Review Article:  Warner M et al; Comparison of Vacuum-assisted Closure to the Antibiotic Bead Pouch for the Treatment of Blast Injury of the Extremity. ORTHOPEDICS, 2010; 33: pp77-87.

A retrospective study of 24 patients suffering blast injuries to the lower extremities.  Prior to closure, half were initially treated with VAC (vacuum assisted closure) and half with an antibiotic bead pouch. The same surgeons performed all surgeries. Findings: VAC-therapies produced more late Methicillin-resistant Staphylococcus aureus (MRSA) infections (30% vs 0%), more unanticipated returns to the operating room (4:12 vs 0:12), required more surgeries to affect closure (at ~12days vs ~8days)and cost ~$1,000 more /patient once a $23,000 investment was made to purchase a single, VAC machine (KCI; SanAntonio, TX).

 Dr. Cierny comments: Although several studies have suggested that VAC will decrease the need for free tissue transfer in like/like wounds following trauma^1,2, others found no significant difference in time to closure³, an increase the amount of S aureus in the wound bed,⁴ a statistically significant increase in colony count during use,⁵ and infection /nonunion rates similar to historical controls (suggesting no benefit to the use of VAC over conventional dressings.⁶   Hallock⁷ contended that VAC does not prolong the time allowed for successful definitive wound closure and Stewart and Keating⁸ found VAC not as good as early soft tissue coverage (for acute wounds).  Although Morris⁹ found weak evidence to suggest that negative pressure therapy is superior to saline dressings when healing chronic wounds, Stannard et al¹⁰ , in a prospective, randomized study of 62 open fractures, found patients treated with NPWT one-fifth as likely to develop an infection compared with patients randomized to controls treated with wet-to-dry dressings until closure.

The consensus:  NPWT is more comfortable /convenient for the patient and healthcare team, effectively decompressing (displacing)  the inevitable need (energy) for complex and sequential reconstructions.  Despite its controversies, the use of external fixation and NPWT in the treatment of blast injuries and gunshot wounds resulting in open fractures with severe soft tissue injuries has become the mainstay of damage control orthopaedics.    In our experience, however,  15%-20% of patients with refractory infections following long-term  NPWT protocols have had retained sponge-fragments (gossypiboma) discovered in their wounds at the time of debridement and all of these fragements grew ‘culture positive’ for the primary, wound pathogen(s).   For us, NPWT is extremely helpful in managing acute /peri-operative wounds.   However, we find it of limited value in the chronic-wound scenario unless the wound has first been rendered 100% live and is no longer in need of any further reconstruction (ie; bone grafts, tendon repairs, etc.).   GC  02/20/10 .

Bibliography (1-10): -1- Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma. 2003; 17(10):683-688. -2- Dedmond BT, Kortesis B, Punger K, et al. Sub-atmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children. J Pediatr Orthop. 2006; 26(6):728-732. -3- Song DH, Wu LC, Lohman RF, Gottleib LJ, Franczyk MPT. Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure. Plast Reconstr Surg. 2003; 111(1):92-97. -4- Mouës CM, van den Bemd GJ, Heule F, Hovius SE. Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospective randomized trial. J Plast Reconstr Aesthet Surg. 2007; 60(6):672-681. -5- Weed T, Ratliff C, Drake DB. Quantifying bacterial bioburden during negative pressure wound therapy: does the wound VAC enhance bacterial clearance? Ann Plast Surg. 2004; 52(3):276-279.  -6-Dedmond BT, Kortesis B, Punger K, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma. 2007; 21(1):11-17.  -7- Hallock GG. To VAC or not to VAC? Ann Plast Surg. 2007; 59(4):473-474. -8- Stewart KJ, Wilson Y, Keating JF. Suction dressings are no substitute for flap cover in acute open fractures. Br J Plast Surg. 2001; 54(7):652-653. -9- Morris GS, Brueilly KE, Hanzelka H. Negative pressure wound therapy achieved by vacuum-assisted closure: Evaluating the assumptions. Ostomy Wound Manage. 2007; 53(1):52-57. -10- Stannard JP, Wolgas DA, Stewart R, et al; Negative Pressure wound therapy after severe open fractures: a rospecive randomized study.  J. Orthop. Trauma, 2009; 23(8): 552-557.