Vacuum-Assisted Closure (V.A.C.?) for Temporary Coverage of Soft-Tissue Injury in Type III Open Fracture of Lower Extremities

Abstract Background and Purpose: The difficulty in the treatment of severe open fractures is a high infection rate and the problem of an adequate temporary coverage of the soft-tissue damage between successive second-look operations. The vacuum-assisted closure (V.A.C.^®) offers good temporary soft-tissue coverage with a proven bacterial clearance and protects, at the same time, the soft tissue against secondary damage. The retrospective study reports the soft-tissue management of severe open fractures of Gustilo type IIIA and IIIB with V.A.C.^® or Epigard^®. Patients and Methods: All open fractures were in the lower extremity and a result of a nonpenetrating trauma. V.A.C.^® was used as a temporary dressing in 14 fractures and an Epigard^® in twelve fractures. Results: One early amputation was observed in each group. In the group with the soft-tissue coverage by Epigard^®, in spite of less type IIIB fractures and less polytraumatized patients, the rate of infections (6/11) was substantially higher compared with patients managed by V.A.C.^® therapy (infection: 2/13). Conclusion: V.A.C.^®, a temporary soft-tissue substitute, reduces the rate of infection and is an alternative of choice for the management of type III open fractures.     

Complications and timing of soft tissue coverage after complete articular,open tibial plateau fractures

PurposeComplete articular tibial plateau fractures are typically high-energy injuries associated with significant soft tissue trauma. The primary aim of this study was to evaluate the incidence of wound complications and need for soft tissue coverage after open, complete articular tibial plateau fractures. The secondary aim was to study the effect of timing of fixation and timing of flap coverage on deep infection rates in these injuries.MethodsThis was a retrospective cohort study of consecutive patients > 18 years undergoing ORIF of a Bicondylar Tibial Plateau (BTP) fracture between 2001 and 2018. Surgical data were recorded for open fractures including number of debridements, timing of definitive ORIF and soft tissue coverage relative to injury. Primary outcomes included rates of deep infection and unplanned reoperation.Results508 AO/OTA 41C BTP fractures were identified, with 51 open fractures included in 50 patients with a mean (SD) age 45.7 (12.3) years and a mean (SD) follow up of 4.3 (3.8) years. There were 20 cases of deep infection, unplanned reoperation occurred in 26 cases. The majority of cases (28 fractures) had initial external fixation placed, while 24 had ORIF at the initial debridement. Twelve patients had a planned flap for definitive closure on average of 6.4 days (SD 3.9) after injury, 14 required a flap for wound complications. Among patients with IIB and C injuries, rates of deep infection (5/6 vs 1/6, p = 0.02) and reoperation (5/7 vs 2/6, p = 0.08) were higher in patients treated with flap coverage >7 days from injury compared to early flap coverage. There were no differences in complication rates between early (<24hrs) and delayed fixation.ConclusionsComplete articular, open tibial plateau fractures are associated with high rates of complications. Time to flap coverage of seven days or more was a significant predictor of deep infection and unplanned reoperation in this cohort. Patients should be counseled about the high rate of unplanned reoperation and definitive soft tissue coverage should be accomplished within a week of injury whenever possible.     

The use of vacuum assisted closure (VAC<Superscript>™</Superscript>) in soft tissue injuries after high energy pelvic trauma

Background Application of vacuum-assisted closure (VAC^™) in soft tissue defects after high-energy pelvic trauma is described as a retrospective study in a level one trauma center. Materials and methods Between 2002 and 2004, 13 patients were treated for severe soft tissue injuries in the pelvic region. All musculoskeletal injuries were treated with multiple irrigation and debridement procedures and broad-spectrum antibiotics. VAC^™ was applied as a temporary coverage for defects and wound conditioning. Results The injuries included three patients with traumatic hemipelvectomies. Seven patients had pelvic ring fractures with five Morel–Lavallee lesions and two open pelviperineal trauma. One patient suffered from an open iliac crest fracture and a Morel–Lavallee lesion. Two patients sustained near complete pertrochanteric amputations of the lower limb. The average injury severity score was 34.1 ± 1.4. The application of VAC^™ started in average 3.8 ± 0.4 days after trauma and was used for 15.5 ± 1.8 days. The dressing changes were performed in average every 3 days. One patient (8%) with a traumatic hemipelvectomy died in the course of treatment due to septic complications. Conclusion High-energy trauma causing severe soft tissues injuries requires multiple operative debridements to prevent high morbidity and mortality rates. The application of VAC^™ as temporary coverage of large tissue defects in pelvic regions supports wound conditioning and facilitates the definitive wound closure.     

