negative pRessuRe wounD theRapy (npwt) anD its

original paper

leczenie ran 2014;11(1):21–30

© Evereth Publishing, 2014

Ireneusz Babiak

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Negative Pressure Wound Therapy (NPWT) and its role in the treatment of infected wounds in orthopedic practice

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Department of Orthopaedics and Traumatology, Medical University of Warsaw

}} Ireneusz Babiak Center for Complex Rehabilitation, 12/14, Gąsiorowskiego Street, PL-05510 Konstancin-Jeziorna, Tel.: +48 22 703 04 34, e-mail: [email protected] Received: 05.12.2013 Accepted: 28.03.2014 DOI: dx.doi.org/10.15374/LR2014004

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Abstract: Introduction Management of wounds accompanying open fractures as well as infected chronic requires complex inter-disciplinary approach. The aim of the study is to assess effectiveness of negative pressure wound therapy (NPWT) in treatment of excessive and/or infected wounds not suitable for microsurgical flaps managed or treated in orthopedic department lacking advanced reconstructive experience. Material and methods NPWT was used in therapy of 30 consecutive wounds in 29 patients. Wound healing and functional results were assessed after termination of the therapy. The average follow up was 3.5 years (range 3 to 6 years). Results and Conclusion NPWT contributed to complete wound healing without microsurgical flaps in 20 from 30 wounds and complete healing of skin grafts in 16 from 17 cases. NPWT allowed for salvage of 9 from 10 traumatized extremities with severe open IIIB and IIIC fractures, and complete healing of 5 from 10 chronic infected wounds. In wounds located within 3 diabetic foots only fair results were achieved.

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Terapia podciśnieniowa ran (NPWT) i jej możliwości w leczeniu zakażonych ran na oddziałach ortopedycznych

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Key words: chronic wounds, Negative Pressure Wound Therapy, tissue regeneration, traumatic wounds, V.A.C.-therapy

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Streszczenie: Wstęp Leczenie ran towarzyszących złamaniom otwartym oraz zakażonych ran przewlekłych wymaga postępowania kompleksowego i interdyscyplinarnego. Celem pracy jest ocena skuteczności terapii podciśnieniowej (ang. Negative Pressure Wound Therapy – NPWT) w leczeniu rozległych i/lub zakażonych ran, nie kwalifikujących się do pokrycia płatem mikrochirurgicznym lub leczonych na oddziale ortopedycznym bez doświadczenia w zaawansowanych technikach chirurgii rekonstrukcyjnej. Materiał i metody Terapię podciśnieniową (NPWT) zastosowano w leczeniu 30 ran u 29 chorych. Wygojenie rany i wyniki funkcjonalne oceniano po zakończeniu terapii. Okres obserwacji wynosił od 3 do 6 lat, średnio 3,5 roku. Wyniki i Wnioski Terapia podciśnieniowa (NPWT) przyczyniła się do całkowitego wygojenia 20 z 30 ran bez użycia płata mikrochirurgicznego oraz do pełnego wgojenia 16 z 17 przeszczepów skóry pośredniej grubości. Terapia podciśnieniowa pozwoliła na uratowanie 9 z 10 z kończyn ze złamaniami otwartymi IIIB i IIIC oraz pełne wyleczenie 5 z 10 zakażonych ran przewlekłych. W trzech ranach stopy w przebiegu cukrzycy uzyskano częściowe wygojenie ran lub częściowe wgojenie przeszczepu skóry.

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Słowa kluczowe: odbudowa tkanek, rany przewlekłe, rany urazowe, terapia podciśnieniowa; terapia V.A.C.

Introduction The aim of the study was to assess the efficacy of Negative Pressure Wound Therapy in the treatment of wounds managed in orthopedic department dedicated for musculoskeletal

infections. The wounds with exception of one were located within extremities. All of wounds were infected; a part of them with exposure of muscles, tendons, bone and joints. Wounds were not suitable for plastic-reconstructive procedures either due to infection, or due to extension or location

kopia do użytku własnego. Udostępnianie i dystrybuowanie wydrukowanych kopii Artykułów bez zgody Evereth Publishing Sp. z o.o. jest zabronione.

