TECHNICAL TRICK
Negative Pressure Wound Therapy and External Fixation Device: A Simple Way to Seal the Dressing Antonio Bulla, MD,*† Francesco Farace, MD,* André-Pierre Uzel, MD,‡ and Vincent Casoli, MD§
Summary: Negative pressure therapy is widely applied to treat lower limb trauma. However, sealing a negative pressure dressing in the presence of an external fixation device may be difficult and time consuming. Therefore, screws, pins, wires, etc, may preclude the vacuum, preventing the plastic drape to perfectly adhere to the foam. To maintain the vacuum, we tried to prevent air leaking around the screws putting bone wax at the junction between the pins and the plastic drape. This solution, in our hands, avoids air leakage and helps maintain vacuum in a fast and inexpensive way. Key Words: negative pressure wound therapy, bone wax (J Orthop Trauma 2014;28:e176–e177)
INTRODUCTION Over the last decade, negative pressure therapy has been widely used to treat traumatic wounds of the lower limb. However, sealing a negative pressure dressing in the presence of an external fixation device may be particularly difficult and time consuming. Oftentimes, screws, pins, wires, etc, may interfere with obtaining a vacuum, because they can prevent the plastic drape from perfectly adhering to the foam. The negative pressure therapy device consists of a foam dressing, plastic drape, canister with tubing, and suction machine. Usually, the foam dressing is applied over the open wound. Once the foam is sealed with the plastic drape, it is connected to a suction machine that delivers a negative pressure (250 to 2125 mm Hg). Several studies have shown the efficacy of negative pressure wound therapy in open fractures.1 Negative pressure wound therapy has been shown to reduce the edema and bacterial colonization and actively promotes vascularization and granulation tissue formation, especially in cases where it is impossible to obtain immediate coverage with grafts or flaps.2,3 Accepted for publication September 12, 2013. From the *Plastic Surgery Unit, Department of Surgery, Microsurgery and Medical Sciences, University Hospital Trust, University of Sassari, Sassari, Italy; †Human Anatomy, Department of Biomedical Sciences, University Hospital Trust, University of Sassari, Sassari, Italy; ‡Service d’orthopédietraumatologie, CHU Pointe-à-Pitre, Pointe-à-Pitre, Guadeloupe, France; and §François-Xavier Michelet Center, CHU de Bordeaux, Place Amélie Raba-Léon, Bordeaux Cedex, France. The authors report no conflicts of interest. Reprints: Antonio Bulla, MD, Plastic Surgery Unit, Department of Surgery, Microsurgery and Medical Sciences, University Hospital Trust, University of Sassari, Via Pasubio 5, 07100 Sassari, Italy (e-mail: abulla80@ gmail.com). Copyright © 2013 by Lippincott Williams & Wilkins
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Certain authors suggest completely sealing the external fixation device with the plastic drape.4,5 However, wrapping the external fixation device entirely may make the negative pressure wound procedure very expensive and cumbersome. Others suggest placing hydrocolloid gel around the pins.2 A bi-adhesive hydrogel is available from KCI (V.A.C. gel ), and a multitude of adhesive hydrocolloid products are on the market. Despite these adjuncts, the reality is that air leakage is still a common problem for trauma patients with external fixation pins in place. In our hospitals, we have unsuccessfully experimented with several substances and finally settled on bone wax as an efficient method of maintaining a seal. We now present our method and results.
TECHNIQUE Our technique is simple. The wound edges and wound bed are cleaned. The surrounding skin and pins must be dry. The VAC sponge is applied directly onto the wound bed around the pins. The plastic drape is then cut in multiple strips. The strips are applied on the foam, in longitudinal and transverse directions around the pins, making a crisscross pattern, until the entire foam surface is covered. There is no attempt to apply the plastic drape on the pins. Then, the negative pressure device is activated. Often, air leaks around the pins. Bone wax is warmed in the surgeon’s hands, and a small amount is applied onto the plastic drape around the pins. This seals the dressing, the vacuum is obtained, and the leakage alarm stops.
