|Year : 2017 | Volume
| Issue : 2 | Page : 64-68
Use of domestic negative pressure wound therapy in traumatic wounds for a cost-effective wound closure
Komla S Amouzou1, Tiemoko M Haidara2, Elodie J. L. Malonga-Loukoula2, Mounia Diouri2, Mohamed Ezzoubi2
1 Department of Surgery, University of Lome, Lome, Togo
2 Department of Plastic and Reconstructive Surgery, Hassan II University, Casablanca, Morocco
|Date of Web Publication||20-Apr-2018|
Dr. Komla S Amouzou
Department of Surgery, University of Lome, Lome 02BP20752
Source of Support: None, Conflict of Interest: None
Negative pressure wound therapy (NPWT) has become a popular tool for wound healing. The use of domestic material has been reported, but it is still not completely documented. We present the use of a domestic NPWT on traumatic wounds to achieve a final minimal reconstructive surgery. We treated three patients presenting with traumatic skin loss of the abdomen, lower leg, and foot with domestic NPWT. A wall suction was used as the source of negative pressure and gauzes as interface over the wounds. We documented the size of wounds, the anatomic structure exposed, the number and the length of cycles of NPWT, and the final reconstructive procedure. The cycles of NPWT ranged 3–5 days. A good granulating tissue appeared in range 17–21 days. Exposed urinary bladder, fractured metatarsal, and fractured lateral malleolus were covered by a good granulating tissue. There was no infectious complication. All the wounds healed with a split thickness skin graft. The cost of the procedure per patient ranged from 65 to 85 US Dollars. Domestic material for negative pressure has been a reliable technique in the management of traumatic wounds and helped pass down the reconstructive ladder.
Keywords: Dressing, negative pressure, skin graft, trauma, wound
|How to cite this article:|
Amouzou KS, Haidara TM, Malonga-Loukoula EJ, Diouri M, Ezzoubi M. Use of domestic negative pressure wound therapy in traumatic wounds for a cost-effective wound closure. Nigerian J Plast Surg 2017;13:64-8
|How to cite this URL:|
Amouzou KS, Haidara TM, Malonga-Loukoula EJ, Diouri M, Ezzoubi M. Use of domestic negative pressure wound therapy in traumatic wounds for a cost-effective wound closure. Nigerian J Plast Surg [serial online] 2017 [cited 2022 Jul 3];13:64-8. Available from: https://www.njps.org/text.asp?2017/13/2/64/230801
| Introduction|| |
Negative pressure wound therapy (NPWT) has become a part of the armamentarium of the reconstructive surgeon in wound care of many etiologies around the world.,,, This helpful tool has been credited for accelerating wound healing by decreasing bacterial load and improving granulation tissue that, at final in some circumstances, can make unnecessary the need of a flap especially in traumatic wounds.,,, This is especially helpful in low-income countries where equipments are not available for some surgeries, and where patients do not have the means for expensive procedures. The procedure has proven its reliability, and evidence-based efficiency for wound bed preparation and even for spontaneous wound healing.,,, In high-income countries, commercial VAC® is available and is used for NPWT. In low- and middle-income countries, commercial VAC® and the accessories needed are not currently available. This gap has been filled with the use of local materials such as gauze, wall suction, and suction machines., The use of those local materials is incompletely documented, because no study has readily evaluated the amount of pressure directly delivered to the wound, how the seal of the wound could be really monitored, or the effect of the method on wounds of various etiologies. Nevertheless, domestic NPWT has been used on several types of wounds in many centers around the world.,,
In this publication, we present the use a domestic NPWT on traumatic wounds to achieve a final minimal reconstructive surgery.
