative-pressure therapy group in comparison with the standard wound care group (ratio of median time to healing, 0.74; 95 percent confidence interval, 0.70 to 0.78).
This quantitative meta-analysis of randomized trials suggests that negative-pressure therapy appears to be an effective treatment for chronic wounds. An effect of publication bias cannot be ruled out.
Therapeutic, II.
The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury.
Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009.
103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications.
Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.
Both negative wound pressure therapy (NPWT) and hyperbaric oxygen therapy (HBOT) are useful modalities in the treatment of problem wounds. However, none of the commercially available portable negative-pressure devices have been certified safe for use in a recompression chamber. Thus, the NPWT device is removed while the patient undergoes HBOT. The purpose of this study is to demonstrate that wound negative pressure can be effectively and safely maintained during HBOT.
In a small, prospective, randomised crossover trial, we used commonly available clinical materials to connect the NPWT suction tubing to the negative suction generating device in the hyperbaric chamber. Six patients each underwent one HBOT session with continuous NPWT and one HBOT session without concurrent NPWT. We assessed the patient's pain score, the amount of exudate aspirated by the NPWT during HBOT, and the appearance of the wound dressing after each session was assessed in a blinded manner.
There were no differences in pain scores between the two HBOT sessions. The amount of exudate aspirated during HBOT with NPWT ranged from 5 to 12 ml. Five of the six patients had a better appearance scoring of their dressing when NPWT was maintained during HBOT (P = 0.006).
We successfully demonstrated a simple design that allows the maintenance of NPWT during HBOT without causing additional pain, and with continued extraction of exudate. The maintenance of NPWT during HBOT also allowed the dressing to be maintained undisturbed.
Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional flaps may not be large enough or lack the versatility that allows precise tissue positioning to optimally cover the wound. The anterolateral thigh-vastus lateralis conjoint flap provides a superior reconstructive solution for these difficult wounds.
From Jan 2010 to June 2011, seven patients were reconstructed with the anterolateral thigh-vastus lateralis conjoint flap. Three cases were traumatic degloving injury of the lower limb, three were open fractures of the tibia with extensive soft-tissue loss and one was a large soft-tissue defect as a result of necrotising fasciitis. The skin island and muscle component were raised with independent pedicles to allow complete freedom in the inset of each flap based on a common pedicle. The descending and oblique branches of the lateral circumflex femoral artery were used as the pedicle of the conjoint flap in four and three cases, respectively.
The mean size of the skin flap was 355 cm(2) (range: 312-420 cm(2)) and the volume of the muscle flap was 210 cm(3) (range: 42-360 cm(3)). All flaps survived completely and no infective complications were noted in our patients. The skin and muscle component were widely separated to expand the area of coverage. In cases where specific areas of the wound were severely traumatised with significant tissue loss, the muscle component can be precisely positioned to obliterate the dead space and to optimise soft-tissue coverage of the wound.
The anterolateral thigh-vastus lateralis conjoint flap is superior to conventional flaps available for coverage of extensive defects of the lower limb. It can cover far greater area as well as providing the versatility needed to optimise soft-tissue coverage.
An entire generation of orthopaedic and plastic surgeons has been indelibly and perhaps overwhelmingly influenced by the introduction of microvascular technology to the fields of limb salvage and musculoskeletal reconstruction. Free-tissue transfer using microsurgical techniques has become a valuable method for the salvage of lower extremities after trauma. The goals of free flaps are both soft-tissue coverage and improvement of the functional outcome. The flap selection criteria for lower extremity reconstruction are based on the wound surface area, the type of tissue deficiency, length of the pedicle, volume of deficient tissue components and donor site morbidity. Composite flaps represent the state-of-the-art for reconstructive microsurgery, providing more than one function. Although many different treatment protocols have been proposed, they all highlight the importance of early tissue coverage with bone management performed in a later stage.
Topical negative pressure (TNP) therapy has become a useful adjunct in the management of various types of wounds. However, the TNP system still has characteristics of a "black box" with uncertain efficacy for many users. We extensively examined the effectiveness of TNP therapy reported in research studies.
A database search was undertaken, and over 400 peer-reviewed articles related to the use of TNP therapy (animal, human, and in vitro studies) were identified.
