The use of negative pressure wound therapy for random local flaps at the ankle region

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery: A case report

BACKGROUND

Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence. They require immediate and appropriate management before they progress to an irreversible condition. Although negative pressure wound therapy (NPWT) can prevent wound progression by increasing microcirculation, the inappropriate application of NPWT on complication-threatened transferred and replanted tissues can induce an adverse effect.

CASE SUMMARY

A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap. While applying a heating pad directly to the flap site, she sustained a deep second to third-degree contact burn over 30% of the transferred flap on postoperative 7 d. As the necrotic changes had progressed, we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d. After 4 d of NPWT application, the exposed fatty tissues of the flap changed to dry and brown-colored necrotic tissues. Upon further debridement, we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.

CONCLUSION

Although NPWT has been shown to be successful for treating various wound types, the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Flap monitoring with incisional negative pressure wound therapy (NPWT) in diabetic foot patients

Various types of flaps are considered as reconstructive options for patients with diabetic foot ulcer. However, flap reconstruction for diabetic foot ulcer treatment is particularly challenging because of the relatively limited collateral perfusion in the distal lower extremity. This study evaluated the efficacy and safety of a novel postoperative monitoring procedure implemented in conjunction with negative pressure wound therapy immediately after flap operations for treating diabetic foot. A retrospective analysis was performed on diabetic foot patients who underwent free flaps and perforator flaps from March 2019 through August 2021. The surgical outcomes of interest were the rates of survival and complications. On the third postoperative day, patients underwent computed tomography angiography to check for pedicle compression or fluid collection in the sub-flap plane. Monitoring time, as well as comparisons between NPWT and conventional methods, were analyzed. Statistical analysis was performed between the two groups. This study included 26 patients. Among patients, the negative pressure wound Therapy treated group included 14 flaps and the conventional monitoring group included 12 flaps. There was no significant intergroup difference in flap survival rate (p = 0.83). In addition, there was no significant intergroup difference in the diameters of perforators or anastomosed vessels before and after negative pressure wound therapy (p = 0.97). Compared with conventional monitoring, flap monitoring with incisional negative pressure wound therapy was associated with a significantly lower mean monitoring time per flap up to postoperative day 5. Although conventional monitoring is widely recommended, especially for diabetic foot ulcer management, the novel incisional negative pressure wound therapy investigated in this study enabled effortless serial flap monitoring without increasing complication risks. The novel flap monitoring technique is efficient and safe for diabetic foot patients and is a promising candidate for future recognition as the gold standard for flap monitoring.

Negative pressure wound therapy versus conventional wound care in cancer surgical wounds: A meta-analysis of observational studies and randomised controlled trials

The application of negative pressure wound therapy (NPWT) in cancer surgical wounds is still controversial, despite its promising usage, because of the risks of increased tumorigenesis and metastasis. This study aimed to review the risks and benefits of NPWT in surgical wounds with the underlying malignant disease compared with conventional wound care (CWC). The first outcome was wound complications, divided into surgical site infection (SSI), seroma, hematoma, and wound dehiscence. The secondary outcome was hospital readmission. We performed a separate meta‐analysis of observational studies and randomised controlled trials (RCTs) with CI 95%. Thirteen observational studies with 1923 patients and seven RCTs with 1091 patients were included. NPWT group showed significant decrease in the risk of SSI (RR = 0.45) and seroma (RR = 0.61) in observational studies with P value <0.05, as well as RCTs but were not significant (RR = 0.88 and RR = 0.68). Wound dehiscence (RR = 0.74 and RR = 1.15) and hospital readmission (RR = 0.90 and RR = 0.62) showed lower risks in NPWT group but were not significant. Hematoma (RR = 1.08 and RR = 0.87) showed no significant difference. NPWT is not contraindicated in cancer surgical wounds and can be considered a beneficial palliative treatment to promote wound healing.

Combination of Three Different Negative Pressure Wound Therapy Applications and Free Flap for Open Elbow Joint Injury With Extensive Burns

Negative pressure wound therapy (NPWT) for treating burns has a variety of therapeutic applications. Here, we present a case of a 53-year-old woman with self-inflicted burn injuries in whom NPWT was applied for three different purposes. The injured sites were the anterior neck, bilateral arms from the wrists upwards to the chest, and back. The left arm was deeply injured, and the elbow joint cavity was opened during treatment. First, NPWT was used for bridge to skin grafting on the entire upper left limb. Second, NPWT was used as a bolster dressing for the autograft after skin grafting was performed on the left arm except the open part of the joint. Third, NPWT over flap was used on the subsequent flap surgical site to address prolonged exudate from the flap margin. The exudate resolved after about a week. Good results were obtained using NPWT during the perioperative period of free flap transplantation for extensive open elbow joint burns. The use of NPWT is an effective option in the treatment of burns.

