Abstract:

Traditional negative pressure wound therapy (NPWT) has revolutionized the treatment of complex wounds for nearly 20 years. A decade ago, a modification of the original system added intermittent automated installation of topical wound irrigation solutions to traditional negative pressure wound therapy. This combined therapy, termed negative pressure wound therapy with instillation (NPWTi), has been shown to be effective in the treatment of a variety of complex wounds. Negative pressure wound therapy with instillation has been shown to reduce bioburden and biofilms present in wounds helping heal clinically infected wounds. It has also been used with success to jump-start stalled wounds, in relieving wound pain and treating infected foreign bodies including infected orthopedic hardware and some types of exposed abdominal wall mesh. The system includes a foam dressing placed in the wound covered by a semi-occlusive drape. A tubing placed over a hole cut in the drape connects the foam dressing to a pump run by a computerized micro-processor that delivers negative pressure to the dressing and wound. A preset volume of instillation fluid is automatically delivered via the instillation tubing to the wound. The fluid is held in the foam to bath the wound for a predetermined time period. Negative pressure is then re-started draining the irrigation fluid and any wound exudate into a collection canister. The entire sequence is automated and consists of three phases: (1) fluid instillation; (2) holding the fluid for a period of time in the wound which is fully expanded since the negative pressure is off during this phase; and then (3) a cycle of continuous negative pressure. The entire sequence repeats itself automatically. Typically the dressing is changed three times a week. The variables involved in treating patients with negative pressure wound therapy with instillation include: the indicated wound types; the system settings; the choice of the irrigation solution and the duration of therapy. This article will serve as a reference to help the clinician navigate through treating patients with NWTi from patient selection, system settings to the completion of therapy.

Authors:

Tom A. Wolvos MSc, MD, FACS , Chairman of the Division of General Surgery, Scottsdale Healthcare Osborn Medical Center , Scottsdale, Arizona USA

PMID:  24574014

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Integra

Abstract:

Integra® Bilayer Wound Matrix is composed of cross-linked bovine tendon collagen and glycosaminoglycan with a semi-permeable polysiloxane membrane. This bioengineered tissue provides a matrix for organized cellular migration and proliferation needed to facilitate wound healing while minimizing an inflammatory response. The scaffold provided by Integra® Bilayer Wound Matrix is particularly helpful for building a durable base for coverage of deep soft tissue defects in wounds of all types. We consider the current literature on Integra® Bilayer Wound Matrix and discuss the peri-application management, as well as introduce our treatment algorithms for its use in complex soft tissue reconstruction in the lower extremity.

Authors:

Paul J. Kim, DPM, MS, Associate Professor, Center for Wound Healing & Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia, Christopher E. Attinger, MD, Professor, Division Chief, Center for Wound Healing & Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia, John S. Steinberg, DPM, Associate Professor, Center for Wound Healing & Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia, Karen K. Evans, MD, Assistant Professor, Center for Wound Healing & Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University Hospital, Washington, District of Columbia

PMID:  24504739

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Abstract:

Combined use of adjunctive negative pressure wound therapy (NPWT) and instillation of topical wound solutions and suspensions (NPWTi) has proven to be an effective next-generation NPWT technique for wounds at risk for compromised healing. Fluid instillation has been shown to enhance exudate and debris removal, provide regular cleansing of the wound bed, and add moisture to the wound. Positive results have been demonstrated with NPWTi in assisting healing of stalled wounds and treating painful wounds as well as wounds at high risk for amputation. NPWTi has been used instead of conventional NPWT in wounds with thick exudate and slough content, acute traumatic wounds, wounds acutely debrided due to infected soft tissue, large areas of post-debrided exposed bone, and cases of critical bacterial colonization. Instilled solutions have included topical solutions such as saline, topical wound cleansers, and antiseptics. While various systems that combine instillation or irrigation with NPWT have been commercialized during the past decade, until very recently these have been relatively cumbersome to use and limited in their ability to regulate solution volume delivery. Recent advances in NPWTi technology (V.A.C. VeraFlo™ Therapy, KCI USA, Inc., San Antonio, TX) include automated volumetrically controlled delivery of fluids and upgraded foam dressing technology to provide better control and delivery of solutions to the wound bed. This article describes the latest NPWTi technology and provides recommendations for successful application of NPWTi in an effort to inform clinicians about product decision-making and practice.

