Hindawi Publishing Corporation

Advances in Orthopedics
Volume 2013, Article ID 245940, 8 pages
http://dx.doi.org/10.1155/2013/245940

Clinical Study
Vacuum Assisted Closure Therapy versus Standard Wound
Therapy for Open Musculoskeletal Injuries

Kushagra Sinha,1 Vijendra D. Chauhan,2 Rajesh Maheshwari,1

Neena Chauhan,3 Manu Rajan,4 and Atul Agrawal1
1
Department of Orthopaedics, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand 248140, India
2
Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand 248140, India
3
Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand 248140, India
4
Department of Plastic Surgery, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand 248140, India

Correspondence should be addressed to Vijendra D. Chauhan; vchauhan16@yahoo.co.in

Received 7 March 2013; Revised 18 May 2013; Accepted 29 May 2013

Academic Editor: Hiroshi Hashizume

Copyright 2013 Kushagra Sinha et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. This study was performed to evaluate the results of vacuum assisted wound therapy in patients with open muscu-
loskeletal injuries. Study Design and Setting. Prospective, randomized, and interventional at tertiary care hospital, from 2011 to
2012. Materials and Methods. 30 patients of open musculoskeletal injuries underwent randomized trial of vacuum assisted closure
therapy versus standard wound therapy around the upper limb and lower limb. Mean patient age was 39 18 years (range, 18 to 76
years). Necrotic tissues were debrided before applying VAC therapy. Dressings were changed every 3 or 4 days. For standard wound
therapy, debridement followed by daily dressings was done. Data Management and Statistical Analysis. The results obtained were
subjected to statistical analysis. Results. The size of soft tissue defects reduced more than 5 mm to 25 mm after VAC (mean decrease of
26.66%), whereas in standard wound therapy, reduction in wound size was less than 5 mm. A free flap was needed to cover exposed
bone and tendon in one case in standard wound therapy group. No major complication occurred that was directly attributable to
treatment. Conclusion. Vacuum assisted wound therapy was found to facilitate the rapid formation of healthy granulation tissue on
open wounds in the upper limb and lower limb, thus to shorten healing time and minimize secondary soft tissue defect coverage
procedures.

1. Introduction surgical methods have been developed to obtain coverage

in these difficult situations. These include skin grafts, local
Wound healing is a complex and dynamic process that rotation flaps, and myocutaneous or fasciocutaneous tissue
includes an immediate sequence of cell migration leading transfers. Although skin grafts are readily obtainable, they
to repair and closure. This sequence begins with removal of are dependent on the vascularity of its recipient bed and may
debris, control of infection, clearance of inflammation, angio- be contraindicated when exposed bone, cartilage, tendons, or
genesis, deposition of granulation tissue, contraction, remod- surgical implants exist [3]. In such situation, a local rotation
elling of the connective tissue matrix, and maturation. When flap may be needed. When the soft tissue defect prevents local
wound fails to undergo this sequence of events, a chronic coverage [4], free tissue transfers are usually required, but the
open wound without anatomical or functional integrity transfer may produce donor site morbidity and require late
results [1]. revisions due to the size of the muscle flap [5].
High-energy open fractures require both skeletal stability Although nonoperative modalities, such as hyperbaric
and adequate soft tissue coverage. In such injuries, debride- oxygen, have been used to enhance wound coverage, these
ment of all nonviable tissue can produce significant soft- devices may not be available to all patients and may not be
tissue defects precluding healing through primary closures, adequate for use in patients presenting with high-energy
delayed primary closures, or secondary intention [2]. Various injuries due to edema, retraction of the skin and soft tissue,
2 Advances in Orthopedics

wound size, or loss of available local coverage [6]. Attempts

have been made to identify an alternative treatment of wound
management in these patients.
Clinically, chronic wounds may be associated with pres-
sure sore, trauma, venous insufficiency, diabetes, vascular dis-
ease, or prolonged immobilization. The treatment of chronic,
open wounds is variable and costly, demanding lengthy hos-
pital stays or specialized home care requiring skilled nursing
and costly supplies. Rapid healing of chronic wounds could
result in decreased hospitalization and an earlier return of
function. A method that improves the healing process could
greatly decrease the risk of infection, amputation, and length
of hospital stay and result in an estimated potential annual Figure 1: Foam was cut according to wound size.
savings of billions of rupees of healthcare cost [1].
Initially developed in the early 1990s, for the management
of large, chronically infected wounds that could not be closed
in extremely debilitated patients, the use of vacuum-assisted
closure (VAC) has been more recently used in the treatment
of traumatic wounds [7].
The purpose of this study is to evaluate the results of this
therapy for the management of patients presenting with open
musculoskeletal injuries.