A novel negative pressure wound therapy (NPWT) monitoring system for postoperative flap management

Various types of flaps are widely utilized as reconstructive options for patients with soft tissue defects. However, the postoperative monitoring of the flap requires a large amount of time and effort. The aim of this study was to evaluate the efficacy and safety of this novel monitoring procedure using negative pressure wound therapy (NPWT) immediately after the flap operations.A retrospective analysis was performed on patients who underwent free flaps and perforator flaps from March 2019 to December 2020. The flaps were managed by either novel NPWT method or conventional dressing. Among NPWT group, computed tomography angiography was performed in randomly selected 5 flaps on the third postoperative day for evaluation of pedicle compression. Statistical analysis was performed between the 2 groups.A total of 54 flaps were included in this study. Twenty seven flaps were managed using novel NPWT method and 27 flaps were managed using conventional dressing. There was no statistically significant difference in flap survival rates between the 2 groups (P = .91). The patency of flap pedicles in the NPWT group was confirmed by comparing the computed tomography angiography findings. The estimated total flap monitoring time and cost for 5 days was significantly decreased by the application of the novel NPWT monitoring system.Through the application of the novel postoperative monitoring system using NPWT, there is efficient evaluation of the flap. Furthermore, safe flap monitoring is possible with the reduced risk of infection by the avoidance of multiple manual dressing performed in the conventional method.

Immediate application of negative pressure wound therapy following lower extremity flap reconstruction in sixteen patients

Negative pressure wound therapy (NPWT) is usually applied in wound management and soft-tissue salvage after the development of complications. However, immediate postoperative application of NPWT over the flap coverage is seldom reported. We evaluate the effectiveness of immediate postoperative application of NPWT following fasciocutaneous or muscle flap coverage for lower leg reconstruction. A retrospective review of patients who underwent either fasciocutaneous or muscle flap coverage of lower leg soft-tissue defects applied with NPWT immediately after surgery was conducted in a level I trauma center. Sixteen patients, with an average age of 51.2 years, were included in the study. Nine patients had trauma-related soft-tissue loss, six had subsequent soft-tissue defects after debridement, and one had burn injury. Two patients had been treated with free anterolateral thigh flaps, 11 with pedicle flaps, and three with muscle flaps. All flaps survived except for those in two patients with venous congestion on postoperative day 1, which needed further debridement and skin grafting. Therefore, the use of immediate incisional NPWT is an alternative for wound care following flap coverage. The U-shaped design allows easy flap observation and temperature check. Furthermore, this method eliminates any concerns of vascular pedicle compression under negative pressure.

Compromised Flap Salvage With Closed Incision Negative Pressure Therapy Under Real-Time Indocyanine Green Fluorescence Assessment

BACKGROUND

Skin flap transfer is a commonly used technique by surgeons; however, compromised blood flow may result in flap ischemia and necrosis. We describe the use of closed incision negative pressure therapy (ciNPT) to help manage skin flap reconstructions with indocyanine green fluorescence angiography (ICG-FA) to assess perfusion of the flaps before and after ciNPT.

METHODS

Three female and 5 male patients underwent various skin flap reconstructions, including local flaps, pedicled flaps, and propeller flaps, for wound defects related to trauma, infection, or cancer. After flap setting and suturing, ciNPT (-125 mm Hg) was applied to the closed incision for 7 days. Perfusion was assessed using ICG-FA before applying ciNPT and again at 24 hours later. The Shapiro-Wilk test and Wilcoxon signed rank test were used in statistical analysis.

RESULTS

Initial postoperative survival was observed for all skin flaps; however, 1 flap failed after 2 weeks due to uncontrolled infection. The remaining 7 flaps healed well without any surgical revision. All patients were initially determined to have impaired flap perfusion; however, skin flap perfusion was significantly higher after ciNPT than before ciNPT in each case (P = 0.012).

