V.A.C. Instill® therapy –
indications and technical applications
First V.A.C. Instill® symposium in Germany
November 21st 2008 in Heidelberg
This issue is
available online at
www.springerlink.com/content/1439-0973
Infection 2009, 37 (Suppl. I): 1-46
DOI 10.1007/s15010-009-1001-4
ISSN 0173-2129
V.A.C. Instill® therapy – indications and technical applications
01 The history of the V.A.C. Instill® therapy
W. Fleischmann
4
02 Therapy options with V.A.C. Instill® in the treatment of open, superinfected injuries of the
lower limps – the Erlangen algorithm
M.H. Brem, S. Schulz-Drost, J. Gusinde, A. Stuebinger, F.F. Hennig, A. Olk
5
03 V.A.C. Instill® treatment in severe septic abscess forming and perforating Ludwig’s angina with
large abscess formation in the neck and lower jawbone osteomyelitis due to dental caries with tooth
root abscess – a case report
C. Wiedeck
7
04 Application of V.A.C. Instill® therapy in case of periprosthetic infection in hip arthroplasty
B. Lehner, S. Weiss, A. J. Suda, D. Witte
13
05 Management of early periprothetic infections in the knee using the vacuum-instillation therapy
G. Köster
18
06 First experience with the V.A.C. Instill® therapy in the treatment of vascular prosthesis infections
Th. Karl
21
07 Instillation therapy and chronic osteomyelitis – preliminary results with the V.A.C. Instill® therapy
M. Leffler, R.E. Horch, A. Dragu, U. Kneser
24
08 The impact of V.A.C. Instill® in severe soft tissue infections and necrotizing fasciitis
M.V. Schintler, E.-Ch. Prandl, G. Kreuzwirt, M.R. Grohmann, S. Spendel, E. Scharnagl
31
09 Vacuum-assisted closure and instillation dressing (V.A.C. Instill®) in the treatment of open fractures
G. Amtsberg, M. Frank, J. Lange, M. Gondert, A. Kramer, A. Ekkernkamp, P. Hinz
33
10 Optimizing the microbiologic diagnostics in septic orthopedics
M. Kommerell, S. Brunner, O. Nolte, B. Lehner
34
11 First experiences with the vacuum-instillation therapy in plastic surgery
J.P. Stromps, G. Kolios, C.Y. Choi, C.C. Cedidi
37
12 V.A.C. Instill® technology in spinal column surgery
R. Neef, M. Planert, K. Brehme
38
13 The application of instillation combined with vacuum therapy in visceral surgery
H.B. Reith
41
14 First experience using V.A.C. Instill® therapy in pediatric surgery
A. Fette
43
Imprint
46
2
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
Editorial
B. Lehner
Head of septic surgery and oncology unit
orthopaedic university hospital Heidelberg
Ladies and gentlemen, dear colleagues,
the first V.A.C. Instill® symposium on the 21th of November 2008 taking place in the orthopedic university hospital
in Heidelberg, was a great success. More than 150 participants had the opportunity to gain knowledge of the latest
results of V.A.C. Instill® therapy. The purpose of the
event was to cover the whole spectrum of V.A.C. Instill®
therapy including its indications and technical applications. The presentations clearly showed, that this treatment modality has become a very successful and broadly
applicable tool in several surgical-medical indications
only a few years after its introduction. As at the time of
introduction, the main focus of V.A.C. Instill® therapy is
Infection 37 · 2009 · Supplement I © Urban & Vogel
the treatment of endoprosthetic infections and implant
infections in orthopaedic surgery and traumatology. Also
soft tissue infections in anatomically difficult regions can
be treated successfully. Altogether, it could be concluded,
that V.A.C. Instill® has become a full-blown and valuable
member of the VAC family.
Therefore, I’m delighted, to present the whole spectrum
of V.A.C. Instill® applications from the perspective of the
different specialities in this supplement. Especially the
exchange of experiences between different specialities
and professional groups formed the base of a symposium,
which was very successful and fruitful for the participants.
I want to take the opportunity to thank all speakers and
all participants for their cooperation and engagement
contributing to the success of the event and the realisation
of that supplement.
With kind regards from Heidelberg,
B. Lehner
3
V.A.C. Instill® therapy – indications and technical applications
01
The history of the V.A.C. Instill® therapy
W. Fleischmann
Vacuum therapy is applied successfully in the treatment of
wound infections. The underlying mechanisms are not fully
understood. It seems that vacuum therapy creates a hostile
environment for many bacteria, removes the germs and
their toxic products from the wound and impairs the virulence and communication abilities of the bacteria. However, there are two fundamental problems accounting for
a failure of vacuum therapy.
1. Due to wound exsudations, the foam gets sticky.
2. The infection persists in wound areas difficult to access
and therefore not in direct contact with the foam.
The V.A.C. Instill® therapy is advantageous, because
it offers the opportunity for a germ directed local antibiotic
treatment, maintains the porosity of the foam, stretches the
wound and soaks it completely with the bactericidal instillation solution.
The instillation technique was developed in our clinic
in 1996, and first was used only if vacuum treatment of
septic wounds was not successful [1]. After convincing initial results it became the standard treatment in every
wound infection. Antiseptics (Polyhexanid) or antibiotics
(Nebacetin) were instilled with a syringe three- to fivetimes
daily into the suction drain in the foam and drained by reapplying the vacuum after allowing for a reaction time of
20 minutes. This procedure resulted in a rapid resolution
of the wound infection, but on the other hand, it is very
labor intensive and associated with a high risk of contamination when disconnecting and re-assembling the drains.
