The use of external fixation combined with vacuum sealing drainage to treat open comminuted fractures of tibia in the Wenchuan earthquake

A case report of delayed treatment of acute exertional osteofascial compartment syndrome in the anterior compartment of the calf

RATIONALE

Acute exertional osteofascial compartment syndrome (OCS) is a rare cause of lower-leg pain and is often associated with delayed diagnosis, which can lead to irreversible muscle and nerve damage.

PATIENT CONCERNS

A 23-year-old man presented with acute-onset anterior calf pain and ankle dorsiflexion after hiking.

DIAGNOSIS

The patient's pain was initially diagnosed as muscle strain at a county hospital, but was eventually diagnosed as OCS at our hospital 8 days after the injury. This case presents several challenges in the diagnosis and treatment phases.

INTERVENTIONS

Three surgeries were performed in total. On the day after admission (9 days after injury), fasciotomy was performed, followed by vacuum sealing drainage (VSD). Six days after the first surgery, necrotic muscle debridement was performed and VSD was reperformed. Ten days after the second surgery, the covering foam material was removed and the incision was sutured.

OUTCOMES

Satisfactory postoperative results were achieved. The erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count were within normal ranges. The skin healed well, and nerve damage and muscle strength improved significantly 3 months after surgery.

LESSONS

OCS in the absence of trauma or fracture is rare, but treatment delays can have devastating consequences. Acute nontraumatic OCS requires prompt diagnosis and surgical intervention to prevent adverse outcomes. VSD is an effective surgical treatment for this disease.

Negative pressure wound therapy promotes healing and reduced pain in patients with acute suppurative mastitis

Background

The purpose of this study was to compare the outcomes of vacuum sealing drainage (VSD) and conventional incision and drainage (I&D) for treating acute suppurative mastitis.

Methods

Hospital medical records were searched for patients 20–50 years of age who were diagnosed with acute suppurative mastitis from January 2014 to December 2018, and treated with traditional I&D or VSD. Patients were divided into those treated with VSD and I&D, and outcomes including pain, healing time, length of hospital stay, and length of antibiotic course were compared between the groups. Pain was evaluated with a numeric rating scale from 0 (no pain) to 10 (most severe pain). Subgroup analysis of lactating women was also performed.

Results

There were 110 women who received traditional I&D, and 105 women that received VSD included. The 2 groups were similar with respect to age (31.1 ± 4.8 vs. 29.9 ± 4.4, p = 0.058), and disease characteristics. The median pain score of women who received VSD (5 [IQR 5–6]) was significantly less than that of women who received I&D (8 [IQR 7–8]) (p < 0.001). The time for healing was significantly less in women who received VSD (40 days [IQR 30–45 days]) compared to I&D (60 days [IQR 45–70 days]) (p < 0.001). The length of hospital say and the length of antibiotic treatment were similar between the 2 groups. Results were similar for lactating women.

Conclusions

VSD is effective for treating acute suppurative mastitis with reduced pain and shortening healing time.

Negative pressure wound therapy over two ipsilateral external skeletal fixators for management of high grade open fractures in a cat

Case summary

A 7-month-old female neutered Bengal cat was referred to the Queen Mother Hospital for Animals following unknown trauma. Clinical and radiographic examination revealed a grade IIIB open, comminuted, mid-diaphyseal fracture of the left tibia and fibula, and grade IIIB open mid-diaphyseal fractures of the left metatarsals II-V. The fractures were stabilised with tibial and metatarsal external skeletal fixators. The open wounds were initially debrided surgically using conventional dressings, resulting in a small amount of circumferential granulation tissue formation by 10 days postoperatively. Following this 10-day period of conventional wound management, negative pressure wound therapy (NPWT) was applied over the external skeletal fixators and wounds. After 8 days of NPWT complete granulation tissue coverage was achieved in the tibial wound, and only small areas of two metatarsals remained exposed. The tibial wound was left to heal by second intention; a free meshed skin graft was applied to the pedal wound. Twenty weeks postoperatively, all wounds had completely healed and revision surgery with internal fixation was performed to treat a non-union of the tibia. Thirty weeks after the initial surgery, radiographic union of the tibia and metatarsals II-IV was confirmed.

Relevance and novel information

This is the first report of NPWT application over external fixation for the management of wounds associated with open fractures in veterinary medicine. This case was presented to introduce a novel, well-tolerated and simple technique for the management of tissue loss over an open fracture immobilised with external fixation.

External fixator combined with three different fixation methods of fibula for treatment of extra-articular open fractures of distal tibia and fibula: a retrospective study

Background

To compare the efficacy of three different fixation methods of fibula combined with external fixation of tibia for the treatment of extra-articular open fractures of distal tibia and fibula.

