Role of negative pressure wound therapy (V.A.C) in orthopaedics
ROLE OF NEGATIVE PRESSUREROLE OF NEGATIVE PRESSURE
WOUND THERAPY (V.A.C ) IN OPENWOUND THERAPY (V.A.C ) IN OPEN
AND INFECTED WOUNDS INAND INFECTED WOUNDS IN
DR JOYDEEP MANDALDR JOYDEEP MANDAL
YEAR PG TRAINEEYEAR PG TRAINEE
PMCH , PATNAPMCH , PATNA
Delayed wound healing is a significant problem inDelayed wound healing is a significant problem in
orthopaedics . In addition to the pain and suffering ,orthopaedics . In addition to the pain and suffering ,
failure of the wound to heal also imposes social ,failure of the wound to heal also imposes social ,
mental and financial burdens.mental and financial burdens.
Basic wound management comprises of regularBasic wound management comprises of regular
thorough debridement and dressing.thorough debridement and dressing.
Dressing of a wound helps in –Dressing of a wound helps in –
promoting healingpromoting healing
absorption of dischargeabsorption of discharge
maintain a clean and moist environmentmaintain a clean and moist environment
V.A.C. Therapy a.k.a. NPWTV.A.C. Therapy a.k.a. NPWT
Negative pressure wound therapy (NPWT)Negative pressure wound therapy (NPWT)
or V.A.Cor V.A.C is a non invasive , active wound closureis a non invasive , active wound closure
system that uses controlled , localised negativesystem that uses controlled , localised negative
pressure to promote healing in acute and chronicpressure to promote healing in acute and chronic
HISTORYHISTORY : Research started at 1989 by Dr. Louis: Research started at 1989 by Dr. Louis
Argenta and Prof. Michael Morykwas of WakeArgenta and Prof. Michael Morykwas of Wake
Forest University School of Medicine in NorthForest University School of Medicine in North
Originally designed to treat chronic wounds.Originally designed to treat chronic wounds.
Clinical Benefits of V.A.C.Clinical Benefits of V.A.C.
Maintenance of moist, protected environmentMaintenance of moist, protected environment
Removal of excess interstitial fluid from the woundRemoval of excess interstitial fluid from the wound
Increased local vascularityIncreased local vascularity
Decreased bacterial colonizationDecreased bacterial colonization
Quantification/qualification of wound drainageQuantification/qualification of wound drainage
Increased rate of granulation tissue formationIncreased rate of granulation tissue formation
Increased rate of contraction ( decrease in woundIncreased rate of contraction ( decrease in wound
size )size )
Increased rate of epithelizationIncreased rate of epithelization
Open fractures ( Gustilo and Anderson TYPE 2,3AOpen fractures ( Gustilo and Anderson TYPE 2,3A
& 3B.& 3B.
Full-thickness surgical woundsFull-thickness surgical wounds
Chronic woundsChronic wounds
– Stage 3 pressure ulcersStage 3 pressure ulcers
– Stage 4 pressure ulcersStage 4 pressure ulcers
– Diabetic ulcersDiabetic ulcers
Dehisced woundsDehisced wounds
Acute bleeding, patients on anticoagulants, orAcute bleeding, patients on anticoagulants, or
difficult wound homeostasis and patients withdifficult wound homeostasis and patients with
bleeding disorders.bleeding disorders.
Allergies to adhesive drape and silver based foams.Allergies to adhesive drape and silver based foams.
Exposed nerves, vessels, organs or anastomosis.Exposed nerves, vessels, organs or anastomosis.
Inherent skin diseaseInherent skin disease..
Malignancy in wound.Malignancy in wound.
Necrotic tissue with eschar.Necrotic tissue with eschar.
Untreated osteomyelitis.Untreated osteomyelitis.
Fistulas to organs or body cavities.Fistulas to organs or body cavities.
Do not place V.A.C. dressing over exposed arteriesDo not place V.A.C. dressing over exposed arteries
or veins.or veins.
Materials And MethodsMaterials And Methods
Period of study : September 2014 to DecemberPeriod of study : September 2014 to December
Place of study : Patna Medical College andPlace of study : Patna Medical College and
Hospital, Patna.Hospital, Patna.
