ROLE OF NEGATIVE PRESSURE ROLE OF NEGATIVE PRESSURE WOUND THERAPY (V.A.C ) IN OPEN WOUND THERAPY (V.A.C ) IN OPEN AND INFECTED WOUNDS IN AND INFECTED WOUNDS IN ORTHOPAEDICSORTHOPAEDICSAUTHORAUTHORDR JOYDEEP MANDALDR JOYDEEP MANDAL22NDND YEAR PG TRAINEE YEAR PG TRAINEEPMCH , PATNAPMCH , PATNA

IntroductionIntroduction

Delayed wound healing is a significant problem Delayed wound healing is a significant problem in orthopaedics . In addition to the pain and in orthopaedics . In addition to the pain and suffering , failure of the wound to heal also suffering , failure of the wound to heal also imposes social , mental and financial burdens.imposes social , mental and financial burdens.

Basic wound management comprises of regular Basic wound management comprises of regular thorough debridement and dressing.thorough debridement and dressing.

Dressing of a wound helps in – Dressing of a wound helps in – promoting healingpromoting healing absorption of dischargeabsorption of discharge maintain a clean and moist environmentmaintain a clean and moist environment

V.A.C. Therapy a.k.a. NPWTV.A.C. Therapy a.k.a. NPWT

Negative pressure wound therapy Negative pressure wound therapy (NPWT) or V.A.C (NPWT) or V.A.C is a non invasive , active is a non invasive , active wound closure system that uses controlled , wound closure system that uses controlled , localised negative pressure to promote localised negative pressure to promote healing in acute and chronic wounds.healing in acute and chronic wounds.

HISTORYHISTORY : Research started at 1989 by Dr. : Research started at 1989 by Dr. Louis Argenta and Prof. Michael Morykwas of Louis Argenta and Prof. Michael Morykwas of Wake Forest University School of Medicine in Wake Forest University School of Medicine in North Carolina.North Carolina.

Originally designed to treat chronic wounds.Originally designed to treat chronic wounds.

Clinical Benefits of V.A.C. Clinical Benefits of V.A.C. TherapyTherapy Maintenance of moist, protected environmentMaintenance of moist, protected environment Removal of excess interstitial fluid from the Removal of excess interstitial fluid from the

wound peripherywound periphery Increased local vascularityIncreased local vascularity Decreased bacterial colonizationDecreased bacterial colonization Quantification/qualification of wound drainageQuantification/qualification of wound drainage Increased rate of granulation tissue formationIncreased rate of granulation tissue formation Increased rate of contraction ( decrease in Increased rate of contraction ( decrease in

wound size )wound size ) Increased rate of epithelizationIncreased rate of epithelization

Mechanism Of ActionMechanism Of Action

IndicationsIndications

Open fractures ( Gustilo and Anderson TYPE Open fractures ( Gustilo and Anderson TYPE 2,3A & 3B.2,3A & 3B.

Full-thickness surgical woundsFull-thickness surgical wounds Chronic woundsChronic wounds

– Stage 3 pressure ulcersStage 3 pressure ulcers– Stage 4 pressure ulcersStage 4 pressure ulcers– Diabetic ulcersDiabetic ulcers

Dehisced woundsDehisced wounds

PrecautionsPrecautions

Acute bleeding, patients on anticoagulants, Acute bleeding, patients on anticoagulants, or difficult wound homeostasis and patients or difficult wound homeostasis and patients with bleeding disorders.with bleeding disorders.

Malignancy.Malignancy. Allergies to adhesive drape and silver based Allergies to adhesive drape and silver based

foams.foams. Exposed nerves, vessels, organs or Exposed nerves, vessels, organs or

anastomosis.anastomosis. Inherent skin diseaseInherent skin disease..

ContraindicationsContraindications

Malignancy in wound.Malignancy in wound. Necrotic tissue with eschar.Necrotic tissue with eschar. Untreated osteomyelitis.Untreated osteomyelitis. Fistulas to organs or body cavities.Fistulas to organs or body cavities. Do not place V.A.C. dressing over exposed Do not place V.A.C. dressing over exposed

arteries or veins.arteries or veins.

Materials And MethodsMaterials And Methods

Period of study : September 2014 to December Period of study : September 2014 to December 2015.2015.

Place of study : Patna Medical College and Place of study : Patna Medical College and Hospital, Patna.Hospital, Patna.