2. Materials and Methods

The study was conducted on 30 patients in the Department of
Orthopaedics, Himalayan Institute of Medical Sciences, over Figure 2: Sterile drape was applied covering the foam and 2-3 cm of
a period of 12 months, after obtaining the permission from the surrounding skin.
institutional ethical committee and taking informed and
written consents from the patients.
All patients above 18 years of age with open musculoskele- 2.1. Vacuum Assisted Wound Therapy Procedure
tal injuries in extremities that required coverage procedures
were included in the study. However, patients with preexisting 2.1.1. Wound Preparation. Any dressings from the wound
osteomyelitis in the wounds, neurovascular deficit in the were removed and discarded. A culture swab for micro-
injured limb, diabetics, malignancy, and peripheral vascular biology was taken before wound irrigation with normal
disease were excluded from the study. saline. Necrotic tissues were surgically removed (surgical
The patients were prospectively randomized into one of debridement), and adequate haemostasis was achieved. Prior
the two treatment groups receiving either the vacuum assisted to application of the drape, it was essential to prepare the peri-
closure therapy or standard saline-wet-to-moist wound care. wound skin and ensure that it was dry.
Files were marked with red (vacuum assisted closure therapy)
or yellow (saline-wet-to-moist dressings) labels on the inside 2.1.2. Placement of Foam. Sterile, open-pore foam (35 ppi
panel and were randomly organized. A file was randomly density and 33 mm thick) dressing was gently placed into the
picked for each wound with the treatment determined by the wound cavity. Open-pore foams are polyurethane with 400
label colour. 600 microns size having hydrophobic open cell structured
Participation in the study did not deviate from the stan- network. Such sizes of pores are most effective at transmitting
dard care of the acute wound. All patients for wound man- mechanical forces across the wound and provide an even
agement were subjected to distribution of negative pressure over the entire wound bed
to aid in wound healing (Figure 1).
(1) standard radiological assessment of the injured
2.1.3. Sealing with Drapes. The site was then sealed with an
wound,
adhesive drape covering the foam and tubing and at least
(2) routine haematological investigation, for example, three to five centimetres of surrounding healthy tissue to
complete blood count, ESR, blood sugar, HIV and ensure a seal (Figures 2 and 3).
HbsAg, gram stain and culture,
2.1.4. The Application of Negative Pressure. Controlled pres-
(3) all patients were supplemented with standard nutri- sure was uniformly applied to all tissues on the inner surface
tional supplements, including zinc and multivitamin of the wound. The pump delivered an intermittent negative
daily. pressure of 125 mmHg. The cycle was of seven minutes in
Advances in Orthopedics 3

Table 1: Decrease in wound size from day 0 to day 8.

Saline-wet-to-moist
Measurements (mm) VAC ( = 15)
( = 15)
14.9 4 (26.66%) 14 (93.33%)
59.9 1 (6.66%) 0
1014.9 4 (26.66%) 1 (6.66%)
1519.9 3 (20%) 0
2024.9 1 (6.66%) 0
>25 2 (13.33%) 0
Chi Square = 14.4, d.f = 5, = 0.013.

Figure 3: The connecting tube was applied after making a small

opening (3-4 mm) on the drape.
samples for histology and culture. Biopsies were obtained
from the four corners and the most healthy portion of the
wound bed. Samples were taken on day zero, day four, and day
eight. The presence of drainage, edema, erythema, exposed
bone, or exposed tendon wasdocumented. Any complica-
tions associated with vacuum assisted closure therapy were
also documented. Such measurements and findings were
recorded on day zero, day four, and day eight in both the
groups.
The wounds were also evaluated by plastic surgeon on day
one and on day eight to assess the nature of surgical procedure
to be adopted to cover the wound.
The pathologist noted and quantified the presence of
inflammatory cells, bacteria, arterioles, proliferative fibrob-
Figure 4: The connecting tube was connected to the negative pres- lasts, excessive collagen formation, and fibrosis in the biopsy
sure wound therapy. samples.

