Ludwig Labler

Vacuum-assisted closure therapy increases local interleukin-8 and vascular endothelial growth factor levels in traumatic wounds.

BACKGROUND Clinical observations are suggesting accelerated granulation tissue formation in traumatic wounds treated with vacuum-assisted closure (VAC). Aim of this study was to determine the impact of VAC therapy versus alternative Epigard application on local inflammation and neovascularization in traumatic soft tissue wounds. METHODS Thirty-two patients with traumatic wounds requiring temporary coverage (VAC n = 16; Epigard n = 16) were included. At each change of dressing, samples of wound fluid and serum were collected (n = 80). The cytokines interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), and fibroblast growth factor-2 were measured by ELISA. Wound biopsies were examined histologically for inflammatory cells and degree of neovascularization present. RESULTS All cytokines were found to be elevated in wound fluids during both VAC and Epigard treatment, whereas serum concentrations were negligible or not detectable. In wound fluids, significantly higher IL-8 (p < 0.001) and VEGF (p < 0.05) levels were detected during VAC therapy. Furthermore, histologic examination revealed increased neovascularization (p < 0.05) illustrated by CD31 and von Willebrand factor immunohistochemistry in wound biopsies of VAC treatment. In addition, there was an accumulation of neutrophils as well as an augmented expression of VEGF (p < 0.005) in VAC wound biopsies. CONCLUSION This study suggests that VAC therapy of traumatic wounds leads to increased local IL-8 and VEGF concentrations, which may trigger accumulation of neutrophils and angiogenesis and thus, accelerate neovascularization.

Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery

The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.

Atlanto-occipital dislocation: four case reports of survival in adults and review of the literature

Traumatic atlanto-occipital dislocation (AOD) is a rare cervical spine injury and in most cases fatal. Consequently, relatively few case reports of adult patients surviving this injury appeared in the literature. We retrospectively report four patients who survived AOD injury and were treated at our institution. A young man fell from height and a woman was injured in a traffic accident. Both patients survived the injury but died later in the hospital. The third patient had a motorcycle accident and survived with incomplete paraplegia. The last patient, a man involved in a working accident, survived without neurological deficit of the upper extremities. Rigid posterior fixation and complete reduction of the dislocation were applied in last two cases using Cervifix together with a cancellous bone grafting. Previously reported cases of patients surviving AOD are reviewed, and clinical features and operative stabilisation procedures are discussed.

Resuscitative emergency thoracotomy in a Swiss trauma centre

Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce.

“Damage Control” in Severely Injured Patients

AbstractThe concept of “damage control” is established in the management of severely injured patients. This strategy saves life by deferring repair of anatomic lesions and focusing on restoring the physiology. The “lethal triad” hypothermia, coagulopathy, and acidosis are physiological criteria in the selection of injured patients for ”damage control”. Other criteria, such as scoring of injury severity or the time required to accomplish definitive repair, are also useful in determining the need for ”damage control”. The staged sequential procedures of ”damage control” include, after the selection of patients (stage 1), “damage control surgery” or “damage control orthopedics” (stage 2), resuscitation in the intensive care unit (stage 3), “second–look” operations or scheduled definitive surgery (stage 4), and the secondary reconstructive surgery (stage 5). The concept of ”damage control” was carried out in a third of 622 severely injured patients in our division. Although level I evidence is lacking, the incidence of posttraumatic complications and the mortality rate were reduced. However, better understanding of the significance and kinetics of physiological parameters including inflammatory mediators could help to optimize the “damage control” concept concerning the selection of patients and the time points of staged sequential surgery.

Vacuum-Assisted Closure (V.A.C.®) for Temporary Coverage of Soft-Tissue Injury in Type III Open Fracture of Lower Extremities

Background and Purpose:The difficulty in the treatment of severe open fractures is a high infection rate and the problem of an adequate temporary coverage of the soft-tissue damage between successive second-look operations. The vacuum-assisted closure (V.A.C.®) offers good temporary soft-tissue coverage with a proven bacterial clearance and protects, at the same time, the soft tissue against secondary damage. The retrospective study reports the soft-tissue management of severe open fractures of Gustilo type IIIA and IIIB with V.A.C.® or Epigard®.Patients and Methods:All open fractures were in the lower extremity and a result of a nonpenetrating trauma. V.A.C.® was used as a temporary dressing in 14 fractures and an Epigard® in twelve fractures.Results:One early amputation was observed in each group. In the group with the soft-tissue coverage by Epigard®, in spite of less type IIIB fractures and less polytraumatized patients, the rate of infections (6/11) was substantially higher compared with patients managed by V.A.C.® therapy (infection: 2/13).Conclusion:V.A.C.®, a temporary soft-tissue substitute, reduces the rate of infection and is an alternative of choice for the management of type III open fractures.