In daily clinic routine it often was forgotten either to instill
the active agents or to restitute the vacuum.
In 1998, the method was improved by using an instillation drain in addition to the suction drain and by using
three-way valves for operating the instillation and vacuum
phases. Luer-Lock connections facilitated the use of the
instillation technique in the surgical unit and the wards.
The contamination risk and the nursing effort were reduced considerably.
Starting in the end of 1998, fully automatic instillation
systems as prototypes entered the field and increased the
efficacy substantially. The vacuum and instillation phases
could be set to almost every time interval required. And
4
the valve functions were controlled fully automatic “around
the clock”, almost unnoticeable by the patient. Even in frequent, for instance hourly, instillation cycles, the nursing
impact was limited to securing the instillation of the solution, a job well known from infusion treatment. An intermediate top of the development was reached in 2001, when
the pneumatics specialist Festo constructed an “Instillamat” with timer and acoustic alarm working solely based
on pneumatics. A vacuum exceeding 0,8 bar (80 kPa) could
be generated. The instillation phase was initiated by a flush
mechanism, allowing for injection of a predefined small
fluid volume under high pressure. Thereby the foam pores
were extended, the adhesions were solved and the resistance against the following inflow of instillation fluid was
reduced.
Beginning from 2001, KCI started to develop, certify
and market the V.A.C. Instill® working electrically. The
software integrated in the device controls the valve functions fully automatic. The vacuum is produced by an electrical pump, and multiple alarm functions offer high safety
for the user.
Steps of further development of the V.A.C. Instill® will
focus on more effective instillation fluids being able to attack also bacteria in biofilm, on technical improvements
like volume-guiding of the active agents and on optimizing
the foams applied with V.A.C. Instill®.
References:
1. Fleischmann W, Russ M, Westhauser A, Stampehl M: Unfallchirurg
1998:101:649–654.
Correspondence address
Dr. Wim Fleischmann
Unit for Orthopedic, Traumatologic and Reconstructive Surgery
Academic Teaching Hospital University Heidelberg
Riedstr. 12
74321 Bietigheim-Bissingen
Phone: +49 7142 795 5000
Fax: +49 7142 795 5008
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
02
Therapy options with V.A.C. Instill® in the
treatment of open, superinfected injuries of the
lower limps – the Erlangen algorithm
M.H. Brem, S. Schulz-Drost, J. Gusinde, A. Stuebinger, F.F. Hennig, A. Olk
Open fractures with massive soft tissue defects are still an
enormous problem in traumatology. In most cases they are
caused by high velocity accidents. In 37% an amputation of
the limp is necessary because of a superinfection [1].
Common therapies are besides initial stabilisation of the
fracture with external fixation, the specific antibiotic treatment, surgical rinsing and debridement. An enormous advance in the management of infected posttraumatic wounds
was the development of the Vacuum Assisted Closure
(V.A.C.® Kinetic Concepts, Inc., San Antonio, TX, USA)
[2–5]. A wound reduction is achieved by the application of
negative pressure on the wound surface and a granulation
process is initiated [6]. This treatment is a very important
part of the whole treatment path of open fractures with superinfection. The granulation process on the wound surface
improves the healing process of plastic lope surgery [7].
Even in huge posttraumatic soft tissue defects the V.A.C.®
gained influence in the recent years. It offers the possibility
a secondary treatment of soft tissue defects after primary
osteosynthetic treatment [8].
A further development in the treatment of infected
wounds is the V.A.C. Instill ®. This technique offers the possibility of germ reduction. The V.A.C. Instill® offers the advantages of the V.A.C. ® and the possibility of wound rinsing
with local antiseptic liquids. This technique is especially important in the limp saving treatment of significant 3° open
fractures of the lower limp. The V.A.C. Instill® therapy is
more or less integrated in the algorithm of treatment of
posttraumatic wounds. We would like to suggest an algorithm in the treatment of infected posttraumatic wounds
with V.A.C. Instill® (fig. 1).
The Erlangen therapy of open fractures with superinfection of the lower limp starts with an initial external fixation
and debridement (fig. 2). Furthermore in the initial surgery
a careful haemostasis and if necessary a revascularisation
I. Initial treatment on day one
1. Debridement, necrosectomy, external fixation
2. Rinsing of the wound with an antiseptic fluid
3. Wound treatment with a V.A.C.® treatment (125 mmHg
continuous suction) PUR foam (pore size 400–600 μm)
Fig. 2: 3rd degree open fracture of the lower limp after
first revision.
II. Planned revisions
1. V.A.C. Instill® therapy with a local antiseptic fluid until
at least two bacteria free microbiological evaluations are
established
2. Debridement
3. Complementary osteosyntheses
4. If necessary V.A.C.® therapy
5. Reduction of the wound size
III. Final closure of the wound
Fig. 1: The Erlangen algorithm for wound treatment after open fractures of the lower limp.
Infection 37 · 2009 · Supplement I © Urban & Vogel
Fig. 3: Revascularisation
after 3° open fracture with
disruption of the vessels.