Authors:

Allen Gabriel, MD, FACS, Chief of Plastic Surgery, PeaceHealth Medical Group Plastic Surgery, Vancouver, Washington, and, Loma Linda University Medical Center, Loma Linda, California, Kevin M. Kahn, MD, Chief of Orthopedic Trauma, Rebound Orthopedics and Neurosurgery, Vancouver, Washington.

PMID:  24700215

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Smith&Nephew

Abstract:

Surgical site complications (SSC) negatively affect costs of care and prolong length of stay. Crohn’s disease (CD) is a risk factor for SSC. CD patients often need surgery, sometimes requiring stoma. Our primary aim was to compare the effects on SSC of a portable device for NPWT (PICO, Smith & Nephew, London, UK) with gauze dressings after elective surgery for CD. Secondary aims were manageability and safety of PICO and its feasibility as home therapy. Between 2010 and 2012, 50 patients were assigned to treatment with either PICO (n = 25) or conventional dressings (n = 25). Each patient completed 12-month follow-up. Parameters of interests for primary aim were SSC, surgical complications, and readmission rates. Data on difficulties in managing PICO and device-related complications were also collected. Patients receiving PICO had less SSC, resulting in shorter hospital stay. At last follow-up, readmission rates were lower with PICO. No differences were observed in surgical complications between groups. No patients reported difficulties in managing the device. Among patients discharged with PICO, none needed to come back to the hospital for device malfunctioning or inability to manage it. PICO reduces SSC and length of stay in selected CD patients compared with conventional dressings. The device is safe and user friendly.

Authors:

Francesco Selvaggi, MD, EBSQ colo, Associate Professor of General Surgery, Unit of General Surgery, Second University of Naples, Naples, Italy, Gianluca Pellino, MD, Resident in General Surgery, Unit of General Surgery, Second University of Naples, Naples, Italy, Guido Sciaudone, MD, PhD, Researcher in General Surgery, Unit of General Surgery , Second University of Naples, Naples, Italy, Angela Della Corte, MD, General Surgeon, Unit of General Surgery, Second University of Naples, Naples, Italy, Giuseppe Candilio, MD, Resident in General Surgery, Unit of General Surgery, Second University of Naples, Naples, Italy, Ferdinando Campitiello, MD, General Surgeon, Unit of General Surgery, Second University of Naples, Naples, Italy, Silvestro Canonico, MD, Full Professor of General Surgery, Unit of General Surgery, Second University of Naples, Naples, Italy

PMID:  24700216

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Abstract:

The chronic wound environment and the ideal way in which to regenerate healthy tissue remain enigmas in the field of wound healing. There are multiple modalities that have been evaluated in an attempt to discern the most clinically beneficial and cost-effective treatment strategies for the millions of individuals who suffer from chronic wounds and their associated morbidity. Engineered skin substitutes represent one of the novel and continuously evolving approaches to providing wound coverage and regenerating functional skin. Herein we describe a number of the products available and the literature to date on their use and efficacy. We will close with a discussion of the cost-reimbursement structure for these products, which is currently undergoing an important shift.

Authors:

Selena G. Goss, MD, Vascular Surgery Research Fellow, General Surgery Housestaff, St. Luke’s-Roosevelt Hospital Center New York, NY, Sean D. Alcantara, MD, Vascular Surgery Research Fellow, General Surgery Housestaff, St. Luke’s-Roosevelt Hospital Center, New York, NY, John C. Lantis II, MD, Vice Chairman Department of Surgery/ Chief of Vascular/Endovascular Surgery, St. Luke’s-Roosevelt Hospital Center, New York, NY

PMID:  24700217

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Acell

Abstract:

Wound care is a classic example of a surgical realm with a great variation in care. The diversity in wounds and wound treatments, the limited amount of convincing evidence, and the diverging opinions among doctors and nurses involved in wound care contribute to this undesirable variation in care. For chronic wounds, such as arterial or venous ulcers, pressure sores, and diabetic foot ulcers, but also for acute wounds after surgery or trauma, international and national guidelines provide recommendations on diagnostic procedures and treatment options, but rely mostly on expert opinion. We present the available evidence from Cochrane systematic reviews for the systemic treatment (i.e., not prevention) of patients with wounds, as opposed to topical wound treatments. This evidence shows:

