[Wound management with vacuum therapy]. / Wundbehandlung mit der Vakuumtherapie.

Vacuum assisted wound closure (VAC) is a closed system, which applies negative pressure to the wound tissues. Basic studies have shown beneficial effects on wound blood flow and proliferation of healing granulation tissue. Theoretically, the method acts by removal of excess tissue fluid from the extravascular space, which lowers capillary after-load and thereby promotes the microcirculation during the early stages of inflammation. Additionally, the mechanical effect of the vacuum on the tissue at the wound surface appears to have an "Ilizarovian" effect resulting in an exuberant proliferation of healing granulation tissue. This technique has been used in over 2560 patients at the author's institution over the past 10 years for an expanding list of wound applications in several surgical disciplines. Commonly used orthopedic indications include traumatic wounds following débridement, infection (following débridement), fasciotomy wounds for compartment syndrome, and as a dressing for anchoring an applied split thickness skin graft. The author's personal experience consists of 269 patients treated and has not been associated with any major complications. A low incidence (2.5%) of localized superficial skin irritation occurred when a portion of the vacuum sponge overlapped the affected area. This problem is avoided by carefully confining the sponge to the wound tissue and avoiding the overlap of normal skin. The technique is contraindicated in patients with an allergy to any of the components which contact the skin such as the polyurethane sponge, the adhesive, or the plastic film applied to seal the system to the skin around the wound. Patients whose skin is thin and easily damaged will not tolerate the pulling off of the adhesive film, which is done at the time of sponge removal/change. Also, patients who are fully anticoagulated or patients with large wound surface areas (e.g., burns) may need careful monitoring of electrolytes, hematocrit, and/or fluid balance in an intensive care or burn unit setting. The mainstay of wound care is débridement, and vacuum assisted wound closure is not a substitute for this. It is a novel and welcome addition to the methods available to surgeons charged with the management of challenging wounds, and its final role in the overall list of adjunctive wound treatment modalities is still seeking a final definition.

The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone.

Lower-extremity wounds with exposed tendon, bone, or orthopedic hardware present a difficult treatment challenge. In this series of patients, subatmospheric pressure therapy was applied to such lower-extremity wounds. Seventy-five patients with lower-extremity wounds, most of which were the result of trauma, were selected for this study. Dressings made of sterile open-cell foam with embedded fenestrated tubing were contoured to the wound size and placed into the wound. The site was covered with an adhesive plastic sheet. The sheet was placed beneath any external fixation devices, or the fixation device was enclosed within the sheet. The tubing was connected to the vacuum-assisted closure pump. Continuous subatmospheric suction pressure (125 mmHg) was applied to the wound site. The wounds were inspected and the dressings were changed every 48 hours.Vacuum-assisted closure therapy greatly reduced the amount of tissue edema, diminishing the circumference of the extremity and thus decreasing the surface area of the wound. Profuse granulation tissue formed rapidly, covering bone and hardware. The wounds were closed primarily and covered with split-thickness skin grafts, or a regional flap was rotated into the granulating bed to fill the defect. Successful coverage was obtained without complication in 71 of 75 patients. Wounds have been stable from 6 months up to 6 years.

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores.

BACKGROUND: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. METHODS: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. RESULTS: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. CONCLUSIONS: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Characterization of patients with high-energy lower extremity trauma.

PURPOSE: (a) to report the demographic, socioeconomic, behavioral, social, and vocational characteristics of patients enrolled in a study to examine outcomes after high-energy lower extremity trauma (HELET) and to compare them with the general population; (b) to determine whether characteristics of patients undergoing limb salvage versus amputation after HELET are significantly different from each other. DESIGN AND STUDY POPULATION: A prospective study of 601 patients admitted with high-energy lower extremity trauma to eight Level I trauma centers. PROCEDURES: Patients were evaluated during the initial hospitalization. They are being followed up for 24 months postinjury. Study patients are compared with the general population by using census information, population survey data, and published norms. Characteristics of patients undergoing limb salvage versus amputation are also compared. RESULTS: Most patients were male (77 percent), white (72 percent), and between the ages of twenty and forty-five years (71 percent). Seventy percent graduated from high school (compared with 86 percent nationally) (p < 0.05). One fourth lived in households with incomes below the federal poverty line, compared with 16 percent nationally (p < 0.05). The percentage with no health insurance (38 percent) was also higher than in the general population (20 percent) (p < .05). The percentage of heavy drinkers was over two times higher than reported nationally (p < 0.01). Study patients were slightly more neurotic and extroverted and less open to new experiences. When patient characteristics were compared for those undergoing amputation versus limb salvage, no significant differences were found among any of the variables (p > 0.05). CONCLUSION: In conclusion, LEAP patients differ in important ways from the general population. However, the decision to amputate verus reconstruct does not appear to be significantly influenced by patient characteristics.