Almost all encountered studies were related to the use of the commercial VAC device (KCI Medical, United States). Mechanisms of action that can be attributed to TNP therapy are an increase in blood flow, the promotion of angiogenesis, a reduction of wound surface area in certain types of wounds, a modulation of the inhibitory contents in wound fluid, and the induction of cell proliferation. Edema reduction and bacterial clearance, mechanisms that were attributed to TNP therapy, were not proven in basic research.
Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.
Acute and chronic wound infections are the main reasons for the observed increase in mortality rate and represent a significant risk factor in hospitalisation. From the patient's perspective, wound therapy is an uncomfortable, painful and long-term treatment. Modern sternal-wound-treatment systems would be expected to shorten wound healing and hospital stay periods. Vacuum-assisted closure (VAC) therapy is a system that promotes wound healing through the application of negative pressure by controlled suction to the wound surface. The application of controlled levels of negative pressure accelerates healing in many types of wounds. There are a number of scientific publications that have used meta-analysis to compare VAC and traditional therapy, considering changes in wound size. This article surveys the research literature focussing on the management of wound infections. The objective of this study is to assess the impact of VAC compared with conventional therapy on length of stay (LOS) and mortality. Six articles were selected that included a total of 321 patients (169 for VAC therapy and 152 for conventional therapy). The meta-analysis showed that VAC therapy resulted in a decrease of 7.18 days in hospital LOS (confidence interval (CI) 95%: 10.82, 3.54), with no significant impact on mortality. Our data provide robust evidence of the effectiveness of VAC therapy.
To observe the clinical efficacy of artificial skin combined with vacuum sealing drainage (VSD) in treating large-area skin defects.
Totally 18 patients with skin defects, treated with artificial skin combined with VSD from September 2008 to May 2009 in our hospital, were retrospectively analyzed in this study. There were 15 males and 3 females, aged 7-66 years, 34.3 years on average. Among them, 10 cases had skin laceration caused by traffic accidents (7 with open fractures), 1 mangled injury, 1 blast injury, 1 stump infection combined with skin defects after amputation and 5 heel ulcers.
All skin grafts in 16 cases survived after being controlled by VSD for one time. For the rest 2 patients, one with skin avulsion on the left foot was given median thickness skin grafts after three times of VSD, the other with open fractures in the left tibia and fibula caused by a traffic accident was given free flap transplantation. Skin grafts of both patients survived, with normal color and rich blood supply.
Skin grafting in conjunction with artificial skin and VSD is much more effective than traditional dressing treatment and worth wide application in clinic.
This retrospective study compared the clinical outcomes of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum-Assisted Therapy® (V.A.C.® Therapy, KCI Licensing Inc., San Antonio, TX) to non-NPWT/ROCF conventional therapy (CT) in split-thickness skin graft (STSG) survival in all patients to determine whether NPWT/ROCF affects the outcome of the graft survival, in terms of overall graft take, duration of graft take, repeated grafts and complications.
The authors conducted a 10-year retrospective review of 142 patients admitted to a level I trauma centre and treated with an STSG in foot and ankle reconstructive surgeries. Demographic data, wound etiology, dressing type used, time to graft take, NPWT/ROCF duration, complications and outpatient treatments were analysed. There were significantly fewer repeated STSGs required in the NPWT/ROCF group compared to CT [n = 3 (3·5%) versus n = 9 (16%); P = 0·006]. In assessing safety, there were fewer complications in graft failure (seroma, hematoma and infection) in the NPWT/ROCF group as compared to the CT group at 8·9 months (range: 1–12 months). NPWT/ROCF is an excellent alternative for securing an STSG and is associated with improved graft survival as measured by a reduction in the number of repeated STSGs and graft failure complications.
To evaluate the impact of negative pressure wound therapy (NPWT) after severe open fractures on deep infection.
Prospective randomized study.
Academic level I trauma center.
Fifty-nine patients with 63 severe high-energy open fractures were enrolled in this study, with data available on 58 patients with 62 open fractures.
Twenty-three patients with 25 fractures randomized to the control group and underwent initial irrigation and debridement followed by standard fine mesh gauze dressing, with repeat irrigation and debridement every 48-72 hours until wound closure. Thirty-five patients randomized to the NPWT group and had identical treatment except that NPWT was applied to the wounds between irrigation and debridement procedures until closure.