Methods

From January 2017 to July 2019, 91 cases of open fractures of distal tibia and fibula were treated with external fixator, and the fibula was fixed with non-fixation (group A, n = 35), plate-screw (group B, n = 30) and Kirschner wire (group C, n = 26). The operation time, intraoperative blood loss, surgical and implants costs, fracture healing time, postoperative complications, and American Orthopaedic Foot and Ankle surgery (AOFAS) scores were compared among the groups.

Results

Four patients were lost to follow-up, and 87 patients were followed up for 5–35 months (average, 14.2 months). The operation time of group C (114.92 ± 36.09 min) was shorter than that of group A (142.27 ± 47.05 min) and group B (184.00 ± 48.56 min) (P < 0.05). There was no difference in intraoperative blood loss among the three groups (P > 0.05). The surgical and implants costs in group C (5.24 ± 1.21, thousand dollars) is lower than that in group A (6.48 ± 1.11, thousand dollars) and group B (9.37 ± 2.16, thousand dollars) (P < 0.05). The fracture healing time of group C (5.67 ± 1.42 months) was significantly less than that of group A (6.90 ± 1.33 months) and group B (6.70 ± 1.12 months) (P < 0.05). The postoperative complications such as fractures delayed union and nonunion in group C (2 cases, 8.00%) is less than that in group A (13 cases, 39.39%) and group B (11cases, 37.93%) (P < 0.05). The wound infection and needle-tract infection did not differ among the three groups (P > 0.05). The excellent or good rate of ankle function was 69.70% in group A, 72.41% in group B and 84.00% in group C, with no statistical difference among the three groups (P > 0.05).

Conclusion

Compared with simple external fixator fixation and external fixator combined with plate-screw osteosynthesis, external fixator combined with K-wire intramedullary fixation shortens the operative time and fracture healing time, reduced costs and complications of fracture healing, while the blood loss, infection complications and ankle function recovery showed no difference with the other two groups. External fixator combined with plate-screw osteosynthesis had no advantage in treating extra-articular open fractures of distal tibia and fibula when compared with simple external fixation.

Clinical experience of biliary T tube of immobilization of peri-pin membrane in tibial Gustilo III fracture treated with vacuum sealant drainage combined with an external fixator

OBJECTIVE

To determine the effects of an improved method of peri-pin membrane immobilization in tibial Gustilo type III fracture treated with vacuum sealant drainage (VSD) combined with an external fixator.

METHOD

A biliary T tube of suitable size and type was cut into a certain long arm and cross arm which wrapping around a pin to improving traditional peri-pin VSD method. Eighty-six cases of Gustilo type III tibial fracture admitted from January 2016 to December 2019 were prospectively treated, of which 43 cases were treated using a traditional method of VSD (Traditional group) and 43 cases in which VSD treatment was enhanced (Improved group). The 2 groups were compared by some clinical indexes. Statistical software was then used for data analysis. P < .05 was considered statistically significant.

RESULTS

Compared with the Traditional group, the improved group significantly reduced granulation tissue growth time (day) (7.35 + 2.59 vs 11.14 + 2.54, P < .05), antibiotic use time (day) (6.67 + 2.39 vs 8.70 + 1.98, P < .05), operation time (min) (72.44 + 16.79 vs 85.47 + 17.44, P < .05) duration of hospital stay (day) (18.23 + 5.04 vs 21.53 + 4.79, P < .05), wound closure time (day) (9.23 + 2.69 vs 14.19 + 2.67, P < .05), air leakage around the fixed needle (3/43 vs 16/43, P < .05) and postoperative pain score (P < .05). Meanwhile, the white blood cell, C-reactive protein, erythrocyte sedimentation rate of 1 week and 2 weeks post-operation were also reduced after adopting the improved method (P < .05). The difference in infection around the fixation pin and pin loosening between the 2 groups was not significant.

CONCLUSION

The biliary T tube was effctive in improving VSD combined with external fixation for the treatment of tibial Gustilo type III fractures. The materials are easy to obtain and straightforward to use and so is worthy of clinical promotion.