Leczenie ran 2014;11(1)

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of wound surface, stimulates activity of leukocytes and fibroblasts and increases concentration of growth factors in the wound [7]. NPWT is actually the method dedicated for treatment of infected and chronic wounds – either alone or together with surgery [8]. Clinical and economic effectiveness of vacuum wound therapy was proved, especially as regards faster wound healing and optimal preparation of wound for reconstructive procedures [9]. NPWT is successfully used for fixation of free skin graft and Integra® in staged therapy of burns in children as well as in therapy of osteomyelitis of sternum and mediastinal infections [10, 11]. In 1995 FDA (Food and Drug Administration) in USA approved NPWT as indicated for therapy of acute and chronic post-traumatic wounds. In 2000 indications for application of NPWT were extended to cases with the use of skin graft, and in 2002 for therapy of burn-wounds [12]. Also high grade open fractures combined with extensive soft tissue loss represent field of expected benefits from NPWT [13, 14]. Despite the advantages, the NPWT dressings are very demanding and time consuming when applied on an extensive wound on the extremity stabilized with external fixator. Specially challenging is accomplishing of constant vacuum in the presence of multiple pins, Schanz-screws or K-wires. V.A.C.-therapy was initially regarded as contraindicated in wound with exposure of blood vessels or internal organ, but reports on successful extension of application of NPWT even in this cases are present [15].

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of the wound. NPWT is also known under the term Vacuum-Assisted Closure (V.A.C.-therapy). Wound healing is a complex process taking place in several phases: hemostasis, inflammatory phase, proliferation and consolidation of a new tissue. In the proliferation phase take place the parallel processes of granulation, epithelization and wound contraction. In spite of many general, some local factors influence wound healing like wound location, surface and depth of the wound, blood supply within the extremity and the presence of invasive infection. Theoretical guidelines for proper care of wounds are known as TIME strategy: tissue management (T), infection or inflammation control (I), moisture imbalance (M), edge of wound (E) – advancement of the epithelial edge of the wound. The management of the wound is an interdisciplinary issue and as with each interdisciplinary issue the responsibility for wound therapy is „spread”. Patient with acute traumatic wound can be managed at intensive care unit, general surgery or orthopedic department. Whereas patient with chronic wounds can be managed at dermatology, department of internal medicine, geriatrics, as well as orthopedic department, general or reconstructive surgery. Extensive traumatic and chronic wounds state a real problem and challenge at an orthopedic department as many specialists have skills focused on fracture therapy or implantation of artificial joints. Situation when an „ideal” patient with fracture, but without any comorbidity is hospitalized in orthopedic department is rather a rarity. Wounds encounter to this category. In the praxis the problem of wound therapy is delegated to the nurses, who for its part not always have the knowledge and experience necessary for the proper management or modification of the therapy. NPWT states from the end of the 20th century an effective method to manage soft tissue defect of different origin. First reports on application of subatmospheric pressure on infected wound in humans appeared in Russian literature in the 8th decade of 20th century. Kostiuchenok et al. in 1986 described positive effect of vacuum on wound healing as complementary method to surgical debridement before skin grafting [1]. In 1991 Davydov et al. summarised Russian experiences with vacuum method which was positive in 744 cases with infected wounds [2]. In English literature successful wound therapy with negative pressure in 7 patients was first published in 1989 by Chariker et al. [3]. In 1997 Argenta and Morykwas described pathophysiology of wound healing under negative pressure conditions in animal models [4, 5]. It was shown in their experiments in animals that NPWT can increase the number of capillary vessels and the blood flow in the bottom of wound by 400%. In the studies by Zoch, optimal effect on circulation was observed with negative pressure of 125 mmHg whereas subatmospheric pressure of 400 mmHg completely inhibited blood flow in granulation tissue [6]. NPWT decreases bacterial colonization 22