2.3. Data Management and Statistical Analysis. The results

which pump was on for five minutes and off for two minutes obtained were subjected to statistical analysis which was done
(Figure 4). by using statistical software SPSS-version 19. Normality of
The dressings were changed on the fourth day. data was checked by Kolmogorov-Smirnov test for unpaired
-test. Quantitative data was expressed in terms of mean SD.
2.2. Saline-Wet-to-Moist Group Procedure. Wound prepara- Categorical data was analysed by Chi-square and Wilcoxon
tionany dressings from the wound was removed and signed ranks test.
discarded. A culture swab for microbiology was taken before For Wilcoxon signed ranks test, the evaluation of histo-
wound irrigation with normal saline. Surface slough or logical parameters (Inflammatory cells, proliferative fibrob-
necrotic tissue was surgically removed (surgical debride- lasts, collagen formation, and fibrosis) was ranked as absent
ment), and adequate haemostasis was achieved. 0, mild1, moderate2, and severe3.
Daily dressings by conventional methods, that is, cleaning
with hydrogen peroxide and normal saline and dressing the 3. Results
wound with povidone iodine (5%) and saline-soaked gauze
was done and wound examined daily. Mean patient age was 39 18 years (range, 18 to 76 years). All
Resident who had measured the wounds was not involved patients had suffered an acute trauma. Road traffic accident
in the daily care of the study patients. It was not mentioned was found to be most common cause with 22 (73.33%)
to which treatment group the patient was assigned. This patients, followed by machinery injury in 5 (16.66%) patients
blinding arrangement ensured that the person evaluating and 3 (10%) patients had a fall from height. According to
the wound and collecting data initially at day zero and Gustilo Anderson classification, out of 30 patients, 16 patients
whenever dressings were subsequently changed had seen the had grade IIIb injury, 7 had grade IIIc injury, 3 had IIIa injury,
wound only after all dressings, supplies, and equipment were and 4 had grade II injury.
removed from the patient and the room. He took pho-
tographs and measured the wound by Vernier Caliper and Decrease in Wound Size. There was significant decrease in
transparent O.H.P sheets (overhead projector sheet). wound size from day zero to day eight in VAC group in
The resident doctor also clinically assessed the wounds comparison to saline-wet-to-moist group as shown in Tables
for signs of infection and obtained 46 mm punch biopsy 1 and 2.
4 Advances in Orthopedics

Table 2: Mean wound size difference between VAC and saline wet to moist on day 8.

VAC ( = 15) Saline wet to moist ( = 15) value 95% CI

Mean difference (mm) 13.24 8.48 3.02 2.90 0.0001 11.053 to 15.327

Table 3: Bacterial growth ( = 30).

VAC patients ( = 15) Saline wet to moist ( = 15)

Bacterial growth
Day 0 Day 4 Day 8 Day 0 Day 4 Day 8
Present 15 (100%) 12 (80%) 6 (40%) 15 (100%) 15 (100%) 12 (80%)
Absent 0 3 (20%) 9 (60%) 0 0 3 (20%)

Table 4: Comparison of histological parameters from day 0 to day 8 by Wilcoxon signed ranks test.

Saline wet to moist VAC

Stages of wound healing
Positive Negative Equal value Positive Negative Equal value
Inflammatory cells 1 10 4 0.001 1 12 2 0.003
Proliferative fibroblasts 13 0 2 0.001 15 0 0 0.001
Collagen formation 14 0 1 0.001 15 0 0 0.001
Fibrosis 6 0 9 0.03 15 0 0 0.001
value < 0.05.
Positive: ranks of day 8 > ranks of day 0.
Negative: ranks of day 8 < ranks of day 0.
Equal: ranks of day 8 is equal to ranks of day 0.

Bacterial Growth. There was significant decrease in the influenced by locally acting growth factors that affect various
bacterial growth in the VAC group as compared to saline-wet- processes including proliferation, angiogenesis, chemotaxis
to-moist group, as shown in Table 3. and migration, gene expression, proteinases, and protein
On histological comparison too, there was a statistical production [8, 1114]. Disruption of any of these factors may
difference between the VAC group and saline-wet-to-moist adversely affect the healing process, resulting in a chronic or
group, value being less than 0.05 by using Wilcoxon signed nonhealing wound.
rank test between the findings from day zero to day eighth as Blood flow increases and bacterial colonization of wound
shown in Table 4. tissues decreases following the application of subatmospheric
pressure to wounds [7]. Any increase in circulation and
Case No. 1. In an 18-year-male old a case of open grade oxygenation to compromised or damaged tissue enhances the
IIIb fracture both bone right forearm (middle 3rd), wound resistance to infection [15]. Successful, spontaneous healing
was present over anterior aspect of forearm. After thorough and healing following surgical intervention are correlated
debridement and fracture fixation VAC was applied (see with tissue bacterial counts of less than 105 organisms per
Figure 5). gram of tissue [16]. Higher levels uniformly interfere in
wound healing. Increase in local tissue oxygen levels reduce
Case No. 2. In a 57-year-male old sustained injury open grade or eliminate the growth of anaerobic organisms, which have
IIIa olecranon, debridement was done, and VAC was applied been correlated to decreased healing rates [17, 18]. Addition-
(see Figure 6). ally, the increased flow should make greater amounts of oxy-
gen available to neutrophils for the oxidative bursts that kill
4. Discussion bacteria [19].
Healing is an intricate, interdependent process that involves Our study showed that in VAC group after day 4, there
complex interactions between cells, the cellular microenvi- were 20% of patients who had no bacterial growth, and on
ronment, biochemical mediators, and extracellular matrix day 8 there were 60% of patients who had no bacterial growth,
molecules that usually results in a functional restoration of whereas in saline-wet-to-moist patients only 20% of patients
the injured tissue [8, 9]. The goals of wound healing are had no bacterial growth on the 8th day. There have been
to minimize blood loss, replace any defect with new tissue similar studies by Morykwas and Argenta [7], Banwell et al.
(granulation tissue followed by scar tissue), and restore an [20], and Morykwas et al. [21] which showed clearance of
intact epithelial barrier as rapidly as possible. bacteria from infected wounds using VAC therapy.
The rate of wound healing is limited by the available On the other hand, Weed et al. while quantifying bac-
vascular supply and the rate of formation of new capil- terial bioburden during negative pressure wound therapy
laries and matrix molecules [10]. These events are heavily concluded with serial quantitative cultures that there is no
Advances in Orthopedics 5