Prophylactic vacuum sealing drainage (VSD) in the prevention of postoperative surgical site infections in pediatric patients with contaminated laparotomy incisions

Surgical site infection (SSI) continues to be an issue in abdominal surgery, especially for contaminated (class III) and dirty-infected (class IV) wounds. Vacuum sealing drainage (VSD) was reported effective in the management of various types of wounds or skin grafts. Our goal was to investigate the efficacy of prophylactic VSD to better orient their medicosurgical care of high-risk incisions following laparotomy in a pediatric population.A total of 331 pediatric patients with contaminated (class III) and dirty-infected (class IV) wounds following emergency laparotomy were retrospectively reviewed between January 2005 and January 2013. Among them, 111 cases were placed with prophylactic VSD when incisions were closed. Clinical outcomes, including, overall surgical site complication, device effectiveness, and mean postoperative LOS were evaluated based on VSD usage or not.VSD was applied for an average of 5.8 days (range, 5-7 days), with 3 to 15 mL sucked fluid. The overall SSIs rate was 3% for patients with prophylactic VSD and 17% for patients with convention dressing (OR, 0.27; 95% CI, 0.10-0.71, P = 0.004). In patients with prophylactic VSD, only 1 of 96 wound developed postoperative incision dehiscence, which is significant reduced compared with patients for conventional dressings (OR, 0.12; 95% CI, 0.01-0.95; P = 0.017) (Table 2). It also exhibited a decreased mean postoperative LOS (P < 0.001) for prophylactic VSD over conventional dressings.Our study demonstrated beneficial postoperative clinical effects of prophylactic VSD for high-risk laparotomy incisions following emergency laparotomy, such as shorter length of hospitalization, which may be attributed to the reduced overall SSIs rate.

Vacuum Sealing Drainage Treatment Combined with Antibiotic-Impregnated Bone Cement for Treatment of Soft Tissue Defects and Infection

Background

This study aimed to evaluate the combined effect of vacuum sealing drainage (VSD) and antibiotic-loaded bone cement on soft tissue defects and infection.

Material/Methods

This prospective non-blinded study recruited 46 patients with soft tissue defects and infection from January 2010 to May 2014 and randomly divided them into experimental and control groups (n=23). Patients in the experimental group were treated with VSD and antibiotic-loaded bone cement, while the patients in the control group were treated with VSD only.

Results

In the experimental group, the wound was healed in 23 cases at 4 weeks postoperatively, of which direct suture was performed in 12 cases, and additional free flap transplantation or skin grafting was performed in 6 cases and 5 cases, respectively. No infection reoccurred in 1-year follow-up. In the control group, the wound was healed in 15 cases at 6 weeks postoperatively, of which direct suture was performed in 8 cases, and additional free flap transplantation or skin grafting was performed in 3 cases and 4 cases, respectively. In the other 8 cases the wound was healed at 8 weeks postoperatively. Infection reoccurred in 3 cases during the follow-up. The experimental group had significantly fewer VSD dressing renewals, shorter time needed until the wound was ready for surgery, shorter duration of antibiotic administration, faster wound healing, and shorter hospital stay than the control group (p<0.01).

Conclusions

The combination of VSD and antibiotic bone cement might be a better method for treatment of soft tissue defects and infection.

Vacuum-Assisted Closure in the Management of Degloving Soft Tissue Injury: A Case Report

We report the case of a patient with an extensive degloving injury to his right foot involving severe subcutaneous soft tissue disruption and contamination. The initial treatment consisted of debridement, which was kept to a minimum, copious irrigation, primary wound closure at a few sites, and coverage of the remaining skin defects with vacuum-assisted closure (VAC) dressings. After a few weeks of VAC therapy for wound bed preparation, definitive coverage with a meshed skin graft was possible. Additional plastic surgical procedures were not required. At the last follow-up visit, the patient had no complaints and was able to participate in normal social life without limitations. Wounds that are grossly contaminated or associated with extensive soft tissue defects often require a multistage approach before delayed primary wound closure or plastic surgical procedures can be performed. Vacuum therapy can be used for temporary soft tissue coverage and has been shown to improve bacterial clearance, to increase local blood flow, and to promote granulation tissue formation. In contrast, plastic surgical procedures initially achieve safe and stable wound closure; however, the absence of sensitivity can lead to secondary problems. This is of particular relevance if the graft recipient site is subject to heavy stress and the restoration of function is of paramount importance, such as in the present case. Vacuum therapy is an effective and safe treatment of degloving injuries. We achieved a very good functional outcome, which was particularly important in view of the high stresses and strains to which a foot is exposed.

Minimally invasive surgical technique: Percutaneous external fixation combined with titanium elastic nails for selective treatment of tibial fractures

INTRODUCTION

Several techniques have been described to treat tibial fractures, which respectively remains defects. This article presents a novel intra- and extramedullary fixation technique: percutaneous external fixator combined with titanium elastic nails (EF-TENs system). The purpose of this study is to introduce this new minimally invasive surgical technique and selective treatment of tibial fractures, particularly in segmental fractures, diaphysis fractures accompanied with distal or proximal bone subfissure, or fractures with poor soft-tissue problems.