Soft tissue injuries in compound fractures (author's transl)]

Problems in the management of soft tissue injuries in compound fractures are presented. They usually originate from the initial traumatic force, but may be the result of pitfalls of the primary treatment as well. The management of open fractures--as it is performed in this clinic--is presented in detail. After primary stabilization of the fracture attention is directed to the associated soft tissue injuries, which require utmost care in the further course of treatment. Primary wound closure should never be forcefully obtained, since closure under tension will result in severe secondary tissue damage. In our experience temporary open wound treatment and delayed closure is the method of choice in the initial management of open fractures. For temporary cover we successfully use the synthetic skin substitute Epigard. Since we adopted this policy, the rate of infection declined drastically, and anaerobic infections as well as generalized sepsis could be totally avoided.     

Antibiotic bead pouch versus negative pressure wound therapy at initial management of AO/OTA 42 type IIIB open tibia fracture may reduce fracture related infection: A retrospective analysis of 113 patients

IntroductionFracture related infection (FRI) may be a devastating complication of open tibial shaft fractures. We sought to determine if antibiotic bead pouch, negative pressure wound therapy, or negative pressure wound therapy over antibiotic beads as the initial coverage method for type IIIB open tibial shaft fractures is associated with risk of FRI.Patients and methodsRetrospective cohort study with radiograph and chart review of patients aged ≥16 years with isolated, displaced, extra-articular, Gustilo-Anderson type IIIB open diaphyseal AO/OTA 42 tibial fractures requiring rotational or free tissue transfer for soft tissue coverage at one Level 1 trauma center between 2007 and 2020. An association of dressing applied at the first surgical debridement (application of antibiotic bead pouch, negative pressure wound therapy, or combined therapy) with a primary outcome of FRI requiring debridement or amputation was analyzed by multivariable logistic regression considering demographic, injury, and treatment characteristics.Results113 patients met eligibility criteria. Median follow-up was 33 months (interquartile range 5–88). 41 patients were initially treated with NPWT, 59 with ABP, and 13 with ABP+NPWT at the initial surgical debridement. 39 (35%) underwent subsequent debridement or amputation for FRI. One amputation occurred in the ABP group for refractory deep surgical site infection (p = 0.630). Initial wound management with an antibiotic bead pouch versus either negative pressure wound therapy alone or negative pressure wound therapy combined with an antibiotic bead pouch was associated with lower odds of debridement or amputation for FRI (β = -1.08, 95% CI -2.00 to -0.17, p = 0.02).ConclusionsIn our retrospective analysis, antibiotic bead pouch for initial coverage of type IIIB open tibial shaft fractures requiring flap coverage was associated with a lower risk of FRI requiring debridement or amputation than negative pressure wound therapy applied with or without antibiotic beads. A prospective clinical trial is warranted.     

Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma

BackgroundThe 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.MethodsRetrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009.Results103 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.ConclusionsFollowing 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.     

Salvage of a partially avulsed sole following complex foot trauma by anchor fixation

BackgroundThe prognosis of complex trauma to the foot is often determined by the soft tissue condition. Degloving injuries are rare but especially challenging soft tissue lesions. Larger studies are lacking, but it is a general agreement to preserve in particular the unique plantar skin, if feasible.Material & MethodsIn the present case a 28-year old woman suffered a severe trauma of the foot, being rolled over by a forklift. The shearing forces led to unstable fractures of all toes and non-displaced fractures of the tarsal bones with an open décollement of the dorsum and closed degloving of the medial sole.Results and ConclusionsThe individual concept of debridement of all necrotic tissue including amputation of the first to third toe, wound conditioning through negative pressure wound therapy, split-skin grafting of the dorsum and reattachment of the plantar skin with suture anchors and additional reefing resulted in a plantigrade and pain free foot with a stable soft tissue coverage. The unique tissue of the sole can sometimes be reattached and preserved with simple surgical methods.     

