Soft Tissue Management in Open Fractures of the Lower Leg: The Role of Vacuum Therapy

Abstract : The management of severe open fractures of the lower leg continues to challenge the treating surgeon. Major difficulties include high infection rates as well as adequate temporary soft tissue coverage. In the past, these injuries were commonly associated with loss of the extremity. Today, vacuum therapy provides not only safe temporary wound coverage but also conditioning of the soft tissues until definitive wound closure. Amongst other advantages, bacterial clearance and increased formation of granulation tissue are attributed to vacuum therapy, making it an extremely attractive tool in the field of wound healing. However, despite its clinical significance, which is underlined by a constantly increasing range of indications, there is a substantial lack of basic research and well-designed studies documenting the superiority of vacuum therapy compared to alternative wound dressings. Vacuum therapy has been approved as an adjunct in the treatment of severe open fractures of the lower leg, complementing repeated surgical debridement and soft tissue coverage by microvascular flaps, which are still crucial in the treatment of these limb-threatening injuries. Vacuum therapy has in general proven useful in the management of soft tissue injuries and, since it is generally well tolerated and has low complication rates, it is fast becoming the gold standard for temporary wound coverage in the treatment of severe open fractures of the lower le

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 fracture

"Damage Control” in Severely Injured Patients: Why, When, and How?

Abstract : The concept of "damage control” is established in the management of severely injured patients. This strategy saves life by deferring repair of anatomic lesions and focusing on restoring the physiology. The "lethal triad” hypothermia, coagulopathy, and acidosis are physiological criteria in the selection of injured patients for ”damage control”. Other criteria, such as scoring of injury severity or the time required to accomplish definitive repair, are also useful in determining the need for ”damage control”. The staged sequential procedures of ”damage control” include, after the selection of patients (stage 1), "damage control surgery” or "damage control orthopedics” (stage 2), resuscitation in the intensive care unit (stage 3), "second-look” operations or scheduled definitive surgery (stage 4), and the secondary reconstructive surgery (stage 5). The concept of ”damage control” was carried out in a third of 622 severely injured patients in our division. Although level I evidence is lacking, the incidence of posttraumatic complications and the mortality rate were reduced. However, better understanding of the significance and kinetics of physiological parameters including inflammatory mediators could help to optimize the "damage control” concept concerning the selection of patients and the time points of staged sequential surger

Traumatic Hemipelvectomy

Purpose:: Open or closed traumatic hemipelvectomy is defined as a uni- or bilateral avulsion of the bony hemipelvis in combination with rupture of the large pelvic nerves and vessels and is usually accompanied by injuries of the genitourinary tract and bowel. According to a literature review between 1960 and 2005, 96 cases of traumatic hemipelvectomy were documented. Patients and Methods:: Between 1998 and 2004, nine male patients fulfilled the criteria for a traumatic hemipelvectomy, out of 1.8% pelvic injuries (n = 507) and of 2.4% pelvic ring injuries (n = 373). Seven patients were admitted directly to the authors' trauma center, one patient was admitted 3 h after the accident, and one patient was stabilized in another hospital and transferred 5 days later. Results:: All seven patients admitted primarily after trauma and the patient transferred 3 h later were in shock class IV. The traumatic hemipelvectomy was unilateral in eight patients with one complete avulsion and bilateral in one patient. Injuries of the pelvic vessels occurred in all patients. Most of the patients had injuries of both the genitourinary tract and the intestine. Associated injuries were mostly those of extremities, thorax and head. Neurologic deficits could be documented clinically on admission in four patients. Laparotomy for damage control with packing of the abdominal cavity and the retroperitoneum was performed in all cases. Four patients died during stabilization attempts in hemorrhagic shock during the first 4 h of treatment and three patients died after 3, 5, and 7 days in the intensive care unit because of septic complications. Two patients survived with a follow-up of 21 and 34 months. Conclusion:: Traumatic hemipelvectomy is a most severe pelvic ring injury. If the diagnosis of traumatic hemipelvectomy is clear, surgical hemipelvectomy should be performed. Limb-saving procedures endanger patient's life. Early and frequent second-look operations and aggressive management of associated pelvic injuries minimize wound problems and septic complication

Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery

The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infectio

The Role of Surgical Hip Dislocation in the Treatment of Acetabular and Femoral Head Fractures

