Radial forearm flap donor side defects can be treated by vacuum therapy and conventional wound dressing. The aim of this study was to compare different wound management considering wound healing, including risk factors and cost effectiveness.

Retrospective study including patients treated with radial flaps in the Department of Head and Neck Surgery in Erlangen from January 2005 to August 2013. Wound healing was assessed regarding complications considering several risk factors and comorbidities. Data were analyzed comparing conventional dressing and vacuum therapy, including a calculation of costs.

The study included 138 patients (n = 55 conventional dressing; n = 83 vacuum dressing). The incidence of wound complications in the vacuum group was 50.6 and 32.7% in the conventional dressing group (p = .058). The presence of risk factors and comorbidities did not have significant impact on the occurrence of complications. Costs for vacuum therapy turned out to be at least five times higher.

In view of the current state of research, these results show that using vacuum dressings has no significant benefit in the wound management of forearm donor side defect covered with full-thickness skin grafts. If the costs and economical aspects are also considered, conventional wound dressing may be preferred.

Soft tissue and wound treatment after orthopaedic interventions (especially after trauma) is still an enormously challenging situation for every surgeon. Since development of negative pressure wound therapy (NPWT), new indications have been consistently added to the original field of application. Recently, NPWT has been applied directly over high-risk closed surgical incisions. Review of the literature indicates that this therapy has shown positive effects on incisions after total ankle replacement or calcaneal fractures, preventing haematoma and wound dehiscence. In those cases reduced swelling, decreased pain and healing time of the wound were seen. Additionally, NPWT applied on incisions after acetabular fractures showed a decreased rate of infection and wound healing problems compared with published infection rates. Even after total hip arthroplasty, incisional NPWT reduced incidence of postoperative seroma and improved wound healing. In patients with tibial plateau, pilon or calcaneus fractures requiring surgical stabilisation after blunt trauma, reduced risk of developing acute and chronic wound dehiscence and infection was observed when using incisional NPWT. To conclude, incisional NPWT can help to reduce risk of delayed wound healing and infection after severe trauma and orthopaedic interventions.

Infection is a major complication after open reconstruction of Achilles tendon ruptures. We report on the use of vacuum-assisted closure (VAC) therapy in the treatment of late deep infections after open Achilles tendon reconstruction. Six patients (5 males [83.33%], 1 female [16.67%]; mean age, 52.8 [range 37 to 66] years) were been treated using an identical protocol. Surgical management consisted of debridement, lavage, and necrectomy of infected tendon parts. The VAC therapy was used for local wound preconditioning and infection management. A continuous negative pressure of 125 mm Hg was applied on each wound. For final wound closure, a split-thickness skin graft was performed. The skin graft healing process was also supported by VAC therapy during the first 5 days. The VAC dressings were changed a mean average of 3 (range 1 to 4) times until split-thickness skin grafting could be performed. The mean total duration of the VAC therapy was 13.6 ± 5.9 days. The mean hospital stay was 31.2 ± 15.9 days. No complications with regard to bleeding, seroma, or hematoma formation beneath the skin graft were observed. At a mean follow-up duration of 29.9 (range 4 to 65) months, no re-infection or infection persistence was observed. The VAC device seems to be a valuable tool in the treatment of infected tendons. The generalization of these conclusions should await the results of future studies with larger patient series.

To devise a simple, cheap and effective improvised method of treating deep sternal wound infections (DSWI) by negative pressure obviating high cost of patented systems.

Records of ten post CABG patients operated via median sternotomy approach over a two and half year period and treated for DSWI were analysed. Sterile foam with drain was placed in the wound, which was covered with Ioban (Steridrape), the drain being connected to a suction unit maintaining 100mmHg pressure (<$12 cost).

Ten (10) patients of DSWI were managed with this therapy. Mean age was 60.4 years. Pseudomonas found in 1 (10%), Acinetobacter and Pseudomonas in 1 (10%) with Escherichia coli in 1 (10%). Five (50%) patients had diabetes mellitus. Mean hospitalisation period was 43 days. Seven (70%) patients underwent secondary suturing. Two (22%) patients had relapse, which was managed with dressings and secondary intention suturing. One patient who underwent a muscle flap cover had major recurrence with multiple sinuses. Excellent wound healing in 9 (90%) patients with no (0%) 90-day mortality. Improvised components can be safely employed to provide effective negative pressure therapy for DSWI with excellent results.

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

1) Compare skin graft healing of the radial forearm free flap (RFFF) donor site when using a negative pressure dressing (NPD) versus a static pressure dressing (SPD). 2) Examine the association of graft size and medical comorbidities with healing of RFFF donor site.

Randomized, controlled trial.

Tertiary care hospital.

After the study was approved, consenting adults undergoing RFFF for head and neck reconstructions were randomized into two arms: SPD and NPD groups. Fifty-four patients were enrolled from March 2007 to August 2009. Pre- and postoperative data were collected, including medical comorbidities, graft size, and area of graft failure/tendon exposure. Data were collected at two postoperative time points.

