Effects of Innovative Customised Negative Pressure Wound Therapy in the Management of Compound Fracture of Long Bone

 

 

Abstract               Background: This is a prospective study was conducted to assess the efficacy of topical negative pressure wound dressings as compared to conventional moist wound dressings in improving the healing process in wounds and to prove that negative pressure dressings can be used as a much better treatment option in the management of wounds. Hence the present study was carried out to find out the efficacy of topical negative pressure dressing in healing of wounds, and to observe for the adverse events that occur in NPWT. Methods: This study was conducted in 30 cases over a period of 2 years from November 2014 to November 2016. Material used for the application of topical negative pressure dressings needs the following materials. A paraffin impregnated gauge (Cuticell), a sponge foam/ sterilized dressing pad (Cutisorb), a pair of Redon drainage tubes with suction in wards. Results: Majority of the cases showed better wound healing in 1-2 weeks while 16.67% of the cases who were above 60 years of age, showed healing by the end of 3-4 weeks. Although a sample size of 30 patients is sufficient for statistical analysis, a randomized controlled study with a much larger population may help to further substantiate the findings or reveal variations. Conclusion: Negative pressure wound therapy can be used as an excellent initial dressing after wound debridement, because it effectively reduces wound edema, controls local bacterial growth, and promotes the formation of granulation tissue.

Key Word: Compound fracture, Wound therapy, Long bone, Customised negative pressure

 

 

INTRODUCTION

Indeed the art of healing mentioned thousand years ago the medicine in pre historic era was intermingled with superstition, religion, magic and witchcraft etc. Real breakthrough happened with development of bacteriology as a science by a pioneering work of Louis Pasteur (1822-95). Pasteur's work prompted Joseph Lister to work on wound sepsis, this he achieved in 1867 with striking successful results by which scope of surgery hitherto limited by fear of sepsis, was enormously increased. It is fascinating to know that the naturally occurring materials used over thousands of years for wound management include spider webs, dung, various species of animals and insects, leaves, tree bark, honey, vinegar.^1,3 Today when the advances in medical technology and literature has reached its pinnacle, where mankind has succeeded in deciphering the human genetic code, the issue of wound management still remains an enigmatic challenge. Wounds can also affect patients' ability to function in their environment, causing financial, social, and psychological consequences as well as affecting patients' quality of life. The peculiarity of some wounds is that, lack of healing and delayed healing in spite of various management methods. The notion that wounds should be kept dry, although still held by a considerable number of clinicians, is steadily losing ground. We now know that wounds re-epithelialize much faster, or develop granulation tissue faster when treated with dressings which allow moist wound healing. We recognize that air tight covering of the wounds does not lead to infection.^3,6   A wound care revolution is currently in the making. Many techniques have been developed and tried over the centuries to heal wound. Although wound dressing have been used for at least two millennia, there exists no ideal dressing. Surgical dressing of both open and closed wounds is based mainly on tradition, training and the surgeon’s own philosophy. During the last two decades a wide variety of innovative dressings have been introduced. Wound management represents a considerable burden on health services and requires considerable manpower, frequent specialist consultation, and adjunct therapies; an important example of these adjunct therapies is the negative pressure wound therapy (NPWT), which was suggested to offer an important option for the advanced management of various wound types. Recent studies have shown that application of a sub atmospheric pressure in a controlled manner to the wound site has got an important role in assisting wound healing. Argenta LC et al² presented the original description of Negative Pressure Wound Therapy. The concept is based on mechanics of Physics. NPWT can be adjunctive therapy before or after surgery or an alternative to surgery in the extremely ill. Alternative names for NPWT include VAC (vacuum assisted closure), topical negative pressure, sub-atmospheric pressure, sealed surface wound suction, vacuum sealing and foam suction dressing.^7,8 The present study was conducted to assess the efficacy of topical negative pressure wound dressings as compared to conventional moist wound dressings in improving the healing process in wounds and to prove that negative pressure dressings can be used as a much better treatment option in the management of wounds in the Orthopedics ward.

MATERIAL AND METHODS

This prospective randomized study included 30 patients with taumatic wounds with open fractures admitted to Department of Orthopaedic Surgery of Pravara Rural Medical Collage, Loni, Ahmednagar, Maharashtra between November 2014 and November 2016 satisfying all the inclusion criteria mentioned below after the clearance from the ethical committee was obtained. This study was done as a prospective randomized controlled study to find out outcome of the efficacy of negative pressure wound therapy to conventional moist wound dressing in management of wounds of patients in the Orthopedics ward. The application of topical negative pressure dressings needs the following materials. A paraffin impregnated gauge (Cuticell), a sponge foam/ sterilized dressing pad (Cutisorb), a pair of Redon drainage tubes with suction in wards.