The presence or absence of deep wound infection or osteomyelitis, wound dehiscence, and fracture union were primary outcome measures.
Control patients developed 2 acute infections (8%) and 5 delayed infections (20%), for a total of 7 deep infections (28%), whereas NPWT patients developed 0 acute infections, 2 delayed infections (5.4%), for a total of 2 deep infections (5.4%). There is a significant difference between the groups for total infections (P = 0.024). The relative risk ratio is 0.199 (95% confidence interval: 0.045-0.874), suggesting that patients treated with NPWT were only one-fifth as likely to have an infection compared with patients randomized to the control group. NPWT represents a promising new therapy for severe open fractures after high-energy trauma.
To evaluate the results and complications of combined simultaneous arterial re-vascularisation and free flap transfer in patients with critical limb ischaemia and large soft-tissue defects that would otherwise have required major amputation.
Retrospective analysis of all combined procedures performed between 1993 and 2007 with regard to complications and outcome.
Seventy-eight procedures were performed in 76 patients with a mean age of 60 years (range: 18-80 years). The majority had diabetes (70.5%). Follow-up was obtained from hospital charts and telephone contacts with patients or GPs.
The limb-salvage rate was 93% after 1 year, 80% after 3 years and 71% after 5 years. Perioperative complications occurred in 50% of the patients; six out of 78 (7.7%) arterial reconstructions and 13 out of 78 (16.7%) flaps had to be revised during the early postoperative period. However, most flaps could be saved by a secondary procedure resulting in an early failure (amputation) rate of 6%. In-hospital mortality was 3.8%. End-stage renal disease was the only factor predicting limb loss. In total, 65% of the patients survived and were able to walk on their reconstructed limb at 1-year follow-up. Combined survival and limb-salvage rates were 85%, 66% and 51% after 1, 3 and 5 years.
Combined arterial re-vascularisation and free flap transfer can be performed safely with acceptable morbidity and mortality and should be considered for every mobile patient with large soft-tissue deficit (>10cm(2)) without end-stage renal disease prior to major amputation.
The cost of treating complex traumatic wounds is substantial because of trauma severity, potential for infection, and delayed closure. Negative pressure wound therapy using reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum-Assisted Closure* (KCI Licensing, Inc, San Antonio, Texas) is an established, viable option for treating traumatic wounds. The authors used retrospective data to study the clinical and cost-effective benefits of using NPWT/ROCF early on day 1 or day 2 of treatment for traumatic wounds as compared with using it late (on day 3 or later).
Hospital data records from trauma wound patients treated with NPWT/ROCF were retrospectively analyzed. Data were subdivided into 2 groups based on start of treatment. The group of patients treated on day 1 or 2 of their hospital stay was referred to as the early group, and that composed of patients treated on day 3 or later as the late group. Clinical and cost-effective metrics were compared between the 2 groups.
For the early group, 518 patient records were included; 1000 records were reviewed for the late group. Early-group patients had fewer hospital inpatient days (10.6 vs 20.6 days; P < .0001), fewer treatment days (5.1 vs 6.0 days; P = .0498), shorter intensive care unit (ICU) stays (5.3 vs 12.4 days; P < .0001), and higher ICU admission rates (51.5 vs 44.5%; P = .0091) than the late group. Compared with late-group patients, early-group patients had lower total and variable costs per patient discharge ($43,956 vs $32,175; P < .0001 and $22,891 vs $15,805; P < .0001, respectively).
Acute-care trauma wound patients receiving early NPWT/ROCF demonstrated significant reductions in length of stay, treatment days, and ICU stay, which resulted in significant reduced patient treatment costs. These results indicate that early intervention with NPWT/ROCF has potential clinical and cost-effective benefits for the treatment of traumatic wounds.