Electromyography monitoring for percutaneous placement of iliosacral screws.

OBJECTIVE: To report our experience with the use of continuous electromyography (EMG) for placement of iliosacral screws. DATA SOURCES: Concurrently acquired data as well as patient charts, intraoperative EMG records, x-rays, and pelvic computed tomography (CT) scans. DESIGN: The monitored group of twenty-nine patients was studied prospectively. The control group consisted of twenty-two patients studied retrospectively. SETTING: Level One trauma center. METHODS: Continuous electromyograms were recorded for twenty-nine patients and compared with those from a group of twenty-two antecedent patients who were not monitored. The primary parameter of interest of this study was the presence or absence of neurologic change after iliosacral screw placement. This information was obtained prospectively in the study group and by retrospective review in the historical control. RESULTS: Four patients in the control group had postoperative and/or sensory motor changes prompting a postoperative CT scan; in each of these patients, a misdirected screw was identified and subsequently removed in a second procedure. There were no neurologic changes subsequent to placement in the twenty-nine patients who were monitored (7.5 percent versus 0 percent; p = 0.029, Fisher's exact test). All monitored patients had postoperative CT scans and showed the screw in a safe position with no significant violations of the S1 tunnel. CONCLUSION: Continuous EMG monitoring during iliosacral screw placement may be a useful neuroprotective tool.

Acute compartment syndrome in ruptured Baker's cyst.

We present a case report of a previously healthy 43-year-old man with a Baker's cyst and spontaneous venous bleeding in a leg compartment, which caused a compartment syndrome. A thorough evaluation of this case and the treatment are explored.

Interpretation of fracture follow-up roentgenograms: is a second opinion routinely necessary?

To determine whether a second interpretation of follow-up roentgenograms is necessary in fracture management, we analyzed 300 fracture follow-up visits to two orthopaedists with regard to the efficacy of obtaining a radiologist's interpretation of the follow-up films. Fracture management decisions were made at the time of the visit without the benefit of the radiologist's interpretation of the films. Both the clinic note and the radiologist's official report of the x-ray films were independently compared by two "blinded" physician observers. Major discrepancies were defined as those warranting an alteration of treatment plan. Only one major discrepancy was found, judged by both observers to be an incorrect interpretation by the radiologist. No major discrepancies were found in the treating physician's interpretation. The maximal prevalence of discrepancy was less than 1%. We conclude that the need for a second interpretation of routine fracture follow-up x-rays is questionable from the standpoint of quality of care.

Antibiotic resistance in staphylococci adherent to cortical bone.

The surface-adherent mode of bacterial growth has been shown to play a pivotal role in the persistent nature of infections involving retained foreign bodies, biomaterials, or dead bone (e.g., osteomyelitis). The hypothesis tested herein is that bone and implant materials--polytetrafluoroethylene (PTFE), and polymethylmethacrylate (PMMA)--provide a surface environment that promotes a type of bacterial growth characterized by an enhanced antibiotic resistance. The antibiotic resistance estimates of three staphylococcal subtypes were determined for organisms grown in an adherent state on the aforementioned surfaces as well as in their nonadherent or suspended state. Antibiotic resistance was found to vary with mode of bacterial growth. Secondly, for the staphylococcal subtypes, antibiotics and modes of growth studied herein, adherent growth on bone was associated with the most antibiotic resistance.

Exertional compartment syndrome in a Marine grunt.

Exercise-induced exertional compartment syndrome was first described by Vogt in 1945 as "march gangrene." The authors report a case of a 20-year-old United States Marine presenting with the florid findings of acute crural compartment syndrome. The patient's history of prior episodes of crural pain following long hikes led the authors to conclude that this patient had a chronic exertional compartment syndrome.

Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.