Material and methods The prospective cohort study includes 29 consecutive patients with 30 acute and chronic traumatic and non-traumatic wounds treated in the period 2005–2010 with the use of NPWT. The average follow up was 3.5 years (range: 1 to 6 years) after termination of the therapy. There were 16 women and 13 men, aged 20–75 years (average: 51 years). For practical reasons and due to different characteristics the following types of wounds were distinguished: wounds accompanying open fractures (9 cases with 10 wounds), postoperative or acute traumatic wounds without fracture (6 cases), primary infected wounds secondary to osteomyelitis or arthritis (4 cases) and chronic wounds (10 cases). Open fractures included three cases with grade IIIC and five with grade IIIB tibia fractures, one open IIIB femur fracture and one case with open clavicle fracture with post-traumatic aneurysm of subclavian artery. Acute postoperative or traumatic wounds without fracture managed with NPWT were located: one within hand and two within foot, one over Achilles tendon, one post-fasciotomy wound within calf musculature and one wound resulting from subcutan haematoma during acenocumarol therapy. Primary infected wounds included: two wounds related to joint infection (acute metacarpal



leczenie ran 2014;11(1)

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and influenced the whole therapy. In case No. 1 with open tibia IIIC fracture the segmental tibia defect ranging 14 cm required reconstruction by internal segmental transport of fibula (tibialisation of fibula). Another patient (case No. 3) suffered from bilateral open fractures: tibia fracture IIIC on right side and open IIIB of the left femur. On both extremities NPWT was used, but eventually patient was transferred to trauma center in another country, where he underwent below – the knee amputation of the right leg. In case No. 5 suffering from open IIIB tibia fracture, one stage reconstruction of a complex skin-muscle and bone defect of the lower leg was performed (Fig. 1A–K). After preparation of the wound by NPWT, distally pedicled gastrocnemius flap and STSG was used for complete wound closure. At the same surgery one-plane external fixation of the tibia (ZESPOL) was replaced by interlocking nail and the bone defect filled with acrylic cement spacer loaded with highdose antibiotics (0.55 g gentamicin and 2 g meropeneme per 40 g of cement). Wound management with NPWT in case No. 2 was successful (Fig. 2A–D), but therapy was complicated by infection of the medullary cavity of tibia, which was effectively managed by reaming, brushing and irrigation of medullary cavity and local application of collagen spongue with 130 mg garamicin and 2 g meropenem. During the reaming of tibia fragments, the pins of external fixator were removed and next exchanged to a new conical pins. In two open tibia fractures grade IIIC (case No. 1 and No. 2) apart from external fixation and NPWT additionally recombinant human bone morphogenic protein (rhBMP-7) was used at the place of delayed bone healing. In every case one vial of Osigraft® preparation containing 3.5 mg rhBMP-7 as powder for suspension was used. In one case of the traumatic wound

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joint arthritis – 1, acute tarsal joints of foot infection – 1 and two wounds accompanying chronic osteomyelitis of the tibia. Chronic wounds included: 4 leg ulcers, 3 wounds within diabetic foot, 1 neuropathic foot, 1 sacral pressure ulcer and 1 pressure ulcer within a scar on the foot. Characteristics of treated cases was presented in Table 1. All the wounds were infected, in part with the exposure of muscles, tendons and bone were not suitable for plastic-reconstructive procedures either due to infection, or due to extension or location of the wound. All patients received initially preemptive and next targeted antibiotics intravenously. After obtaining culture with sensitivity results – intravenous antibiotics were changed to oral, where the oral form warranted proper efficacy and availability. Antibiotics were continued during NPWT until the signs of invasive wound infection were present. NPWT was carried out with the use of V.A.C. System® (Kinetic Concepts Incorporation, San Antonio, USA) which consists of black polyurethane foam with porosity 400– 600 µm, self adhesive foil, connective tube, container and vacuum pump. Subatmospheric pressure of 125 mmHg in constant mode (not intermittent) was applied. Dressings were changed every 48–72 hours. In 17 cases split thickness skin graft (STSG) was used after preparation of the wound with NPWT and in two cases with open tibia fractures NPWT was also used for fixation of the skin graft. Before application of NPWT dressing, the STGG was sutured to the wound edges, covered by paraffin gauze and afterwards polyurethane foam was tailored to the wound shape and fixed with the adhesive foil. For this purpose constant subatmospheric pressure of 75 mmHg was used and foam dressing was removed after two days. Patients with open fractures have accessory injuries and complications, which increased the complexity of problems

