Negative Pressure Therapy as a Bridge to Free Tissue ...



Title: Defining the Role for Negative Pressure Therapy in the Treatment Algorithm of Extremity Wounds

Authors: Liza C. Wu, MD; Loren S. Schechter, MD; Robert F. Lohman, MD; Robin Wall, PA; Mieczyslawa Franczyk, PT, PhD

Introduction: Negative pressure therapy is promoted as a method of simplifying wound care and reducing the extent of soft tissue reconstruction in complex extremity wounds. Studies have shown the VAC device decreases edema, wound size, and bacterial counts, and increases blood flow and the rate of granulation tissue formation. These properties make the VAC device attractive for the surgeon that deals with complex wounds. The role of this new therapy has yet to be fully defined.

With extensive, traumatic extremity wounds Free tissue transfer has become standard treatment for many extremity wounds. Authors the such as Godina and Lister have emphasized theimportance of early soft tissue reconstruction utilizing free tissue transfer is well established for limb salvage. Adequate debridement followed by early coverage with vascularized tissue has been advocated by Godina, Byrd, Cierny, and others. However, other issues (referral patterns, availability of trained microsurgeons, other injuries to the patient)associated injuries, availability of trained microsurgeons, and referral patterns may delay reconstruction of these wounds. A cohort of patients receiving negative pressure wound therapy followed by free tissue transfer for the treatment of a complex extremity wound was evaluated. The goal was to determine the role of negative pressure therapy in the treatment algorithm for this population. Recently, negative pressure wound therapy has been promoted as a way to simplify wound care, and to possibly reduce the need for soft tissue reconstruction. The role of this new therapy has yet to be fully define

Methods: All patients undergoing soft tissue reconstruction of the extremities were entered into a prospective data base. A subset of patients undergoing treated with both negative pressure wound therapy and free tissue transfer were was evaluatedanalyzed. Data regarding patient demographics, operative details, and outcomes was collected.

Results: From 6/99 to 6/02, 176 patients with extremity wounds were treated with a combination of negative pressure wound therapy and free tissue transfer. There were 15 males and 2 females; 14 wounds involved the lower extremity [L] and 3 involved the upper extremity [U]. The median age was 48 years (range 6 – 69); 8 patients had chronic comorbid conditions; 6 patients smoked cigarettes. Thirteen patients had culture proven osteomylitisosteomyelitis; 13 patients had open fractures. Wounds occurred as a result of trauma [T] (14),; vascular insufficiency (1), a brown recluse spider bite (1), and from radiation injury to the femur (1). The median Mangled Extremity Severity Score [MESS] was 5 (range 2 – 9). Wounds were also divided into the Swartz and Mears classification system.

Two patients presented with avulsed limbs and underwent completion amputation (*) upon presentation. Patients underwent a median of 2 operations debridements (range 1 –5) for debridement beforeprior to definitive closure. Reconstruction was done with three different flaps: free rectus muscle flap [FR] (11), free radial forearm flap [FRFF] (5), and free gracilis muscle flap [FG] (1). Major complications requiring reoperation occurred in 7 (41%) patients. These included total flap loss (2), persistent osteomyelitis necessitating calcanectomy (1), abscess under the flap requiring drainage and hardware removal (1), and tibial non-union requiring a vascularized bone graft (1), hematoma under the flap requiring drainage (1), and loss of skin graft (1) from the flap requiring repeat grafting. Complications did not appear to be related to age, co-morbidities, method of injury, or MESS. However, the mean number of days between injury and soft tissue reconstruction [DOI-DOR] differed between the patients without complications, 47.9 (range 4 – 165) compared to the patients with complications, 5194.9 (range 17-224). The mean number of days of negative pressure therapy for patients without complications was 12.5 (range 2 – 85), compared to 2543.9 (range 8 – 100) for patients with complications (p < 0.05).