No. of patients studied : 10 patients. All the No. of patients studied : 10 patients. All the have open fractures ( 7 patients having Gustilo have open fractures ( 7 patients having Gustilo type lllA wounds and 3 patients having Gustilo type lllA wounds and 3 patients having Gustilo type lllB wounds. )type lllB wounds. )

Foam used : polyurethane foam.Foam used : polyurethane foam. Intermittent Sub atmospheric negative pressure Intermittent Sub atmospheric negative pressure

applied ( 75mmHg ) using ROMOVAC drains.applied ( 75mmHg ) using ROMOVAC drains.

Materials And MethodsMaterials And Methods

Frequency of dressing changes : 48 hours.Frequency of dressing changes : 48 hours.

Number of dressing changes : 3Number of dressing changes : 3

Wounds have been treated until they are Wounds have been treated until they are ready for closure, split thickness skin grafting ready for closure, split thickness skin grafting or flap coverage.or flap coverage.

Dressing Application OverviewDressing Application Overview

Place foam on the Place foam on the wound.wound.

Cover with semi-Cover with semi-occlusive dressing.occlusive dressing.

Secure tubing.Secure tubing.

Connect tubing to the Connect tubing to the V.A.C. therapy unit V.A.C. therapy unit (ROMOVAC drain).(ROMOVAC drain).

ResultsResults

Dressing done for an average of 10 days.Dressing done for an average of 10 days.

Number of patients requiring skin grafting Number of patients requiring skin grafting following treatment : 8 patients ( 7 patients following treatment : 8 patients ( 7 patients with Gustilo type lllA wounds and 1 patient with Gustilo type lllA wounds and 1 patient with type lllB wound.)with type lllB wound.)

Number of patient requiring flap coverage Number of patient requiring flap coverage following treatment : 2 patients with Gustilo following treatment : 2 patients with Gustilo type lllB wounds.type lllB wounds.

Case 1Case 1

MaleMale8 years8 yearsOpen fracture Rt. Open fracture Rt. TibiaTibiaGustilo type lllB.Gustilo type lllB.

A 10cm x 7cm A 10cm x 7cm elliptical wound over elliptical wound over antero-lateral antero-lateral aspect of distal leg aspect of distal leg with periosteal with periosteal stripping.stripping.

ResultsResults

V.A.C AppliedV.A.C Applied 11STST Dressing Dressing

ResultsResults

• After removal of After removal of 33rdrd dressing. dressing.•Size of the wound Size of the wound diminished.diminished.•Granulation tissue Granulation tissue increased.increased.•Patient required Patient required only split thickness only split thickness skin grafting.skin grafting.

Case 2Case 2•MaleMale•60 years60 years•Open fracture of Open fracture of shaft of radius and shaft of radius and ulna Lt. side.ulna Lt. side.•Gustilo type lllB.Gustilo type lllB.•Two 7cm x 5cm Two 7cm x 5cm wounds present wounds present over anterior aspect over anterior aspect of Lt. forearm and of Lt. forearm and antero-medial antero-medial aspect of Lt. elbow.aspect of Lt. elbow.

ResultsResults

V.A.C AppliedV.A.C Applied 11STST Dressing Dressing

Final DressingFinal Dressing

•NOTE – Wound size NOTE – Wound size decreased.decreased.•Significant Significant increase in increase in granulation tissue.granulation tissue.•Absence of Absence of infection.infection.

•Result – Flap Result – Flap coverage required.coverage required.

LimitationsLimitations

Application of sub-atmospheric pressure (about Application of sub-atmospheric pressure (about 75 mmHg).75 mmHg).

Difficult to create a closed chamber over the Difficult to create a closed chamber over the wound.wound.

Compliance of the patient’s relative is required.Compliance of the patient’s relative is required.

Chance of bleeding during removal of dressing.Chance of bleeding during removal of dressing.

Key PointsKey Points

Non-invasive active therapy for wound healingNon-invasive active therapy for wound healing Indicated to treat a variety of acute & chronic woundsIndicated to treat a variety of acute & chronic wounds Dressing changes every 48 hoursDressing changes every 48 hours Reduced frequency of dressing changes thus Reduced frequency of dressing changes thus

decreased nursing care and increased patient decreased nursing care and increased patient comfort.comfort.

Reduced length of hospital stay , portable devices are Reduced length of hospital stay , portable devices are also available now-a-days.also available now-a-days.

Cost effectiveCost effective Easy to applyEasy to apply Early closure of the woundEarly closure of the wound

ConclusionConclusion

Negative pressure wound therapy (V.A.C) Negative pressure wound therapy (V.A.C) may be considered as a better alternative to may be considered as a better alternative to conventional dressing of wounds for the conventional dressing of wounds for the management of acute , chronic , open , management of acute , chronic , open , infected and non-infected wounds in infected and non-infected wounds in orthopaedics.orthopaedics.

Still further studies in this domain are Still further studies in this domain are needed.needed.