Fig. 1. A–B – radiographs showing open tibia fracture IIIB after external fixation; C – appearance of the leg with traumatized soft tissue before debridement; D – after debridement.



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Table 1. Characteristics of patients managed with NPWT, concomitant injuries, therapy and final result. STSG – split thickness skin grafting. Age (years)

Wound and accompanying injury

Therapy

Clinical results

Results

1.

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Open tibia fracture IIIC, segmental tibia loss 14 cm, closed proximal fibula fx., circular skin and muscle defect on medial side, damage of anterior and posterior tibial vessels, damage of peroneal and tibial nerve

External fixation, debridement, NPWT, STSG, tibialization of fibula by local bone transportation of fibula with Ilizarov frame in defect within tibia, application of rh-BMP-7 at proximal docking site

Complete wound healing, bone healing after 16 months, maintained neutral foot position, able to walk without crutches, using Toe-Off orthosis

Good

2.

35

Open tibia fracture IIIC and open fibula fracture IIIC, circular skin defect, muscle defect on medial side, damage of anterior and posterior tibial vessels, damage of peroneal nerve

External fixation (Dynastab), NPWT, STSG, reaming of medullary cavity of tibia and local antibiotic treatment, exchange of stabilization to Ilizarov frame, application of rh-BMP-7 (Ossigraft) at fracture site

Complete wound healing, bone fusion after 18 months, foot position in 10 degr. plantarflexion, able to walk with crutches, using Toe-Off orthosis

3.

22

Open right tibia fracture IIIC, open left femur fracture IIIB

Tibia: external ring fixation; Femur: external Monotube fixation, NPWT on leg and femur, STSG

Tibia: below knee amputation, salvage of left lower extremity, able to walk with crutches

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45

Open tibia fracture IIIB, multiple other fractures

External fixation, debridement, NPWT, STSG

Complete wound healing, bone fusion after 28 months, able to walk without crutches

Good

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22

Open tibia fracture IIIB, open femur fracture I, multiple other fractures, brachial plexus paresis

Tibia: external fixation, debridements, NPWT, conversion to IMN + gastrocnemius flap + STSG; after soft tissue healing – external bone transport

Complete wound healing, bone fusion after 18 months, foot position in 10 degree, able to walk with crutches, using Toe-Off orthosis

Good

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Open tibia fracture IIIB, multiple other fractures, lung carcinoma

IMN fixation; external ring fixation + segmental resection, NPWT Therapy not completed due to neoplastic disease

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17

Open medial malleolus fracture IIIB with circular skin defect over ankle joint

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9.

Good

Poor/ fair

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Patient number

Fair

Internal fixation of fracture, debridement, NPWT, STSG


Good

Open tibia fracture IIIB, skin defect on lateral side distal of leg

External fixation, debridement, NPWT, STSG


Good

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Wound over fractured clavicle, complication of haematoma and hemorrhage from post-traumatic subclavian artery aneurysym

Endovascular management of subclavian artery aneurysym; debridement, NPWT

Healing of the wound

Good

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Traumatic wound of foot, necrosis of toes, circular wound of distal ½ of foot, wound in popliteal fossa, subtrochanteric fracture, bimalleolar fracture

Internal fixation of subtrochanteric i malleolar fractures + wound debridement + STSG + NPWT dressing for STSG fixation – all in one session

Complete healing of all wounds; femur – bone fusion after 6 months; ankle – bone fusion after 3 months; able to walk without crutches