Abstract : Background and Purpose: : Surgical hip dislocation by trochanteric flip osteotomy facilitates access to acetabular and femoral head fractures. Furthermore, it allows evaluation of cartilage damage and vascularity of the femoral head. In this study the potential benefits of this procedure for improved fracture management and for prognostic assessment were investigated. Patients and Methods: : From July 1997 to October 1999, 20 selected patients with displaced acetabular fractures (n = 12), femoral head fractures (n = 7), or combined injuries (n = 1) were included. Inclusion criteria for acetabular fractures were either displaced posterior wall fragments with cranial extension or complex acetabular fractures involving a displaced transverse fracture line. Open reduction and fixation of either complex acetabular fractures or femoral head fractures were carried out through Kocher-Langenbeck approach, trochanteric flip osteotomy, and complete surgical hip dislocation. Additionally, the extent of cartilage destruction and femoral head perfusion were assessed. Results: : Anatomic reduction (≤ 1 mm displacement) of acetabular fractures was achieved in 69% of patients and good reduction (≤ 3 mm) in 31%. In patients with acetabular fractures, severe cartilage destruction of the acetabulum was found in 38% and of the femoral head in 15%, while patients with isolated femoral head fractures revealed severe cartilage damage of the femoral head in 57%. Arterial bleeding from the femoral head, tested by drilling, was observed in all patients. Secondary dislocation of the trochanteric osteotomy occurred in one patient and made refixation necessary. Patients were reexamined at least 2 years after intervention. 77% of patients with acetabular fractures and all patients with femoral head fractures showed good or excellent results after 32.6 ± 6.1 months according to the functional score of D'Aubigné & Postel. Conclusion: : Surgical hip dislocation allows adequate reconstruction of complex acetabular and femoral head fractures and intraoperative evaluation of local cartilage damage and femoral head perfusio

Prophylaxis of Heterotopic Ossification in Patients Sedated after Polytrauma: Medical and Ethical Considerations

Background and Purpose:: Heterotopic ossification (HO) often follows acetabular fractures after multitrauma. Irradiation is a mean for prophylaxis. We established a standard procedure in our hospital for patients under sedation, when obtaining informed consent for HO prophylaxis is impossible. Patients and Methods:: We reviewed current scientific evidence, calculated the risks of radiation and presented the ethical and legal framework. The subject was scrutinised by an interdisciplinary panel. Results:: Irradiation is the most effective means for prophylaxis and has few adverse effects in adult patients with fractures of the acetabulum. The lifetime risk of radiation-induced cancer or infertility are insignificant. Conclusions:: Informed consent for irradiation should be obtained before operation whenever possible. When this cannot be done prophylaxis can be postponed for a maximum of 3 days in order to obtain consent. If the patient is not able to communicate within this period, prophylactic irradiation should be given after consulting the relatives. The patient must be informed as soon as possibl

The Severity of Injury and the Extent of Hemorrhagic Shock Predict the Incidence of Infectious Complications in Trauma Patients

Abstract : Background: : Trauma patients are at high risk of developing systemic inflammatory response syndrome (SIRS) and infections. The aim of this study was to evaluate the influence of the severity of injury and the extent of hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications. Methods: : A total of 972 patients who had an injury severity score (ISS) of ≥ 17, survived more than 72 h, and were admitted to a level I trauma center within 24 h after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were measured in patientswith different severities of injury as assessed by ISS, or with various degrees of hemorrhagic shock according to ATLS® guidelines, andwere compared using both uni- and multivariate analysis. Results: : Infection rates and septic complications increase significantly (p < 0.001) with higher ISS. Severe hemorrhagic shock on admission is associated with a higher rate of infection (72.8%) and septic complications (43.2%) compared to mild hemorrhagic shock (43.4%, p < 0.001 and 21.7%, p < 0.001, respectively). Conclusion: : The severity of injury and the severity of hemorrhagic shock are risk factors for infectious and septic complications. Early diagnostic and adequate therapeutic work up with planned early "second look" interventions in such high-risk patients may help to reduce these common posttraumatic complication

Impact of bisphosphonate wash-out prior to teriparatide therapy in clinical practice

Concurrent use of bisphosphonate therapy reduces the anabolic effect of teriparatide. Consequently, in clinical practice bisphosphonates are discontinued and teriparatide therapy held for a few months to allow bone turnover to increase. We aimed to evaluate the effect of prior bisphosphonate exposure and the effect of bisphosphonate wash-out on the treatment response to teriparatide. Thirty-nine patients with primary osteoporosis (mean age 63.6±14.0years), including 26 patients previously treated with oral bisphosphonates (median duration 53months) and 13 bisphosphonate-naïve patients were started on teriparatide (20μg daily) and followed prospectively over 12months. The primary study outcome was change in bone formation markers (PINP, bone ALP, osteocalcin). Secondary outcomes included changes in bone resorption (βCTX) and 12-month changes in BMD. Markers of bone formation increased early during teriparatide therapy and were followed by an increase in βCTX (p<0.001). The magnitude of the increase in bone markers was comparable in both patient groups irrespective of prior bisphosphonate exposure; similarly, increases in BMD after 12months were not significantly different between bisphosphonate-pretreated and bisphosphonate-naïve patients (lumbar spine 7.1 vs. 8.9%, p=0.58; total hip 4.1 vs. 1.1%, p=0.48). The response of teriparatide was not related to the duration of bisphosphonate wash-out (median duration 4.2months). This study confirms that beneficial effects of teriparatide on intermediate bone endpoints can be translated into clinical practice with less constringent methodological circumstances than in RCTs. Furthermore, as bisphosphonate wash-out does not appear to influence the treatment effect, teriparatide therapy can be started immediately after ceasing bisphosphonate therapy and wash-ou