CONCLUSIONS

This study showed good healing outcomes for skin flap reconstructions without complications, despite the fact that each flap had compromised flap perfusion to some extent during the surgery. This case series is novel in that it used laser-assisted ICG-FA to provide a real-time assessment of skin flap perfusion before and after ciNPT.

Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review

Venous congestion is a frequent problem in flap surgery. Other than surgical revision, there are a multitude of procedures in the literature to tackle this problem, but their effectiveness is not clear. Through a systematic review, we aimed to identify and evaluate the different interventions available for managing flap venous congestion.

Methods

The MEDLINE, PubMed central, Embase, and Cochrane databases were searched. The study selection process was adapted from the PRISMA statement. All English and French original articles describing or comparing a method for managing flap venous congestion were included. For each article, a level of evidence was assigned, as defined by the Oxford Centre for Evidence-based Medicine. Lastly, we specifically analyzed the effectiveness of postoperative non-surgical methods. No formal analysis was performed.

Results

Through literature searches carried out in various databases, we identified 224 articles. Finally, 72 articles were included. The majority of these studies had a low-level evidence. A total of 17 different methods (7 pre- and intraoperative, and 10 postoperative) were found. Concerning non-surgical methods, the most represented were leeches, local subcutaneous injection of heparin with scarification, venocutaneous catheterization, negative pressure therapy, and hyperbaric oxygen therapy.

Conclusions

Risks of venous congestion of flaps must always be present in a surgeon's mind, at every stage of flap surgery. Apart from studies on the use of leeches, which have a significant follow-up and large enough patient numbers to support their efficacy, the low-level evidence associated with studies of other methods of venous congestion management does not allow us to draw a scientifically valid conclusion about their effectiveness.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017

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.

Closure of a Complex Lower Extremity Wound With the Use of Multiple Negative Pressure Therapy Modalities

Complex lower extremity wounds can present challenges in healing due to the cause of injury or previous surgery, presence of infection or tissue necrosis, patient comorbidities, or a combination of these factors. Negative pressure wound therapy (NPWT) modalities play a major role in the perioperative management of patients with complex wounds and their adjunctive use continues to evolve with time. In this case study, we discuss the use of adjunctive NPWT with instillation and dwell time (NPWTi-d) and closed incision negative pressure therapy (ciNPT) to assist with the management of a complex lower extremity wound. The patient was a 25-year-old female who presented with an actively draining Morel-Lavallée lesion of the left lateral thigh that she had previously sustained after being struck by a motor vehicle as a pedestrian. She was initially evaluated and admitted for the avulsion injury approximately two weeks prior to this and had a drain placed at that time. However, due to issues with compliance, she had not been re-evaluated. She now presented with a suspected infection of her left lower extremity, and was thus admitted, placed on intravenous cefazolin and underwent several rounds of excisional debridement and irrigation. The patient was then managed operatively by the plastic surgery service. This care included three rounds of tissue advancement, followed by a seven-day course of NPWTi-d. Cycles consisted of normal saline instillation with a one-second dwell time, followed by six hours of continuous negative pressure at −125 mm Hg. The patient was then taken back for a final round of reconstruction with tissue advancement. A split-thickness skin graft was used at that time to cover the remaining area of the wound that the advancement could not close. A seven-day course of ciNPT (PREVENA RESTOR BELLA•FORM™ System; 3M + KCI, San Antonio, TX) was then applied to manage the incisions and bolster the graft. This was followed by simple dressing changes several times weekly for four weeks. In this case, we demonstrate how the adjunctive use of multiple NPWT modalities resulted in a completely healed wound within two months, without any major complications.

Successful Salvage of a Lower Extremity Local Flap Using Multiple Negative Pressure Modalities

Wounds from orthopedic limb reconstruction are often difficult to heal due to the surgery, patient comorbidities, or a combination of these factors. The role of negative pressure wound therapy (NPWT) modalities in the perioperative management of patients with complex lower extremity wounds is evolving. Here, we present a case study using adjunctive NPWT with instillation and a dwell time, standard NPWT, and closed-incision negative pressure therapy (ciNPT) to manage a complex lower extremity wound. The patient was a 51-year-old man who presented with severe scarring of the lower extremity and infection following plate osteosynthesis of a tibial shaft fracture. Following lower extremity reconstruction, the patient received 5 days of NPWT with instillation and a dwell time with cycles that consisted of instilling normal saline with a 1-second dwell time, followed by 2 hours of continuous negative pressure at −125 mm Hg. The wound is then covered with an adjacent local tissue flap, which showed signs of vascular complication. ciNPT is applied over the flap incision for 7 days, which resulted in restored normal coloration; ciNPT is continued for another 7 days. A skin substitute is applied over the flap donor site, followed by NPWT using a silver foam dressing. Dressing changes are performed weekly for 4 weeks. At 8 weeks postsurgery, a skin graft is applied over the donor site. In this case, adjunctive use of multiple NPWT modalities resulted in a completely healed wound within 12 months with no complications.

