In selected foot injuries, can the amputation level be changed with vacuum assisted wound
closure system treatment? : a case report
Kömür Baran1, Mutlu Serhat1, Yilmaz Baris2, Mutlu Harun3, Kaan Erdem4, Bicer Elcil Kaya5, Özyalcin Halit5
1Orthopaedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, Istanbul-Turkey
2Orthopaedics and Traumatology Department, Fatih Sultan Mehmet Training Hospital, Istanbul-Turkey
3Orthopaedics and Traumatology Department, Gaziosmanpasa Taksim Training Hospital, Istanbul-Turkey
4Orthopaedics and Traumatology Department, Dr.Ersin Arslan Devlet Hastanesi, Gaziantep-Turkey
5Orthopaedics and Traumatology Department, Ege University, Medical Faculty, Izmir-Turkey
Corresponding author: Kömür Baran; Email: firstname.lastname@example.org
Citation: Baran K, Serhat M, Baris Y, Harun M, Erdem K, Kaya BE, Halit Ö. In selected foot injuries, can the amputation level be changed with vacuum assisted wound closure system treatment? : a case report. J Minim Invasive Orthop, 2014, 1(7): e7. doi:10.15383/jmio.7.
Competing interests: The authors have declared that no competing interests exist.
Conflict of interest: None
Copyright: 2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract: Foot injuries are frequently seen injury types, upper and lower extremity injuries with soft tissue defects have a long and difficult treatment period. Early revascularisation is very important in such situations but is not always possible in every case and under all conditions. The case is here presented showing recovery in a different manner to that predicted. The patient had an injury which seemed to require amputation, and with the vacuum assisted wound closure system, grafting was applied to the wound, then with an appropriate orthosis and rehabilitation, successful preservation of the extremity was completed.
Keywords: Foot; Foot injury; Amputation; Amputation level
Foot injuries have always been one of the most common types of injuries. These injuries require a multi-disciplinary approach and closely monitored treatment. The greatest problem is that when vascular and nerve injuries are overlooked, diagnosis is delayed. Loss of soft tissue is one of the most significant problems affecting the success of treatment . Although amputation rates were very high in these type of injuries in the past, improvements in patient transport, improved anesthesia techniques, more widespread use of angiographic tests and improved surgical techniques have increased the chances of success of treatment in recent years .
A 26-year old male mine labourer with a saw blade injury refused the amputation which was suggested at another centre and so presented at our Emergency Department approximately 8 hours after the trauma. On the left foot there was an injury starting from the 3rd phalanx web and extending longitudinally as far as the ankle and heel, which had created a bone and soft tissue defect by avulsion of the calcaneal fat pad. As there was injury within the fat pad in the heel area, Syme amputation was not indicated. After consultation with a cardiovascular surgeon, vascular repair was not indicated. Starting from the 4th and 5th phalangeas in the lateral region, there was an incomplete area without bleeeding, which extended to the heel and ankle (Figure 1). After irrigation and debridement, routine tetanus prophylaxis and prophylactic antibotherapy in the Emergency Department, the patient was admitted to the operating theatre for osteosynthesis with open reduction and K-wire for the metatarsal fractures. At one week postoperatively, as necrosis had developed on the lateral flap of the injury (Figure 2), 4th and 5th ray amputation was applied. Circulation was observed to have continued on the medial side. As there was no soft tissue covering the lateral part of the 3rd metatarsal, after hemostasis was obtained in this area on the first day postoperatively, vacuum assisted wound closure system treatment was started. During follow-up, in the wound site where primary repair had been applied on the lateral heel and plantar surface, as seropurulent discharge started in the early period, it was decided to commence vacuum assisted wound closure system in those areas. No reproduction was determined in the samples taken from the discharge.
Figure 1. Image of the wounded extremity in the Emergency Department.
Figure 2. Necrosis in the lateral flap of the wound at 1 week postoperatively.
