Vacuum-Assisted Closure over an External Fixation Device

Abstract

Sir: Since its initial description in 1997,1,2 the vacuum-assisted closure device (KCI, San Antonio, Texas) has been commonly used to manage complex traumatic wounds of the lower extremities. The device significantly reduces tissue edema, increases local perfusion, and stimulates granulation tissue formation.2 The negative pressure environment alters the cytoskeleton of cells in the wound bed and causes increased rates of cellular proliferation.3 In addition, bacterial contamination and colonization can be reduced significantly and rapidly.2 Coverage of acute traumatic wounds of the lower extremities with the vacuum-assisted closure device is often necessary to optimize the wound before definitive soft-tissue reconstruction with skin grafting, local flaps, or free tissue transfer. However, we have found the device to be particularly difficult and cumbersome to use in the setting of a circumferential wound and the presence of an external fixation device. With large or circumferential wounds, it is difficult to maintain a seal around the fixation hardware due to poor skin adhesion, pin-site gapping, and tearing of the adhesive drape over the hardware itself once negative pressure is applied. We present the case of a 26-year-old woman with an acute traumatic injury to the left lower extremity due to a motorcycle collision. A comminuted fracture of the tibia and fibula was present and associated with a nearly circumferential degloving of the leg and foot. Limb salvage with free tissue transfer was planned but delayed due to other traumatic injuries. An external fixation device was placed to maintain reduction of the tibial fracture, and the vacuum-assisted closure device was utilized to manage the soft-tissue injury until formal reconstruction could be performed. The soft-tissue component of the injury was substantial and involved the tissue immediately under and surrounding the external fixator hardware (Fig. 1, above). The black foam was cut to the dimensions of the wound and a separate piece of foam was then used to cover the prominences of the hardware. An adhesive barrier (Ioban; 3M, St. Paul, Minn.) was wrapped circumferentially without undue tension, and the device’s tubing was then attached and connected to the vacuum-assisted closure pump (Fig. 1, below). Before completion of the dressing, it is important to assess the dressing for leaks, which are often seen (or heard) in areas of “tenting.” Areas of tenting between the Ioban and skin required additional, geometrically cut-out vacuum-assisted closure sponges. In summary, important technical points include (1) adequate padding of all the hardware, particularly prominences of the pins and rods; (2) avoiding areas of dead space (i.e., tenting between the Ioban and underlying skin) to prevent rupture of the adhesive barrier from application of negative pressure; and (3) final assessment of a proper seal (“listen and look”). We have found the above technique to be both efficient and effective in allowing placement of the vacuum-assisted closure dressing onto complex wounds when an external fixation device is present.Fig. 1.: (Above) Traumatic lower extremity wound consisting of a nearly circumferential degloving of the leg and foot and a comminuted fracture of the tibia maintained in reduction with an external fixation device. (Below) Black foam over the wounds and covering the entire external fixation device is held in place by Ioban, and negative pressure is maintained.Joshua A. Lemmon, M.D. Jamil Ahmad, M.D. Ashkan Ghavami, M.D. Sean M. Bidic, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, Texas