Technique of Application: It is recommended to clean wound with saline solution. This should be undertaken at each dressing. Remove of devitalised Tissue, achieve Haemostasis, prepare wound skin, placement of Foam, sealing  and draping of the wound, application of Negative Pressure (75 to 125 mm of Hg), position of tubing (away from bony prominences)⁹

Duration of Study:   2 years from November 2014 to November 2016.

Sample size: Total 30 cases.

Inclusion criteria:

1. Traumatic wounds with soft tissue loss.
2. Post- op and dehisced surgical wounds with exposed bone,
3. Fasciotomy wounds in compartment syndrome.

Exclusion criteria:

1. Wounds with exposed vessels, nerve and tendon.
2. Patients with malignancy, bleeding disorders, psychiatric disorders, allergy to any component required for the procedure, on anti-coagulants, on immune-suppressants
3. Non co-operative patients.
4. Those who were not willing were subjected dressings

Statistical Analysis: The data was analyzed by computer software MS Excel and statistical package for the social science SPSS version 18.0.

 

RESULTS

The 30 patients admitted for the study which was subjected to negative pressure wound therapy.

Table 1: Patient's characteristics

 

Table 2: Age and Gender distribution of patients

 

 

 

 

Table 3: Day-wise progress in wound

Bacteriological results of wound discharge

The discharge from the wound was analyzed to determine the most common organism causing the infection. It was present either as a single organism or present along with other bacteria. Organisms isolated were E. coli, Staph, aureus, Pseudomonas sp. Klebsiella, etc along with good numbers of "No growth' reports.

Table 4: Organisms isolated

 

Table 5: Treatment given to the patients

 

Majority of the patients have no complications during the entire course of treatment. Except around 13.33% patients had minor complications like pain during the application of negative pressure, or during removal of the dressing; some had bleeding with exuberant granulation tissue formation: and one had minor allergy to the adhesive drape. One patient on NPWT had necrosis of the surrounding skin which may be attributed to the desiccation of the wound, or due to pressure point, or may be also because of the primary insult presenting subsequently.

Figure 1: case A

                                                                                                  Figure 2: case B

 

DISCUSSION

This study mainly enrolled the polytrauma with compound fractures patients following accidents of varying causes. This study includes patient ratio of age range of 22 to 80 years, common being 30 to 60 years and mostly due to more dynamism and exposure to accidents. The sex ratio in males to females is 1.8:1, showing male dominance due to male exposure to more stress and strain. Subsequent to the observation of progressive changes in granulation tissue formation in percentages of floor coverage in course of treatment follow ups (7, 14, 21 and 28 days). The analyze results shows the standards development around two weeks 54.5% (SD=23.93). The results showed highly significant differences in the rate of granulation tissue formation. The total hospital stays for the patients showed a mean period of 30.39 days which is significantly less than the standard other modalities followed in normal practice.^7,8 Wound dressings have evolved from the status of providing physical protection to the raw surface; absorbing exudates and controlling local infections by local medications; to the level of providing adequate environment promoting wound healing. This has been achieved by modern wound dressing techniques by promoting granulation tissue formation. The concept of moist wound dressings which came into practice in the 1960's which revolutionized wound care. This led to further research in this direction leading to influx of many products like semi permeable plastic film dressings, hydrocolloids, hydro gels, collagen dressings into the wound care scenario, each claiming a better wound healing rate than the others.^9,10 Baynham et al.¹¹ found that three-stage intravenous sacral and ischial wounds, which were refractory to surgical therapy for the past 10 months, got healed in about 2 months with VAC. The device operated at negative pressure of 125 mmHg with 5 min on and 2 min off cycle. Marcus et al.¹² presented a prospective study of randomizing 22 patients. Two groups of 11 patients each with pressure sores in the pelvic region were included. The time difference to heal was almost the same in the group treated with VAC (27 days) and the traditional group with Ringer’s solution dressings thrice a day (28 days). However, no hospital stay, reduced costs, and improved comfort were noted in the VAC group. Philbeck et al.¹³ estimated the average annual cost for treating each of 100 diabetic foot ulcers to be $23,066 with NPWT and $27,899 with saline-moistened gauze. That study assumed that at 20 weeks, wound healing would be higher in the NPWT-treated group (50 %, compared with 31 % of the control group). Study conducted by M. Singh et al.¹⁴ reported gratifying results with manually operated vacuum devices. As the concept of "outcome based medicine' evolved, the need for a better wound dressing modality became more acute. Now wound dressing systems were compared not only on the basis of the rate of granulation tissue formed, or the rate of wound healing, but also on the cost and duration of hospital stay of the patient which was considered as a measure of the morbidity of the patient. The outcome of our study with excellent outcome is 66%. These results are comparable to randomized controlled cross over trial by Mark TE et al.¹⁵ who achieved an average 59 % wound volume reduction in patients on vaccum assisted closure.

