Negative pressure wound therapy for soft tissue injuries around the foot and ankle

  • Hyun-Joo Lee1,

    Affiliated with

    • Joon-Woo Kim1,

      Affiliated with

      • Chang-Wug Oh1Email author,

        Affiliated with

        • Woo-Kie Min1,

          Affiliated with

          • Oog-Jin Shon2,

            Affiliated with

            • Jong-Keon Oh3,

              Affiliated with

              • Byung-Chul Park1 and

                Affiliated with

                • Joo-Chul Ihn1

                  Affiliated with

                  Journal of Orthopaedic Surgery and Research20094:14

                  DOI: 10.1186/1749-799X-4-14

                  Received: 25 August 2008

                  Accepted: 09 May 2009

                  Published: 09 May 2009

                  Abstract

                  Background

                  This study was performed to evaluate the results of negative pressure wound therapy (NPWT) in patients with open wounds in the foot and ankle region.

                  Materials and methods

                  Using a NPWT device, 16 patients were prospectively treated for soft tissue injuries around the foot and ankle. Mean patient age was 32.8 years (range, 3–67 years). All patients had suffered an acute trauma, due to a traffic accident, a fall, or a crush injury, and all had wounds with underlying tendon or bone exposure. Necrotic tissues were debrided before applying NPWT. Dressings were changed every 3 or 4 days and treatment was continued for 18.4 days on average (range, 11–29 days).

                  Results

                  Exposed tendons and bone were successfully covered with healthy granulation tissue in all cases except one. The sizes of soft tissue defects reduced from 56.4 cm2 to 42.9 cm2 after NPWT (mean decrease of 24%). In 15 of the 16 cases, coverage with granulation tissue was achieved and followed by a skin graft. A free flap was needed to cover exposed bone and tendon in one case. No major complication occurred that was directly attributable to treatment. In terms of minor complications, two patients suffered scar contracture of grafted skin.

                  Conclusion

                  NPWT was found to facilitate the rapid formation of healthy granulation tissue on open wounds in the foot and ankle region, and thus, to shorten healing time and minimize secondary soft tissue defect coverage procedures.

                  Introduction

                  Tendon and/or bone exposure commonly occurs in the foot and ankle region after acute trauma [1]. The conventional treatment method used for these uncovered, open wounds in the foot and ankle is skin grafting after the formation of healthy granulation tissue by wet dressing [2]. However, the duration of treatment may be prolonged, and patients may experience severe pain during dressing changes [3]. Furthermore, it is difficult to form healthy granulation tissue by simple wet dressing, when a tendon, bone, or implant is exposed. Accordingly, free flap surgery is often required, which requires substantial effort and introduces the issue of donor site morbidity [4].

                  Negative pressure wound therapy (NPWT) was first described by Argenta and Morykwas [2]. This technique can be used to cover exposed bone or soft tissue defects without frequent dressing changes, and reduces chronic edema and increases local blood supply, which enhances the formation of healthy granulation tissue. Several reports have been issued on the application of NPWT to soft tissue defects of the extremities, abdomen and chest [5, 6]. However, reports regarding its use in the foot and ankle region are limited, though in this region tendon and bone exposures frequently occur after external injury or due to chronic ulcerative disease. The purpose of this study was to determine how NPWT helps healing and whether the technique can reduce the need for flap surgery for the treatment of acute or chronic open wounds in the foot and ankle region.

                  Materials and methods

                  Over the four year period from 2003 to 2006, 16 patients (12 males and 4 females) with soft tissue injuries in the foot and ankle region were treated with an NPWT device (V.A.C.,® Vacuum Assisted Closure, KCI, San Antonio, United States) at the authors' institute. All 16 patients were followed for more than 12 months (mean: 19 months, range: 13–39 months). Mean patient age was 32.8 (range: 3–67). All patients had experienced an acute injury, caused by either a traffic accident in 12, a falling from a height in 2, and a crush injury in 2. Wound locations were on the medial side of the ankle in 3 cases, the lateral side of the ankle in 1 case, and of the dorsum of the foot in 12 cases. All patients had at least one tendon or bone exposed at the initiation of NPWT, and four had an associated infection (Table 1).
                  Table 1

                  Patient and wound details before and after negative pressure wound therapy

                  No

                  Age

                  Sex

                  Injury

                  Site

                  Wound grade(before)

                  Wound grade(after)

                  Size

                  (before)

                  Size

                  (after)

                  Duration

                  Additional procedure

                  Complication

                  1

                  3

                  M

                  Ped TA

                  Dorsal

                  2

                  1

                  92

                  60

                  14

                  STSG

                   

                  2

                  7

                  M

                  Ped TA

                  Dorsal

                  3

                  1

                  23

                  9

                  17

                  STSG

                  scar contracture

                  3

                  7

                  M

                  Ped TA

                  Dorsal

                  2

                  1

                  60

                  42

                  16

                  STSG

                  scar contracture

                  4

                  10

                  M

                  Ped TA

                  Dorsal

                  3

                  1

                  36

                  16

                  13

                  STSG

                   