Good

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75

Traumatic wound right hand, amputation of 2nd finger

Debridments, NPWT, STSG

Complete STSG healing, poor mobility of fingers. Fair

Good

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Traumatic wound involving 85% of plantar surface of foot with exposure of calcaneus

Debridments, NPWT, STSG; at 2nd stage vascularised fascio-cutaneous flap from thigh

Complete wound healing, able to walk without crutches

Good

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Wound dehiscence after Achilles tendon suture with exposure of tendon

Debridements, NPWT, STSG

Complete STSG healing, able to walk without crutches

Good

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Post-fasciotomy wound; compartment syndrom


Complete STSG healing

Good

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Wound of the leg due to subcutan haemorrhage/haematoma; acenocumarol therapy

Debridements, NPWT, without STSG

Partial healing

Fair

16.

66

Acute infected wound of dorsal part of the foot in kidney graft recipient


Complete STSG and wound healing

Good

17.

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Acute infection of MCP I joint with pathologic luxation of the thumb; acute leukemia

Debridement of wound, fixation of MCPI, NPWT

Healing of wound, infection control. Died due to complications of leukemia

Good

18.

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Chronic osteomyelitis of tibia; with chronic wound over anterior side of tibia without exposure of the bone

Debridement, attempt of NPWT

Poor tolerance of NPWT – dressing foil, no improvement

Poor

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Chronic osteomyelitis of tibia; wound over infected pseudoarthrosis with exposure of the bone. Chronic kidney insufficiency

Resection of pseudoarthrosis, external ring fixation, segmental transport, NPWT

Healing of wound, infection control, bone fusion after 26 months

Good

20.

22

Pressure ulcer within a scar on the dorsal side of the foot

Debridement, NPWT, without STSG

Poor tolerance of NPWT – dressing foil due to the scar, partial improvement

Fair

21.

43

Pressure ulcer over sacrum; polytrauma


Complete wound healing without infection

Good

22.

58

Chronic leg ulcer

Debridement, NPWT, STSG


Good

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58

Chronic leg ulcer for 20 years

Debridement, NPWT 10 days, STSG


Good

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48

Chronic leg ulcer



Good

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58

Chronic leg ulcer


Incomplete STSG healing

Fair

26.

42

Neuropatic foot, chronic wound on plantar aspect of 1st MTP joint


Complete wound healing without infection

Good

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55

Diabetic foot ulcer on plantar surface of midfoot



Fair

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56

Diabetic foot ulcer over calcaneus

Debridements, NPWT

Partial healing

Fair

29.

62

Diabetic foot ulcer of forefoot

Amputation of toes, debridement, NPWT, STSG


Fair

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Complete wound healing over bone, without bone fusion




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Fig. 1. E – application of V.A.C.-dressing; F – after removal of external fixation and stabilization with IM nail and intercalary acrylic cement spacer with antibiotic, preparation of gastrocnemius flap and fixation of flap within tissue defect; G – wound healing; H–I – radiograph shoving cement spacer within bone defect; J–K – radiograph showing successful bone regeneration during segmental transport over IM nail.

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Fig. 2. A – open tibia fracture IIIC after external fixation, appearance of soft tissue necrosis; B – circular VAC dressing; C – granulation tissue after NPWT; D – healed wound.

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over the second metacarpal bone, resulting from the crush of 2nd finger, eventually amputation of the 2nd finger was necessary, and NPWT, together with STSG, was used for healing of the residual wound of the hand (Fig. 3A–D). Patient suffering from the fracture of the left clavicle (case No. 9) with the accompanying posttraumatic aneurysm of the left subclavian artery required firstly endovascular treatment of the pseudoaneurysm at vascular surgical department. © Evereth Publishing, 2014

Afterward the V.A.C.-dressing was applied. The fracture itself was treated conservatively due to soft-tissue condition and infection within the wound. The wound healed without skin graft. In case No. 12 with traumatic wound involving 85% of the plantar surface of the foot, V.A.C.-dressing was used to manage extensive skin defect with exposure of the plantar fascia and calcaneus. After preparation of the wound with NPWT, STSG was applied and the wound healed. After


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Fig. 3. A – radiograph of the traumatized hand after loss of 2nd finger and metacarpal bone; B – soft-tissue necrosis before debridement; C – after debridement and application of NPWT; D – after complete skin graft healing.

