Case Study on the Use of Dual Therapy: Treating a Non-Healing Right Below Knee Amputation Wound (RBKA) with Negative Pressure Vacuum-Assisted Closure (V.A.C.) in Conjunction with an Ossur Silicone Liner

Orthopedic trauma wounds with extensive soft tissue damage can be costly and time consuming to heal. This case report illustrates a positive outcome using negative pressure wound therapy in tandem with a silicone gel liner to treat a nonhealing, dehisced incision following a below-the-knee amputation. The primary goal of using the 2 therapies together was to close the wound while actively reshaping and shrinking the residual limb for a prosthesis. The simultaneous use of these therapies resulted in quicker limb maturation and a reduction in the time for prosthetic fitting compared to the previous standard of care at the authors’ institution.

54-year-old man was involved in a motor vehicle crash as the driver of a motorcycle. He sustained an open right ankle crush fracture, which transected his right posterior tibial artery. Six days after admission to a tertiary hospital, after 2 surgical attempts at limb salvage and 17 units of packed cells, a below-the-knee amputation (BKA) was performed. Twenty days later at a follow-up visit, an orthopedic surgeon removed the sutures over the BKA, and the incision line dehisced with eventual formation of brown, necrotic tissue and yellow slough.

To remove the nonviable tissue and reduce bacterial colonization, an enzymatic debriding agent [*ACCUZYME®, Healthpoint, Ltd., Fort Worth, Tex] and cadexomer iodine [*IODOFLEX®, Healthpoint, Ltd.] were applied in an alternating fashion. This debriding and treatment regimen was continued until the insurance authorization for negative pressure wound therapy [*NPWT, V.A.C.® Therapy™ System, KCI, San Antonio, Tex] was obtained. Negative pressure wound therapy is not a substitute for debridement; the angiogenic stimulation of the therapy has maximal benefit on a clean wound bed. (1, 2) On Day 71 postwound dehiscence, NPWT was initiated with the silicon gel liner.

The periwound area was protected with a skin preparation solution and covered with a transparent drape. A medical grade reticulated polyurethane ether sterile foam dressing [*V.A.C.® GranuFoam®, KCI] was placed in the wound cavity and covered with a semi-occlusive adherent drape to create an airtight seal. Tubing was then applied to the foam dressing in the wound.

A silicone postoperative gel liner [*Iceross Original, Ossur, Reykjavik, Iceland] was modified to be placed over the NPWT dressing. The distal locking piece was removed from the bottom of the white, 2-mm thick liner, which created a hole from which the tubing could exit. The liner was turned inside out, and the outside was sprayed with 70% isopropyl alcohol for smoother application. The liner was then rolled over the NPWT dressing and stump. An optional cotton sleeve was placed over the gel liner for added protection. The tubing exiting the liner was then connected to a collection canister, which was contained within a computer-controlled portable NPWT unit [V.A.C. Freedom®, KCI] used to deliver controlled negative pressure.

The NPWT unit was set to deliver 125 mmHg continuous sub atmospheric pressure with dressing changes every other day, based on previously published and recommended parameters.(3-5) At each dressing change, the silicone gel liner was removed, cleansed with soap and water, and dried with a towel. The NPWT dressing was replaced, and the gel liner was reapplied over the dressing. This combination therapy was applied for 26 days until the wound was granulated to the surface, at which time NPWT was discontinued.

Negative pressure wound therapy was introduced by Argenta and Morykwas in 1995 based on the principle of applying topical sub atmospheric pressure to the wound cavity.(6-7) This mechanically-induced sub atmospheric pressure removes excess fluid from the extracellular space, delivers mechanical stress to the wound, and has been shown to enhance blood flow, reduce edema, and increase the proliferation of reparative granulation tissue.(8-12) Negative pressure wound therapy is a closed system that helps protect the wound from bacterial invasion and maintains a moist wound healing environment.(1,13)

Webb et al.(1) published orthopedic indications for NPWT to include traumatic wounds after debridement, infection after debridement, and fasciotomy wounds for compartment syndrome. Negative pressure wound therapy can also be used as a dressing for anchoring or bolstering a split-thickness skin graft.(1) The technique is contraindicated in patients with thin, easily bruised, or abraded skin; those with neoplasm as part of the wound floor; and those with allergic reactions to any of the components that contact the skin.(1) Negative pressure wound therapy is also contraindicated in cases of untreated osteomyelitis, malignancy in the wound, nonenteric and unexplored fistulas, necrotic tissue with eschar present, and over exposed blood vessels or organs.

Recent studies (1, 14-19) have documented successful outcomes of NPWT on a variety of orthopedic wounds. Wongworawat et al. (17) published a study showing that when NPWT was applied to a series of 14 infected orthopedic wounds, wound size decreased an average of 43% during a mean duration of 10 days. Page et al. (18) published controlled results of applying NPWT to wounds with large soft tissue defects, resulting in a statistically significant reduction in risk for additional complications, additional surgeries, and hospital readmission compared to wounds treated with wet-to-moist dressings.

The modified silicone gel liner allowed for total contact with the skin and applied uniform compression to the entire stump. It also allowed for gentle splinting of the residual limb in extension, which prevented contraction. (20, 21) The liner was easy to apply, clean, and re-use. Contraindications for silicone liner treatment are purulent infection and senile dementia.(22) Maintaining a NPWT seal around extremities of orthopedic trauma patients can be challenging, and placing the liner over the dressing provided additional stability to the dressing.(19) No leaks occurred for the duration of NPWT.