                  5

                  11

                  M

                  Sports injury

                  Lateral

                  4

                  1

                  27

                  20

                  23

                  STSG

                   

                  6

                  18

                  F

                  In car TA

                  Dorsal

                  2

                  1

                  70

                  50

                  19

                  STSG

                   

                  7

                  22

                  M

                  In car TA

                  Dorsal

                  3

                  1

                  94.5

                  87

                  17

                  STSG

                   

                  8

                  26

                  M

                  F/D

                  Medial

                  2

                  1

                  9

                  4

                  12

                  STSG

                   

                  9

                  27

                  M

                  In car TA

                  Dorsal

                  3

                  1

                  103

                  85

                  15

                  STSG

                   

                  10

                  44

                  M

                  Crushing

                  Dorsal

                  3

                  1

                  52

                  35

                  17

                  STSG

                   

                  11

                  47

                  F

                  Ped TA

                  Dorsal

                  2

                  1

                  151

                  91

                  27

                  STSG

                   

                  12

                  53

                  M

                  F/D

                  Medial

                  2

                  1

                  14

                  8

                  11

                  STSG

                   

                  13

                  54

                  F

                  Crushing

                  Medial

                  3

                  1

                  72.5

                  17

                  12

                  STSG

                   

                  14

                  63

                  F

                  Motorcycle TA

                  Dorsal

                  3

                  1

                  12

                  8

                  18

                  FTSG

                   

                  15

                  66

                  M

                  In car TA

                  Dorsal

                  3

                  3

                  45

                  39

                  21

                  free flap

                   

                  16

                  67

                  M

                  Ped TA

                  Dorsal

                  3

                  1

                  104

                  81

                  29

                  STSG

                   

                  Mean

                  32

                  (years-old)

                     

                  2.69

                  1.13

                  56.4(cm2)

                  42.9(cm2)

                  18.4(days)

                    

                  TA: traffic accident, Ped(pedestrian), F/D: fall down, STSG(split thickness skin graft), FTSG(full thickness skin graft)

                  Technique

                  An NPWT device was applied after debriding necrotized tissues and cleansing contaminated wounds. When fractures were present, internal or external fixation was performed before application. The V.A.C.®system was used throughout. This consists of an evacuation tube, a collecting canister, a vacuum pump, and a multiporous polyurethane sponge, which directly contacts the wound. The sponge, which was designed to be 3–5 cm larger than wounds, was applied to defect sites and sealed with transparent cohesive film. The vacuum dressing was changed every 3–4 days and most procedures were performed at bedside. However, when necessary, debridement was performed in an operating room. A negative pressure vacuum pump was applied to wounds in continuous mode at a pressure of 100~125 mmHg. NPWT was stopped after confirming the formation of healthy granulation tissue. Skin grafting was performed when further coverage was required.

                  Wound types (acute or traumatic versus chronic) and location were noted, and durations, numbers, and frequencies of V.A.C. system applications were recorded. Before and after NPWT treatment, sizes of soft tissue defects were assessed using squared paper. Wounds were categorized into 5 groups based on degree of exposure and the presence of concomitant infection, which was graded from 0 to 4 (Table 2). Final coverage techniques, including primary closure, split thickness skin grafting, and pedicled local and vascularized free flap grafting were documented. Furthermore, any complications attributable to NPWT treatment were noted.
                  Table 2

                  Details of the open wound scoring system used

                  Score (grade)

                  Status of wound

                  0

                  Closed wound

                  1

                  Skin or soft tissue defect

                  2

                  Bone, tendon, implant exposure(any 1)

                  3

                  Bone, tendon, implant exposure(any combination of 2 or more)

                  4

                  Associated or Residual infection

                  Results

                  The mean duration of therapy was 18.4 days (range, 11–29 days), and dressings were changed 4.5 times on average. Mean wound size at treatment initiation was 56.4 cm2 (9–151 cm2), and this reduced to 42.9 cm2 (4–81 cm2) at treatment completion, an average wound area reduction of 24%. Fifteen of the 16 patients achieved an improved wound status, and in these exposed tendons or bone was covered with healthy granulation tissue (Figures 1, 2). After NPWT, skin grafting was performed to cover granulation tissue in 15 cases (a split-thickness skin graft in 14 cases and a full-thickness skin graft in 1 case). One patient experienced treatment failure, and required a free flap to cover exposed bone and tendon. The average wound grade was 2.69 at the start of treatment, and 1.13 at the end of treatment.
                  http://static-content.springer.com/image/art%3A10.1186%2F1749-799X-4-14/MediaObjects/13018_2008_Article_111_Fig1_HTML.jpg
                  Figure 1

                  A severe open fracture around the ankle in a 20 year-old woman (A & B). After the debridement of necrotized tissue (C), NPWT was applied (D).

                  http://static-content.springer.com/image/art%3A10.1186%2F1749-799X-4-14/MediaObjects/13018_2008_Article_111_Fig2_HTML.jpg
                  Figure 2

                  At 22 days of NPWT, sufficient granulation covered tendons (E) to perform skin graft. At 1 year postoperatively, the wound had healed well (F & G).