5
V.A.C. Instill® therapy – indications and technical applications
Fig. 4: V.A.C.® Instill application after a 3° degree open
fracture of the lower limp.
surgery is performed (fig. 3). The wound is rinsed thoroughly
with a local antiseptic fluid. Initially the wound is closed
with a V.A.C. Instill® system.
In the first planned revision of the wound we perform
once again a debridement and necrosectomy. Furthermore we rince the wound carefully with a local antiseptic
fluid and the wound is closed with a V.A.C. Instill® system (fig. 4). The wound is rinsed with a local antiseptic
fluid and the residence time of 20 minutes. This is followed
by a period of 120 minutes of continuous suction. We use
a PUR foam (pore size 400–600 µm, black). After five to
six days we change the V.A.C. Instill® system and revise
the wound. Again debridement, necrosectomy and rinsing
is performed during the surgery. In every surgery tissue
samples for microbiological evaluation are taken. The
specific systemic antibiotic therapy is adjusted to the
microbiological findings. After at least two negative,
bacteria free microbiological evaluations we change the
V.A.C. Instill® system to an V.A.C.® system, depending
on the wound size or close the wound with sutures. Furthermore a complementary osteosyntheses is preformed
after a bacteria free wound is established. Finally the
wound is closed by plastic lope surgery or skin mash craft.
The Erlangen algorithm is shown in two case reports of
open fractures with superinfection.
Case 1:
A 17 year old boy was admitted to our hospital after a high
velocity trauma. He suffered from a 3° open femur fracture
with a massive tissue loss. Initially the leg was stabilised
with external fixation and a careful haemostasis was
performed. The large wound was temporarily covered by
artificial skin. An initial treatment with V.A.C.® was not
possible because of the massive soft tissue bleeding. A superinfection of the heavily traumatised soft tissue could not
be avoided. We found the following bacteria in the wound
area: Pseudomonas aeruginosa, Stenotrophomonas maltophiliae and Enterobacter cloacae. In the first revision a
V.A.C. Instill® system was put into place after re-evaluation
of the wound, debridement, necrosectomy and extensive
rinsing. We instilled Lavasept, kept it for 20 minutes on the
6
wound surface and exhausted the liquid in a sequence of 120
minutes of continuous suction with 125 mmHg.
We repeated this treatment for twelve consecutive days.
A re-evalution of the wound area was done after six days
and the V.A.C. Instill® system was changed. After this treatment we could not find any bacterian either in tissue samples
or wound swaps. For the follow up treatment we changed
the V.A.C. Instill® treatment to an ordinary V.A.C.® system
for further wound preparation. The V.A.C.® therapy lasted
for a total of 40 days. During the whole treatment period we
used a PUR foam (pore size 400–600 µm, black).
Finally we were able to change the external fixation to
an femur locking nail and were able to perform a mesh
craft transplantation on the enormous wound area [9].
Case 2:
A 47 year old patient suffered of a 3° open fracture of the
lower leg after a motor cycle accident. Furthermore he
suffered from diabetes mellitus typ 2, chronic alcohol abuse and chronic nicotine addiction. The initial treatment
was performed in a small rural hospital. A plate osteosyntheses was done on the distal fibula, a tension band fixation was done on the medial tibia and a screw fixation of
the syndesmoses proceeded. The wound was temporary
closed with artificial skin.
In the course the patient developed a wound infection.
In the microbiologial examinations the following bacteria
were found: Klebsiella pneumoniae, Enterobacter cloacae
and Staphylococcus aureus. After some unsuccessful
wound revisions the patient was transferred to our hospital.
We changed the osteosyntheses to an external fixation, did
a radical debridement and extensive rinsing of the wound.
We established a V.A.C. Instill® system (PUR foam, pore
size 400–600 µm, black). We instilled Lavasept®, kept it for
20 minutes on the wound surface and exhausted the liquid
in a sequence of 120 minutes of continuous suction with 125
mmHg. The following treatment was performed after a
modified Erlangen algorithm. After six days we did the
first re-evaluation of the wound with once again debridement, necrosectomy, rinsing and V.A.C. Instill® treatment.
All together four planned revisions were necessary to establish a bacteria free wound area. Finally a wound closure
was performed.
References
1. Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta J, Kulp B et
al. J Orthop Trauma 2007 Jan;21(1):11–7.
2. Fleischmann W, Strecker W, Bombelli M, Kinzl L. Unfallchirurg 1993
Sep;96(9):488–92.
3. Herscovici D, Jr., Sanders RW, Scaduto JM, Infante A, DiPasquale T.
J Orthop Trauma 2003 Nov-Dec;17(10):683–8.
4. Labler L, Keel M, Trentz O. Zentralbl Chir 2004 May;129 Suppl 1:
S14–9.
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
5. Labler L, Trentz O. Langenbecks Arch Surg 2006 Sep 16.
6. Willy C. Die Vakuumtherapie. 1 ed. Ulm; 2005.
7. Hardwicke J, Paterson P. Int J Low Extrem Wounds 2006
Jun;5(2):101–4.
8. Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. J Plast Reconstr Aesthet Surg 2008 Mar 24.
9. Brem MH, Blanke M, Olk A, Schmidt J, Mueller O, Hennig FF et al.
Unfallchirurg 2008 Feb;111(2):122–5.
