A Role for Vacuum-Assisted Closure in Lower Limb Trauma: A Proposed Algorithm

Anterior Tibial to Dorsalis Pedis Bypass to Manage Acute Ischemia Attributed to Pilon Fracture

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessity staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Cling Wrap Technique: An Inexpensive and Simple Way to Seal Negative Pressure Wound Therapy on External Fixation Devices

Negative pressure therapy is often applied to treat limb traumas with or without bone exposure. However, sealing a negative pressure dressing in the presence of an external fixation device may be complicated and time consuming. In this technique, we attempted to maintain vacuum conditions by preventing air leakage around the screws using plastic drape and cling wrap as the final layer over the external fixation device. To prevent rupturing of the wrap, the prominences of the pins and rods were covered using cotton wool roll. This novel solution is also effective for complex and extended wounds, with no need for additional dressing changes and no occurrence of complications for approximately 4 days. Furthermore, it is an inexpensive, quick, and readily available technique requiring minimal training to perform. It is also adaptable to any anatomical region, allowing the inspection of the limb when required.

[Application of VSD in 6 Cases of Postoperative Infection -A Clinical Experience Sharing]

背景与目的

手术切口感染是胸外科术后常见并发症之一，其危害与感染程度、部位等相关，轻者致局部疼痛、住院时间延长、费用增加，重者可导致严重感染，甚至感染性休克、危及生命。因此，妥善处理切口感染，有利于促进恢复、降低疾病负担、奠定进一步治疗良好基础。切口感染传统外科处理措施包括彻底引流、加强换药、使用抗生素等，存在治疗过程长、治疗效果不确切等不足。本研究对我科6例胸部手术术后发生感染患者尝试性使用负压封闭引流装置（vacuum sealing drainage, VSD）的经验进行总结，以期改进传统应对患者胸部手术术后感染的处理模式。

方法

对我院近一年来出现胸部手术术后切口感染或手术切口瘘的患者相关临床数据进行回顾和总结，选择了其中6例使用VSD材料治疗术后感染的患者，对其使用VSD处理的过程和最终临床结果进行总结讨论。

结果

本研究中所有患者在使用VSD后6 h-10 h内发热、伤口渗出症状消失。7天-10天后拔除引流装置，5例患者创面感染情况明显改善，伤口分泌物消失，手术切缘肉芽组织生长良好，二期手术关闭胸腔和皮肤。1例患者感染严重，去除VSD后分泌物仍较多，效果不明显，再次放置VSD装置，7天后去除VSD装置，患者手术切口无渗出，肉芽组织生长良好，二期手术关闭胸腔和皮肤。所有6例患者最终感染症状缓解，症状改善，手术切口愈合良好出院。2例食管癌患者中，平均手术时间427.5 min，术后平均住院天数40天，术后平均换药次数8.5次，住院期间平均总花费111, 893.47元；4例慢性脓胸患者中，平均手术时间192.5 min，术后平均住院天数27.75天，术后平均换药次数5.5次，住院期间平均总花费48, 237.71元。

结论

VSD在处理胸外科手术术后切口感染患者中效果良好，减少了患者的痛苦和负担，保证了发生术后感染患者的生活质量。

Vacuum sealing drainage therapy in the presence of an external fixation device: A case report

RATIONALE

Vacuum sealing drainage (VSD) is widely utilized for treating traumatic wounds.

PATIENT CONCERNS

It is particularly difficult and time consuming to use in combination with an external fixator.

DIAGNOSES

This is because the hardware or pins used for fixation interfere with maintaining a seal, resulting in poor adhesion and subsequent air leakage.

INTERVENTIONS

To resolve this problem, we have devised a new method for sealing the wound dressing, while maintaining the required vacuum.When using this technique, a rubber strip is wrapped around each pin in 3 circles outside the plastic drape, and then tightly tied.

OUTCOMES

After completing this procedure, a vacuum is obtained, and any air leakage stops. We employed this technique to treat a cohort of patients in our department over a period of two years, and obtained good healing of soft tissue without air leakage, as well as good clinical outcomes.

LESSONS

We have observed that patients treated with this method experienced good clinical outcomes without air leakage, and we recommend its use in treating cases where an external fixation device is present.

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 and external fixation device: a simple way to seal the dressing

Negative pressure therapy is widely applied to treat lower limb trauma. However, sealing a negative pressure dressing in the presence of an external fixation device may be difficult and time consuming. Therefore, screws, pins, wires, etc, may preclude the vacuum, preventing the plastic drape to perfectly adhere to the foam. To maintain the vacuum, we tried to prevent air leaking around the screws putting bone wax at the junction between the pins and the plastic drape. This solution, in our hands, avoids air leakage and helps maintain vacuum in a fast and inexpensive way.