| Participants and methods|| |
We treated three patients presenting with traumatic wounds in the National Burn Centre and Plastic Surgery (Casablanca, Morocco) during the period from January to July 2016. All patients signed the consent form for the procedure and for using the pictures for a scientific publication. We proceeded the NPWT as described earlier by Amouzou et al. In this study, only wall suction was used as the source of negative pressure and was set at 125 mmHg for all patients. Each cycle for NPWT was planned for 5 days. A break of the seal presented as the leakage of wound fluids around the dressing or sensation of breathing at the auscultation of the wound. Simple breathing without wound fluids leakage was considered minor and was not indicative of dressing change. When there was a leak of wound fluids, we considered it as a major break and that was indicative of dressing change even before a 5 days cycle. Additionally, to the primary description of the procedure, we used Vaseline tulle as interface beneath the gauzes when granulating tissue started to appear. The wounds outcome was assessed by clinical inspection during every dressing change. We documented wound characteristics (location, size, exposed structures), treatment, and outcome features (delay between admission and beginning of NPWT, duration of the treatment under NPWT, the wound coverage method, and the healing time). Results were presented as a series of cases.
| Results|| |
A 36-year-old man with no significant social and medical history was admitted for pelvic closed trauma, and degloving injury of the lower abdomen post road traffic accident. There was a hypogastric skin loss [[Figure 1]A], a degloved viable skin over a partial exposition of a traumatic shear of the urinary bladder [[Figure 1]B]. The latter was treated by direct suture and urine diverting. The bone injury presented as a pubic and sacroiliac disjunction that was treated by external fixation and bed rest. The wound was necrotic and fibrinous initially. After five cycles of NPWT [[Figure 1]D and [Figure 1]E], the wound was cleaned with good granulation tissue. The dead space under the degloved skin was closed [[Figure 1]C]. The wound healing was achieved by a split skin graft [[Figure 1]F]. Pain at the baseline of the NPWT decreased slowly within hours and needed no complementary analgesics. There was no bleeding or infectious complication along the procedure. The patient was discharged and followed in orthopedics and urologists departments. He has been scheduled for abdominal wall reconstructive surgery. The total cost of the NPWT was estimated at 75 US Dollars (USD, no charge for wall suction). The patient was very satisfied with the procedure.
|Figure 1: (A) Traumatic abdominal skin lost. (B) Degloved skin over the urinary bladder. (C) Good granulating tissue ready for skin graft. (D) Manometer for wall suction calibration. (E) Domestic negative pressure wound therapy with gauzes. (F) Wound healed after split thickness skin graft|
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A young 16-year-old girl with no significant social and medical history, got into a road traffic accident and presented with open metatarsal fractures with extensive skin loss of dorsum of the right foot [[Figure 2]A and [Figure 2]B]. She had a fracture fixation with Kirshner Wires by orthopedics and was referred to our Plastic and Reconstructive Department. The wound was debrided and treated with NPWT [[Figure 2]C]. A bleeding appeared at the third cycle due to trauma to the foot while she was sleeping. The NPWT was stopped and the dressing removed. Blood coagulation test and complete blood count performed showed no abnormalities. After 12 h, we resumed the NPWT with a pressure at 50 mmHg to minimize the hemorrhagic risk. Progressively, we increased the pressure at 125 mmHg within 48 h. No other complication appeared. The bones were covered with a good granulating tissue after five cycles of NPWT [[Figure 2]D]. A split thickness skin graft was performed and the wound healed [[Figure 2]E and [Figure 2]F]. Orthopedic board assessed the bone healing. The cost the NPWT was estimated at 85 USD. The girl was satisfied with the procedure but complained about the obligation to stay bedridden. Pain at the baseline of the procedure disappeared gradually within hours without the need for analgesics.
|Figure 2: (A) Traumatic wound of the foot with necrotic tissue. (B) Skin lost after debridement, exposition of the first metatarsal. (C) Domestic negative wound therapy with gauzes. (D) Granulating tissue partially covering the exposed bone. (E) and (F) Wound healed after split thickness skin graft|
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A young 17-year-old boy with no significant social and medical history was admitted for traumatic 1/3 lower leg and ankle open trauma with skin loss and partial exposition of fractured lateral malleolus [[Figure 3]A]. After debridement [[Figure 3]B], NPWT was used [[Figure 3]C] while keeping the leg and foot in a plaster of paris posterior splint. Four consecutive cycles of NPWT were performed in 17 days. A good granulating tissue was observed that covered the exposed fractured bone [[Figure 3]D]. A split thickness skin graft was performed to achieve wound healing. Immobilization of the leg was continued with a plaster of paris cast. There was no bleeding or infectious complication during the treatment. The cost of the NPWT was estimated at 65 USD. The patient was satisfied with the procedure but expressed concern about the fact to stay bedridden. He reported a minor pain at the baseline of the procedure that quickly disappeared without analgesics.
