SLR - February 2010 - Mark S Co
Reference:
Barnett, T.M., Shilt, J.S. (2009). Use of vacuum-assisted closure and a dermal regeneration template as an alternative to flap reconstruction in pediatric grade IIIB open lower-extremity injuries. American Journal of Orthopedics. 6, 301-305.
Scientific Literature Reviews
Reviewed by: Mark S Co , DPM
Residency Program: Kaiser Foundation, Hayward/Fremont
Podiatric Relevance:
Severe degloving injuries to the pediatric lower extremity are challenging to treat. This article presents an alternative to local or free flap coverage through the combination of vacuum-assisted closure with a dermal regeneration template.
Methods:
This was a retrospective review of all pediatric patients with grade IIIB lower extremity injuries treated with VAC® and Integra® at the Wake Forest University School of Medicine, Department of Orthopedic Surgery between November 2001 and May 2006. Each patient's initial treatment was similar consisting of early irrigation and debridement of wounds, bony stabilization, and use of negative-pressure VAC. After initial management, the patients were transferred to the pediatric orthopedics service for wound and fracture management. Wound care consisted of formal irrigation and debridement with VAC dressing changes every 2 to 4 days until the wound was considered appropriate for coverage with Integra. After suitable serial debridements insuring absence of nonviable tissue and debris, the dermal matrix graft was sized to the wound, "piecrusted" and sutured in place with absorbable monofilament suture. A negative pressure dressing was placed over the graft for 5 to 6 days. The patient then returned to the operating room for removal of the dressing, including the silicone layer of the dermal matrix, and placement of a meshed split-thickness skin graft. Another negative-pressure dressing was applied with nonadherent gauze between the graft and sponge. The dressing was left undisturbed for 4 days. The dressing was either removed at bedside or with patient under anesthesia. Skin grafts were dressed with petroleum jelly gauze dressings daily until healed. The patient medical record was reviewed to determine wound size, number of debridements before coverage with Integra, length of hospital stay, presence or absence of infection, nonunion, need for subsequent bony or soft-tissue procedures, and need for subsequent flap reconstruction or amputation.
Results:
Of the seven patients (5 boys, 2 girls) treated with this protocol, there were 3 open tibia fractures, 3 foot and ankle degloving injuries and 1 open ankle fracture-dislocation. Mean patient age was 7.4 years (range 2-12 years), mean follow-up was 24.4 months (range, 10-57 months), mean wound size was 196 sq cm (range 60-324 sq cm), mean number of formal debridements before dermal matrix placement was 4.6 (range 2-9), and mean hospital stay associated with initial injury was 21 days (range 7-42 days). All wounds and fractures healed without flap reconstruction or amputation. One acute infection developed from initial injury and treatment. The external fixator pin which created a deep infection was removed with successful resolution. Two patients developed complications of the Integra and split-thickness skin graft site. In one patient, delayed healing of a 1-cm area responded to dressing changes. In the other patient an ulcer over the lateral malleolus was treated with debridement and secondary closure at 3 months. One patient developed growth arrest secondary to physeal bar and subsequent equinus contracture that required additional surgery. One patient had segmental tibial bone loss, was treated with bone transport which went on to nonunion, was then treated with iliac crest bone grafting which then resulted in valgus deformity, and finally successfully treated with osteotomy.
Conclusions:
Vacuum-assisted closure and dermal regeneration template has shown good results as a means of successfully managing pediatric grade IIIB injuries without performing complicated flap reconstructions. This method offers less donor site morbidity, less need for complicated microvascular reconstructions, and possibly improved cosmetic and functional outcomes.