Negative-Pressure Wound Therapy in Foot and Ankle Surgery

Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.

What Is the Treatment "Algorithm" for an Infected Total Ankle Arthroplasty (TAA)?

RECOMMENDATION

The treatment of an infected total ankle arthroplasty (TAA) is largely dictated by the acuity of the infection. The following treatment algorithm modified for TAA is recommended.¹⁹.

LEVEL OF EVIDENCE

Limited.

DELEGATE VOTE

Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).

Negative Pressure Wound Therapy on Closed Surgical Wounds With Dead Space: Animal Study Using a Swine Model

Background

Closed incisional wound surgery frequently leaves dead space under the repaired skin, which results in delayed healing. The purpose of this study was to evaluate the effect of negative pressure wound therapy (NPWT) on incisional wounds with dead space after primary closure by evaluating the fluid volume through the suction drain, blood flow of the skin, tensile strength, and histology of the wounds.

Methods

Bilateral 25-cm-long incisional wounds with dead space were created on the back of 6 pigs by partially removing the back muscle and then suturing the skin with nylon sutures. NPWT (experimental group) or gauze dressing (control group) was applied over the closed incision for 7 days. Analysis of the wound included monitoring the amount of closed suction drain, blood perfusion unit, tensile strength of the repaired skin, and histology of the incision site.

Results

The drainage amount was significantly reduced in the experimental group (49.8 mL) compared to the control group (86.2 mL) (P = 0.046). Skin perfusion was increased in the experimental group with statistical significance compared to the control group (P = 0.0175). Collagen staining was increased in the experimental group. The tensile strength of the incision site was significantly higher in the experimental group (24.6 N at 7 days, 61.67 N at 21 days) compared to the control group (18.26 N at 7 days, 50.05 N at 21 days) (P = 0.02).

Conclusion

This study explains some of the mechanism for using NPWT in closed incision wounds with dead space. It demonstrates that NPWT significantly reduces drainage amount, increases skin perfusion, increases tensile strength, and has the tendency to promote collagen synthesis for closed wound with dead space indicating enhanced healing.

Soft Tissue Reconstruction After Total Ankle Arthroplasty

Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.

Effects of Incisional Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study

BACKGROUND

Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest.

METHODS

This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled.

RESULTS

There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group.

CONCLUSION

The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Evidence based review of negative pressure wound therapy

Vacuum-assisted closure, sometimes referred to as microdeformational wound therapy or most commonly negative pressure wound therapy (NPWT), has significantly improved wound care over the past two decades. NPWT is known to affect wound healing through four primary mechanisms (macrodeformation, microdeformation, fluid removal, and alteration of the wound environment) and various secondary mechanisms (including neurogenesis, angiogenesis, modulation of inflammation, and alterations in bioburden) which are described in this review. In addition, the technique has many established uses, for example in wound healing of diabetic and pressure ulcers, as well as burn and blast wounds. This therapy also has many uses whose efficacy has yet to be confirmed, for example the use in digestive surgery. Modifications of the traditional NPWT have also been established and are described in detail. This therapy has various considerations and contraindications which are summarized in this review. Finally, future perspectives, such as the optimal cycling of the treatment and the most appropriate interface material, are touched upon in the final segment. Overall, despite the fact that questions remain to be answered about NPWT, this technology is a major breakthrough in wound healing with significant potential use both in the hospital but also in the community.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Negative pressure wound therapy for the management of flaps with venous congestion

PURPOSE

The aim of this report is to evaluate the utility of negative pressure wound therapy (NPWT) for rescuing flaps with venous congestion not attributable to a mechanical etiology and that cannot be surgically salvaged.

PATIENTS AND METHODS

A total of 12 patients suffered from partial or total flap congestion after pedicle or free-flap reconstruction was included. All patients underwent NPWT between 3 and 10 days postoperatively.