Correspondence address
Dr. Matthias Brem
Universitätsklinikum Erlangen
Abteilung für Unfallchirurgie
Krankenhausstr. 12
91054 Erlangen
E-mail: [email protected]
03
V.A.C. Instill® treatment in severe septic
abscess forming and perforating Ludwig’s angina
with large abscess formation in the neck and
lower jawbone osteomyelitis due to dental caries
with tooth root abscess – a case report
C. Wiedeck
Introduction
A severe septic course of an extended soft tissue infection
with abscess formation is a disease with systemic organ involvement and therefore associated with a high mortality.
Due to the frequently hyperacute nature of the disease a
rapid surgical sanitation of the causative foci and extensive
interventions are often required. This is in many cases
made more difficult by the multifocal spread of the septic
foci and repeated flare-ups of the inflammation thought to
be under control already. The systemic inflammatory response on one side impedes radical surgical interventions,
because complications like disseminated intravascular coagulation occur, but on the other side, particularly that radicalness is necessary to interrupt the vicious circle. Furthermore, the surgeon is confronted with the problem, that
he needs to perform extensive interventions in order to
save the patients life, but also wants to avoid mutilating and
cosmetically unfavourable results.
In addition, logistic problems can exist like limited
operating room capacities or staff shortage, impeding frequent revisions. Also high cost is a growing problem in intensive care.
A patient admitted to the hospital with a severe soft
tissue infection first of all must undergo a thorough clinical
evaluation, because the visible signs of the infection might
Infection 37 · 2009 · Supplement I © Urban & Vogel
lead to an underestimation of the severity of the disease.
Laboratory findings and imaging procedures are not sufficient to judge the severity and prognosis of the disease reliably.
An extensive abscess forming soft tissue infection with
a beginning systemic inflammatory reaction is an emergency requiring an immediate surgical intervention in cases
presenting with a surgically accessible cause. Thereafter,
intensive care of the sepsis patient and frequent controls of
the operation field and, if necessary surgical revisions are
mandatory. For analgesia, in most patients repeated anaesthesias have to be performed, except in sepsis patients requiring assisted ventilation. If the patient survives the acute
phase, and signs of clearing and healing of the local situation appear, there generally is still a long way to go until
definite wound closure occurs and a functionally and cosmetically satisfying result is achieved.
Case report
In the following, we report about a men aged 49 years
(table 1) presenting with intraoral pus secretion originating
from the lower jawbone accompanied by a large area of
redness and hyperthermia of the neck. Due to a difficult
social situation and continued abuse of alcohol the patient
had failed to seek medical help early enough. As an under-
7
V.A.C. Instill® therapy – indications and technical applications
lying disease the patient suffered from alcoholic cardiomyopathy with an ejection fraction of less than 20%, and
he was a heavy smoker.
Upon clinical examination, a carious dental status (fig.
1a–1c) was found together with a purulent fistula from the
lower molar teeth to the floor of the mouth. Because the
affection extended to the floor of the mouth and to the
neck and laboratory markers of inflammation were massively increased, a CT of the head and neck was performed.
It showed abscess formation in the ventral neck area below
the peripheral and medial neck fascia. The inflammatory
soft tissue affection reached up to the upper mediastinum
and to the M. sternocleidomastoidei on both sides.
Fig. 2: Abscesses of the neck following incision.
1a
1b
1c
Fig. 1: Carious dental status with purulent fistula.
8
The abscesses were lanced through six incisions (fig. 2),
debrided and rinsed with Lavasept®. Thereafter, large-lumen Robinson drain-tubes were inserted. Two lower molar
teeth were extracted and lower jawbone sequesters were
removed. Intra-operatively it was discovered, that the floor
of the mouth was already perforated and that the abscess
formation had spread in caudal direction. The patient received broad spectrum antibiotics. Lavages through the
drain-tubes were performed up to six times daily.
Due to soft tissue swelling, the intubation required for
anaesthesia could only be accomplished fibreoptically
using the endonasal way. Only a tube with an ID of 7,0
could be placed in that patient being 190 cm tall and
weighing over 100 kg. An extubation after the intervention
could not even be thought of.
After progressive worsening of the septical status, a
first revision was performed on the third post-operative
day, showing a further extension of abscess formation.
Also the revision did not lead to an improvement. Disseminated intravascular coagulation developed; also liver
and lung function deteriorated considerably. An increase
of troponin levels was observed, and pericardial as well as
pleural effusions developed.
The CT scan showed abscess formation reaching below
the inner neck fascia, over the parapharyngeal space up to
the skull base and the spine, and in cranial direction below
the fascia temporalis (fig. 3a–3d). The patient did not respond to the triple antibiotic treatment, although it was
perfectly adapted to microbial sensitivity testing results.
Considering the increasing abscess formation, it became clear, that further spacious incisions of abscesses,
large-lumen drains and regular rinsing combined with frequent surgical revisions would not be a successful treatment
strategy, and even lead to deterioration of the patient.
At this point, we decided to initiate the V.A.C.
Instill® therapy as ultima ratio. Another surgical revision
was performed, all abscesses visible in the CT were in-
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
a
b
c
d
cided liberally lavaged and filled with PU-foam. We positioned altogether four Redon-drains (size 16) into the
deepest points for lavage: to spine coming from the ventrolateral side, behind the jugulum leading in temporal
direction, below the contralateral inner neck fascia and
below the left lower jawbone. In addition we performed
an extensive debridement again (fig. 4a, b), removed sequesters from the left lower jawbone which had undergone osteolytic destruction caused by abscess formation,
and extracted the last remaining left lower molar tooth.
