Abstract
Modern medicine gives treatment options even in cases, where this has not been possible in the past. We want to present how negative pressure wound therapy (NPWT) helps in limb salvage. The case report brings our insight and experience on how to be successful with NPWT.
We present a high-energy injury with an open tibial fracture IIIB according to Gustillo-Anderson classification
Author Contributions
Copyright© 2019
Miroslav Budoš MUDr., et al.
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests The authors have declared that no competing interests exist.
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Introduction
Medicine, as well as other disciplines over the past few years, has had a progressive rise in the field of healing. Today's possibilities push the treatment forward and we are able to heal effectively what we could not be able heal in the past. We want to present two case reports with serious injury of tibia and soft tissue. These are two high-energy limb trauma with an open tibial fracture. The mechanism of injury in both cases is the passing of the limb by the bus wheel. Both patients were treated in a specialized clinic and the procedure of diagnostic and osteosynthesis was standard trauma protocol. An important part for the treatment of soft tissues was the vacum therapy called negative pressure wound therapy or vacum assisted closure therapy (V.A.C.). In both cases there was no injury to marginal vessels and nerves. Ischemia on the periphery or missing pulse was not detected. Mess score classification was used to determinate surgery strategy. NPWT is a modern and successful treatment of soft tissues. The principle of therapy is a closed system of controlled negative pressure environment wound. The vacuum system drains the exudate into the special container. Eliminates infection or reduced bacterial colonization in the wound. Vacuum stimulates granulation by local hyperemia and also promotes neovascularization. Secretion removal further contributes to reducing soft tissue swelling around the wound and reducing limb edema. Biological acceptability has been demonstrated in animal models where vacuum therapy leads to decreased swelling, increased tissue perfusion and increased granulation tissue. An open fracture and high-energy trauma in relation to the time of treatment present a risk of slow bone healing. NPWT heals faster soft tissue and gives the possibility of better bone healing.
Materials And Methods
We present two case reports with serious injury of tibia and soft tissue. It is high-energy limb trauma with an open tibial fracture. Both patients were treated at a specialized traumatic clinic with standard traumatic guidance. Urgent initial laboratory examination, diagnostics (X-ray, CT, AGCT) and osteosynthesis up to 6 hours with soft tissue treatment. An important part for the treatment of soft tissues was the negative pressure wound therapy. We cooperate with Hartmann company and use Vivano device. The method that influenced treatment in these cases was vacuum therapy. The principle is a closed system of controlled negative pressure environment wound or defect. The wound is primarily cleaned and free of necrotic parts and then covered with a special polyurethane foam. Then the wound with foam is covered with a special thin foil. A closed environment is created. In the middle of the foil is a hole with a special port with tubing, which is connected to the device. The device maintains a stable vacuum 125 mmHg and removes secretions from the wound. The vacuum is maintained continuously throughout the treatment period. The vacuum system drains the exudate into the special container. Eliminates infection or reduced bacterial colonization in the wound. Vacuum stimulates granulation by local hyperemia and also promotes neovascularization. Secretion removal further contributes to reducing soft tissue swelling around the wound and reducing limb edema. In our case we are using vNPWT for open fractures of tibia type G-A IIIB. Parts of the skin cover were destroyed by injury. Parts were loss of skin and subcutaneous defects or necrotic decollemetal parts. In this case we used a synthetic skin cover at the beginning (Synkryt), and then vacuum therapy. We hade used dermoepidermal graft as a method of definitive closure of skin defects. This method is simple and has less nutritional requirements than a full thickness graft. Graft is in thickness 0.3-0.4 mm and contains dermis and epidermis structures. Removal graft performed using an electrodermatome in the required size. Standard metods to acute treatment in the department of emergency admission is debrits of the limb, desinfection, antiseptic dressing, temporary fixation, diagnostics (X-ray, CT, angiography, angio CT), initial ATB therapy, urgent preoperative preparation, transport to the operation hall. Our Acute Surgery methods are complete limb debritman, excision of necrotic parts of skin, subcutis, removal of other microscopic impurities. Than stabilization of the tibia OS by external fixation. Reconstruction of soft structures, muscles, fascias, subcutis and skin. Application of Synthetic Skin Cover /Synkryt / or NPWT immediately. Limb wound dressing for vacuum therapy is every 4-5 days.
Results
Both cases of treatment open tibial fracture using NPWT have been cured successfully. The median duration of treatment was 8.5 months. The case report No.1., old lady was cured of skin cover and skeleton in 8 months. The case report No.2., 44 years man was heal in 9 months but his soft tissue injury was more extensive. Standard ATB procedures were used during treatment. Individual photos present how quickly and effectively NPWT can help heal a soft tissue defect. The use of this therapy was essentially underestimated until the skin cover healed. A case report of NPWT confirms, that treatment of severe limb injury can be positively influenced. Therapy positively affects the rate of healing, elimination of bacterial load and ultimately successful healing of the dermopeidermal graft
Discussion
Discussion of limb salvage or amputation is appropriate for such serious injuries. However salvaged limb does not guarantee functionality, normal life, a pain-free extremity or employability We think that the NPWT has made treatment relatively fast with minimal complications. Classical therapy for wound healing would take longer and be uncertain according to more risk of bacterial load and slow granulation of soft tissues. This method is considered the method of choice in the treatment of severe limb injuries with soft tissue laceration. After successful therapy, limb function is another target in the treatment.
Conclusion
The great advantage of therapy is the acceleration of wound healing and overall shortening of the patient's treatment. Our case reports provide a view of treatment using vacuum therapy. Presented case report confirms the effectiveness and importance of therapy. Treatment with NPWT shortens the length of hospitalization, lower the number of regular dressings, therefore, treatment is economically effective in a complex concept. Recent experience has determined that this method is required for each trauma of this type. NPWT: negative presure wound therapy V.A.C: vaccum assisted closure ATB: antibiotics G-A: Gustillo Anderson open fracture classification 125 mmHg: pressure 125 millimeters of hydrargyrum