In free flap transfer, the recipient vessel is often sacrificed to provide the pedicle anastomosis. As the recipient vessel is likely necessary for distal circulation, preserving its patency is also important, especially in the extremities of aged or chronic vasculopathy patients, such as those with diabetes. If a reliable proximal branch is included in the T-shaped pedicle preparation, the pedicle can be interposed between two ends of the recipient vessel, thus allowing for T-anastomosis. This technique can be used to preserve recipient flow as well as for other clinical purposes depending on the recipient vessel condition. T-anastomosis was planned in cases that required the recipient flow to be preserved, for example, if peripheral vasculopathy was present. Various clinical applications of T-anastomosis have been performed, such as preserving recipient flow, preserving donor flow, rebuilding deficient vascular flow, balancing and dispersing blood flow or pressure, chimeric patterns, reusing a pedicle in the staged reconstruction or a combination of the above. Vascular systems with reliable proximal branches of the proper diameters, such as subscapular or lateral circumflex femoral vessels, appear to be good source vessels for the T-shaped pedicle. The T-anastomosis was used in 45 cases for single and dual purposes. The dominant recipient vessel was preserved in 11 extremity reconstructions, and a single remnant recipient vessel was saved in six traumatic extremities and four chronic vasculopathy patients. The recipient vessels that were selected for preserving the flow included the posterior tibial (n=21), anterior tibial (n=8), radial (n=3), ulnar (n=2) and other arteries. The source vessel of the latissimus dorsi or anterolateral thigh perforator flap was most often used for preparing the T-shaped pedicle. T-anastomosis of the pedicle in the free flap transfer is another reliable option for preserving recipient flow. In addition, the anastomosis is quite useful in difficult recipient sites and for many purposes, such as chronic diabetes or traumatic vascular injury. With this technique, a single recipient vessel can be reused in a staged reconstruction. In perforator flaps, the concentrated flow through a narrow perforator pedicle with a small diameter can be dispersed until the autoregulation of new flow distribution in the flap is stabilised.
Contoured wounds needing closure with skin grafts are often located in complex anatomic regions or are in unusual positions, which make conventional skin graft stabilization techniques cumbersome and ineffective. Often after 72 hours, a skin graft covered with a bolstered dressing has poor take secondary to shear stresses, as well as hematoma formation or serum collection, negating the effectiveness of the stabilizing dressing. The Food and Drug Administration has recently approved vacuum-assisted closure (V.A.C.), an innovative technique using negative pressure, for closure of chronic wounds. This reportedly leads to enhanced granulation tissue formation and consequently more rapid reepithelialization of wounds compared with conventional packing with saline-moistened gauze. Experimental studies have demonstrated increased oxygen tension, decreased bacterial counts, and increased granulation formation occurring under negative-pressure systems. Extending the use of this concept, we have coupled skin grafting with negative-pressure dressings for closure of large, complex open wounds. Our results indicate greater than 95% graft take in all patients in this study. This technique is extremely efficacious, with increased graft take due to total immobilization of the graft, thereby limiting shear forces, elimination of fluid collections, bridging of the graft, and decreased bacterial contamination. Moreover we have noted decreased edema in rotated muscle flaps, improved contour conformity, and shortened hospitalizations.
The coverage of large soft-tissue defects usually requires a large flap transfer, especially in a combination and expanded form. However, some large soft-tissue defects still cannot be covered by such flaps. In this article, we present a case of a civil war injury in a patient from Afghanistan who had severe trauma to the right knee, lower thigh, and upper leg and a marked soft-tissue defect. This large soft-tissue defect was covered with a large combined free flap of the expanded parascapular and latissimus dorsi muscle, including a large retrograde hinge flap of the tissue expander capsule and a complementary skin graft. The defect was covered completely, and the final result was excellent.
Topical negative pressure (TNP) has achieved widespread use in the treatment of problematic wounds. We report the case of a patient treated with TNP for groin-wound dehiscence following inguinal block dissection. During treatment, clinical signs of sepsis developed, in association with a progressively worsening anaerobic wound infection. This infection settled with antibiotic therapy and cessation of TNP treatment. We postulate that the air-free environment created by TNP potentiated the growth of the anaerobic bacteria, resulting in significant sepsis, and therefore recommend close surveillance of bacterial flora while using this therapy, particularly in susceptible patients.
To evaluate the results of a vacuum-assisted closure device in patients presenting with open high-energy soft tissue injuries.
Consecutive nonrandomized clinical study.
From August 1999 through October 2000, 21 patients, with 21 high-energy soft tissue wounds (6 tibial, 10 ankle, and 5 with wounds of the forearm, elbow, femur, pelvis, and a below-knee stump) were treated with a vacuum-assisted closure device at a Level 1 trauma center.
A negative atmospheric pressure device used for the management of complex open injuries. Infected wounds had dressings changed every 48 hours, whereas all others had dressings changed every 72 to 96 hours.