外固定支架结合负压封闭引流在伴有软组织严重损伤的小腿开放性骨折中的应用

目的探讨外固定支架结合负压封闭引流(VSD)在伴有软组织严重损伤的小腿开放性骨折中的治疗效果。方法本组22例病例均为严重软组织损伤的开放性小腿骨折,给予外支架固定骨折,同时使用VSD处理创面。结果全部患者持续负压引流1~3次后,创面经植皮或直接缝合愈合;骨折无分离移位.外支架无松动移位断裂。结论联用外支架与VSD处理伴严重软组织损伤的开放性小腿骨折,稳定骨折迅速,封闭引流创面安全有效,伤口愈合好,并发症少。     

High-energy tibial plateau fractures:Staged management

High-energy fractures of the tibial plateau create difficult treatment scenarios. Both osseous and soft tissue injuries can challenge the most experienced trauma surgeon. Because the injury is frequently the result of a crushing mechanism the soft tissues of the proximal leg may initially present an envelope unsuitable for extensile surgical incisions. A closed soft tissue envelope may be associated with marked contusion or significant degloving threatening skin viability, while rapid swelling may prohibit acute surgical wound closure. An open fracture may require multiple debridements, skin grafts, or free tissue transfer to achieve ultimate sterile wound coverage. Still, the vast majority of these fractures benefit from skeletal stabilization with restoration of joint congruity and coronal and sagittal alignment. We routinely deal with this combination of severe bone and soft tissue injury with provisional knee spanning external fixation within 24 hours of injury, aggressive management of open wounds followed by a period of soft tissue rest, then delayed ORIF 2 to 3 weeks after fixator application. Well planned minimal surgical incisions at this time accompanied by meticulous attention to soft tissue handling reproducibly result in successful restoration of alignment and fracture and soft tissue healing.     

Vacuum-assisted-closure-Therapie

This article reports the case of a 23-year-old woman who sustained severe soft tissue injuries with open fractures of the left distal femur, the left proximal tibia, a subtotal amputation of the left foot with injuries to the anterior and posterior tibial artery due to a bomb blast. When the patient was transferred to our hospital 17 days after the trauma, all primarily closed wounds were severely infected. The fractures were treated by external fixateur and k-wire fixation. After debridement and initiation of negative pressure therapy the anterior tibial artery was reconstructed after 3 days and partial wound closure by a rectus abdominis muscle flap was achieved after 19 days. After almost total wound closure was accomplished open reduction internal fixation (ORIF) was performed for the distal femur fracture and a modification of the external fixateur for the tibial and foot fractures. The negative pressure therapy is an important component for treatment of complex soft tissue injuries and open fractures; however, it must be embedded in an interdisciplinary treatment plan with well-defined treatment goals.     

The V.A.C. system (vacuum assisted closure) as bridging between primary osteosynthesis in conjunction with functional reconstructed of soft tissue--open fractures type 2 and type 3

Open fractures are complex injuries affecting the integrity of bones and adjacent soft tissue. The therapeutic goals in dealing with open fractures should consist of primary osteosynthesis in conjunction with functional reconstruction of soft tissue. In a period over 2 years, 26 patients were treated with extensive trauma in an interdisciplinary approach. These patients suffered from open fractures type 2 and 3. All patients were treated by primary osteosynthesis, and temporary wound closure with V.A.C.-system. Definitive wound closure was achieved by day 31 after injury. In contrast to a review of the pertinent literature we report the successful free tissue transfer in 21 patients during the critical period between 72 hours and several months preceded by the use of V.A.C.-system for the temporary coverage of open wounds.     