CLINICAL SERIES Between 2009 and 2012, we have applied this technique to 16 patients. There were 5 open fractures of the tibia, 2 distal lower leg fractures, 1 complex knee injury secondary to a boat propeller accident (Fig. 1), 2 crush injuries of the foot, 2 humeral fractures, 2 elbow fractures, and 2 wrist fractures. Each patient was given appropriate antibiotics according to protocol. No patient developed signs of a pin tract infection after the application of bone wax. The mean length of VAC treatment was 14.6 days (standard error, 1.13 days). The dressings were usually replaced on the third or fourth day. After the negative pressure treatment, 5 patients underwent skin grafting, 6 patients local flap surgery (2 sural flaps, 1 pedicled Anterolateral Thigh flap, 2 fasciocutaneous flaps, and 1 propeller flap), and 4 patients free flap surgery (2 Anterolateral Thigh flaps, 1 latissimus dorsi flap, and 1 serratus anterior flap). J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
Fast Sealing of Negative-Pressure Dressings
DISCUSSION Bone wax is a mixture of beeswax and paraffin and has been used for bone hemostasis for decades. Bone wax is cheap and sterile and has good adhesion to the plastic dressing, staying in place at least 72 hours. If an air leak occurs accidentally, at a later time, the bone wax can be molded and reapplied to stop it. The wax never reaches the wound bed nor is aspirated by the suction device. No wax remnants can be found in wound bed or around the reconstructed tissues. Furthermore, bone wax can be easily removed from the pins with an iodopovidone-soaked gauze. In conclusion, bone wax may improve the efficacy of negative pressure therapy in open fractures treated with external fixation, making the whole procedure less expensive and more efficient.
FIGURE 1. The application of beeswax to seal a negative pressure dressing on a large loss of substance of the knee and lower leg caused by a boat propeller accident, treated with an Orthofix external fixator. After 3 weeks of treatment, the wound was successfully covered with a pedicled fasciocutaneous flap from the thigh. At 1-year follow-up, there were no signs of chronic infection. Arrow 1 indicates the bone wax that perfectly adheres to the 2 wires connected to the external fixator. Arrow 2 shows that the vacuum is maintained by the suction system and the plastic drape correctly adheres to the foam.
One patient (crush injury of the foot with tibial nerve damage) underwent foot amputation.
Ó 2013 Lippincott Williams & Wilkins
REFERENCES 1. Stannard JP, Volgas DA, Stewart R, et al. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma. 2009;23:552–557. 2. Hardwicke J, Paterson P. A role for vacuum-assisted closure in lower limb trauma: a proposed algorithm. Int J Low Extrem Wounds. 2006;5: 101–104. 3. Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002;10:303–311. 4. Ozer K, Smith W. A simple technique for applying vacuum-assisted closure therapy over the circular type external fixation device. Ann Plast Surg. 2006;56:693–694. 5. Lemmon J, Ahmad J, Ghavami A, et al. Vacuum-assisted closure over an external fixation device. Plast Reconstr Surg. 2008;121: 234e–235e.
www.jorthotrauma.com |
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Negative Pressure Wound Therapy and External Fixation Device: A Simple Way to Seal the Dressing Antonio Bulla, MD,*† Francesco Farace, MD,* André-Pierre Uzel, MD,‡ and Vincent Casoli, MD§
Summary: Negative pressure therapy is widely applied to treat lower limb trauma. However, sealing a negative pressure dressing in the presence of an external fixation device may be difficult and time consuming. Therefore, screws, pins, wires, etc, may preclude the vacuum, preventing the plastic drape to perfectly adhere to the foam. To maintain the vacuum, we tried to prevent air leaking around the screws putting bone wax at the junction between the pins and the plastic drape. This solution, in our hands, avoids air leakage and helps maintain vacuum in a fast and inexpensive way. Key Words: negative pressure wound therapy, bone wax (J Orthop Trauma 2014;28:e176–e177)
INTRODUCTION Over the last decade, negative pressure therapy has been widely used to treat traumatic wounds of the lower limb. However, sealing a negative pressure dressing in the presence of an external fixation device may be particularly difficult and time consuming. Oftentimes, screws, pins, wires, etc, may interfere with obtaining a vacuum, because they can prevent the plastic drape from perfectly adhering to the foam. The negative pressure therapy device consists of a foam dressing, plastic drape, canister with tubing, and suction machine. Usually, the foam dressing is applied over the open wound. Once the foam is sealed with the plastic drape, it is connected to a suction machine that delivers a negative pressure (250 to 2125 mm Hg). Several studies have shown the efficacy of negative pressure wound therapy in open fractures.1 Negative pressure wound therapy has been shown to reduce the edema and bacterial colonization and actively promotes vascularization and granulation tissue formation, especially in cases where it is impossible to obtain immediate coverage with grafts or flaps.2,3 Accepted for publication September 12, 2013. From the *Plastic Surgery Unit, Department of Surgery, Microsurgery and Medical Sciences, University Hospital Trust, University of Sassari, Sassari, Italy; †Human Anatomy, Department of Biomedical Sciences, University Hospital Trust, University of Sassari, Sassari, Italy; ‡Service d’orthopédietraumatologie, CHU Pointe-à-Pitre, Pointe-à-Pitre, Guadeloupe, France; and §François-Xavier Michelet Center, CHU de Bordeaux, Place Amélie Raba-Léon, Bordeaux Cedex, France. The authors report no conflicts of interest. Reprints: Antonio Bulla, MD, Plastic Surgery Unit, Department of Surgery, Microsurgery and Medical Sciences, University Hospital Trust, University of Sassari, Via Pasubio 5, 07100 Sassari, Italy (e-mail: abulla80@ gmail.com). Copyright © 2013 by Lippincott Williams & Wilkins
e176
| www.jorthotrauma.com
Certain authors suggest completely sealing the external fixation device with the plastic drape.4,5 However, wrapping the external fixation device entirely may make the negative pressure wound procedure very expensive and cumbersome. Others suggest placing hydrocolloid gel around the pins.2 A bi-adhesive hydrogel is available from KCI (V.A.C. gel ), and a multitude of adhesive hydrocolloid products are on the market. Despite these adjuncts, the reality is that air leakage is still a common problem for trauma patients with external fixation pins in place. In our hospitals, we have unsuccessfully experimented with several substances and finally settled on bone wax as an efficient method of maintaining a seal. We now present our method and results.