After 24 hours, the excessive oedema in the foot had reduced to minimal and the circulation was observed to have returned to normal. At the end of 3 weeks treatment with the vacuum assisted wound closure system, the bone tissue together with the surrounding tissue was covered with granulation tissue and the necrosis was determined to have significantly decreased (Figure 3). A split thickness skin graft was applied to the wound, which was healing with granulation tissue in the lateral of the foot. As a circulation problem developed during follow-up in an area of approximately 1 x 3 cm on the skin graft over the cuboid bone, split thickness grafting was re-applied by excising sequestered bone. On approximately the 20th day of follow-up, the wound site was seen to have completely healed. Ten weeks after the first operation, the K-wire was removed. The patient was mobilised in the early period but full weight-bearing was only allowed in the postoperative 12th week after healing in the surface and grafting area. To support the area where ray amputation had been applied, the patient was mobilised with an ankle-foot orthosis (Figure 4).
Figure 3. The development of granulation tissue observed after 3rd and 4th metatarsal ray amputation and 3 weeks of vacuum assisted wound closure system treatment.
Figure 4. The patient was mobilised with an appropriate ankle-foot orthosis.
The vacuum assisted wound closure system of treatment was developed primarily for patients with extensive infected wounds. It is currently used in diabetic wound care and is becoming increasingly used in the care of post-traumatic wounds . Treatment with the vacuum assisted wound closure system has been shown to rapidly reduce oedema in the wound bed and accelerate the development of granulation tissue. This effect is thought to be made especially by a distancing of the superficial purulent layer which is seen in open wounds and by reduction of the fluid which increases pressure between tissues . Due to the negative pressure of the vacuum assisted wound closure system it is possible to remove the fluid between tissues. In these tissues there are factors which inhibit the factors which accelerate wound healing, such as fibroblasts, vascular endothelial cells and keratinocytes . Thus the anaerobic colonisation potential of these tissues and the number of bacteria per gram are reduced. Previous studies have shown that arteriole dilatation is provided by this negative pressure that is created and the blood flow in the tissue is increased, thereby contributing to the proliferation of granulation tissue. This effect is thought to be made by increasing capillary flow . Apart from this, with the effect of the applied negative pressure, mechanical pressure is made on the surrounding soft tissues and this pressure directs cells which cannot contract to the centre of the defective wound site and thereby reduces the expanse of the wound site .
There are some important points which must not be forgotten during treatment with the vacuum assisted wound closure system. The first is that this treatment method was designed as a method to prepare the wound site for surgery. Proliferation of granulation tissue occurs because the vacuum assisted wound closure system treatment has removed local necrotic tissue and reduced inflammatory mediators. Through this, the soft tissue surgical procedure is reduced to a minimum [8, 9]. In addition, it is accepted as an alternative method for patients who cannot be operated on because of anaesthesia and surgical risks. To reduce bacteria colonisation of the wound site to a minimum, the vacuum assisted wound closure system should be re-applied after every debridement. While vacuum assisted wound closure system is applied once every 3 days in clean wounds, when discharge persists in these cases, by changing the dressings of the vacuum assisted wound closure system treatment every 24 hours, wound care is applied and the wound site is prepared for grafting.
In the prognosis of high energy injuries, it is of great importance that there is stable bone tissue and sufficient soft tissue to be able to cover the wound [10, 11]. That the live area of this soft tissue coverage contributes to the circulation of the area where the grafting is to be applied is extremely important. Vacuum assisted wound closure system treatment increases the chance of maintaining the remaining live tissue and to have the opportunity of observing limits, more accurate determinations can be provided of graft limits in these types of injuries. In the case presentd here, the treatment with vacuum assisted wound closure system was used for wound care and to reduce the need for grafting.
Taking into consideration the ease of application and low costs, although below-the-knee amputation seems to be an appropriate choice in the first evaluation of a case presenting with crush injuries of the foot, in cases that are young and without concomitant morbidities and/or injuries, it is possible to obtain pleasing results with surgical approaches to preserve the extremity as far as possible. Amputation reduces hospitalisation time and hospital costs and is appropriate treatment for some patients but extremity preserving approaches must be prioritised for patients who are indecisive or reject a decision for amputation.
In conclusion, the vacuum aspiration method, which has recently become more widespread in use, accelerates wound healing and prepares the area for grafting. With appropriate antibiotherapy support and daily debridement, infections with the risk of leading to loss of the extremity, can be brought under control. In the case presented here, it was seen that the extremity could be saved, contrary to the predicted view of amputation level at the first evaluation. In cases where the amputation level cannot be fully determined, treatment with the vacuum assisted wound closure system should firstly be considered for wound care.
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