Distal Tibial Fracture Fixation with Locking Compression Plate (LCP) Using the Minimally Invasive Percutaneous Osteosynthesis (MIPO) Technique

Abstract Background:   Treatment of distal tibial fractures has always been a challenge. Distal tibia is more superficial, with less soft tissue coverage and blood supply. Therefore, operative treatment can lead to complications. We aim to see the results of the distal tibial fracture fixation with LCP using MIPO. Patients and Methods:   Twenty-one consecutive patients were prospectively reviewed. AO types 43A, 43B and 43C were included. Fourteen male and seven female patients with a mean age of 51 years were included. Results:   Mean time to union was 5.5 months (range 3–13 months). Seventeen fractures healed with good functional outcome. One patient had delayed union. One patient had nonunion and underwent revision; the fracture ultimately healed with good functional outcome. Two patients developed superficial wound infections but the fractures united completely. Discussion:   The MIPO technique for distal tibia has shown good results with many additional advantages over the conventional methods. Early mobilization without risk of secondary displacement helps to prevent stiffness and contracture.     

单边外固定器治疗小腿严重开放性粉碎骨折

目的观察单边动力加压式外固定器在治疗小腿严重开放性骨折并软组织挤压伤中的疗效。方法采用单边动力加压式外固定器治疗小腿严重开放性粉碎骨折88例。结果随访2～12个月，下肢功能恢复佳，仅2伪延迟愈合，1例骨不愈合。结论该手术操作简单，固定可靠，无畸形愈合，疗效满意。     

一期内固定联合负压封闭引流治疗严重软组织缺损的下肢开放性骨折

[目的]合并严重软组织缺损的下肢开放性骨折是一种高能量损伤,常伴有重度污染。本文探讨这一类型的骨折运用一期内固定联合负压封闭引流(VSD)技术治疗的效果。[方法]从2008年6月～2010年10月共收治58例合并严重软组织缺损的下肢开放性骨折患者,分为两组处理。对照组:27例,男18例,女9例,给予普通清创二期内固定、植皮或皮瓣;VSD组:31例,男18例,女13例,急诊彻底清创后均采用一期内固定联合VSD固定骨折并封闭创口,7～21 d后根据肉芽生长情况给予二期缝合、植皮或皮瓣转移。[结果]对照组:28例患者骨折愈合时间6～18个月,平均(9.8±2.91)个月,创面愈合时间20～95 d,平均(46.81±16.80)d。VSD组:31例患者骨折愈合时间4～10个月,平均(6.29±1.88)个月,创面愈合时间14～33 d,平均(19.68±5.30)d。对照组与VSD组的骨折及创面愈合时间有统计学差异(P=0.041,P<0.001),VSD组明显好于对照组,GustilⅢA、ⅢB型骨折愈合时间无明显差异(P=0.906,P=0.080),而创面愈合时间有统计学差异(P<0.001,P=0.035)。...     

VSD结合外固定支架在西藏高原地区胫腓骨开放性骨折分期治疗中应用

目的：探讨负压吸引敷料结合外固定支架技术在西藏高原地区胫腓骨开放性骨折分期治疗中的应用及临床疗效。方法2014年8月-2015年8月收治16胫腓骨开放性骨折患者,其中男性12例,女性4例,年龄19~66岁,平均年龄39.4岁(19~66岁);胫腓骨中上段骨折4例,下段骨折12例。待患者病情稳定后患者生命体征稳定后,无继发性损伤,予行清创、外固定支架固定骨折端,并采用负压吸引敷料覆盖创面或创腔。7 d后更换VSD或予行二期缝合或软组织覆盖。 X线检查明确骨折愈合时间并记录相关并发症。结果本组16例创面均二期愈合,未见感染、皮肤或皮瓣坏死等软组织并发症。本组共随访患者12例(电话通知来院复诊),4例失访,平均随访18个月(12~24个月)。影像学检查明确平均骨折愈合时间为5.5个月(3~7个月),其中骨折一期临床愈合9例(75%),延迟愈合3例(25%)。随访期间除2例出现钉道感染,经保守治疗后治愈,余患者未见深部感染、植皮或皮瓣坏死、畸形愈合、骨不连或骨髓炎发生。结论负压吸引敷料结合外固定支架治疗西藏高原地区胫腓骨开放性骨折,在迅速有效地稳定骨折的同时,能安全有效地封闭创面,缩短二期创面修复时间,促进骨折愈合,减少并发症。     