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Fig. 4. A – traumatized foot with extensive skin defect and exposure of calcaneus; B – application of VAC-dressing; C – granulation in the course of NPWT; D – healed split skin graft. E – appearance after free vascularised fascio-cutaneous flap.

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Fig. 5. A–C – appearance of the thumb of right hand with septic MCPI arthritis after fixation of MTP I with K-wires; D – application of VAC-dressing using bridge-technique.

one year the area of healed STSG was replaced by microvascular fascio-cutaneous flap at the plastic-reconstructive department with the aim to improve the quality of soft tissue coverage of the calcaneus (Fig. 4A–E). In one case of wound accompanying acute infection of MCPI joint of the thumb of the right hand, after debridement of the joint and fixation with Kirschner wire, 26

V.A.C.-dressing using bridge-technique was applied (Fig. 5A–D). In another case (patient No. 26; see Table 1) chronic wound was located on the plantar surface beneath the 1st metatarso-phalangeal (MTP) joint within neuropathic foot. Patient suffered also from arthropathy of MTP I-II-III joints, and underwent previously amputation of 4th and 5th toe. In this case also bridge-technique allowed for application




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Fig. 6. A, B – radiograph and appearance of the neuropathic foot with arthropatic MTP I-II-III joints, after amputation of 4th and 5th toe. Chronic pressure sore on plantar aspect of MTP I joint; C – application of V.A.C.-dressing using bridge-technique; D – wound after completing of NPWT.

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Fig. 7. A – appearance of the chronic wound of the leg treated 20 years with dressings; B – after debridement and application of V.A.C.-dressing; C – after 10 days of NPWT; D – after split skin grafting.

Results of NPWT

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Type of wound

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Table 2. Results of wound therapy with NPWT.

No.

Good

Fair

Poor

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10

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Wounds accompanying open fractures

2.

Postoperative or acute traumatic wounds without fracture

3.

Primary infected wounds secondary to osteomyelitis/arthritis

3

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1

4

4.

Chronic wounds

5

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of V.A.C.-dressing after debridement of the wound (Fig. 6A–D). In another „model” patient treated for chronic leg ulcer for 20 years with dressings, after debridement, 10 days of NPWT management and split skin grafting, wound healed completely (Fig. 7A–D). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from each patient.

Results Results of NPWT in 30 wounds were classified as good (i.e. complete wound or split skin graft healing without © Evereth Publishing, 2014

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infection), fair (incomplete i.e. over 75% of wound area healing without infection) and poor (less than 75% of wound area healing or/and active wound infection). Good results were achieved in therapy of 20 from 30 wounds, fair in 8 and poor in 2 cases. No improvement was noted in one patient with intolerance of adhesive foil and in another case amputation of traumatized leg was performed in another country. Best results were achieved in acute traumatic wounds, wounds accompanying open IIIC and IIIB fractures and wound secondary to bone or joint infection (Table 2). In chronic wounds good and fair results stated respectively 50%. In wounds located within three diabetic foots only fair results were achieved. NPWT allowed for salvage of 9 from


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10 traumatized extremities with severe open fractures IIIB and IIIC, and complete healing of 5 from 10 chronic infected wounds. STSG healed completely in 16 from 17 cases.