A Septopal-chain was placed into the bone cavity.
As early as in operating room the first cycle of instillation, reaction time and negative pressure suction was tes-
4a
Fig. 3a–3d: CT scans of soft tissue infection
of the neck.
ted, because it seemed unlikely to achieve a sealing against
the oral cavity. However, the V.A.C. Instill® system immediately appeared to be sealed sufficiently. This was achieved by the oedematous and swollen tongue of the patient,
covering the floor of the mouth perforation and the jawbone gap like a pad. According to the results of the microbial sensivity testing we lavaged with Gernebcin®. The
solution was instilled for 30 sec by means of a pressure bag,
followed by a reaction time of one minute and vacuum application. The machine was programmed for two hourly
cycles, i.e. 48 times in 24 hours.
During the following nine days (day 13 to 21 after the
first operation) the V.A.C. Instill® dressing was changed
4b
Fig. 4: VAC Instill application following surgical debridement of the soft tissue abscess formation.
Infection 37 · 2009 · Supplement I © Urban & Vogel
9
V.A.C. Instill® therapy – indications and technical applications
Table 1
Time course of the disease
Day 1–2:
Local situation:
CT:
OP:
Dressing change:
Antibiotics:
Clinical impression:
Day 3–7:
Local situation:
Clinical impression:
OP:
Dressing change:
Antibiotics:
Day 8–12:
Local situation:
OP:
Dressing change:
Antibiotics:
Day 13–21:
Local situation:
OP:
Dressing change:
Antibiotics:
Day 22–25:
Local situation:
OP:
Dressing change:
Clinical impression:
Clinical impression:
Day 26–48:
OP:
Dressing change:
Antibiotics:
Day 49:
Dressing change:
Antibiotics:
Clinical impression:
Dental caries of left lower jawbone molar teeth with abscess formation in the tooth roots, fistula formation in
the lower jawbone, Ludwig's angina and perforation of the floor of the mouth, abscess extension into the neck
Signs of a beginning mediastinitis
6 incisions, lavage, drainage
1–4 x/d in addition to manual lavage
Triple antibiotic therapy
septic disease, artificial respiration required due to swelling of the neck soft tissue, inflow congestion
Abscess extension beneath the inner neck fascia and to the parapharyngeal space
DIC, hepatic insuffiency, SIRS, worsening of lung function, pleural effusions, deterioration of cardiac function,
pericardial effusions, increase of troponin levels, abscess extension
Revision, tooth extraction, lavage, drainage
3–6 x/d in addition to manual lavage
Triple antibiotic therapy
Further abscess extension beneeth the lower inner neck fascia to the spine, dorsal mediastinum, and over the
parapharyngeal space in the direction of the skull base, temporal abscess formation
Resection of the ventral neck soft tissue, debridement, V.A.C. Instill® with 4 instillation drains (spine, skull base,
vessel and nerve bed, jugulum)
1 x in 5 days, lavage with V.A.C. Instill® 48 x/d
Triple antibiotic therapy and local antibiotics via V.A.C. + septopal chain
No further abscess spreading, soft tissue almost free of pus; but pus and sequesters in the lower jawbone
2 x, debridement, V.A.C. Instill® with 3 rsp. 2 instillation drains to the spine, skull base, vessel and nerve bed;
lower jawbone sequestrectomy
2 x in 9 days, lavage with V.A.C. Instill® 48 x/d
Triple antibiotic therapy + local antibiotics via V.A.C. Instill® + septopal chain in the lower jawbone
Soft tissue + lower jawbone cleared
V.A.C. Instill® with 1 instillation drain to the spine, translaryngeal dilatation tracheostomy
1 x in 4 days, lavage with V.A.C. Instill® 48 x/d
Increasing stabilisation, rapid improvement of lung function, letting the patient wake up under ventilation, start
of weaning
ARDS, FIO2 100%
None, change to “normal” V.A.C.® day 26
1 x every 4 days
Double antibiotic therapy
End of V.A.C.® therapy
1 x every second day PU-foam plaster
Withdrawal
Patient without sedation, awake, start with building up of nutrition and mobilisation outside the bed, weaning
from respiration
Day 56:
Transfer to standard care unit
Tag 57:
Tube removal
10
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
twice in the operating room, the wounds were debrided,
and the instillation drains could be pulled back and shortened. The abscesses stopped to extend further, and the
coagulation as well as the liver function of the patient stabilised. Unfortunately, an ARDS developed, and it was
not possible to provide enough respiratory toilet and ventilation through the existing 7,0 endonasal tube. An attempt to replace that by a wider tube failed, and a change
to an endotracheal intubation seemed to be impossible
because of the massive swelling. Under a 1,0 oxigenation
the blood gas values deteriorated rapidly, so that there
was an urgent need for action.
We performed an open dilatation tracheostomy in the
operating room (fig. 5–7). A small area of the trachea was
exposed and thereafter punctured and dilated under visual, not endoscopic control, so that a large-lumen catheter could be placed. This was put through the foam. The
plate usually securing the correct position of the tube at
skin level was fixed with a button suture. Beneath and on
top of it also foam was applied. As expected, it turned out
to be very difficult to seal the tube. This could only be
achieved by additionally nodding in the tube into the foil
using a Mersilene strap.
