Use of vacuum-assisted closure in pediatric open fractures with a focus on the rate of infection.

The use of the vacuum-assisted closure device (VAC; KCI, San Antonio, Texas) has given the orthopedist a new tool for the successful management of severe traumatic wounds and open fractures. While the VAC's role in the adult population is proving itself as an improved therapy compared to "traditional wound care," it's role within pediatric orthopedics remains less well defined. Questions remain whether VAC therapy provides benefit regarding decreased infection rates as well as decreased need for extensive soft tissue coverage procedures. A review was therefore performed of a pediatric level I trauma center's experience using the VAC therapy for pediatric open fractures with a focus on the rate of superficial, deep, and chronic infection. A retrospective chart review spanning 4.5 years of all pediatric patients younger than 18 years with an open fracture initially treated with VAC therapy was conducted at a level I pediatric trauma center. This yielded 28 patients with 37 open fractures aged 2 to 17 years who were initially treated with wound VAC therapy. Subsequent chart review of these patients was performed examining in-hospital records, operative notes, and clinical follow-up visits for documented cases of superficial, deep, or chronic infection. Of 37 open pediatric fractures treated with a wound VAC, there were no cases of superficial infection and 2 cases of deep infection for an overall infection rate of 5%. Both infections resolved with surgical intervention and antibiotics without chronic infection development. When compared with historical controls, the use of VAC therapy for pediatric open fractures appears to be an equally safe and effective modality to help reduce infection in pediatric open fractures and should be considered a valuable tool in treating these injuries.

Incisional vacuum-assisted wound closure in morbidly obese patients undergoing acetabular fracture surgery.

We studied the effect of incisional vacuum-assisted closure (IVAC) on wound complications (dehiscences, infections) associated with surgical treatment of acetabular fractures in morbidly obese patients (body mass index, >40 kg/m(2)). No wound complications were found in 19 consecutive patients over 5 years of IVAC use. IVAC is an attractive treatment adjunct for minimizing postoperative wound complications in morbidly obese patients undergoing acetabular fracture surgery.

The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures.

OBJECTIVES: To evaluate the utility of negative-pressure wound therapy (NPWT) in the setting of high-energy open tibial shaft fractures. DESIGN, SETTING, AND PATIENTS/PARTICIPANTS: This was a retrospective consecutive series in a level 1 university-based trauma center. Forty-nine consecutive patients presenting to a level 1 trauma center between 1996 and 2004 with 50 grade/type III open tibial shaft fractures were assessed. INTERVENTION: The open wounds associated with each fracture were each treated with NPWT before definitive wound closure or coverage. MAIN OUTCOME MEASUREMENTS: Infection rate, need for amputation after attempted definitive coverage, problems with bony healing requiring surgical intervention, reoperation rate after definitive coverage, and the type of definitive coverage required. RESULTS: The overall infection rate for all grade/type III open fractures was 15 of 50 fractures (30%), with 11 of 50 (22%) requiring repeated surgery for infection. The infection rate was 12.5% for grade/type IIIA open fractures, 45.8% for grade/type IIIB, and 50% for grade/type IIIC. Twenty-four of 50 fractures (48%) required subsequent surgery to facilitate fracture healing. Five fractures required amputation after attempted coverage. Seven of 24 fractures initially classified as grade/type IIIA and 10 of 24 fractures initially classified as grade/type IIIB ultimately required free tissue transfer or rotational muscle flap coverage. CONCLUSIONS: Infection and nonunion rates with the use of NPWT for temporary coverage of wounds associated with grade/type III open tibial shaft fractures are similar to those of historical controls, but this technique may be beneficial in decreasing the need for free tissue transfer or rotational muscle flap coverage.

Subatmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children.

PURPOSE: This study was designed to evaluate the use of subatmospheric pressure dressings on high-energy open tibial shaft fractures in children. We hypothesized that the use of a negative-pressure dressing in these fractures would result in a decreased incidence of infection and decreased need for pedicled muscle flaps and free tissue transfer. METHODS: A retrospective case series of 15 consecutive pediatric patients with 16 type III open tibial shaft fractures (8 type IIIA, 7 type IIIB, and 1 type IIIC). The patients' age ranged from 2 to 17 years. All patients underwent a standard protocol of serial irrigation and debridement of the open wound with bony stabilization. Temporary coverage of the open wound was obtained with the use of a subatmospheric pressure dressing until definitive wound coverage or closure. RESULTS: Infection occurred in 5 of 16 fractures, 2 requiring antibiotics alone (1 type IIIA and 1 type IIIB) and 3 requiring surgical intervention (2 type IIIB and 1 type IIIC). Seven of 16 (3 type IIIA, 3 type IIIB, and 1 type IIIC) fractures required repeat surgical intervention to facilitate bony healing. Only 3 patients required free tissue transfers or rotational muscle flaps for coverage, a 50% decrease compared with the initial classification. CONCLUSIONS: Compared with other described methods, the use of subatmospheric pressure dressings in the temporary treatment of soft tissue wounds associated with high-energy open tibial shaft may reduce the need for major soft tissue coverage procedures. Its effect on infection and fracture healing rates requires further study. SIGNIFICANCE: A reduction in the need for major soft tissue coverage procedures with the use of negative-pressure dressings in this setting should result in decreased morbidity for these patients and in decreased social and financial costs.