The use of vacuum assisted closure (VAC™) 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 ± 0.4days after trauma and was used for 15.5 ± 1.8days. The dressing changes were performed in average every 3days. 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 closur

V.A.C.™ instillation: in vitro model. Part 2 V.A.C.™ Instillation: ein in vitro Modell. Teil 2

The behavior of a liquid in foam in the course of the V.A.C.™ instillation was investigated in an in vitro model by visualization using an aqueous color solution and by a quantitative determination of changing concentration of Ringerlactate solutio

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

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

"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

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

A comparative analysis of phenotype expression in human osteoblasts from heterotopic ossification and normal bone

Background and aims: Heterotopic ossification (HO) is a pathological bone formation process in which ectopic bone is formed in soft tissue. The formation of bone depends on the expression of the osteoblast phenotype. Earlier studies have shown conflicting results on the expression of phenotype markers of cells originating from HO and normal bone. The hypothesis of the present study is that cells from HO show an altered expression of osteoblast-specific phenotype markers compared to normal osteoblasts. The aims of the study were to further characterize the expression of osteoblast phenotypemarkers and to provide a comparison with other study results. Patients and methods: Using an in vitro technique, reverse transcription polymerase chain reaction (RT-PCR), real-time PCR and immunohistochemistry, we compared the phenotype gene expression (type I collagen, alkaline phosphatase, Cbfa-1, osteocalcin) of osteoblasts from resected HO and normal bone (iliac crest). Results: Cells from HO expressed the osteoblast phenotype (type I collagen, alkaline phosphatase) but were characterized by a depleted osteocalcin expression. The expression of Cbfa-1 (osteocalcin transcription gene) showed a large variety in our study. Preoperative radiotherapy had no effect on phenotype expression in cells from HO. Conclusion: Our results provide a characterization of cells originating from HO and support the thesis of an impaired osteoblast differentiation underlying the formation of HO. The transcription axis from Cbfa-1 to osteocalcin could be involved in the pathogenesis of H

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

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

Temporary Kirschner Wire Ankle Transfixation and Delayed ORIF: A Staged Operative Treatment for Closed Ankle Fractures with Tibiotalar Dislocations and Soft-Tissue Damage

Abstract : Background and Purpose: : Immediate ORIF (open reduction and internal fixation) is the treatment of choice for displaced ankle fractures. However, definitive treatment may have to be delayed due to compromised soft tissues. The value of temporary Kirschner wire ankle transfixation with staged ORIF for closed displaced ankle fractures with tibiotalar dislocations was determined. Patients and Methods: : In this retrospective case series (1997-2001), 92 patients (mean age 54 years, range 20-86 years) who underwent a staged procedure for isolated and closed displaced ankle fractures with tibiotalar dislocations were studied. Patients were primarily treated by means of immediate closed reduction. For stable fractures and adequate soft tissues a split plaster cast was applied (n = 50). K-wire transfixation was performed for unstable fracture-dislocations and/or critical soft tissues (n = 42). All patients underwent delayed ORIF after recovery of the soft tissues. Results: : In the K-wire group (KWG), local complication rate was 7%. Mean operating time was 30 min (5-65 min). In the plaster cast group (PCG), local complication rate was 10% (p = 0.72, not significant). Three redislocated ankles (6%) had to be transfixed secondarily. A higher grade of soft-tissue injuries in the KWG (p < 0.05) resulted in a longer time interval between primary treatment and staged ORIF (7 vs. 5 days; p < 0.05) and a longer hospital stay (19 vs. 17 days; p < 0.05) for the KWG. Conclusion: : Temporary K-wire ankle transfixation is an effective method for initial treatment of closed displaced ankle fractures with tibiotalar dislocation, if ORIF has to be delayed and immobilization in a split plaster cast is not suitable. Retention is reliable with a low complication rat