Better Than The Alternative
Limb salvage with negative pressure wound therapy |
| by Jay Lieberman, DPM, FACFAS |
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This gentleman may very well have been the most compliant patient ever to come through my office. Prior to the downturn of our economy, he had a well paying job that provided him with good health insurance. He would appear in my office every two months. Each visit, I would check his neurovascular status and provide prophylactic foot care.
Then he lost his job and health insurance, got divorced, and went two years without proper medication for his Type II diabetes. After some time, he reached a state of crisis and was admitted to the hospital with uncontrolled blood sugar. He also had gangrene of the left forefoot and fifth toe of the right foot.
On two separate occasions, he underwent related foot surgery. First, a right fifth ray resection and then a left trans metatarsal amputation.
Flaps were raised in an attempt to approximate the wound and close the dead space. On the left foot, coverage was incomplete and the stump of the first metatarsal was exposed (see x-ray below).
When wounds probe to bone, we tend to “assume osteomyelitis.” In this case, the patient was on IV antibiotics for five days prior to surgery and was not reported to have osteomyelitis. What we “CAN” assume is that there was fairly good antibiotic penetration into the bone adjacent to the failed component of the flap. Rather than resecting more proximally and altering the parabola of the metatarsals, we instituted negative pressure wound therapy. Before long, rich granulation tissue covered the cortical bone and the patient went on to heal uneventfully.
The next patient underwent amputation of the hallux and second toe. The weight-bearing surface of the metatarsals was preserved, however, the articular cartilage was denuded, and the cancellous bone was exposed to promote healing.
The plantar flap necrosed postoperatively and only a small section between the first and second metatarsals was preserved. The first photograph demonstrates the residual flap with exposure of the stumps of the first and second metatarsals..
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| Week 1 |
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Negative pressure wound therapy (V.A.C.®) was instituted and by week three, a poor quality granulation tissue completely covered the bone.
The patient was then sent for hyperbaric oxygen therapy and healed uneventfully. Had the exposed bone been resected, the patient would have invariably gone on to a trans metatarsal head resection.
We tend to think negative pressure wound therapy is for large defects or heavily exudating wounds. In the cases shown here, it was used to promote rapid granulation over exposed bone and to prevent more proximal resection. The transition was made to hyperbaric oxygen to enrich the granulation tissue and prepare the patient for skin grafting.
Vacuum assisted wound closure is technically considered closure by secondary intention:
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Draws the wound edges together |
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Maintains a clean environment |
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Removes infectious material |
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Removes edema exudates |
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Promotes granulation tissue |
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Stimulates angiogenesis |
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Borderline wounds with marginal peripheral vasculature will tend to have better outcomes with the use of vacuum assisted wound closure. We want to leave no stone unturned before considering amputation.
By June 2006, more than three hundred articles on negative pressure wound therapy had been published. PRESENT Podiatry has five lectures on vacuum assisted wound closure; two by Dr. Lavery, two by Dr. Steinberg and one by Dr. Armstrong. You can follow the links below to view them:
I believe that as more literature comes out in its support, negative pressure wound therapy will continue to be utilized more widely and more frequently for the benefit of patients.
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V.A.C. Therapy
Since its introduction, V.A.C.� Therapy has changed the way wounds are healed. With more published clinical evidence than any other form of Negative Pressure Wound Therapy, V.A.C. Therapy has been selected as the treatment of choice for more than 3,000,000 people worldwide.
V.A.C. Therapy promotes wound healing through Negative Pressure Wound Therapy (NPWT). By delivering negative pressure (a vacuum) at the wound site through a patented dressing, this helps draw wound edges together, remove infectious materials and actively promote granulation at the cellular level.
KCI is proud to introduce the next generation of V.A.C.® Therapy for the acute care environment with enhanced data gathering and ease-of-use capabilities:
InfoV.A.C. Therapy Unit
Easier Negative Pressure Wound Therapy by Design
Specifically designed for the acute care environment, the InfoV.A.C.® Therapy System is designed to make V.A.C.® Therapy simpler and more informative through enhanced technology, ease-of-use improvements and access to wound progress data than the V.A.C. ATS® System. Follow this lin to learn more about the InfoV.A.C. Therapy Unit and other V.A.C. Therapy Units and Systems.
Check out our newest dressing products, V.A.C. Simplace Dressings and V.A.C. Granufoam Bridge Dressings.
Watch a video on the history of V.A.C. Therapy for more information.
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To learn more about KCI® and all of its products,
visit www.kci1.com or call 1-800-275-4524. |