During the next days, the local situation and the overall condition of the patient improved considerably, so that
also the last remaining instillation drain next to the spine
could be pulled back and finally removed. On day 26 after
the initial operation we changed to the “normal” V.A.C.®
system. On day 49 the V.A.C. Instill® therapy was stopped.
In the following, for wound care once every second day a
rimless foam plaster around the tube was used, and the
antibiotic treatment was stopped. On the 56th postoperative day the patient was transferred to the standard care
5
6
Table 2
Overview of time consumption
Intensive care unit:
Artificial respiration:
Antibiotic treatment:
55 days
52 days, tube removal after
56 days
49 days
„Conventional“ therapy:
7 days (2 surgical interventions =
4,5 h, 4–6 dressing changes/d +
6 lavages/d = ca. 252 h, i.e more
than 10 h/d for dressing changes)
V.A.C. Instill® therapy:
18 days (4 surgical interventions,
0,22 dressing changes/d + 48 lavages/d = ca. 15 h, i.e. less than
1 h/d for dressing changes)
„Normal“ V.A.C.® therapy:
23 days (no surgical intervention,
6 dressing changes (= 0,26 dressing changes/d) = ca. 6 h, i.e.
less than 1/2 h/d for dressing
changes)
Infection 37 · 2009 · Supplement I © Urban & Vogel
7
Fig. 5, 6, 7: Open tracheotomy (5), ventilation via tracheotomy (6) and
V.A.C. Instill® application around tracheotomy (7).
11
V.A.C. Instill® therapy – indications and technical applications
Fig. 8: Healed soft tissue of the neck at the end of treatment.
Fig. 9: Patient shortly before discharge.
unit, on the 57th day the tube was removed. Figures 8 and
9 show the patient shortly before discharge.
sealing. No respiration leckage or tracheal arrosion was
observed.
Altogether, the V.A.C. Instill® therapy was shown to
be a completely new treatment option hardly to compare
with standard options including the conventional V.A.C.®
therapy. However, it was very advantageous with respect
to time consumption for surgical interventions and care,
showing a superior cost-benefit relation.
V.A.C. Instill® therapy offers a new treatment option
in septic surgery, especially in cases with a diffuse phlegmon and multiple abscess formation. Also the use in infected endoprostheses seems feasible as well as in traumatology in infected osteosyntheses or osteomyelitis and severe soft tissue infections, requiring the creation of large
wound areas, which on the other side is problematic due to
infection risk or to the existing infection. The continuousintermittent lavage at any time points and the continousintermittent ample drainage through the PU-foam could
offer new chances for sanitation.
Summary
V.A.C. Instill® therapy was started at the point, when conventional surgical and intensive care options were utilised
surgery alone could not be successful, because the neck soft
tissue were interspersed with multiple small abscesses and
inflamed due to a severe phlegmon. Only multiple daily
surgical revisions would have been sufficient in that situation. But surgery was limited by the fact, that important
anatomical structures were closely adjacent (V. jugularis
on both sides, A. carotis, N. vagus, N. hypoglossus, Trachea). An additional threat for more complications emerged from the rapid extension of the infection endangering
further critical structures (spine, skull base). So, there was
a vital indication for therapy enhancement and intensification not only because of the life threatening septic state.
After initiating frequent lavage using germ-oriented
antibiotic solutions (cycles with instillation, short reaction
time and vacuum clearing every 30 minutes) through the
V.A.C. Instill ® system targeted to the most problematic
infection areas, the local situation and the clinical global
impression improved rapidly. No development of lavage
streets was observed; this has apparently been inhibited by
the ample suction through the PU-foam. It also did not turn
up to be a problem to seal the oral cavity against the perforation of the floor of the mouth. Also in the tracheostomy care no problems occurred except the very difficult
12
Correspondence address
Dr. Claudia Marie Wiedeck
Städt. Kliniken Ffm.-Höchst
Gotenstr. 6–8
65929 Frankfurt
Phone: +49 69 31 06 0
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
04
Application of V.A.C. Instill® therapy in case
of periprosthetic infection in hip arthroplasty
B. Lehner, S. Weiss, A. J. Suda, D. Witte
Summary
Periprosthetic infection remains a main complication in arthroplasty. Increasing numbers of primary and revision arthroplasties will be followed by increasing numbers of periprosthetic infections. In case of a possible infection the
surgeon has to have a concept of treatment which can be
individually adjusted. In early and secondary infections component retention can be successful. Surgical debridement is
the key for success. To increase the success of implant retaining surgery V.A.C. Instill® therapy was performed in 23
patients with periprosthetic hip infection. All patients came
from orthopaedic university clinic Heidelberg. 19 of the patients had an early and 4 a late infection of the arthroplasty.
Introduction
Periprosthetic infections are among the most severe complications in endoprosthetic surgery. They occur in about 1 to
3% of all joint replacement interventions. In endoprosthetic
exchange operations or insertions of mega-implants their
frequency is even higher [1, 6, 8, 10, 17]. Due to the increasing number of implantations an increase of infections requiring treatment must be expected even when taking into account a declining infection rate. Several treatment options
are applicable for these infections depending from the time
of their emergence [9, 16]. In early infections occurring during the first six to eight weeks following the implantation of
the endoprosthesis an aggressive surgical debridement combined with wound lavage and, if necessary, multiple repetitive operations can permit to preserve the implant in many
cases. Such a treatment can also be performed in later secondary infections caused by hematogenic spread as well as in
cases with a short interval between infection outbreak and
treatment in cases with tightly fixed prosthesis. In all remaining late infections usually the implant must be removed completely due to bacterial contamination and formation of biofilm followed by a one- or two-step implant exchange [9,
22].