METHODS

Following ethical approval, thirty-two patients with tibial fractures were treated by the EF-TENs system between January 2010 and December 2012. The follow-up studies included clinical and radiographic examinations. All relevant outcomes were recorded during follow-up.

RESULTS

All thirty-two patients were achieved follow-ups. According to the AO classification, 3 Type A, 9 Type B and 20 Type C fractures were included respectively. According to the Anderson-Gustilo classification, there were 5 Type Grade II, 3 Type Grade IIIA and 2 Type Grade IIIB. Among 32 patients, 8 of them were segmental fractures. 12 fractures accompanied with bone subfissure. Results showed no nonunion case, with an average time of 23.7 weeks (range, 14-32 weeks). Among them, there were 3/32 delayed union patients and 0/32 malunion case. 4/32 patients developed a pin track infection and no patient suffered deep infection. The external fixator was removed with a mean time of 16.7 weeks (range, 10-26 weeks). Moreover, only 1/32 patient suffered with the restricted ROM of ankle, none with the restricted ROM of knee.

CONCLUSION

This preliminary study indicated that the EF-TENs system, as a novel intra- and extramedullary fixation technique, had substantial effects on selective treatment of tibial fractures.

Vacuum Sealing Drainage as Treatment of Severe Buttocks and Perianal Infection: A Case Report and Review of the Literature (Care-Compliant)

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.

Effect of vacuum sealing drainage in osteofascial compartment syndrome

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.

Novel application of vacuum sealing drainage with continuous irrigation of potassium permanganate for managing infective wounds of gas gangrene

Traumatic gas gangrene is a fatal infection mainly caused by Clostridium perfringens. It is a challenge to manage gas gangrene in open wounds and control infection after debridement or amputation. The aim of the present study was to use vacuum sealing drainage (VSD) with continuous irrigation of potassium permanganate to manage infective wounds of gas gangrene and observe its clinical efficacy. A total of 48 patients with open traumatic gas gangrene infection were included in this study. Amputations were done for 27 patients, and limb salvage procedures were performed for the others. After amputation or aggressive debridement, the VSD system, including polyvinyl alcohol (PVA) foam dressing and polyurethane (PU) film, with continuous irrigation of 1:5000 potassium permanganate solutions, was applied to the wounds. During the follow-up, all the patients healed without recurrence within 8-18 months. There were four complications. Cardiac arrest during amputation surgery occurred in one patient who suffered from severe septic shock. Emergent resuscitation was performed and the patient returned to stable condition. One patient suffered from mixed infection of Staphylococcal aureus, and a second-stage debridement was performed. One patient suffered from severe pain of the limb after the debridement. Exploratory operation was done and the possible reason was trauma of a local peripheral nerve. Three cases of crush syndrome had dialysis treatment for concomitant renal failure. In conclusion, VSD can convert open wound to closed wound, and evacuate necrotic tissues. Furthermore, potassium permanganate solutions help eliminate anaerobic microenvironment and achieve good therapeutic effect on gas gangrene and mixed infection. VSD with continuous irrigation of potassium permanganate is a novel, simple and feasible alternative for severe traumatic open wounds with gas gangrene infection.

Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures?

BACKGROUND

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.

QUESTIONS/PURPOSES

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?

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 OF EVIDENCE

Level III, therapeutic study.

Wound management in disaster settings

BACKGROUND

Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management.

METHODS

We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy.

RESULTS

We included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons.

CONCLUSION

Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.

External fixators and sudden-onset disasters: Médecins Sans Frontières experience

PURPOSE

Carrying out osteosynthesis is challenging, and controlling for results and complications is necessary to define the limits of acceptable complications. Within the context of sudden-onset disasters, comparing internal with external osteosynthesis remains controversial.

METHODS

The most recent and significant Médecins Sans Frontières (MSF) experience with osteosynthesis was following the earthquake in Haiti in 2010: 353 external fixators were used in the 12 months following the catastrophe, 62 of which were used in the first month. Carrying out internal osteosynthesis was possible two weeks following the earthquake.

RESULTS

The most common indication for open tibial fracture was Gustillo grade 2 or 3. Conversion rate from external to internal osteosynthesis remains anecdotal for several practical reasons. Advantages and drawbacks of external fixators are discussed in the context of precarious situations frequently encountered by MSF.

CONCLUSIONS

External osteosynthesis as a primary and definitive treatment for open fractures, especially of the leg, remains the most frequently used and best-adapted procedure in the context of sudden-onset disasters, even though not ideal.