Management of a circumferential lower extremity degloving injury with the use of vacuum-assisted closure.

Abstract: A 58-year-old male presented with a large circumferential degloving injury and was immediately taken to the operating room for further assessment of his wound. At that time, a plastic surgeon was consulted to manage the wound due to its size and significant soft tissue loss. The decision was made to manage the patient's wound with the vacuum-assisted closure (VAC) device to prepare the wound bed for grafting. After three weeks of VAC therapy, the wound bed was revascularized with granulation tissue and was ready for grafting. The patient underwent a successful split thickness skin graft on hospital Day 23 and was discharged home. Follow-up visits revealed no scar contracture or functional limitations.

Key Words: vacuum-assisted closure therapy, degloving injury, split thickness skin graft

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High velocity motor vehicle crashes and occupational accidents are the most common cause of degloving injuries, which can result in tremendous avulsions of the skin and subcutaneous (SC) tissues. (1) Hemodynamic instability, lengthy repair of orthopaedic or vascular trauma, and/or other associated life-threatening injuries frequently delay expedient intervention by the plastic surgeon. Consequently, large degloving injuries can be problematic for the plastic surgeon in regards to treatment and closure. In the past, these wounds have been treated with repeated serial debridements and painful dressing changes with the eventual placement of split thickness skin grafts (STSG) on compromised tissues. Grafting these chronic fibrotic wound beds often results in only partial graft take and/or graft contractures.

Vacuum-assisted closure (VAC) has been extremely successful in the treatment of acute and chronic wounds (2) and has been reported as a method for securing full and split thickness skin grafts in degloving injuries. (3,4) This report describes the initial use of the VAC system in a large degloving injury with circumferential loss of the skin and SC tissue of a lower extremity, for the purpose of preparing the wound bed for eventual grafting. Large degloving wounds have copious amounts of drainage, bacterial contamination, and relatively avascular wound beds, all of which impede successful closure with skin grafts. Vacuum-assisted closure dressings control and monitor wound drainage, decrease bacterial colony counts, and stimulate granulation of the wound bed. (4,5) Therefore, preparation of the wound for closure with split thickness skin grafts is expedited.

This case report describes how a large, circumferential degloving wound can be successfully managed with negative pressure wound therapy.

Case Report

A 58-year-old train yard worker suffered a degloving of the right lower extremity (RLE) from the groin to the ankle when his clothing was caught by the steel wheel of a freight car dragging him beneath the car for several feet. X-rays showed no fractures of the lower extremities and the patient's RLE remained neurologically intact despite the extensive damage to the soft tissue. The patient was taken immediately to the operating room to obtain hemostasis and explore the deeper structures of the RLE. No significant vascular or neurologic injury was identified. A large circumferential area of tissue had been sheared along a musculofascial plane; therefore, a plastic surgeon was consulted for assistance with closure of the degloved RLE. During the first operation, the nonviable tissue was excised and the questionably viable tissue was loosely tacked in place to allow for further demarcation. During the second operation, it was apparent that the remaining tissue that had been loosely tacked in place was now nonviable and was excised (Fig. 1). As a result, the excised skin could not be used for future skin grafts. The wound was subsequently vacuum dressed with one medium and seven large sponges (Fig. 2). Over a period of three weeks, the patient underwent four irrigation and debridement procedures and replacement of the vacuum dressing before the wound bed was fully granulated and ready to be grafted. On hospital Day 23, the patient underwent a split thickness skin graft to the right lower extremity. A fibrin-based tissue glue was used to affix a 2,700 [cm.sup.2] split thickness skin graft in addition to staples. The VAC system was not reapplied to the wound after affixing the STSG. Instead, the leg was dressed with a moist dressing and a splint to keep the leg immobile. There was a 99% take of the skin graft at the first dressing change on postoperative Day 3. Daily dressing changes were followed with subsequent physical therapy for range of motion to the RLE. The patient's wounds were healed completely by postoperative Day 16. After discharge from the hospital, the patient continued with outpatient physical therapy. Routine checkups revealed no postoperative contractures or complications (Fig. 3). Nine months postoperatively, the patient showed no evidence of contractures or limited range of motion or mobility. Although the patient was unable to return to his original labor-intensive job, he was able to ambulate without assistance and was not physically restricted from activities of daily living.

