V.A.C.™ Instillation: in vitro model. Part 1

The reproducibility of a V.A.C.™ (Vacuum Assisted Closure) instillation system was investigated by means of an in vitro model. The relation between the volume of a delivered solution and its removal from the system was studied in foams of various size. The relationship of instillation time periods and the volume of delivered solution was determined. Mittels eines in vitro Models wurde die Reproduzierbarkeit der V.A.C.™ (Vacuum Assisted Closure) instillation untersucht. Die Beziehung zwischen den Volumina der infundierten Flüssigkeiten und des Abflusses wurde in Schaumstoffen verschiedener Grösse untersucht. Das Verhältnis zwischen Instillationszeit und Volumen der infundierten Flüssigkeit wurde ermittel

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

Management of Morel-Lavallee Lesion Associated with Pelvic and/or Acetabular Fractures

Abstract : Objective: : Management of Morel-Lavallee soft tissue lesion (MLL) in patients with associated pelvic and/or acetabular fractures is still under discussion. Especially, the sequence of treatment of MLL soft tissue management and osteosynthesis of pelvic and acetabular injury remains controversial. Methods: : We report all consecutive patients with MLL associated with pelvic ring and/or acetabular fractures during an 8-year period at our hospital. Surgical access and techniques were analyzed concerning complications and outcome. Results: : Altogether, 20 patients were included in the study. One patient was treated conservatively and MLL healed without complications; 19 patients had an operative treatment of MLL. In 15 patients debridement was performed within one day after injury and in four patients with delay of 5 days at least. Ten patients had surgery for an associated pelvic ring or acetabular fracture. In four of them MLL was operated before, in six patients simultaneously to osteosynthesis. In three patients, the same surgical approach for osteosynthesis and debridement of MLL was used; none of them showed postoperative complications. Altogether, in nine operated patients (47.4%) MLL healed without any complications. Nine operated patients presented prolonged wound healing, however, during long term follow-up, all patients showed complete healing of the MLL. One patient died during resuscitive surgical procedures. Conclusions: : We recommend debridement for early and delayed treatment of MLL. Osteosynthesis during first debridement may be performed without adverse outcome. Identical surgical access for both procedures can be used. In case of repeated surgical debridement VAC® therapy may be a helpful tool for dead space reduction and wound conditionin

"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

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

Entrapment der A.tibialis anterior in einer distalen Tibiafraktur nach intramedullärer Nagelung

Zusammenfassung: Es wird ein Fallbericht über ein Entrapment der A.tibialis anterior im Rahmen der Versorgung einer distalen geschlossenen Tibiafraktur mit Hilfe eines Tibianagels präsentiert. Wegen offenen Metatarsalefrakturen mit einer schwerer Weichteilverletzung der gleichen Seite wurde nach mehreren Débridements eine freie Latissimus-dorsi-Lappenplastik zur Deckung geplant. Die präoperative Angiographie zeigte einen Verschluss der A.tibials anterior auf Frakturhöhe. Der Verschluss wurde als eine sekundäre Gefäßokklusion interpretiert, die durch eine Intimaverletzung des Gefäßes im Rahmen der Verletzung verursacht wurde. Das Entrapment der Arterie im Frakturspalt wurde erst intraoperativ während der Präparation für die Gefäßanstomosierung der Lappenplastik festgestell

Bogota-VAC - A Newly Modified Temporary Abdominal Closure Technique

Abstract : Background: : We present Bogota-VAC, a newly modified temporary abdominal closure (TAC) technique for open abdomen condition after abdominal compartment syndrome (ACS). Methods: : A thin isolation bag (Bogota bag) and a vacuum assisted closure (VAC) system were combined. A matching bag was tension-free fixed on the abdominal fascia by fascia suture. A ring shaped black polyurethane foam of the VAC system was placed into the gap between Bogota bag, abdominal fascia and the wound edge. A constant negative topic pressure of 50-75 mmHg was used in the VAC system. Results: : Intra-abdominal pressure (IAP: 22 ± 2 mmHg) of four patients with ACS after severe traumatic brain injury and one patient with isolated ACS after blunt abdominal trauma decreased significantly (p = 0.01) after decompressive laparotomy and treatment with Bogota-VAC (IAP: 10 ± 2 mmHg) and remained low, measured via urinary bladder pressure. Intracranial pressure (ICP) in the four traumatic brain injury patients decreased from 42 ± 13 mmHg to 15 ± 3 mmHg after abdominal decompression. Cerebral perfusion pressure (57 ± 14 mmHg) increased to 74 ± 2 mmHg. Conclusion: : The advantage of the presented Bogota-VAC is leak tightness, wound conditioning (soft tissue/fascia), skin protection and facilitation of nursing in combination with highest volume reserve capacity (VRC), thus preventing recurrent increased intra-abdominal and intracranial pressure in the initial phase after decompression of ACS compared to other TAC technique