Preconditioning of open wound surfaces with a synthetic skin substitute

Surgical principles Primary open wound treatment is frequently indicated in fractures with severe soft tissue damage in order not to compromise the impaired local vascularization. The soft tissue defect requires temporary wound coverage with a synthetic substitute to avoid desiccation of the wound surface as well as bacterial contamination. The synthetic material must have close contact with the wound surface to unfold its maximum effect. It is therefore necessary to create clean-cut and even surfaces in primary debridement of open fractures. Ragged wound cavities and wound pockets must be avoided. All damaged soft tissues with insufficient blood supply must be removed from the wound. The synthetic graft is shaped to the exact size of the wound and is applied to the defect under slight compression. Retraction of the skin margins should be avoided by deep sutures crossing the defect, especially after fasciotomy. The synthetic material is changed every 24 to 28 hours. This procedure leads to a rapid wound conditioning and enables the surgeon to perform an early definitive wound coverage, usually by meshgraft transplantation. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 272–280 (German Edition).     

External fixation of tibial shaft fractures with severe soft tissue injuries by Hoffmann-Vidal-Adrey osteotaxis

The operative results in 65 patients with 66 tibial shaft fractures and severe soft tissue injuries, stabilized by an external fixation frame according to Hoffmann or Vidal-Adrey, are reviewed and the treatment principles are discussed. Four patients required secondary amputations. Fifty-three patients could be followed up for an average of 23.2 months. The infection rate was 9.2% and nonunion was found in 11.1% of cases. Two patients had a refracture after removal of the fixation device. Twenty-three patients (42.6%) required one or more secondary operations. Of the 65 patients, 70.4% had very good or good end results, 16.7% acceptable, and 12.9% poor. External fixation according to Hoffmann or Vidal-Adrey affords excellent definitive stabilization in simple fractures of the lower leg with soft tissue injuries. In comminuted fractures of the lower leg with loss of bone fragments and severe tissue damage, external fixation is better used as a means of temporary stabilization until soft tissues permit definitive rigid stabilization.     

Heel Coverage Using a Distally Based Sural Artery Fasciocutaneous Cross-leg Flap: Report of a Small Series

One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. In extreme conditions of pedal soft tissue loss, in patients who are not satisfactory candidates for local or free-tissue transfer, the cross-leg flap remains an option for surgical reconstruction. We present the results of 7 patients with multiple lower limb open fractures associated with ipsilateral degloving injuries, and/or secondary pressure ulcers of the hindfoot with exposure of the calcaneus, in which a distally based sural artery island fasciocutaneous flap, elevated from the contralateral leg and crossed to the injured side, was used to repair the soft tissue defect of the recipient heel. All of the flaps survived and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. To the best of our knowledge, this is the first report in which this technique has been used to repair hindfoot soft tissue defects associated with complex bone and vascular injuries of the lower limb in polytrauma patients. Level of Clinical Evidence: 4.     

Clinical course of open metatarsal fractures

Little information exists regarding open fractures of the foot and no studies have reported open metatarsal fractures. Limited local soft tissue coverage makes this a distinct type of injury. Ten patients with open metatarsal fractures were treated. Six sustained Gustilo Grade I or II injuries; all healed without the need for additional soft tissue coverage. Four patients with Gustilo IIIB developed complications and all went on to eventually require amputation. This data indicates less severe open metatarsal fractures heal without complications, but more severe injuries require amputation.     

外固定支架在严重多发伤并胫腓骨开放性骨折中应用的病例对照研究

目的：探讨早期外固定架固定开放性胫腓骨骨折对严重多发伤患者治疗和预后的影响。方法：采用回顾性对比分析，73例严重多发伤（ISS〉16分）患者按胫腓骨骨折手术方法不同分2组。治疗组42例，男31例，女11例；平均年龄40．2岁；均急诊行清创、骨折复位外固定支架固定术。对照组31例，男22例，女9例；平均年龄42．6岁；均急诊行清创、跟骨牵引术或石膏外固定术。比较两组患者急性呼吸窘迫综合征（ARDS）、多器官功能障碍综合征（MODS）发生情况及病死率、小腿创面感染率、创面及骨折愈合时间。结果：两组的并发症（ARDS）发生率差异有统计学意义，行外固定架治疗组低于对照组（P〈0．05），治疗组感染率明显低（P〈0．05），创面愈合时间明显短。结论：外固定架治疗严重多发伤并胫腓骨开放性骨折，明显减少并发症发生率，降低创面感染率。