(a) (b)

(c) (d)

(e) (f)

(g)

Figure 5: (a) Day 0: wound size, 146 135 mm. (b) Day 0: photomicrograph number 1-H and E stained section (100x) shows: dense
neutrophilic exudates on the surface of wound. (c) Day 4: wound size, 130 120 mm. (d) Day 4: photomicrograph number 2-H and E stained
section (100x) shows: fibrinous exhudate on the surface and base of ulcer is formed by moderately inflamed granulation tissue. (e) Day 8:
wound size, 130 117 mm. (f) Day 8: photomicrograph number 3-H and E stained section (100x) shows: many newly formed blood vessels
and dense fibro collagenous tissue. (g) SSG uptake seen.

consistent bacterial clearance with the VAC therapy, and the the cells when negative pressure is applied [23]. This allows
bacterial growth remained in the range of 104 106 [22]. the VAC to move distensible soft tissue, similar to expanders,
Thomas first postulated that application of mechanical towards the centre of the wound, thereby decreasing the
stress would result in angiogenesis and tissue growth. Unlike actual size of the wound [24].
sutures or tension devices, the VAC can exert a uniform force Our study showed a decrease in size of 1 to 4.9 mm in
at each individual point on the edge of the wound drawing 26.66% of patients in VAC group whereas 93.33% in control
it toward the centre of the defect by mechanically stretching group from day 0 to day 8. A decrease in size of 10 to 19.9 mm
6 Advances in Orthopedics

(a) (b)

(c) (d)

(e) (f)

(g)

Figure 6: (a) Day 0: wound size, 146 61 mm. (b) Day 0: photomicrograph number 1-H and E stained section (100x) shows: thick neutrophillic
exhudate on the surface and skeletal muscle bundles. (c) Day 4: wound size, 141 51 mm. (d) Day 4: photomicrograph number 2-H and E
stained section (100x) shows: Inflammed granulation tissue with little exhudate on the surface. (e) Day 8: Wound size, 135 51 mm. (f) Day
8: photomicrograph number 3-H and E stained section (100x) shows: healthy granulation tissue without any exhudate. (g) Secondary closure
done.

was seen in 46.66% of patients of VAC group and only 6.66% widths of wound over time compared to standard wound
in control group. A decrease in size of more than 25 mm was dressings.
seen in 13.33% in VAC group. Our study showed that VAC increases the vascularity and
There have been similar studies by Joseph et al. [1], the increase in rate of granulation tissue formation compared
Morykwas and Argenta [7], and Morykwas et al. [21] to standard wound dressing. Histologically, VAC patients
which showed that VAC proved effective in shrinking the showed angiogenesis and healthy tissue growth as compared
Advances in Orthopedics 7

to the inflammation and fibrosis seen in standard wound required to obtain adequate coverage, the use of this device
dressing. Inflammation had increased in those treated with appears to decrease their need overall.
standard wound therapy and decreased in those patients
treated with VAC. Disclosure
The highly significant increase in the rate of granulation
tissue formation of subatmospheric pressure-treated wound Regarding your statistical software SPSS-version 19, Himala-
is postulated to be due to transmission of the uniformly yan Institute of Medical Sciences had purchased the software
applied force to the tissues on the periphery of the wound. for data analysis for all its ongoing projects. So, even our
These forces both recruit tissues through viscoelastic flow and clinical trial was analyzed with the same software.
promote granulation tissue formation. Currently, the Ilizarov
technique and soft tissue expanders both apply mechanical
stress to tissues to increase mitotic rates [25, 26]. Conflict of Interests
Standard wound dressings adhere to devitalized tissue There is no conflict of interests of any sort regarding the
and within four to six hours the gauze can be removed, software.
along with the tissue, as a form of mechanical debridement.
This method of wound care has been criticized for removing
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Parkinsons
Disease

Computational and
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in Medicine
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
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