The duration of vacuum-assisted closure use, final wound closure outcome, costs versus standard dressing changes or free flaps, and a list of all complications were recorded. All patients were followed for 6 months postcoverage.
Patients averaged 4.1 sponge changes, 77% performed at bedside, with the device used an average of 19.3 days. Twelve wounds (57%) required either no further treatment or a split-thickness skin graft, and 9 (43%) required a free tissue transfer.
The vacuum-assisted closure appears to be a viable adjunct for the treatment of open high-energy injuries. Application can be performed as a bedside procedure but additional soft tissue reconstruction may be needed for definitive coverage. This device does not replace the need for formal debridement of necrotic tissue, but it may avoid the need for a free tissue transfer in some patients with large traumatic wounds.
We reconstructed a large-sized defect at the weight-bearing plantar region by a free anterolateral thigh flap successfully. This is the first case report of using the anterolateral thigh flap for reconstruction of the plantar foot. Based on the preoperative and postoperative pedogram examinations, the pressure distribution on the weight-bearing area reconstructed by the transferred flap was obviously improved and demonstrated a nearly normal pattern. No previous report has compared the weight-bearing pattern before and after large plantar reconstruction with a free flap. The anterolateral thigh free flap, which provides adequate bulk and contour of the foot, and which withstands weight pressure and shearing force and has the ability to provide recovery of sensation, is considered a good alternative in covering a large weight-bearing plantar defect.
From our own experience, the VAC is a promising new technology in the field of wound healing. With multiple applications in a variety of wounds including those that can prove difficult to heal: pressure sores, amputation sites, skin grafts, lower limb ulceration, sternotomy wounds, burns and abdominal wounds. Broadly speaking, the applications are for both acute and chronic wounds, salvage procedures or as an adjuvant therapy to improve results of various surgical procedures.
¹
• Banwell P.E.
• Teotl L.
Topical negative pressure (TNP): the evolution of a novel wound therapy.J Wound Care. 2003; 12: 28-30
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A flow-through flap is useful in cases where the recipient artery must not be sacrificed. The aim of this study was to investigate Y-shaped configurations in the subscapular arterial system that can safely be used in harvesting a flow-through flap from the scapular region.
Sixteen dissections of the subscapular arterial system were carried out in eight embalmed cadavers. The origins and external diameters of branches in the subscapular arterial system were recorded. The distances between the origins of each branch were measured.
The branches that showed a consistent presence and had a reliable diameter of more than 1.0 mm were the circumflex scapular artery, the bony branch of the circumflex scapular artery, the thoracodorsal artery, the angular branch, and branches to the serratus anterior and latissimus dorsi muscles. It was demonstrated that using the Y-shaped configuration between these branches enables the harvesting of a flow-through flap in various length versions of the Y-shaped vascular pedicles. A significant anatomical variation (i.e., both the thoracodorsal and circumflex scapular artery arose directly from the axillary artery) was found in three of 16 dissections. In this vascular variation, sacrificing the axillary artery must be avoided, so Y-shaped pedicles using the origin of the thoracodorsal or circumflex scapular artery cannot be created. On the basis of these results, flow-through flaps using this arterial system were applied in 10 patients for reconstruction of lower extremities, and satisfactory results were obtained.
The results of our study are available for determining preoperatively and intraoperatively which Y-shaped configuration to use in harvesting a flow-through flap from the scapular region.
Current treatment modalities for chronic leg ulcers are time consuming, expensive, and only moderately successful. Recent data suggest that creating a subatmospheric pressure by vacuum-assisted closure (V.A.C., KCI Concepts, San Antonio, Texas) therapy supports the wound healing process.
The efficacy of vacuum-assisted closure in the treatment of chronic leg ulcers was prospectively studied in a randomized controlled trial in which 60 hospitalized patients with chronic leg ulcers were randomly assigned to either treatment by V.A.C. or therapy with conventional wound care techniques. The primary outcome measure was the time to complete healing (days). Statistical analysis was performed on the intention-to-treat basis.