TECHNIQUE Our technique is simple. The wound edges and wound bed are cleaned. The surrounding skin and pins must be dry. The VAC sponge is applied directly onto the wound bed around the pins. The plastic drape is then cut in multiple strips. The strips are applied on the foam, in longitudinal and transverse directions around the pins, making a crisscross pattern, until the entire foam surface is covered. There is no attempt to apply the plastic drape on the pins. Then, the negative pressure device is activated. Often, air leaks around the pins. Bone wax is warmed in the surgeon’s hands, and a small amount is applied onto the plastic drape around the pins. This seals the dressing, the vacuum is obtained, and the leakage alarm stops.
CLINICAL SERIES Between 2009 and 2012, we have applied this technique to 16 patients. There were 5 open fractures of the tibia, 2 distal lower leg fractures, 1 complex knee injury secondary to a boat propeller accident (Fig. 1), 2 crush injuries of the foot, 2 humeral fractures, 2 elbow fractures, and 2 wrist fractures. Each patient was given appropriate antibiotics according to protocol. No patient developed signs of a pin tract infection after the application of bone wax. The mean length of VAC treatment was 14.6 days (standard error, 1.13 days). The dressings were usually replaced on the third or fourth day. After the negative pressure treatment, 5 patients underwent skin grafting, 6 patients local flap surgery (2 sural flaps, 1 pedicled Anterolateral Thigh flap, 2 fasciocutaneous flaps, and 1 propeller flap), and 4 patients free flap surgery (2 Anterolateral Thigh flaps, 1 latissimus dorsi flap, and 1 serratus anterior flap). J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
Fast Sealing of Negative-Pressure Dressings
DISCUSSION Bone wax is a mixture of beeswax and paraffin and has been used for bone hemostasis for decades. Bone wax is cheap and sterile and has good adhesion to the plastic dressing, staying in place at least 72 hours. If an air leak occurs accidentally, at a later time, the bone wax can be molded and reapplied to stop it. The wax never reaches the wound bed nor is aspirated by the suction device. No wax remnants can be found in wound bed or around the reconstructed tissues. Furthermore, bone wax can be easily removed from the pins with an iodopovidone-soaked gauze. In conclusion, bone wax may improve the efficacy of negative pressure therapy in open fractures treated with external fixation, making the whole procedure less expensive and more efficient.
FIGURE 1. The application of beeswax to seal a negative pressure dressing on a large loss of substance of the knee and lower leg caused by a boat propeller accident, treated with an Orthofix external fixator. After 3 weeks of treatment, the wound was successfully covered with a pedicled fasciocutaneous flap from the thigh. At 1-year follow-up, there were no signs of chronic infection. Arrow 1 indicates the bone wax that perfectly adheres to the 2 wires connected to the external fixator. Arrow 2 shows that the vacuum is maintained by the suction system and the plastic drape correctly adheres to the foam.
One patient (crush injury of the foot with tibial nerve damage) underwent foot amputation.
Ó 2013 Lippincott Williams & Wilkins
REFERENCES 1. Stannard JP, Volgas DA, Stewart R, et al. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma. 2009;23:552–557. 2. Hardwicke J, Paterson P. A role for vacuum-assisted closure in lower limb trauma: a proposed algorithm. Int J Low Extrem Wounds. 2006;5: 101–104. 3. Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002;10:303–311. 4. Ozer K, Smith W. A simple technique for applying vacuum-assisted closure therapy over the circular type external fixation device. Ann Plast Surg. 2006;56:693–694. 5. Lemmon J, Ahmad J, Ghavami A, et al. Vacuum-assisted closure over an external fixation device. Plast Reconstr Surg. 2008;121: 234e–235e.
www.jorthotrauma.com |
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