The Use of Vacuum Closure-assisted Device in the Management of Compound Lower Limb Fractures with Massive Soft Tissue Damage.

Stavros Angelis,Alexandros P Apostolopoulos,Theodore Balfousias,Lefteris Kosmas,Athanasios Papanikolaou

doi:10.7759/cureus.5104

Abstract

The simultaneous exposure of tissue and bone poses specific management challenges. Patients with extended soft tissue damage and high-grade compound fractures present a demanding clinical challenge, requiring a complex approach and multiple orthopaedic, plastic, and vascular-reconstructive procedures. Management involves combinations of wound debridement and closure by secondary intention, use of vacuum-assisted closure (VAC) devices, and various reconstructive plastic surgery methods. We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and VAC device. The mean wound size was 24 cm in length and 12 cm in width. The aim of treatment was to cover the bone with soft tissue and achieve healing of the fracture without persistent infection. Wound healing was achieved in all three cases within 30-42 days (mean 34). In one case, the skin graft was applied on day 33.Utilizing this method as part of a multi-directional approach, the VAC system helps the patient recover faster. Moreover, it acts as a feasible and valuable method to treat compound fractures with massive soft-tissue defects. VAC can replace microsurgical soft-tissue transfer, reduce the risk of infection and allow salvaging the limb.

Highlights

Fractures accompanied by an open wound, at or near the fracture site, are called open or compound [1]
We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and vacuum-assisted closure (VAC) device
Management of compound fractures with extensive soft tissue damage is a challenging task for the trauma and orthopaedic team

Summary

Introduction

Fractures accompanied by an open wound, at or near the fracture site, are called open or compound [1]. X-rays and computed tomography (CT) scan revealed a fracture of the lateral femoral condyle and a comminuted fracture of the proximal third of the left tibia (Gustilo-Anderson type IIIB) These fractures were associated with extended soft tissue damage (wound defect size 37 cm x 15 cm, 555 cm2) at the lateral side of the left femur and tibia (Figures 1A, 1B). The patient was admitted and transferred to the operation room where the wound was explored and debrided and an external fixation system was applied (Hoffmann® II External Fixation System Stryker®; Figures 5A, 5B). The primary survey revealed a compound comminuted fracture of the left tibial shaft with a 15 x 12-cm (180 cm2) wound defect on the anterior and lateral aspect of the distal third of the tibia. Notice tissue regeneration and progressive filling of tissue gap through Figures A to D (white arrows)

Discussion

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