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NPWT is a potent and effective therapeutic method for wound management. Since introduction at end of the 20th century it is still investigated and currently used in therapy of both acute and chronic, traumatic and non-traumatic wounds, ulcers (diabetic and pressure ulcers), dehisced wounds, partial-thickness burns and even post-sternotomy osteomyelitis. NPWT reduces the wound depth and surface area until the wound is relatively superficial and reepithelization can progress under another wound management or a lesser surgical procedure can be performed [16]. The application of NPWT can allow wound improvement to the point that surgery is not needed or a lesser surgical procedure can be performed. If the pressure ulcer is to heal by secondary intention, NPWT can be used until the wound achieves a fully granulated surface, with elimination of tunnels and edge undermining. If the wound does not progress or deteriorates under NPWT, the wound can require surgical reconstruction of the pressure ulcer or use of another adjunctive modality. NPWT can also be used to prepare the donor site for the flap. The economic aspects of wound therapy with NPWT has been also assessed and it was shown by Birke-Sorensen that compared with conventional therapy, NPWT reduces costs of wound therapy through combination of better outcomes and reduced use of nursing resources [17]. NPWT simplifies soft tissue coverage and allows quicker graft incorporation [14]. It has been proven that NPWT improves quality of STSG as compared with standard bolster dressings [18]. In presented paper group skin graft healed completely in 16 from 17 cases. In two assessed patients with open tibia fractures IIIB, NPWT was used for two days for fixation of STSG with good result. It allowed for better skin graft adhesion to irregular wound surface and excellent healing of whole skin graft. Undesired overgrowth of granulation tissue into mesh graft was avoided using NPWT for only two days with constant pressure of 75–100 mmHg and by application of foam dressing on graft covered by paraffin gauze and not directly on STSG. The role of NPWT in therapy of traumatic wounds and open fractures is still under research. The aim of therapy in open fractures is to achieve healing of the fracture without infection and good soft tissue coverage of the bone. After bone fixation, usually multiple debridements are performed with the aim to prevent infection of bone and achieve good quality of soft tissue over the bone. The energy of external impact can cause waste and deep damage of skin

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and muscle, which in orthopedic ward without plastic-reconstructive unit can be difficult to manage. Application of NPWT reduces the risk of infection in the wound and at the fracture site. This positive effect of NPWT on healing of traumatic wound was proven in open tibia fractures grade IIIA and IIIB. In the study by Labler et al. the superiority of NPWT over Epigard in healing of posttraumatic wounds has been shown [13]. NPWT reduced frequency of deep infection in open tibia fractures IIIA or IIIB from 50% to 14% and delayed fracture healing from 25% to 7%. Beneficial effects of NPWT has been also proven in war conditions in Iraq [19]. In 88 high-energy soft tissue wounds in 77 patients the wound infection rate and overall wound complication rate was 0%. In the assessed in this paper 10 open IIIB and IIIC fractures, wounds granulated under NPWT conditions within 21–25 days – either completely or to the stage, when skin grafting was possible. In 9 from 13 wounds, NPWT allowed for complete skin graft healing and in another two – healing of at least 75% of STGS, without other reconstructive methods. Only one wound accompanying open IIIB fracture was reconstructed by distally pedicled gastrocnemius flap and STSG. Untreated osteomyelitis is regarded as contraindication for the use of NPWT. However NPWT can be appropriate when treatment for osteomyelitis has been initiated. Tan published good results of NPWT combined with debridement and other reconstructive measures in 30 cases of acute and chronic osteomyelitis [20]. Similarly good effects of NPWT on bone infection found Ford in 3 cases of osteomyelitis in pressure ulcer cases [21]. Diefenbeck investigated influence of NPWT on invasive post-traumatic osteomyelitis and bacterial colonization of wound under NPWT in 43 patients [22]. Results have shown, however that compared to another treatment options in acute postoperative osteomyelitis, especially implantation of local antibiotics, V.A.C.-therapy does not diminished the number of debridements and rate of recurrences of bone infection. In presented paper 4 patients with wounds accompanying bone and joint infections, NPWT was intended not to treat the bone infection, but to manage accompanying infected wound. Two from four patients improved significantly under NPWT without the need of more aggressive reconstruction of soft tissue. One patient was allergic to adhesive foil and NPWT therapy was stopped and not terminated. Despite the effectiveness of NPWT in reducing critical bacterial colonization, the complexity of tissue damage in case No. 2 was reason for developing invasive bacterial infection of the tibia, which might have lead to segmental osteomyelitis and potentially to amputation. The osteomyelitis – intramedullary type, in this case was effectively managed by temporary removal of pins of external fixator, reaming of medullary cavity and local application of antibiotic carrier.

