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Role of negative pressure wound therapy (V.A.C) in orthopaedics

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application of negative pressure on wound bed using ROMOVAC drains.

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Role of negative pressure wound therapy (V.A.C) in orthopaedics

  1. 1. 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 ORTHOPAEDICSORTHOPAEDICS AUTHORAUTHOR DR JOYDEEP MANDALDR JOYDEEP MANDAL 22NDND YEAR PG TRAINEEYEAR PG TRAINEE PMCH , PATNAPMCH , PATNA
  2. 2. IntroductionIntroduction  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
  3. 3. 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 wounds.wounds.  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 Carolina.Carolina.  Originally designed to treat chronic wounds.Originally designed to treat chronic wounds.
  4. 4. Clinical Benefits of V.A.C.Clinical Benefits of V.A.C. TherapyTherapy  Maintenance of moist, protected environmentMaintenance of moist, protected environment  Removal of excess interstitial fluid from the woundRemoval of excess interstitial fluid from the wound peripheryperiphery  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
  5. 5. Mechanism Of ActionMechanism Of Action
  6. 6. IndicationsIndications  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
  7. 7. PrecautionsPrecautions  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.  Malignancy.Malignancy.  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..
  8. 8. ContraindicationsContraindications  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.
  9. 9. Materials And MethodsMaterials And Methods  Period of study : September 2014 to DecemberPeriod of study : September 2014 to December 2015.2015.  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.
  10. 10. 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 coverage.coverage.
  11. 11. Dressing Application OverviewDressing Application Overview  Place foam on thePlace foam on the wound.wound.  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).
  12. 12. ResultsResults  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.
  13. 13. Case 1Case 1 MaleMale 8 years8 years Open fracture Rt.Open fracture Rt. TibiaTibia Gustilo type lllB.Gustilo type lllB. A 10cm x 7cmA 10cm x 7cm elliptical wound overelliptical wound over antero-lateralantero-lateral aspect of distal legaspect of distal leg with periostealwith periosteal stripping.stripping.
  14. 14. ResultsResults V.A.C AppliedV.A.C Applied 11STST DressingDressing
  15. 15. ResultsResults • After removal of 3After removal of 3rdrd dressing.dressing. •Size of the woundSize of the wound diminished.diminished. •Granulation tissueGranulation tissue increased.increased. •Patient required onlyPatient required only split thickness skinsplit thickness skin grafting.grafting.
  16. 16. Case 2Case 2 •MaleMale •60 years60 years •Open fracture of shaftOpen fracture of shaft of radius and ulna Lt.of radius and ulna Lt. side.side. •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. elbow.elbow.
  17. 17. ResultsResults V.A.C AppliedV.A.C Applied 11STST DressingDressing
  18. 18. Final DressingFinal Dressing •NOTE – Wound sizeNOTE – Wound size decreased.decreased. •Significant increase inSignificant increase in granulation tissue.granulation tissue. •Absence of infection.Absence of infection. •Result – FlapResult – Flap coverage required.coverage required.
  19. 19. LimitationsLimitations  Application of sub-atmospheric pressure (about 75Application of sub-atmospheric pressure (about 75 mmHg).mmHg).  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.
  20. 20. 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 woundswounds  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 comfort.comfort.  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 
  21. 21. ConclusionConclusion  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.

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