|Figure 3: (A) Traumatic lower leg wound with necrotic tissue. (B) After debridement, partial exposure of the lateral malleolus. (C) Domestic negative pressure wound therapy with gauzes. (D) Good granulating tissue totally covered the exposed bone and ready for a skin graft|
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[Table 1] summarizes the clinical, therapeutic, and outcome characteristics of the three patients.
| Discussion|| |
The NPWT promotes granulation tissue by stimulating angiogenesis, reducing edema and decreasing bacterial load. The wound is put under a pressure lower than the atmospheric pressure in a closed dressing. A tube connecting the wound to a source of negative pressure allows continuous suction. The pressure of 125 mmHg was adopted following previous studies published by Argenta and Morykwas. The use of domestic materials to perform a NPWT reduces the cost in less affluent settings. Thus, a cycle of NPWT cost around 12 USD in this study (gauze, saline serum, adhesive dressing, and tubes). The wall suction was free of charge. In a recent American study, researchers estimate that equipment costs alone would exceed $4500 for 48 days of treatment with open-NPWT in the treatment of abdominal wound dehiscence. While it is true that the cost of care could not be compared between our setting and the United States, this estimation gives us an idea of what can cost the use of the commercial device for the NPWT.
In the patient with urinary bladder exposure and degloved hypogastric skin, the domestic NPWT has achieved the inset of the skin that covered the urinary bladder and the growth of a good granulating tissue permits a coverage with a split skin graft. This result supports the reports of Sinna et al. and Zwillinger et al. who used NPWT successfully with the commercial VAC® to save skin avulsion and to secure an artificial dermis graft. So, by applying continuous pressure to skin flaps and free grafts on the wound bed, NPWT contribute to clear dead spaces and improve graft take and flaps inset.
The other two patients presented opened bone fractures and were at the risk of infection. In these two patients, the coverage of exposed bones would have needed the use of flaps, something complicated especially in the 16-year-old girl with metatarsals exposition. Microsurgery could have been considered with its associated cost and risk of failure in nonexpert hands. The use of domestic NPWT has promoted granulating tissue in three weeks that covered the exposed bones and finally needed only a skin graft. The properties of accelerating the granulating tissue by increasing angiogenesis, removing excess of wound fluid, and keeping a continuous humid environment of the NPWT were used to achieve this result. The stress over the fact of being bedridden expressed by patients for the domestic NPWT could have been worse with a cross-leg flap. In addition, domestic NPWT has been performed without any major complication. Novak et al. supported the efficiency of NPWT for a delay in traumatic wound coverage with no infectious complication. In the same sense, Joethy et al. compared the two periods of their activity in the management of open fractures in terms of infection. They concluded that the use of NPWT reduced infection in delayed open fractures reconstruction. Although the results in this study could have been influenced by several factors such as the gain of experience by the care team over the time, other authors reported the same findings.,,, Nevertheless, Mouës et al. in a literature review reported no proof for a decrease in the bacterial load of wounds treated with NPWT.
Among possible drawbacks of NPWT is the wound bleeding. This problem in our setting was assessed by the use of interface (Vaseline tulle) beneath gauze layer on the wound. However, one patient accidentally presented a bleeding that was handled by a pause of the procedure and resumed with the NPWT at a lower pressure. All patients expressed a minimal pain at baseline that disappeared without a use of analgesics, consistent with what has been reported by Amouzou et al. In fact, the pain associated with repetitive dressings was avoided that made the patients happy and satisfied. The discomfort related to being bedridden is the problem that remained unsolved with domestic NPWT.
Domestic material for negative pressure has been a reliable alternative in the dressings of traumatic wounds. The absence of major complication, the effectiveness in wound granulation growth, and the low cost of the procedure could make it the first choice in settings with minimal resources.
The obligation for the patient to stay bedridden all along the procedure is rewarded by good wound healing. Moreover, the reconstruction ladder is downgraded to a simpler procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]