No. of patients studied : 10 patients. All the haveNo. of patients studied : 10 patients. All the have
open fractures ( 7 patients having Gustilo type lllAopen fractures ( 7 patients having Gustilo type lllA
wounds and 3 patients having Gustilo type lllBwounds and 3 patients having Gustilo type lllB
wounds. )wounds. )
Foam used : polyurethane foam.Foam used : polyurethane foam.
Intermittent Sub atmospheric negative pressureIntermittent Sub atmospheric negative pressure
applied ( 75mmHg ) using ROMOVAC drains.applied ( 75mmHg ) using ROMOVAC drains.
Materials And MethodsMaterials And Methods
Frequency of dressing changes : 48 hours.Frequency of dressing changes : 48 hours.
Number of dressing changes : 3Number of dressing changes : 3
Wounds have been treated until they are ready forWounds have been treated until they are ready for
closure, split thickness skin grafting or flapclosure, split thickness skin grafting or flap
Dressing Application OverviewDressing Application Overview
Place foam on thePlace foam on the
Cover with semi-Cover with semi-
occlusive dressing.occlusive dressing.
Secure tubing.Secure tubing.
Connect tubing to theConnect tubing to the
V.A.C. therapy unitV.A.C. therapy unit
(ROMOVAC drain).(ROMOVAC drain).
Dressing done for an average of 10 days.Dressing done for an average of 10 days.
Number of patients requiring skin grafting followingNumber of patients requiring skin grafting following
treatment : 8 patients ( 7 patients with Gustilo typetreatment : 8 patients ( 7 patients with Gustilo type
lllA wounds and 1 patient with type lllB wound.)lllA wounds and 1 patient with type lllB wound.)
Number of patient requiring flap coverage followingNumber of patient requiring flap coverage following
treatment : 2 patients with Gustilo type lllB wounds.treatment : 2 patients with Gustilo type lllB wounds.
Case 1Case 1
8 years8 years
Open fracture Rt.Open fracture Rt.
Gustilo type lllB.Gustilo type lllB.
A 10cm x 7cmA 10cm x 7cm
elliptical wound overelliptical wound over
aspect of distal legaspect of distal leg
with periostealwith periosteal
• After removal of 3After removal of 3rdrd
•Size of the woundSize of the wound
•Granulation tissueGranulation tissue
•Patient required onlyPatient required only
split thickness skinsplit thickness skin
Case 2Case 2
•60 years60 years
•Open fracture of shaftOpen fracture of shaft
of radius and ulna Lt.of radius and ulna Lt.
•Gustilo type lllB.Gustilo type lllB.
•Two 7cm x 5cmTwo 7cm x 5cm
wounds present overwounds present over
anterior aspect of Lt.anterior aspect of Lt.
forearm and antero-forearm and antero-
medial aspect of Lt.medial aspect of Lt.
Final DressingFinal Dressing
•NOTE – Wound sizeNOTE – Wound size
•Significant increase inSignificant increase in
granulation tissue.granulation tissue.
•Absence of infection.Absence of infection.
•Result – FlapResult – Flap
coverage required.coverage required.
Application of sub-atmospheric pressure (about 75Application of sub-atmospheric pressure (about 75
Difficult to create a closed chamber over the wound.Difficult to create a closed chamber over the wound.
Compliance of the patient’s relative is required.Compliance of the patient’s relative is required.
Chance of bleeding during removal of dressing.Chance of bleeding during removal of dressing.
Key PointsKey Points
Non-invasive active therapy for wound healingNon-invasive active therapy for wound healing
Indicated to treat a variety of acute & chronicIndicated to treat a variety of acute & chronic
Dressing changes every 48 hoursDressing changes every 48 hours
Reduced frequency of dressing changes thusReduced frequency of dressing changes thus
decreased nursing care and increased patientdecreased nursing care and increased patient
Reduced length of hospital stay , portable devicesReduced length of hospital stay , portable devices
are also available now-a-days.are also available now-a-days.
Cost effectiveCost effective
Easy to applyEasy to apply
Negative pressure wound therapy (V.A.C) may beNegative pressure wound therapy (V.A.C) may be
considered as a better alternative to conventionalconsidered as a better alternative to conventional
dressing of wounds for the management of acute ,dressing of wounds for the management of acute ,
chronic , open , infected and non-infected woundschronic , open , infected and non-infected wounds
in orthopaedics.in orthopaedics.
Still further studies in this domain are needed.Still further studies in this domain are needed.