Vacuum-assisted closure device: a useful tool in the management of severe intrathoracic infections

BACKGROUND

This study is an evaluation of the vacuum-assisted closure (VAC) therapy for the treatment of severe intrathoracic infections complicating lung resection, esophageal surgery, viscera perforation, or necrotizing pleuropulmonary infections.

METHODS

We reviewed the medical records of all patients treated by intrathoracic VAC therapy between January 2005 and December 2008. All patients underwent surgical debridement-decortication and control of the underlying cause of infection such as treatment of bronchus stump insufficiency, resection of necrotic lung, or closure of esophageal or intestinal leaks. Surgery was followed by intrathoracic VAC therapy until the infection was controlled. The VAC dressings were changed under general anesthesia and the chest wall was temporarily closed after each dressing change. All patients received systemic antibiotic therapy.

RESULTS

Twenty-seven patients (15 male, median age 64 years) underwent intrathoracic VAC dressings for the management of postresectional empyema (n=8) with and without bronchopleural fistula, necrotizing infections (n=7), and intrathoracic gastrointestinal leaks (n=12). The median length of VAC therapy was 22 days (range 5 to 66) and the median number of VAC changes per patient was 6 (range 2 to 16). In-hospital mortality was 19% (n=5) and was not related to VAC therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in all surviving patients.

CONCLUSIONS

Vacuum-assisted closure therapy is an efficient and safe adjunct to treat severe intrathoracic infections and may be a good alternative to the open window thoracostomy in selected patients. Long time intervals in between VAC changes and short course of therapy result in good patient acceptance.

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

How to Cover Soft-Tissue Defects After Injuries to the Leg in Precarious Conditions

BACKGROUND

In precarious conditions, bone exposure on the leg is synonymous with amputation. The authors describe their experiences with such injuries in 15 patients.

MATERIALS AND METHODS

Fifteen patients were operated by the same surgeon in Afghanistan and Ivory Coast for bone exposure on the leg after war or roadcrash injuries. A flap was performed after an initial debridement and external fixation. The delay between the flap and the first injury was about 42 days.

RESULTS

The duration of hospitalization following the flap was about eight days. Cicatrization was complete after 25 days. Three patients had complications: one partial necrosis of the skin, one sepsis, and one patient had a leg amputation.

DISCUSSION

In precarious conditions, the management of bone exposure in local civilians and soldiers is limited by the conditions in their country or the conditions at the field hospital. The treatment must be simple and reliable because it may be difficult to perform patient follow-up. A pedicled flap provides new vascularized tissue with anti-infectious properties. Classical indications are: muscular flaps for the proximal and the middle part of the leg; sural flaps for the middle and the distal-third part. In substantial soft-tissue defects, amputation must be discussed.

CONCLUSION

The pedicled flap is an essential technique for fighting against infection, especially in cases where only poor technical and medicinal resources are available. This simple and reliable technique allows most tissue defects on the leg to be covered.

Use of negative pressure wound therapy with reticulated open cell foam for lower extremity trauma

The use of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) has been a valuable adjunct in the treatment of complex lower-extremity injuries. The use of NPWT/ROCF for lower extremity traumatic wounds is based on mechanical effects on the surrounding tissues, biological effects at the cellular level, and simplification of wound care for nursing personnel. For patients with compartment syndrome, risk of secondary infection and need for skin grafting to achieve soft-tissue coverage may theoretically be reduced. For traumatic wounds, dressing care may be simplified and healing encouraged. For surgical incisions, risk of secondary wound dehiscence and infection may be lowered.

Evidence-based medicine: vacuum-assisted closure in wound care management

A review of the evidence base for the use of vacuum-assisted closure (VAC) therapy is presented, analysing both experimental and clinical data.

Treatment principles in the management of open fractures

The management of open fractures continues to provide challenges for the orthopedic surgeon. Despite the improvements in technology and surgical techniques, rates of infection and nonunion are still troublesome. Principles important in the treatment of open fractures are reviewed in this article. Early antibiotic administration is of paramount importance in these cases, and when coupled with early and meticulous irrigation and debridement, the rates of infection can be dramatically decreased. Initial surgical intervention should be conducted as soon as possible, but the classic 6 h rule does not seem to be supported in the literature. All open fractures should be addressed for the risk of contamination from Clostridium tetani. When possible, early closure of open fracture wounds, either by primary means or by flaps, can also decrease the rate of infection, especially from nosocomial organisms. Early skeletal stabilization is necessary, which can be accomplished easily with temporary external fixation. Adhering to these principles can help surgeons provide optimal care to their patients and assist them in an early return to function.