Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy

Abstract

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life-threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum-assisted closure (VAC) therapy for an average of 22 days (range 3-46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split-thickness skin grafts were used to cover granulation tissue in most of the cases (66% -- 24 cases), and then local flaps (13% -- five cases) or direct sutures (8% -- three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC therapy were observed other than one case of severe pain in an amputated stump. The average follow-up duration was 265 days (range 33-874 days). No further tegumentary reconstruction was required. VAC therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.

Exposed tibial bone after burns: Flap reconstruction versus dermal substitute

“…Several publications report on the benefits of NPWT as an advanced means of wound bed preparation in wounds with exposed bone [3,21,[26][27][28][29][30][31][32][33][34][35][36][37].…”

Metalloproteinase Expression is Associated with Traumatic Wound Failure

“…However, recent research asserts that many MMPs have overlapping functions [16]. A thorough literature search has revealed that the major MMPs involved in wound remodeling are MMPs 1,2,3,7,8,9,10,12, and 13, although, with ongoing research, it is likely that all MMPs play essential roles in wound healing. [13,14,[16][17][18][19][20].…”

“…Negative-pressure vacuum-assisted closure device (VAC) usage, in combination with serial debridements of devitalized tissue and high-pressure wound irrigation, has greatly reduced the morbidity of such traumatic extremity wounds [9,10]. Although these methods have been accepted as the standard of care in many institutions, timing of surgical closure of a wound remains a subjective process in which the surgeon relies on criteria such as the patient's overall condition, wound location, wound bed gross appearance, and local perfusion.…”

Use of Negative Pressure Wound Therapy With Reticulated Open Cell Foam for Lower Extremity Trauma

“…Similarly, Bollero et al 14 reported on the use of NPWT/ ROCF for management of complex traumatic soft-tissue wounds in patients for whom immediate flap coverage was desirable but relatively contraindicated because of multisystem trauma or significant medical comorbidities. They reported success with achieving soft-tissue coverage in this population and concluded that use of NPWT/ROCF represented a valid alternative to traditional rotational or free tissue coverage in this challenging population.…”