Citation Information :
Villarreal-Juris A, Villarreal-Juris R, Dyer-Rolando J. Lower Limb Trauma: Salvage Through Vacuum-assisted Closure in an Ecuadorian Tertiary Hospital. Panam J Trauma Crit Care Emerg Surg 2023; 12 (3):136-143.
Introduction: Major trauma causes shear, compressive, and torsional forces to the lower limbs, resulting in complex and devastating soft tissue and bone injuries that challenge the most experienced surgeons. For such injuries, the standard of care is early debridement and coverage, which in recent years has been ubiquitously done using vacuum-assisted closure (VAC).
Objective: Describe the short-term outcomes of adult patients with devastating lower limb injuries from January to December 2022 at the Luis Vernaza Hospital in Ecuador.
Materials and methods: Observational, retrospective, and analytical study. Data was obtained from electronic medical records and analyzed using Statistical Package for the Social Sciences (SPSS) 27.0. Yan's classification was used. Management was early wound excision and coverage using VAC. Main outcomes—wound healing; limb mobility at 180–190 days; infection; length of stay; days-to-skin graft; and mean total surgical time.
Results: A total of 13 patients were included, all male, mean age—31.4 years (20–45 years), mean length of stay—38.9 days (24–65 days). The most common mechanism of injury was motorcycle (58.85%); the left lower limb was the most affected (61.5%); 53.9% of injuries were pattern 2B and 46.1% pattern 3, which increased length of stay (p = 0.004); mean total surgical time (p = 0.349), days-to-skin graft (p = 0.002); and a 4x higher probability of secondary healing [odds ratio (OR)—4.031, p = 0.005]. No significant difference was observed in conventional vs silver-impregnated foam dressings and infection, length of stay, days-to-skin graft, and mean total surgical time. Minor infection significantly increased days-to-skin graft (p = 0.002). All patients had limb mobility by 180–190 days follow-up and none underwent amputation.
Conclusion: The VAC appears to be a useful tool in managing catastrophic lower limb injuries (including pattern 3). Early VAC coverage allows early large defect coverage until surgical reconstruction, may reduce infection, and preserve mobility thus aiding limb salvage.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78(3):285–292. DOI: 10.1097/00006534-198609000-00001
Hou Z, Irgit K, Strohecker KA, et al. Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture. J Trauma 2011;71(6):1705–1708. DOI: 10.1097/TA.0b013e31822e2823
Liu DSH, Sofiadellis F, Ashton M, et al. Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury 2012;43(6):772–778. DOI: 10.1016/j.injury.2011.09.003
Patterson CW, Stalder MW, Richardson W, et al. Timing of free flaps for traumatic wounds of the lower extremity: have advances in perioperative care changed the treatment algorithm? J Reconstr Microsurg 2019;35(8):616–621. DOI: 10.1055/s-0039-1688712
Dini M, Quercioli F, Mori A, et al. Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb. Injury 2012;43(6):957–959. DOI: 10.1016/j.injury.2011.03.020
Josty IC, Ramaswamy R, Laing JHE. Vaccum assisted closure: an alternative strategy in the management of degloving injuries of the foot. Br J Plast Surg 2001;54(4):363–365. DOI: 10.1054/bjps.2000.3565
Burtt KE, Badash I, Leland HA, et al. The efficacy of negative pressure wound therapy and antibiotic beads in lower extremity salvage. J Surg Res 2020;247:499–507. DOI: 10.1016/j.jss.2019.09.055
Costao ML, Achteno J, Knighto R, et al. Negative-pressure wound therapy compared with standard dressings following surgical treatment of major trauma to the lower limb: the WHiST RCT. Health Technol Assess 2020;24(38):1–86. DOI: 10.3310/hta24380
Yan H, Gao W, Li Z, et al. The management of degloving injury of lower extremities: technical refinement and classification. J Trauma Acute Care Surg 2013;74(2):604–610. DOI: 10.1097/TA.0b013e31827d5e00
Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 2018;52(5):259–264. DOI: 10.1080/2000656X.2018.1470979
Joethy J, Sebastin SJ, Chong AKS, et al. Effect of negative-pressure wound therapy on open fractures of the lower limb. Singapore Med J 2013;54(11):620–623. DOI: 10.11622/smedj.2013221
Reiter G, Thomas B, Kühner C, et al. Reconstruction of lower limbs in old age-an interdisciplinary approach: strategies for trauma surgery, vascular surgery and plastic surgery. Chirurg 2019;90(10):806–815. DOI: 10.1007/s00104-019-01023-7
Arnez ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. J Plast Reconstruct Aesthet Surg 2010;63(11):1865–1869. DOI: 10.1016/j.bjps.2009.11.029
Lekuya HM, Alenyo R, Kajja I, et al. Degloving injuries with versus without underlying fracture in a sub-Saharan African tertiary hospital: a prospective observational study. J Orthop Surg Res 2018;13(1):2. DOI: 10.1186/s13018-017-0706-9
Hakim S, Ahmed K, El-Menyar A, et al. Patterns and management of degloving injuries: a single national level 1 trauma center experience. World J Emerg Surg 2016;11:35. DOI: 10.1186/s13017-016-0093-2
Latifi R, El-Hennawy H, El-Menyar A, et al. The therapeutic challenges of degloving soft-tissue injuries. J Emerg Trauma Shock 2014;7(3):228. DOI: 10.4103/0974-2700.136870
Png ME, Madan JJ, Dritsaki M, et al. Cost-utility analysis of standard dressing compared with incisional negative-pressure wound therapy among patients with closed surgical wounds following major trauma to the lower limb. Bone Joint J 2020;102-B(8):1072–1081. DOI: 10.1302/0301-620X.102B8.BJJ-2020-0126.R1
Costa ML, Achten J, Knight R, et al. Effect of incisional negative pressure wound therapy vs standard wound dressing on deep surgical site infection after surgery for lower limb fractures associated with major trauma: the WHIST randomized clinical trial. JAMA 2020;323(6):519–526. DOI: 10.1001/jama.2020.0059