The overall wound complication rate was 38 percent (19/50). Wound complications at the first postoperative visit (44.4% [12/27] SPD and 30.4% [7/23] NPD) were not significantly different between groups (P = 0.816). Similarly, wound complications at the second visit (68.8% [11/16] SPD and 80% [12/15] NPD) were not significantly different (P = 0.55). Percentage of area of graft failure between the groups also showed no difference (4.5% SPD vs 7.2% NPD, P = 0.361). The association of graft size with wound complications was analyzed by dividing the data set into three groups (<50 cm(2), 51-100 cm(2), and >100 cm(2)). This difference was not found to be significant (P = 0.428). Finally, when evaluating comorbidities, 50 percent (8/16) of subjects with comorbidities experienced complications compared with 32.4 percent (11/34) without comorbidities, also not reaching significance (P = 0.203).

Although an attractive option for wound care, the NPD does not appear to offer a significant improvement over an SPD in healing of the RFFF donor site.

Over the last decade, the application of and indications for negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) have grown tremendously. This is particularly true in orthopaedic trauma in the management of injuries to the leg, ankle, and foot. This article reviews the evidence-based medicine in terms of NPWT/ROCF, as a method of reducing bacterial counts in wounds, as a bridge until definitive bony coverage, for treating infections, and as an adjunct to wound bed preparation and for bolstering split-thickness skin grafts, dermal replacement grafts, and over muscle flaps. NPWT/ROCF has been shown to be an adjunct to the mainstays of wound management. No significant complications have been noted in the categories of NPWT/ROCF discussed in this review. In addition, evidence supports a decrease in complex soft tissue procedures in grade IIIB open fractures when NPWT/ROCF is employed. Although more research needs to be done, NPWT/ROCF appears to provide clinical benefit for the treatment of these complex lower extremity wounds.

The radial forearm free flap is a popular reconstructive flap in modern head and neck surgery. Poor wound healing at the forearm donor site is common and frequently results in tendon exposure. The Vacuum-Assisted Closure (VAC) system (Kinetic Concepts Inc., San Antonio, TX) is a topical negative pressure dressing that has been shown to improve skin graft viability when used as a bolster dressing. In this study, we investigated the use of the VAC system in the management of the radial forearm free flap donor site.

A retrospective chart review was performed on all subjects who underwent a radial forearm free flap reconstruction in which the VAC system was used as a bolster dressing at the donor site from January 1, 2003, through March 31, 2005.

Thirty-four consecutive subjects were included in the study. Exposed tendon did not occur in 14 (0%) subjects in which the VAC bolster was used for a minimum of 6 days. Eleven of the 20 subjects (55%) who used the VAC bolster for 5 days demonstrated small amounts of tendon exposure (<2 cm) on follow-up clinic examination. The minimum follow up for all subjects was 4 months.

This study demonstrates that the VAC system is a feasible alternative to conventional bolster dressing in the management of the radial forearm free flap skin-grafted donor site. Based on this study, when used for a minimum of 6 days, the VAC bolster dressing eliminated tendon exposure at the forearm donor site.

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.

Acute wounds which cannot be closed primarily are usually closed with a split skin graft. However a split skin graft has both functional (where tendons are exposed) and esthetic sequelae (contour deformity, different skin in color and texture). A novel technique is described which allows delayed primary closure of either fasciotomy wounds or full-thickness defects after harvest of a free or pedicle flap. The technique described combines the bootlace suture technique (which achieves wound closure by progressive suture tightening) with the VAC (vacuum-assisted closure) system (which reduces tissue edema, facilitating movement of tissue, and also reduces bacterial contamination of the wound). Twelve of 14 wounds (average width of wound after insertion and tightening of bootlace suture was 5 cm) were successfully closed after an average of 8 days (range, 4-23 days) in 11 patients (mean age, 45 years; range, 18-77 years) using this technique. Of the 2 patients where the technique was not successful, one patient was noncompliant and the other developed wound-edge necrosis. Other complications were self-limiting. The combined use of 2 methods of wound management facilitates delayed primary wound closure.

In clinical practice many wounds are slow to heal and difficult to manage. The recently introduced technique of topical negative pressure therapy (TNP) has been developed to try to overcome some of these difficulties. TNP applies a controlled negative pressure to the surface of a wound that has potential advantages for wound treatment and management. Although the concept itself, of using suction in wound management is not new, the technique of applying a negative pressure at the surface of the wound is. This paper explores the origins and proposed mechanisms of action of TNP therapy and discusses the types of wounds that are thought to benefit most from use of this system.