The combination of the V.A.C. therapy with an instillation treatment represents an advancement of the V.A.C.
therapy avoiding the drawbacks of conventional suction-irrigation drainage [23]. It aims at reducing the number of
local germs by an additional instillation of antiseptics. We
Infection 37 · 2009 · Supplement I © Urban & Vogel
Lavasept® was used for irrigation in all patients. Definitive
wound closure was possible following 2.1 V.A.C. exchange
operations in average. The follow up now is in average 15
months (5–24 months). In five of the 23 patients (22%) there
was progressive infection or recurrent infection which made
the explantation of the endoprosthesis necessary. In early
infection the success rate was 84%, in late infection 50%.
The therapy can be especially be used for salvage of infected
endoprosthesis in case of an early infection.
Keywords: Periprosthetic infection – early infection –
V.A.C. therapy – instillation therapy – retention of endoprosthesis
tried to find out, if this treatment can facilitate the implantpreserving sanitation of periprosthetic infections following
total hip joint replacement.
Material and methods
Between 08/2005 and 05/2008, the V.A.C. Instill® therapy
was performed in 23 patients with infected hip endoprostheses (fig. 1). On average, the patients were 72 years (36–
92 years) old, 13 patients were female, ten male. 19 patients
suffered from an early endoprosthesis infection with a medium time interval of 23 days (8–47 days) between prosthesis implantation and first revision. Four patients presented
with a late infection with a mean time interval of 8,2 months
(4–13 months) between implantation of the endoprosthesis
and the onset of infection. These patients had not accepted
the suggested explantation of the prosthesis, because the
prosthesis showed good clinical function in all cases. In one
Fig. 1: Periprosthetic
early infection of a
hip-TEP.
13
V.A.C. Instill® therapy – indications and technical applications
Fig. 2: Intra-operative
sight before soft tissue
debridement.
Fig. 3: Intra-operative
sight after soft tissue
debridement.
of the four patients with a late infection the implant had
been exchanged already. All patients were analysed and
followed prospectively.
If an infection occurred, the surgical revision was performed by the same route as the primary operation. The
entire wound area was debrided radically, and all necrotic
tissue was resected (fig. 2, 3). In the case of infection the
artificial hip joint was luxated and all its mobile components like femoral head or inlay were removed temporarily
and re-implanted after cleaning of the wound and disinfection of the components. The wound cavity was rinsed with
at least five liters of lavage fluid (Ringer solution) using
jet-lavage (fig. 4). After placing back the disinfected components the joint was reset, and a drain (14 Charriere) was
placed deeply into the wound cavity. Depending from the
size of the wound cavity, one to three peaces of polyvinylalcohol foam (PVA, produced by KCI) were applied into
the wound cavity in close contact to the endoprosthesis
(fig. 5, 6). The drains (14 Charriere), which are already prefixed into the foam, and also the single drain were led out
through the wound area. After partially suturing the fascia,
the skin suture was performed leaving a part of the PVAfoam visible for optical control. The wound was closed and
left air- and water-tight by placing the drains in between
the adhesive layers of two foils in a sandwich-like order
(fig. 7). Thereafter, the instillation and suction drains were
connected with the V.A.C. Instill® system. Altogether, the
wound, the foam dressing and the V.A.C. Instill® system
formed a closed and water-tight unit. The duration of the
instillation phase, while the instillation drain is open and
the instillation fluid is running towards the foam following
gravity, was up to 40 seconds depending from the size of
the wound. In all cases, Lavasept® 0,04% polyhexanide
14
(Lavanid 2, produced by Serag-Wiessner Naila, Germany)
was instilled. If fluid accumulated between the visible part
of the foam and the bulging foil, the instillation phase was
shortened. The reaction time was set to 15 minutes, the
under-pressure to 125 mmHg. The duration of the vacuum
phase was 60 minutes in all patients. After completion of
the vacuum phase, the next instillation cycle was started. If
the daily instilled fluid amount declined and the foam in
the vision control area changed its colour to yellow indicating an increasing protein load of the foam leading to a plugging of the pores – a surgical revision was performed three
to five days later. At that time, the PVA-foams were removed, the wound was inspected and tissue samples were taken for microbiologic testing. Depending from signs of
inflammation another surgical debridement was performed
and new PVA-foams were placed. If the wound cavity no
longer appeared to be irritated and the microbiologic testing result was negative following revision, the wound was
closed layer by layer. All exchangeable prosthesis components (femoral head, inlay) were replaced by new parts at
this time (fig. 8). During treatment and until six weeks thereafter a standardised, systemic antibiotic treatment was
performed according to the sensitivity testing results [7].
Results
All study patients were analysed and followed prospectively. The mean follow-up period was 15 months (5–24
months). At the time of diagnosis, the patients showed typical signs of a periprosthetic infection including local tenderness, pain on motion and increased levels of markers of
systemic inflammation. At the time of the first wound revision, a bacterial contamination of the endoprosthesis could
be demonstrated in 22 patients. In one patient the microbiologic result was negative following systemic antibiosis.
