Don’t delay flap procedure, even with vacuum-assisted closure
Vacuum-assisted closure (VAC) devices are commonly used in the treatment of open tibia fractures—providing soft-tissue wound coverage to protect the patient from infection for up to 7 days. But does use of the VAC device allow the free-flap coverage procedure to be delayed more than 7 days?
Timothy Bhattacharyya, MD
A retrospective study
This retrospective study involved 58 patients identified from a trauma registry who had Grade IIIB open fractures and a minimum of 1-year follow-up. Data gathered from each patient’s medical record included time from the injury to definitive wound coverage, type of fixation, type of coverage, and demographic information.
For purposes of the study, infected wounds were defined as those that “required surgical débridement after coverage with positive cultures.”
Not effective beyond 7 days
“Although the VAC is highly effective in preventing infection,” Dr. Bhattacharyya said, “it unfortunately does not expand the window for ‘time for coverage.’ The 7-day window that has been cited in other studies was supported in our work.”
Patients with the lowest rate of infection (12.5 percent) “underwent definitive coverage” within 7 days. In contrast, infections developed in more than half (54 percent) of patients who did not receive definitive coverage for 7 or more days (P<0.008).>0.008).>
The overall rate of infection with routine use of the VAC sponge was 36 percent. Those patients in whom infections developed had a longer mean time to coverage (8.9 days) than those in whom infection did not develop (4.8 days).
Not an answer to scheduling problems
“If you have a patient with an open tibia fracture, the VAC device can be used as a temporary dressing—as long as the flap procedure is done within 7 days,” concluded Dr. Bhattacharyya.
Getting that procedure done in a timely manner in all cases may be problematic, however, because most free-flap procedures are done by plastic surgeons. According to Dr. Bhattacharyya, many plastic surgeons focus on elective procedures, and their practices are not set up to manage emergencies and trauma. As a result, scheduling patients for emergency or trauma treatment on a timely basis is sometimes difficult.
Disclosure information for Dr. Bhattacharyya is available at http://www.aaos.org/disclosure
Annie Hayashi is the senior science writer for AAOS Now. She can be reached at firstname.lastname@example.org