Topical negative pressure has been demonstrated to improve graft take in a number of noncomparative studies. This study aimed to assess whether split-thickness skin graft take is improved qualitatively or quantitatively with topical negative pressure therapy compared with standard bolster dressings. A blinded, prospective, randomized trial was conducted of 22 adult inpatients of Liverpool Hospital between July of 2001 and July of 2002 who had wounds requiring skin grafting. After grafting, each wound half was randomized to receive either a standard bolster dressing or a topical negative pressure dressing. Skin graft assessment was performed at 2 weeks by a single observer blinded to the randomization. Two patients were lost to follow-up and were excluded from the study. There were 20 patients (12 men and eightwomen) in the study group. The median patient age was 64 years (range, 27 to 88 years), and the mean wound size was 128 cm2 (range, 35 to 450 cm2). The wound exposed subcutaneous fat in eight patients, muscle in six patients, paratenon in four patients, and deep fascia in two patients. At 2 weeks, wounds that received a topical negative pressure dressing had a greater degree of epithelialization in six cases (30 percent), the same degree of epithelialization in nine cases (45 percent), and less epithelialization in five cases (25 percent) compared with their respective control wounds. Graft quality following topical negative pressure therapy was subjectively determined to be better in 10 cases (50 percent), equivalent in seven cases (35 percent), and worse in three cases (15 percent). Although the quantitative graft take was not significant, the qualitative graft take was found to be significantly better with the use of topical negative pressure therapy (p < 0.05). Topical negative pressure significantly improved the qualitative appearance of split-thickness skin grafts as compared with standard bolster dressings.

Topical negative pressure (TNP) therapy has emerged as a high-technology, microprocessor-controlled physical wound-healing modality. Complex effects at the wound-dressing interface following application of a controlled vacuum force have been documented. These include changes on a microscopic, molecular level and on a macroscopic, tissue level: interstitial fluid flow and exudate management, oedema reduction, effects on wound perfusion, protease profiles, growth factor and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and improved wound-healing parameters. Primary indications for clinical use have been documented and include traumatic wounds, open abdominal wounds, infected sternotomy wounds, wound bed preparation, complex diabetic wounds and skin-graft fixation. Whilst this therapy now forms an essential part of the wound healing armamentarium, extensive clinical trials are recommended to confirm efficacy and delineate its optimum use.

The annual incidence of pilonidal sinus is approximately 26 per 100,000, of which complex pilonidal sinuses are the minority. Many different approaches have been described for managing simple cases. Treatment options for complex pilonidal sinus include excision with healing by secondary intention or plastic surgical procedures to obliterate the defect. Recently, vacuum-assisted closure has been used by plastic surgeons to facilitate healing of chronic or complicated wounds with particular success in treating pressure wounds overlying the sacrum.

A patient with a complex pilonidal sinus was managed with excision and vacuum-assisted closure.

A large tissue defect after radical excision healed relatively quickly when the subatmospheric pressure dressing was applied. The patient was discharged with the vacuum pump and change of dressings for alternate days.

Vacuum-assisted closure of a complex pilonidal sinus shortened the length of hospital stay and the need for further surgery and provided a cosmetically acceptable result.

Topical negative pressure is a novel non-pharmacological therapy that is now being adopted as a standard of care in wound care management programmes. This review assesses where and how it can be best used.

Exposed tendons after burn injury create a surgical challenge for the treating physician. This is particularly true with regard to the exposed Achilles tendon. This case report reviews the nature of this challenge and traditional solutions, and describes the use of negative pressure wound therapy to facilitate coverage of the Achilles tendon. This therapy may provide a more appropriate therapeutic option for dealing with tendon exposure after severe burns.

Deep sternal wound infection is a serious and potentially lethal complication of cardiac surgery when performed through a median sternotomy. We describe the outcome of a new treatment strategy with C-reactive protein level-guided vacuum-assisted closure used at our department.

Data from 16 consecutive adult patients who had deep sternal wound infections after cardiac surgery were reviewed. Patients with superficial infection or sterile dehiscence were not included. All patients with postoperative deep sternal wound infections were treated with first-line vacuum-assisted closure therapy, followed by direct surgical closure. A purpose-built vacuum-assisted closure system consisting of polyurethane foam pieces and a special pump unit was used. The foam was placed in the wound after debridement of foreign material and necrotic tissue. The wound was covered with adhesive drape and connected to the pump unit, which was programmed to create a continuous negative pressure of 125 mm Hg in the wound cavity. Intravenous antibiotics were given according to tissue-culture results. The patients were immediately extubated after the operation. When ingrowth of granulation tissue was observed in all parts of the wound and the plasma C-reactive protein level showed a steady decline to 30 to 70 mg/L or less without confounding factors, such as tissue injuries or concomitant infections, the sternotomy was rewired, and the wound was closed.

All patients were alive and free from deep sternal wound infection 3 months after the operation. The median vacuum-assisted closure treatment time until surgical closure was 9 days (range, 3-34 days), and the median C-reactive protein level at closure was 45 mg/L (range, 20-173 mg/L). The median hospital stay was 22 days (range, 12-120 days).

Early vacuum-assisted closure treatment, followed by surgical closure guided by the plasma C-reactive protein level, is a reliable and easily applied new strategy in patients with postoperative deep sternal wound infection.

Groin lymphorrhea is an uncommon but serious complication of vascular and cardiac surgery as well as interventional procedures that cannulate the femoral vessels. Treatment options are somewhat controversial. For lymphocutaneous fistulas, a commonly used current modality is early surgical ligation with the assistance of blue-dye staining of the lymphatic anatomy. The purpose of this case series is to give the first description of a new, less invasive, approach using subatmospheric pressure dressing therapy for the treatment of the challenging problem of lymphocutaneous fistulas of the groin.