Management of Morel-Lavallee Lesion Associated with Pelvic and/or Acetabular Fractures

Objective:Management of Morel-Lavallee soft tissue lesion (MLL) in patients with associated pelvic and/or acetabular fractures is still under discussion. Especially, the sequence of treatment of MLL soft tissue management and osteosynthesis of pelvic and acetabular injury remains controversial.Methods:We report all consecutive patients with MLL associated with pelvic ring and/or acetabular fractures during an 8-year period at our hospital. Surgical access and techniques were analyzed concerning complications and outcome.Results:Altogether, 20 patients were included in the study. One patient was treated conservatively and MLL healed without complications; 19 patients had an operative treatment of MLL. In 15 patients debridement was performed within one day after injury and in four patients with delay of 5 days at least. Ten patients had surgery for an associated pelvic ring or acetabular fracture. In four of them MLL was operated before, in six patients simultaneously to osteosynthesis. In three patients, the same surgical approach for osteosynthesis and debridement of MLL was used; none of them showed postoperative complications. Altogether, in nine operated patients (47.4%) MLL healed without any complications. Nine operated patients presented prolonged wound healing, however, during long term follow-up, all patients showed complete healing of the MLL. One patient died during resuscitive surgical procedures.Conclusions:We recommend debridement for early and delayed treatment of MLL. Osteosynthesis during first debridement may be performed without adverse outcome. Identical surgical access for both procedures can be used. In case of repeated surgical debridement VAC® therapy may be a helpful tool for dead space reduction and wound conditioning.

Influence of Injury Pattern on Incidence and Severity of Posttraumatic Inflammatory Complications in Severely Injured Patients

AbstractBackground:Severe trauma causes systemic inflammatory response syndrome (SIRS) which may lead to multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). The aim of this study was to evaluate the influence of the injury pattern on the incidence and severity of SIRS, sepsis, MODS, and mortality.Methods:A total of 1,273 patients with an injury severity score (ISS) of ≥ 9 points and survival of more than 3 days were included in this retrospective study. Outcome parameters were various grades of SIRS, sepsis, MODS, and mortality.Results:Severe non-infectious SIRS occurred in 23%, sepsis in 14%, and severe MODS in 14% of the patients. Serious (abbreviated injury scale (AIS) ≥ 3 points) head injury and the ISS represented the most potent risk factors for severe SIRS. As estimated by multivariate logistic regression analysis, the presence of severe extremity and pelvic injuries, the ISS, and the male gender were found to be independent risk factors for sepsis. Severe injuries of the abdomen were associated with an increased risk for sepsis in the univariate analysis. Severe injuries to the head or abdomen, the ISS, and the male gender represented independent risk factors for the development of severe MODS. Regarding the late (> 3 days after trauma) hospital mortality, severe head injury, the ISS, and the patient’s age were independent risk factors.Conclusions:Head injury predominantly determines the incidence of non-infectious systemic inflammation, MOF, and late hospital mortality of patients with severe trauma. Skeletal or abdominal injuries represent relevant risk factors for septic complications. Thus, the incidence of posttraumatic, life-threatening inflammatory complications is related with certain injury patterns in addition to the gender and the severity of trauma.

Bogota-VAC – A Newly Modified Temporary Abdominal Closure Technique

Background:We present Bogota-VAC, a newly modified temporary abdominal closure (TAC) technique for open abdomen condition after abdominal compartment syndrome (ACS).Methods:A thin isolation bag (Bogota bag) and a vacuum assisted closure (VAC) system were combined. A matching bag was tension-free fixed on the abdominal fascia by fascia suture. A ring shaped black polyurethane foam of the VAC system was placed into the gap between Bogota bag, abdominal fascia and the wound edge. A constant negative topic pressure of 50–75 mmHg was used in the VAC system.Results:Intra-abdominal pressure (IAP: 22 ± 2 mmHg) of four patients with ACS after severe traumatic brain injury and one patient with isolated ACS after blunt abdominal trauma decreased significantly (p = 0.01) after decompressive laparotomy and treatment with Bogota-VAC (IAP: 10 ± 2 mmHg) and remained low, measured via urinary bladder pressure. Intracranial pressure (ICP) in the four traumatic brain injury patients decreased from 42 ± 13 mmHg to 15 ± 3 mmHg after abdominal decompression. Cerebral perfusion pressure (57 ± 14 mmHg) increased to 74 ± 2 mmHg.Conclusion:The advantage of the presented Bogota-VAC is leak tightness, wound conditioning (soft tissue/fascia), skin protection and facilitation of nursing in combination with highest volume reserve capacity (VRC), thus preventing recurrent increased intra-abdominal and intracranial pressure in the initial phase after decompression of ACS compared to other TAC techniques.

V.A.C.® Abdominal Dressing System

Background and Purpose:The study reports experience with the recently commercially available V.A.C.® Abdominal Dressing System, a system designed for a temporary closure of an open abdomen situation under negative pressure. The method allows a late primary fascial closure after laparotomy in case of damage control, abdominal compartment syndrome or severe intra-abdominal spesis and facilitates delayed reconstruction of a large ventral hernia.Patients and Methods:18 patients with an open abdomen after laparotomy were managed between February 2002 and September 2004.Results:Twelve patients after primary, one patient after secondary fascial closure and one patient with partially primary closure and resorbable mesh for abdominal wall reconstruction were free of wound infection or dehiscence of the abdominal wall. Evisceration or enteric fistulas were not observed. Five patients died in consequence of severe injury, a multiple organ failure or septic complications.Conclusion:V.A.C.® Abdominal Dressing System is an effective temporary closure technique for open abdomen in critically ill patients which makes a late primary fascial closure up to 2 months after initial laparotomy possible either in trauma patients or in case of severe intraabdominal infection. The technique is simple and easily mastered.