This surgical wound had been open for 3 months prior to the application of NPWT. The majority of this time (71 days) was spent waiting for insurance authorization for NPWT, during which time a variety of wound care therapies were tried to facilitate closure. Basic wound care principles were followed. The wound was adequately debrided of all devitalized tissue. After repeated debridement and the use of different wound care products, neither the wound depth nor the tunnel measurements had decreased during the 3 months. Since the patient care was outpatient at this time, no additional hospital days were incurred, but the wound therapy material costs and nursing time expended were significant.

Negative pressure wound therapy was initiated with the goal of stimulating granulation tissue formation to fill in the depth and tunneling.(11-17) Once the therapy was initiated, the active removal of third space edema, increased perfusion, and resulting stimulation in granulation tissue formation were apparent. Within 1 week, the wound depth had decreased by over 50%. Within 26 days of the application of dual therapies, the wound had completely granulated to the surface, and a prosthesis could be fitted.

The most common wound that practitioners face in orthopedics is the surgical wound. Often, these wounds are left to heal by secondary intention, (19) but the time to heal is generally considered “lost” by the patient. In the case of a relatively young, active patient who receives a BKA following traumatic injury, an important consideration in the treatment regimen is the patient’s psychological well being in response to the physical changes that accompany limb loss. Attentive care of the limb residuum is imperative in promoting the patient’s present health and future function.(22,23) Applying NPWT with the silicone liner accelerated the rehabilitation process, which in turn reduced the need for physical therapy, decreased the overall number of prosthetic refitting needed, and reduced the risk of thromboembolism.

In this case and many other post amputation cases, the speed in which the wound was closed and the prosthesis fitted impacted the patient’s mental health and lifestyle. Because the wound closure progressed quickly while the stump was being reshaped and shrunk, little time was lost in the wound healing process. The patient felt a higher sense of control of the situation, as he maintained considerable mobility throughout the healing process. He could continue working throughout treatment, which in turn contributed to a higher sense of self worth. All of these factors resulted in the patient’s response of “acceptance with resilience,” meaning that the patient was able to move past his injury and make extraordinary achievements despite a drastic physical change.(24) One year after the amputation, the patient took a ski holiday and was skiing so naturally, his prosthesis went completely unnoticed.

References

1. Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002;10(5):303–311.

2. Fife CE, Otto G, Walker D, Turner T, Smith L. Healing dehisced surgical wounds with negative pressure wound therapy. Ostomy Wound Manage. 2004;50(4A Suppl):28–31.

3. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg. 2001;108(5):1184–1191.

4. Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma. 2003;17(10):683–688.

5. Morykwas MJ, Faler BJ, Pearce DJ, Argenta LC. Effects of varying levels of sub atmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine. Ann Plast Surg. 2001;47(5):547–551.

6. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563–577.

7. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553–562.

8. Wackenfors A, Sjogren J, Gustafsson R, Algotsson L, Ingemansson R, Malmsjo M. Effects of vacuum-assisted closure therapy on inguinal wound edge microvascular blood flow. Wound Repair Regen. 2004;12(6):600–606.

9. Petrie N, Potter M, Banwell P. The management of lower extremity wounds using topical negative pressure. Int J Low Extrem Wounds. 2003;2(4):198–206.

10. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg. 2004;114(5):1086–1095.

11. Joseph E, Hamori CA, Bergman S, Roaf E, Swann NF, Anastasi GW. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. WOUNDS. 2000;12(3):60–67.

12. Ballard K, McGregor F. Use of vacuum-assisted closure therapy following foot amputation. Br J Nurs. 2001;10(15 Suppl):S6–S8.

13. Banwell PE, Téot L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Wound Care. 2003;12(1):22–28.

14. Schoemann MB, Lentz CW. Treating surgical wound dehiscence with negative pressure dressings. Ostomy Wound Manage. 2005;51(2A Suppl):15–20.

15. Morton N. Use of topical negative pressure therapy in postoperative dehisced or infected wounds. J Wound Care. 2004;13(8):346–348.

16. Ferreira MC, Wada A, Tuma P Jr. The vacuum assisted closure of complex wounds: report of 3 cases. Rev Hosp Clin Fac Med Sao Paulo. 2003;58(4):227–230.

17. Wongworawat MD, Schnall SB, Holtom PD, Moon C, Schiller F. Negative pressure dressings as an alternative technique for the treatment of infected wounds. Clin Orthop Relat Res. 2003;(414):45–48.

18. Page JC, Newswander B, Schwenke DC, Hansen M, Ferguson J. Retrospective analysis of negative pressure wound therapy in open foot wounds with significant soft tissue defects. Adv Skin Wound Care. 2004;17(7):354–364.

19. Stannard J. Complex orthopaedic wounds: prevention and treatment with negative pressure wound therapy. Adv Skin Wound Care. 2004;17(1):3–10.

20. Johannesson A, Larsson G-U, Holmquist A, Larsson B. Lower extremity amputations: an aggressive prosthetic management technique. Presented at the 25th Annual Meeting of the American Academy of Orthotists and Prosthetists in New Orleans, La, March 5, 1999.

21. Larsson G-U, Johannesson A, Holmquist A, Larsson B. Lower extremity amputations: a controlled active treatment protocol. Presented at the 25th Annual Meeting of the American Academy of Orthotists and Prosthetists in New Orleans, La, March 5, 1999.

22. Kyes K. Dressing for success: PSTDs and silicone liners facilitate rehab for amputees. Orthopedic Technology Review. 1999;1(2):51.

23. Smith DG, Berke GM, Blanck R, et al. Post-operative management of the lower extremity amputee (official findings of consensus conference). Journal of Prosthetics and Orthotics. 2004;16(3S):2–14.

24. Richie BS, Ferguson AD, Gomez MJ, El Khoury D, Adamaly Z. Resilience in survivors of traumatic limb loss. Disability Studies Quarterly. 2003;23(2):29–41.