 

LIMITATIONS

The most important limitation of the present study is its sample size. Although a sample size of 30 patients is sufficient for statistical analysis, a randomized controlled study with a much larger population may help to further substantiate the findings or reveal variations which were not observed in the present study. The quantitative assessment of the post-operative parameters like wound contraction, pain and residual raw ulcer area was also not included in the present study, which if included, might have given a much better analysis of the efficacy of topical negative pressure moist dressings.

 

CONCLUSION

Negative pressure wound therapy can be used as an excellent initial dressing after wound debridement, because it effectively reduces wound edema, controls local bacterial growth, and promotes the formation of granulation tissue. It provides a safe temporary wound environment so that reconstructive surgery can be electively planned rather than performed urgently. Increased rate of granulation tissue formation was seen in negative pressure dressing. By promoting the rapid formation of granulation tissue, the NPWT decreases the three- dimensional size of the wound. Thus we can allow the wound to heal by secondary intention, or with a simple skin graft and/or local flap. Without the NPWT, the same wound would have needed to be treated with a pedicle or microsurgical free flap. Better graft takes up was seen in negative pressure wound therapy. Shorter duration of hospital stay was observed in the negative pressure wound therapy group. Negative pressure wound therapy was found to be totally safe, although technically demanding, but had better patient compliance. Follow up observations revealed that negative pressure wound therapy group suffered lesser post skin grafting complications like wound contractures, residual raw area and pain. Thus finally it can be rightly said that "NPWT has greatly simplified wound management".

 

REFERENCES

1. Agency for Health Care Policy and Research. Treatment of Pressure Ulcers, Clinical Guidelines number 15. AHCPR Publications No.95- 0652 1994:1-125.
2. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg1997; 38 (6): 563-76
3. Atiyeh BS, El-Musa KA, Dham R. Scar quality and physiologic barrier function after moist and moist exposed dressings of partial thickness wounds. Dermatol Surg 2003; 29(1): 14-20.
4. Armstrong, D.G. and L.A. Lavery, Negative pressure wound therapy after partial diabetic foot amputation: A multicentred, randomised controlled trial. The Lancet, 2005; 366(9498):1704-1710.
5. A. Braakenburg, M. C. Obdeijn, R. Feitz, I.A.L. M. Van Rooij, J. Van Griethuysen, and J. H. G. Klinkenbijl, "The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial," Plastic and Reconstructive Surgery, 2006;118(2):390-97.
6. Chiang TM. The role of protein phosphatases 1 and 2A in collagen platelet interactions.Archives of Biochemistry and Biophysics 1993; 302:52-63
7. Steed DT, Donahoe D, Webster MW, Lindsley L. Diabetic Ulcer Study Group: Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. J Am CollSurg 1996; 183:61-64.
8. Gentzkow GD, Jensen JL, Poliak RA. Improved healing of diabetic foot ulcers after grafting with a living human dermal replacement. Wounds 1999; 11(3):77-9.
9. Fleischmann W, Strecker W, Bombelli M, KinzlL.Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg. 1993; 96(9):488-92.
10. Mullner T, Mrkonjic L, Kwasny O, Vecsei V. The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997; 50(3):194-99.
11. Baynham SA, Kohlman P, Katner HP. Treating stage IV pressure ulcers with negative pressure therapy: a case report. Ostomy Wound Manag. 1999; 45(28–32):34–35. 
12. Marcus BW, Franz S, Beni S, Guido AZ, Gerhard P. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Recons Surg. 2003; 37:28–33.
13. Philbeck TE, Schroeder WJ, Whittington KT. Vacuum-assisted closure therapy for diabetic foot ulcers: clinical and cost analysis. Home Healthc Consult. 2001; 8:27–34.
14. Singh M, Singh R, Singh S, Pandey V, Singh D. Vacuum assisted closure in wound management-Poor man's VAC©. Internet J Plast Surg. 2009; 6:1-3
15. Mark TE, Kellie RB, Gary RS, Jonathan BT, Robert AC. Prospective randomized evaluation of negative–pressure wound dressing for diabetic foot wounds. Ann Vasc Surg. 2003; 17:645–49.