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NPWT combined with proper wound debridements and stable bone fixation in open fractures grade IIIB and IIIC with extensive soft-tissue defect not suitable for microsurgical flaps can contribute to salvage of majority of traumatized extremities. NPWT can allow for wound closure of minor wounds by granulation or complete skin graft healing in acute and chronic wounds of traumatic or non-traumatic origin. Results in chronic wounds are less favorable than in acute wounds. Conflict of interest: The author confirms that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Funding section: This study was conducted as part of our routine work. Acknowledgments: I hereby wish to thank Professor Andrzej Górecki, dr. Jaroslaw Macias, dr. Slawomir Zarek and dr. Marek Wiszniowski from the Department of Orthopaedic and Traumatology Medical University of Warsaw for contribution to this work.

References 1. 2. 3. 4. 5.

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debridement and stable bone fixation in open IIIB and IIIC fractures allowed for limb salvage without microsurgical flaps in 8 from 9 cases. Only one patient needed coverage of the calcaneus with microsurgical fascio-cutaneous flap at 2nd stage – one year after termination of the wound management with NPWT. The V.A.C.-dressing was effectively used even in a „border” case of clavicle fracture, complicated by damage of subclavian artery, after successful endovascular treatment of the pseudoaneyrysm itself.

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NPWT is commonly applied in therapy of diabetic and chronic leg ulcers. Patients with this type of chronic wounds are not „dream patients” in daily orthopedic practice. But skills and experience with them can be necessary as patients with chronic diabetic ulcers or chronic leg ulcers can be hospitalized in any orthopedic department for treatment of all kinds of fractures. In a study published by Joseph et al. twenty four patients with 36 different chronic wound types were evaluated in order to compare wet-to-moist dressings and NPWT [16]. After 6 weeks 64% of the NPWT group demonstrated granulation tissue formation, whereas 81% of the wet-to-moist group had inflammation and fibrosis. NPWT promoted faster healing than standard wet-to-moist dressings and increased the rate of granulation tissue formation. Another data indicate a positive effect of NPWT on diabetic ulcer healing. In a multicenter study on 162 diabetic patients with wounds secondary to partial foot amputation the effect of NPWT was compared to standard moist wound care [23]. Wounds were treated until healing or completion of the 112-day period of active treatment. The rate of wound healing and granulation was faster in the NPWT group (56% vs. 39%) whereas the frequency and severity of adverse events were similar in both groups. A study by Blume at al. showed that during 112 day of treatment of foot ulcers with NPWT, 43.2% of wounds completely healed, compared with 28.9% treated with advanced moist wound therapy (AMWT) and NPWT patients experienced significantly fewer secondary amputations [24]. In presented case cohort only 10 cases of chronic wounds (leg ulcers, wounds located within diabetic and neuropathic foot) were treated. The results of NPWT were either good or fair, but generally less favorable as compared to traumatic wounds. An alternative for traditional – conservative and surgical wound management or NPWT may be biological skin substitutes. They can provide coverage of the wound either as biosynthetic skin substitutes or cultured autologous engineered skin. Their advantage is the availability in large quantities and minimal risk of infection or immunological response [25]. Limitation of their use are their costs. They are also contraindicated in infected wounds. Limitation of the study is the low number of assessed cases. Fortunately, in contrary to war conditions, high energetic open IIIB and IIIC fractures are not so common, as it was the case in presented 10 open fractures. In presented patients cohort NPWT proved to be effective and simple method for therapy of extensive soft-tissue defects accompanying high grade open IIIC and IIIB fractures, even on partially exposed bone, especially in an orthopedic department without experience in microsurgical flaps. In cases of damage of main arteries, in infected wounds, or if the wound area exceeds the dimensions of potential free flap, the microsurgery may have limited usefulness. V.A.C.- dressings together with proper soft tissue © Evereth Publishing, 2014

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