The median time to complete healing was 29 days (95% confidence interval [CI], 25.5 to 32.5) in the V.A.C. group compared with 45 days (95% CI, 36.2 to 53.8) in the control group (P = .0001). Further, wound bed preparation during V.A.C. therapy was also significantly shorter at 7 days (95% CI 5.7 to 8.3) than during conventional wound care at 17 days (95% CI, 10 to 24, P = .005). The costs of conventional wound care were higher than those of V.A.C. Both groups showed a significant increase in quality of life at the end of therapy and a significant decrease in pain scores at the end of follow-up.
V.A.C. therapy should be considered as the treatment of choice for chronic leg ulcers owing to its significant advantages in the time to complete healing and wound bed preparation time compared with conventional wound care. Particularly during the preparation stage, V.A.C. therapy appears to be superior to conventional wound care techniques.
The aim of this review was to provide a comprehensive actual overview of the Vacuum Assisted Closure therapy (VAC). VAC is new method for wound treatment. VAC is assigned especially for per secundam healed wounds. Open-cell foam is placed into the wound with the evacuation drain. The wound side and foam are then covered with an adhesive drape. The evacuation drain is connected to a computerized vacuum pump. The VAC removes excess fluid, reduces the number of microorganisms and increases temperature in the wound. Mechanical stress causes granulation tissue formation and neoangiogenesis. The most of published studies present positive influence of VAC for wound healing. The newest studies present positive influence for healing of contaminated wounds, wounds after thoracic surgery, traumatic wounds and also for wounds of diabetic patients. The use of VAC for oncology patients is controversial, but there are some studies to present VAC positive effect in these cases, too. However there are a few studies to present negative complications of VAC, especially increase of microorganisms in the wound. For all that VAC is not standard for wound healing treatment now, presented studies point out that VAC can by used in generally surgery.
Vacuum-assisted closure wound therapy (vacuum therapy) has been used in our department since 1997 as a tool to bridge the period between debridement and definite surgical closure in full-thickness wounds. We performed a prospective randomised clinical trial to compare the efficacy of vacuum therapy to conventional moist gauze therapy in this stage of wound treatment.
Treatment efficacy was assessed by semi-quantitative scoring of the wound conditions (signs of rubor, calor, exudate and fibrinous slough) and by wound surface area measurements. Tissue biopsies were performed to quantify the bacterial load. Besides this, the duration until 'ready for surgical therapy' and complications encountered during therapy and postoperatively were recorded.
Fifty-four patients were included (vacuum n=29, conventional n=25). With vacuum therapy, healthier wound conditions were observed. Furthermore, a tendency towards a shorter duration of therapy was found, which was most prominent in late-treated wounds. In addition, the wound surface area reduced significantly faster with vacuum therapy. Surprisingly, these results were obtained without a decrease in the number of bacteria colonising the wound. Complications were minor, except for one case of septicaemia and one case of increased tissue necrosis, which compelled us to stop vacuum therapy. For the treatment of full-thickness wounds, vacuum therapy has proven to be a valid wound healing modality.
A review of the evidence base for the use of vacuum-assisted closure (VAC) therapy is presented, analysing both experimental and clinical data.
A large number of aids have been conceived and introduced into clinical practice (nutritional supplements, local dressings, technical innovations) aimed at facilitating and optimising wound healing in both acute and chronic wound settings. Among these advances, negative pressure wound therapy (NPWT) has been introduced during the last 30 years, and has been analysed in over 400 manuscripts of the English, Russian and German literature. Until very recently, vacuum assisted closure (VAC) (KCI, TX, USA) has been the only readily available commercial device that provides localised negative pressure to the wound and is the predominant agent used to deliver NPWT featured in this review. We conducted a comprehensive review of the existing clinical evidence of the English literature on the applications of NPWT in the acute setting of trauma and burns of the lower extremity. Overall, 16 clinical studies have been evaluated and scrutinised as to the safety and the efficacy of this adjunct therapy in the specific environment of trauma. Effectiveness was comparable to the standard dressing and wound coverage methods. The existing clinical evidence justifies its application in lower limb injuries associated with soft tissue trauma.
Controversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC((R))) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction.
We retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection.
A total of 29 male and 13 female patients with 33 open fractures of the lower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC((R)) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay.
According to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature. This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients.
- A V Korompilias
- M G Lykissas
- M D Vekris
Korompilias AV, Lykissas MG, Vekris MD et al: Microsurgery for lower extremity injuries. Injury, 2008; 39(Suppl.3): S103-8