Discussion

Vacuum-assisted closure dressings have many advantages in the management of large degloved wounds. Edema is controlled, bacterial counts are reduced, perfusion is increased, and wound vascularity is improved, (2) all ensuring graft take and wound closure. As a result of the expedited definitive closure, our patient had minimal wound fibrosis and no contractures of the skin grafts.

Other authors have suggested that a specifically designed vacuum system device may be required for management of extensive wounds, (6) but we have not found that to be the case. With the use of proper exposure and positioning and by substituting larger adhesive drapes for the standard size packaged with the sponge, we have been able to perform the dressing application without difficulty. Because the sponges are open cell, large wounds can be treated with multiple sponges and a single suction device. A standard skin stapler maintains edge-to-edge approximation of the multiple sponges, which allows for ease when placing large adhesive drapes. We have also been able to treat multiple wounds/extremities with a single suction machine by using the Y connectors to connect multiple drainage tubes.

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Vacuum-assisted closure therapy can also result in coverage of exposed bone and hardware with granulation tissue, (7) which can ultimately be skin grafted. The mechanism of action of negative pressure wound therapy is thought to include microdeformation at the cellular level promoting cell division, angiogenesis and local elaboration of growth factors. (8) Reduction of edema may also increase perfusion at the microvascular level.

In patients with large surface area open wounds, the VAC dressing has eliminated the need for frequent cumbersome, painful dressing changes and can result in excellent skin graft take because of the increase in granulation tissue to the wound bed. As a result of the foam sponge design, subatmospheric pressure is applied to all wound surfaces in contact with the sponge, even with irregular surface contours such as in our patient. Late contractures and hypertrophic scarring may also be minimized because of the reduction in the amount of healing by secondary intention and contraction needed to achieve wound closure.

Conclusion

As a result of the increasing number of patients able to survive traumatic events with large surface area soft tissue injuries, the need for expedient and effective coverage of these large defects is also increasing. With the proper application of the VAC dressing, VAC therapy can expedite healing as the wound is converted from a nonviable wound to a fully granulated wound bed ready for grafting. Vacuum-assisted wound closure, a well-established technique in plastic and reconstructive surgery, can provide an excellent alternative to traditional wound care for large surface area circumferential wounds before skin grafting.

References

1. McGrouther DA, Sully L. Degloving injuries of the limbs: long-term review and management based on whole-body fluorescence. Br J Plast Surg 1980;33:9-24.

2. Argenta LC, Morykwas MJ Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563-576.

3. DeFranzo AJ, Marks MW, Argenta LC, et al. Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 1999;104:2145-2148.

4. Meara JG, Guo L, Smith JD, et al. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg 1999;42:589-594.

5. Morykwas MJ, Argenta LC, Shelton-Brown El, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553-562.

6. Jeng SF, Hsieh CH, Kuo YR, et al. Technical refinement in the management of circumferentially avulsed skin of the leg. Plast Reconstr Surg 2004;114:1225-1227.

7. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 2001;108:1184-1191.

8. Saxena V, Hwang CW, Huang S, et al. Vacuum-assisted closure: micro-deformations of wounds and cell proliferation. Plast Reconstr Surg 2004;114:1086-1096.

Lesley K. Wong, MD, Robert D. Nesbit, MD, Leslie A. Turner, MSN, ACNP-C, and Larry A. Sargent, MD

From the Department of Plastic and Reconstructive Surgery, Hayes Hand Center, University of Tennessee College of Medicine-Chattanooga Unit, Chattanooga, TN.

Reprint requests to Stacey Blanks or Lesley K. Wong, MD, University of Tennessee College of Medicine-Chattanooga Unit, Department of Plastic and Reconstructive Surgery and Hayes Hand Center, 979 East 3rd Street, Erlanger Medical Mall, Suite C 920, Chattanooga, TN 37403. Email: [e-mail]

Product Acknowledgment: Vacuum-Assisted Closure Therapy, KCI USA INC., 8023 Vantase Drive, San Antonio, Texas 78230, 877-WOUND-VAC, www.woundvac.com

The company provided no funding.

Accepted February 14, 2006.

RELATED ARTICLE: Key Points

* Use of a vacuum-assisted closure system on a 2700 [cm.sup.2] degloving injury of the lower extremity was successful in our patient.

* The techniques and benefits of using a vacuum-assisted closure system to manage large wounds are described.

* Current literature regarding the benefits and disadvantages of this technique are discussed.