Pulmonary embolism is a potentially lethal complication among patients with acetabular fractures requiring surgery. The reliability, safety, and extent of efficacy of pharmacologic as well as existing nonpharmacologic anticoagulation prophylaxis in this patient group has not been determined. A careful analysis of the myriad factors acting on these patients who have had major trauma and have undergone a major surgical procedure about the hip prompted a change in our approach to prophylaxis in this patient group. In the period from March 1984 through October 1987, 51 patients having 52 acetabular fractures underwent osteosynthesis at the Wake Forest University Medical Center. Twenty-four patients had two or more identifiable risk factors and underwent insertion of a Greenfield filter for prevention of pulmonary emboli. Filters were inserted at the time of acetabular surgery with C-arm guidance via the internal jugular vein approach. The average time for insertion was 57 min. Placements were verified by plain roentgenograms. There were no complications during filter insertion. Four patients with filters (17%) developed leg edema; in three the edema was minor, and in one the filter trapped what could have been a fatal embolus but caused lower extremity venous stasis severe enough to result in peripheral lower extremity tissue loss. There were no pulmonary emboli (by clinical criteria). The remaining 27 patients had routine medical prophylaxis and no filters. In this group, two patients had a clinically evident pulmonary embolus (7%), and one of these patients died. Two other patients (7%) had minor chronic leg edema. In one of them, a proximal deep venous thrombosis in the lower extremity was documented with venography, requiring rehospitalization and anticoagulant therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Results in patients with craniocerebral trauma and an operatively managed acetabular fracture.

Results in 23 patients with significant craniocerebral trauma (Glasgow Coma Scale less than or equal to 10) and displaced acetabular fracture requiring surgery were reviewed after a minimum follow-up of 1 year. Despite a postoperative anatomic reduction in all but one case, clinical outcome for these hips was poor, with an average Harris hip rating of 59. Patients older than 40 years had a significantly poorer outcome than did younger patients (p = 0.004). Postoperative problems occurred in 70% of patients (n = 16); the largest portion of these represented symptomatic heterotopic bone, which occurred in 61%. None of the four patients who had an anterior ilioinguinal surgical approach had symptomatic heterotopic ossification. The average Glasgow outcome score was 3.9 out of 5, and 20 of the 23 patients, despite a prolonged convalescence, were able to return to independence and self-care. The authors conclude that patients with combined significant craniocerebral trauma and an operatively managed displaced acetabular fracture are likely to have compromised hip function despite a well-executed osteosynthesis. This was especially true for those patients over age 40 in this series. The authors suggest that if the fracture pattern permits it, the operative management of the acetabular fracture in these patients be by an anterior ilioinguinal approach, so as to minimize the formation of heterotopic bone.

Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails.

Treatment of infected nonunion of tibial fractures has focused on irradicating infection before attempting to secure union. To secure union in the presence of infection in cases not amenable to conventional treatment, intramedullary nailing combined with open wound management was the treatment in 19 fractures of infected tibial nonunions in 18 patients. Eighteen fractures united. Drainage lessened or ceased after union of fractures and/or removal of nails. Only three cases had bone grafts. All were initially Type III open fractures. The majority occurred in motorcycle accidents. Time to union averaged 6.6 months (range, three to 14 months). Fourteen cases (15 tibias) healed without further drainage; four had minimal but persistent drainage. In properly selected cases, the treatment was safe and effective.

Comparative in vitro antibiotic resistance of surface-colonizing coagulase-negative staphylococci.

The MBCs of nafcillin, vancomycin, gentamicin and daptomycin (LY146032) were determined for three clinical isolates of coagulase-negative staphylococci grown in suspension and adherent to biomaterials. Strains studied were the slime-producing strain Staphylococcus epidermidis RP-12 (ATCC 35983), S. hyicus SE-360, and the non-slime-producing strain S. hominis SP-2 (ATCC 35982). All three strains were allowed to colonize surgical-grade disks of stainless steel, polymethylmethacrylate, and ultrahigh-molecular-weight polyethylene for 24 h, and the disks were then exposed to various concentrations of antibiotics for 24 h. Surviving adherent bacteria were mechanically dislodged from the disks and quantitated by standard broth dilution plating techniques. Biomaterial-adherent RP-12 and SE-360 yielded approximately 10 times more CFU per disk than non-slime-producing SP-2 did. For all organisms, 10 times more bacteria bound to polymethylmethacrylate disks than to the other biomaterials. In general, bacteria adherent to biomaterials exhibited greater resistance to antibiotics than the same strains in suspension did. Resistance was independent of bacterial slime-producing characteristics and was related to the biomaterial colonized.

