Use of a Subatmospheric Dressing as a Bridge to Free Tissue Transfer in the Treatment of Open Distal Tibia Fractures


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Slide 1 : Use of a Subatmospheric Dressing as a Bridge to Free Tissue Transfer in the Treatment of Open Distal Tibia Fractures Brian Rinker, MD, Jonathan C. Amspacher, MS, Patrick C. Wilson, MD, and Henry C. Vasconez, MD University of Kentucky, Division of Plastic Surgery Lexington, KY
Slide 2 : Disclaimer This presentation includes discussion of commercial products, but the investigators have no financial interest or other relationship with the manufacturers
Slide 3 : Background Microsurgical techniques have dramatically improved the management of Gustillo III tibia fractures
Slide 4 : Background Since work of Godina in the 1980s, it has been understood that the timing of free flap reconstruction affects complication rate Increased infectious complications in the “subacute” period
Slide 5 : Background The relationship between flap timing and complications is thought to be due to increased bacterial colonization Early reconstruction is not always feasible: medical instability, presence of other life threatening injuries, operating room availability
Slide 6 : Subatmospheric Dressings Long history in wound management Commercially available as the VAC® device since 1995
Slide 7 : Subatmospheric Dressings Combines moist occlusive dressing with evacuation of exudate and debris Shown (in some studies) to reduce bacterial counts in chronic wounds
Slide 8 : Purpose To review a large clinical experience with the management of Gustillo IIIB and IIIC ankle fractures to determine if the use of a subatmospheric dressing as a “bridge” to free tissue transfer has affected complication rates.
Slide 9 : Does using the VAC extend the “acute” period?
Slide 10 : Methods Records were reviewed of 105 consecutive patients who underwent a free muscle flap transfer for treatment of a Gustillo IIIB or IIIC ankle fracture between 1991 and 2005. Patients were divided into three groups: acute: flap performed days 1-7 post-injury subacute: flap on days 8-42 chronic: flap after day 42
Slide 11 : Methods The three groups were tested for homogeneity, using Student’s t-test, Fishers exact test, or Chi-squared, as appropriate age and gender mechanism of injury presence of other life threatening injuries smoking history presence of an associated vascular injury preexisting chronic medical conditions flap choice
Slide 12 : Methods The three groups were then compared using 5 outcome measures 1) incidence of infectious complications (osteomyelitis, infectious nonunion, cellulitis, or abscess) 2) incidence of flap-related complications (takeback, partial or total flap loss) 3) total number of surgical procedures 4) length of hospital stay 5) time to bony union
Slide 13 : Methods Subacute group was further divided into those who underwent subatmospheric dressings prior to free flap surgery and those who did not Five outcome measures were compared between these two subgroups (Fisher’s exact test and Student's t-test) Significance was defined as p<0.05.
Slide 14 : Results Study group consisted of 105 patients (111 free muscle flaps) Acute: 32 patients (32 flaps) Subacute: 55 patients (60 flaps) Chronic: 18 patients (19 flaps) 72 males, 33 females Age range 6 to 78 years (median 39)
Slide 15 : Results Flap choice
Slide 16 : Results Mechanism of injury
Slide 17 : Results No significant differences were observed between the three groups (acute, subacute, chronic) in regards to age, gender, mechanism of injury, premorbid conditions, or flap choice Within the subacute group, no differences were observed between the VAC and no-VAC subgroups
Slide 18 : Results Flap choice
Slide 19 : Results Flap choice
Slide 20 : Results
Slide 21 : Results
Slide 22 : Results
Slide 23 : Conclusions The use of a subatmospheric dressing as a “bridge” to free flap reconstruction of Gustillo III ankle fractures was associated with a reduced complication rate in this study Patients who had subatmospheric dressing therapy prior to free flap surgery in the subacute period (days 7-42) had a complication profile similar to patients who underwent flap surgery in the acute period
Slide 24 : Conclusions Use of a subatmospheric dressing seems to effectively extend the “acute period” in the treatment of complex lower extremity trauma
Slide 25 : Thank You

 


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