• Venous ulcers: High-compression therapy is the classic and evidence-based treatment for treating venous ulcers. Oral pentoxifylline promotes ulcer healing with and without compression therapy. Oral zinc is not effective to heal venous ulcers.
• Acute wounds: Recombinant human growth hormone accelerates healing of large burn wounds and donor sites, while high-carbohydrate feeding might reduce the risk of pneumonia. Linezolid is more effective than vancomycin for treating skin and soft tissue infections. Hyperbaric oxygen may help heal crush wounds and skin grafts. Therapeutic touch does not heal acute wounds.
• Pressure sores: Air-fluidized and some low-tech devices appear effective for treating existing pressure ulcers. Oral zinc, protein, or vitamin C supplements seem ineffective. Also, evidence is lacking on the effectiveness of repositioning regimes as a treatment option.
• Diabetic ulcers: Hyperbaric oxygen therapy and pressure-relieving devices may improve healing rates.
• Arterial ulcers: Prostanoids and spinal cord stimulation may be effective in healing ischemic ulcers.

Authors:

Dirk T. Ubbink, MD, PhD, MSc, Senior Research Physician and Clinical Epidemiologist, Trijntje B. Santema, MD, MSc, PhD Student, Robert M. Stoekenbroek, BSc, PhD Student, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

PMID:  24700218

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Abstract:

The current staging system by the National Pressure Ulcer Advisory Panel (NPUAP) classifies the stages of pressure ulcers (PUs) based on clinical assessment and visual inspection. We postulate that patients presenting with clinically superficial PUs (Stage I and Stage II) will have a greater depth of injury than predicted. On admission, patients with sacral PUs were staged according to the NPUAP classification system. Patients who were classified as having a Stage I or Stage II ulcer or suspected deep tissue injury were assessed with high-frequency (12-MHZ) ultrasonography (US) to identify any evidence of injury to the deep tissue. The study included 20 patients undergoing US for PUs of the sacrum. All patients, regardless of PU stage were found to have some evidence of deep tissue injury upon ultrasonographic examination. In patients with suspected deep tissue injury, we have found US to be a reliable diagnostic tool that confirms the clinical suspicion of deep tissue injury. PUs classified as superficial may have a component of deeper tissue damage.

Authors:

Kristen Aliano, MD, Research Fellow, Long Island Plastic Surgical Group, Garden City, New York, Christopher Low, MD, Attending Physician, Take Shape Plastic Surgery, Plantation, Florida, Steve Stavrides, PA-C, Physician Assistant, Long Island Plastic Surgical Group, Garden City, New York, Jonathan Luchs, MD, Attending Physician, Metropolitan Diagnostic Imaging Group, Garden City, New York, Thomas Davenport, MD, FACS, Attending Physician, Long Island Plastic Surgical Group, Garden City, New York

PMID:  24526418

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Abstract:

In general, the development of a tracheocutaneous fistula (TCF) after tracheotomy is a seldom but recurrent clinical problem in long-term ventilated patients. In cases of prolonged wound healing with no spontaneous wound closure or insufficient later closure by secondary suture, different surgical procedures have been previously described for the closure of TCFs. Nonetheless, each procedure has its individually associated complications so that definite closure of TCFs still remains a challenge. The purpose of this case report is to present a unique case of a patient with a persistent TCF that was successfully closed using a local cartilo-musculo-cutaneous bilobed flap.

Authors:

Wiebke Petersen, Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany, Amro Amr, MD, Department of Hand, Micro, Reconstructive and Breast Surgery, Marienhospital Stuttgart, Stuttgart, Germany, Manuel Held, MD, Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany, Jan-Ole Werner, Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany, Hans-Eberhard Schaller, MD, Professor of Surgery, Chief of Medicine, Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany, Afshin Rahmanian-Schwarz, MD, Chief of Medicine, Department of Plastic, Hand, Reconstructive and Aesthetic Surgery , Helios Clinic Wuppertal GmbH, University Witten/Herdecke, Wuppertal, Germany

PMID:  24700220

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