Disruption of the posterior pelvic ring caused by vertical shear.

Disruption of the posterior pelvic ring caused by vertical shearing forces is associated with significant morbidity and mortality. We reviewed the intermediate results in 18 patients who had 20 disruptions of the posterior pelvic ring. Depending on the location of the injury, patients were treated by either skeletal traction or open reduction and internal fixation. Patients who had open reduction and internal fixation had a significantly shorter hospitalization, a shorter confinement to bed, a shorter time to full weight-bearing, and fewer early complications. In addition, on intermediate follow-up, these patients had less back and leg pain and fewer gait disturbances, and were more likely to be able to do heavy work. Further study is needed to determine whether these results will be preserved on long-term follow-up.

Two-hole plate fixation for traumatic symphysis pubis diastasis.

Techniques for managing traumatic diastasis of the pubic symphysis include bed rest, hip spica casting, pelvic slings, external fixation, and internal fixation. We report herein our experience with 14 consecutively managed patients in whom we successfully stabilized traumatic pubic diastasis with a single two-hole plate fixation. The average age of the 13 men and one woman was 30 years; followup averaged 17 months. Most of the patients had associated injuries (Injury Severity Score average, 19). Nine patients had concomitant disruption of the sacroiliac joint requiring either delayed open reduction and internal fixation or prolonged skeletal traction; among the five remaining patients, time to mobilization (bed to chair) averaged 1 day. There were no complications attributable to the procedure; i.e., no infections, and no failures of fixation. In this small series of patients early two-hole plate fixation of the traumatic diastasis of the pubis satisfactorily restored the disrupted anterior pelvic ring, contributed to early mobilization of the patients, and made reduction of a concomitantly disrupted sacroiliac joint easier, whether accomplished by skeletal traction or open reduction and internal fixation during a second procedure.

Unstable femoral shaft fractures: a comparison of interlocking nailing versus traction and casting methods.

Among 60 femur fractures not amenable to fixation by simple intramedullary nailing, 30 were treated with balanced skeletal traction followed by cast bracing or spica casting, and 30 were treated with closed interlocking nailing. The criteria for using an interlocking nail were fractures with less than 50% cortical contact or fractures with rotationally insecure purchase of the nail in either the proximal or distal fragment. In terms of fracture severity, patient age, injury severity, and clinical follow-up, the patient groups were similar. There were three open fractures in each group. The average hospital stay was 61 days for the traction group, and 19 days for the interlocking nail group (p less than 0.001). Time to clinical and radiographic union averaged 34 weeks with traction and casting and 18 weeks with interlocking nail fixation (p less than 0.001). Failure by the criteria of Johnson et al (2) occurred in 67% of the traction group and in 3% of the interlocking nail group (p less than 0.001). Minor complications were more common in the traction group. On the basis of this study and the experience of others, interlocking nail fixation appears to be the method of choice for managing unstable femoral shaft fractures.

Inability to deploy the distal fixator fin of a Brooker-Wills nail.

While a Brooker-Wills nail was being placed in an osteotomized femur during the course of a closed femoral shortening procedure, the slot holding the distal fixator fin was deformed as it was driven across the fracture/osteotomy site (approximately 50% apposition), and the fin could not have been deployed had it been needed for stabilization of the fracture. This case illustrates the importance of maintaining a meticulous closed reduction and of obtaining oblique image intensifier views of the distal portion of this nail while it is being inserted.

Bioimplant surfaces: binding of fibronectin and fibroblast adhesion.

The adhesion of baby hamster kidney 21C/13 fibroblasts to surfaces of passivated titanium, carbon fibers, bioactive glasses B5 and B6, fibronectin-precoated passivated titanium, and fibronectin-precoated B6 was quantified. The order of adhesive cell avidity for the uncoated surfaces was passivated titanium (greatest), B6 and carbon fibers (intermediate), and B5 (least). Precoating with fibronectin enhanced the adhesive characteristics of fibroblasts on passivated titanium and B6 by 74% and 118%, respectively.