|Patient |Age |Sex |Extremity |Systemic dz |Tobacco |Cause |MESS/ |# debride |VAC Days |DOI-DOR |Flap |Osteo |Complications |

| | | | | | | |Swartz | | | | | | |

|1 |29 |M |L |N |N |T |3/1a |1 |4 |30 |FRFF |N |N |

|2 |35 |M |L |N |N |T |6/3b |1 |4 |7 |FRFF |Y |N |

|3 |37 |M |U |N |Y |T |8*/3b |2 |2 |4 |FR |Y |N |

|4 |38 |M |L |N |Y |T |4/3a |4 |4 |29 |FR |N |N |

|5 |42 |M |L |Y |N |T |2/1b |1 |8 |24 |FR |Y |N |

| | | | |IBD, Steroid | | | | | | | | | |

| | | | |use | | | | | | | | | |

|6 |47 |M |L |Y |N |T |4/1b |5 |3 |47 |FR |Y |N |

| | | | |NIDDM | | | | | | | | | |

|7 |50 |M |U |N |Y |T |9*/3b |2 |6 |8 |FR |? |N |

|8 |56 |M |L |N |Y |Recluse |n/a/1a |2 |5 |146 |FR |N |N |

| | | | | | |spider | | | | | | | |

| | | | | | |bite | | | | | | | |

|9 |65 |M |U |N |N |T |7/3b |3 |4 |19 |FR |Y |N |

|10 |69 |M |L |Y |Y |T |6/3b |2 |85 |165 |FR |Y |N |

| | | | |DM, PVD, HTN | | | | | | | | | |

|11 |6 |M |L |N |N |T |4/1b |2 |39 |96 |FG |Y |Total flap loss|

|12 |39 |M |L |Y |N |PVD |3/2b |4 |8 |89 |FRFF |Y |Hematoma |

| | | | |DM, PVD, | | | | | | | | | |

| | | | |Transplant | | | | | | | | | |

| | | | |patient, | | | | | | | | | |

| | | | |Steroid use | | | | | | | | | |

|13 |48 |M |L |N |N |T |7/3b |3 |35 |75 |FRFF |Y |Partial skin |

| | | | | | | | | | | | | |graft loss |

|14 |49 |M |L |Y |Y |T |3/1b |3 |45 |224 |FRFF |Y |Persisent osteo|

| | | | |DM, PVD | | | | | | | | | |

|15 |59 |M |L |Y |N |T |5/3b |4 |100 |137 |FR |Y |Tibial |

| | | | |DM, HTN | | | | | | | | |non-union |

|16 |61 |F |L |Y |N |T |7/3b |3 |15 |26 |FR |Y |Abscess |

| | | | |HTN, CADz, | | | | | | | | | |

| | | | |Hyperchol | | | | | | | | | |

|17 |61 |F |L |Y |N |Osteoradio|n/a/3b |1 |65 |17 |FR |Y |Total flap loss|

| | | | |Obesity | |-necrosis | | | | | | | |

| | | | | | |of femur | | | | | | | |

Table 1: Patient demographics

Conclusions: The benefits of negative pressure therapy are well established and multifold. The VAC device optimizes the wound bed by decreasing edema and increasing blood flow. It protects the wound from dessication. It is more convenient and comfortable for the patient then the traditional daily dressing changes. For these reasons, negative pressure therapy has a role in the management of complex extremity wounds.

Despite these advantages, the VAC device does not replace the need for aggressive debridement and vascularized tissue coverage. A delay in soft tissue reconstruction continues to have a high compliction complication rate. Furthermore, negative pressure wound therapy does not seem to change the basic principles of extremity reconstruction, e.g. the need for adequate debridement, and removal of contaminated hardware. All of the complications in this series occurred in patients who required more than 7 days of negative pressure wound therapy, while those requiring fewer days of negative pressure therapy had no complications. There was a significant difference of total number of days of VAC therapy between patients without and with complications following free flap coverage (p ................
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