                  No complication occurred that could be directly attributed to NPWT, such as, a deep infection or bleeding. In terms of minor complications, four patients experienced itchiness of skin in the region of NPWT application. In addition, 2 patients experienced scar contractures in grafted areas, which were rescued using a releasing procedure.

                  Discussion

                  Traumatic injuries around the foot and ankle are often associated with significant skin loss, which results in the exposure of tendons, bone, or hardware, and associated wound-management difficulties. These injuries are similar in many ways, to chronic ulcerative lesions of the foot associated with ischemic diseases, such as, diabetes mellitus. The rapid formation of granulation tissue and blood vessels are essential for the healing of these wounds. Traditionally, frequent wet dressing changes (3–4 times/day) are used to treat such cases, but this treatment is protracted and painful [3, 7]. Furthermore, interstitial fluid from open wounds reduces local blood supply and disturbs wound healing due to its collagenase and metalloproteinase constituents [8, 9]. From this viewpoint, NPWT is highly effective at clearing interstitial fluid, and in the majority of our patients, wounds were covered with healthy granulation tissue after 4.5 sponge changes, without additional flap surgery. DeFranzio5 also reported that NPWT enhances rapid granulation formation in over 80% of patients as compared with a simple wet dressing. Furthermore, it has been well reported that NPWT provides a continuous physical stimulus that enhances the formation of new vessels and granulation tissues [10, 11].

                  Soft tissue defects in the foot and ankle region usually require local or free flap surgery when a skin graft procedure is not applicable due to limited granulation tissue formation1. A split-thickness skin graft is not recommended for wounds with exposed bone or neurovascular structures, or for wounds involving the weight-bearing surface of the foot [12]. In a comparative study of traditional dressings and NPWT for lawnmower injuries of the lower leg [13], the need for free flap surgery was found to be decreased by 30%. A remarkable reduction in the requirement for secondary soft tissue operation is believed to be a big advantage of NPWT [14]. Dedmond [15] also reported that wounds of grade 3 with an accompanying open tibial fracture healed without the need for a secondary soft tissue operation, such as, a free flap. In the present study, the severities of open wounds were noticeably reduced after NPWT; only one patient needed a free flap to cover exposed bone and tendon.

                  The prevention of deep infection is essential during the treatment of soft tissue defects, and simple wet dressing may be inadequate in this context, because wounds are inevitably exposed to the atmosphere. On the other hand, NPWT not only seals open wounds but evacuates hematomas, exudates, and possible pathogens by the application of negative pressure [10, 16, 17]. Furthermore, it has been reported that NPWT is effective at treating deep infections [18]. In the present study, no case of infection during the treatment period occurred. Accordingly, we consider that NPWT probably also reduces soft tissue defect infection rates.

                  Some technical difficulties have been reported when NPWT was used to treat foot wounds [19], but we did not encounter these problems. In terms of complications, we did encounter 2 cases of skin graft scar contractures, which can reduce foot function. Successful scar release was achieved in these two cases. But, in certain cases, flap surgery may be considered to prevent scar contractures [20], instead of NPWT.

                  This study has several limitations that require consideration, namely, that the size of data is small, and there was no control group, which reduced objectivity. We suggest that a prospective randomized multicenter trial be undertaken to determine the merits of NPWT for the treatment of soft tissue defects of the ankle and foot. However, based on the results of previous studies on its use for the treatment of other injuries at other locations, it appears that NPWT plays a significant role in the formation of granulation tissue and in the prevention of infection [21].

                  Our results add to growing evidence that NPWT is a useful adjunctive treatment for open wounds around the foot and ankle. In the present study, it was found to facilitate the rapid formation of granulation tissue, to shorten healing time, and to reduce remarkably the need for additional soft tissue reconstructive surgery.

                  Declarations

                  Acknowledgements

                  The authors thank Hwa-Ryun, Sarah, Park (Archmere Academy, Senior Wilmington, Delaware, United States) for her editorial assistance with the manuscript. This work was supported by BK 21. This study was conducted at Kyungpook National University Hospital, Daegu, Korea

                  Authors’ Affiliations

                  (1)
                  Department of Orthopedic Surgery, Kyungpook National University Hospital
                  (2)
                  Department of Orthopedic Surgery, Yeungnam University Hospital
                  (3)
                  Department of Orthopedic Surgery, Korea University Guro Hospital

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                  Copyright

                  © Lee et al; licensee BioMed Central Ltd. 2009

                  This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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