RESULTS

All congested flaps survived after the application of NPWT. Nine patients suffered partial flap loss and this was addressed through debridement of the devitalized tissue and primary closure. Three patients required blood transfusions during the course of their management. All patients presented complete coverage of the defects without further problems in the flaps after the treatment.

CONCLUSION

NPWT may be considered an alternative management strategy for flaps, which has undergone venous congestion not due to a mechanical cause. © 2016 Wiley Periodicals, Inc. Microsurgery 36:467-473, 2016.

Effect of negative pressure wound therapy on wound healing

The efficacy of NPWT in promoting wound healing has been largely accepted by clinicians, yet the number of high-level clinical studies demonstrating its effectiveness is small and much more can be learned about the mechanisms of action. In the future, hopefully we will have the data to assist clinicians in selecting optimal parameters for specific wounds including interface material, waveform of suction application, and the amount of suction to be applied. Further investigation into specific interface coatings and instillation therapy are also needed. We believe that advances in mechanobiology, the science of wound healing, the understanding of biofilms, and advances in cell therapy will lead to better care for our patients.

Negative-pressure wound therapy over surgically closed wounds in open fractures

PURPOSE

To evaluate the outcome of open fracture surgery with negative-pressure wound therapy (NPWT) applied directly over surgical wounds.

METHODS

Medical records of 10 men and 4 women aged 6 to 70 (mean, 43.7) years who underwent internal fixation, external fixation, or splint application for open fractures of the lower leg (n=7), foot and ankle (n=5), or knee (n=2), and NPWT were reviewed. The NPWT was applied directly over the surgical wound without a non-adherent contact layer. The foam was changed every 3 days. The standard negative pressure was 125 mm Hg. The NPWT was stopped when the wound discharge became <50 ml per day. The duration of NPWT and the level of negative pressure were recorded, as were wound condition, reasons for NPWT, and outcome.

RESULTS

The mean duration of NPWT was 9.1 (range, 3-24) days. Four patients developed maceration of the skin under the foam, whereas 2 patients developed skin blisters under the drape. No necrosis of flap skin or infection occurred, and all the fractures eventually united.

CONCLUSIONS

Maceration of the skin was seen in some cases but did not affect the overall outcome. NPWT directly over the skin surface had no deleterious effect on wound and fracture healing.

Effects of negative pressure wound therapy on healing of free full-thickness skin grafts in dogs

OBJECTIVE

To compare healing of free, full-thickness, meshed skin grafts under negative pressure wound therapy (NPWT) with bolster dressings in dogs.

STUDY DESIGN

Randomized, controlled experimental study, paired design.

ANIMALS

Dogs (n = 5) METHODS: Full-thickness skin wounds (4 cm × 1.5 cm) were created bilaterally on the antebrachia of 5 dogs (n = 10). Excised skin was grafted to the contralateral limb. Grafts were randomized to NPWT or bolster dressings (control; CON). NPWT was applied continuously for 7 days. Grafts were evaluated on Days 2, 4, 7, 10, 14, and 17, biopsied on days 0, 4, 7, and 14, and had microbial culture on Day 7. Outcome variables were: time to first appearance of granulation tissue, percent graft necrosis, and percent open mesh. Significance was set at P < .05. Histologic findings, culture results, and graft appearance were reported.

RESULTS

Granulation tissue appeared earlier in the NPWT grafts compared with CON grafts. Percent graft necrosis and remaining open mesh area were both greater in CON grafts compared with NPWT grafts at most time points. Histologic results showed no significant difference in all variables measured, and all cultures were negative.

CONCLUSIONS

Variables of graft acceptance were superior when NPWT was used in the first week post-grafting. Fibroplasia was enhanced, open meshes closed more rapidly and less graft necrosis occurred with NPWT application. More preclinical studies are required to evaluate histologic differences.

A topical negative-pressure technique with skin flap transplantation to repair lower-limb wounds with bone exposure

The treatment of chronic skin ulcers with exposed bone in the lower extremity is difficult. The development of topical negative pressure (TNP) technology and microsurgical techniques have achieved good clinical results in the repair of such ulcers. Between January 2007 and March 2012, TNP combined with flap transfer was applied to repair lower-limb skin and soft-tissue defects associated with exposed bone in 22 cases at our hospital, and good results were achieved that are reported herein.