But the histological examination of the tissue samples taken during surgical revision clearly showed an infection
also in this patient. The infection was caused by Staphylococcus aureus in eight patients, Staphylococcus epidermidis in five patients and Staphylococcus lugdunensis in four
patients. In three cases an infection with Enterococcus faecalis and in one case each with Enterobacter cloacae or
streptococci was found. On average, 2,1 V.A.C.-foam exchange operations (1–4) were performed until definite
wound closure. Including wound revisions without exchange of the V.A.C. Instill® system 3,9 operations (3–7
surgical revisions) were performed. At the time of the last
operation microbiologic testing did not show bacterial contamination any longer in 22 of the 23 patients. In the one
patient with bacterial contamination shown only in enrichment culture at the time of definite wound closure, the tissue sample had been sterile at the previous operation. In
one of the 23 patients the wound was not closed definitely
despite negative bacterial culture, but the endoprosthesis
was explanted, because there was a macroscopic impression of infection at the time of the surgical revision. In four
other patients re-infection occurred during follow-up also
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
requiring the explantation of the prosthesis. The cases of
endoprosthesis explantation included three early and two
late infections. Therefore, the success rate for early infections was 84%, for late infections 50%. At the time of endoprosthesis explantation the infection causing agent had
not changed. In the remaining patients no re-infection in
the operation area was observed during further follow-up.
Taking the individual age of the patients into account, a
loss of function of the operated joints could be avoided by
multiple revisions while preserving the prosthesis. The
V.A.C. Instill® system showed to be easy to handle after
having run through a short learning curve. However, education of the involved personal is necessary in order to
avoid operating errors and to manage function disturbances
rapidly. The V.A.C. Instill® therapy did not cause pain in
any patient and allowed to mobilise the patients with the
system in place (fig. 9). So far, in two of the five patients,
who had undergone endoprosthesis explantation, a twostep re-implantation could be performed. Also, another
patient will soon receive a new implant, two patients have
adapted to a Girdlestone situation in their daily life acitivities and don’t want to receive a new implant.
Fig.4: Jet-lavage during primary surgical
revision.
Fig. 5: PVA-foam
placed periprosthetically in the hip joint.
Discussion
Several strategies are followed in the treatment of hip periprosthetic infections. Decision factors include the time
interval between the implantation of the endoprosthesis
and the onset of the infection, the implant function, the
causing bacterial agent and the general condition of the
patient [8–10, 16, 17, 19, 22, 24]. In early infections and
acute hematogenic infections in patients with well functioning implants without signs of loosening, it is justified to try
an endoprothesis preserving operation. Meehan et al. reported a re-infection rate of only 10,5% in patients with
firmly fixed prosthesis after a successful treatment of the
infection [14]. If the time interval exceeds six to eight
weeks, bio-film formation and glycocalix development
caused by the most frequent bacteria (staphylococci) must
be expected, making the bacteria neither accessible for the
endogenous immune system nor for antibiotics. However,
early infection is defined differently by several authors as
a time interval from two to twelve weeks between prosthesis implantation and onset of infection [3, 6, 16, 22].
In the treatment of early infections the surgical revision with debridement, wound lavage, programmed joint
lavage and replacement of exchangeable implant components is the generally accepted standard [9, 16, 19, 22]. Especially in cemented implants however, an exchange is
associated with a loss of trabecular bone and bone matter
even in early infection, usually requiring a revision implantation. Particularly in the acetabular region often an acetabuloplasty is necessary to compensate for bone loss. Fisman et al. consider preserving the endoprothesis in early
infections to be reasonable also under economic aspects
[4]. The pure V.A.C. therapy in early infections is hampered by the rapid plugging of the PVA- and polyurethane-
Infection 37 · 2009 · Supplement I © Urban & Vogel
Fig. 6: „Filling“ of the
wound with PVAfoam.
Fig. 7: Water- and airtight positioning of
the instillation drain
and the four suction
drains between the
adhesive layers of two
foils (sandwich technique).
Fig. 8: Replacement of
all exchangeable components at the time of
definite wound closure. Old components
above, new components below.
15
V.A.C. Instill® therapy – indications and technical applications
Fig. 9: Maintained
mobility of the patient
during V.A.C. Instill®
therapy.
Fig. 10: Polyurethanefoam after five days
of application with
partially growing in of
soft tissue.
foam with cell-debris and protein-containing wound secretions. The frequently used suction irrigation drainage,
showed sanitation rates of below 50% in the treatment of
early joint implant infections. The earlier and more thoroughly the surgical debridement was performed, the more
successful the interventions turned out to be [15]. A problem of suction irrigation drainage however is, that „lavage
tracks“ develop leaving behind dead spaces with septic material. The V.A.C. Instill® system offers the opportunity to
combine V.A.C. therapy with an intermittent infiltration of
an antiseptic solution, while treatment phases can be
adjusted continuously variably. It combines the positive
effect of under-pressure in the wound area on the formation of granulation tissue with the local antiseptic lavage
reducing the number of germs and avoiding the development of soft tissue cavities associated with the risk of retention of secretions [5, 12]. The best sanitation results by
multiple lavages and surgical debridements were achieved
in streptococci infections with a success rate of 88%, while
in infections with staphylococci or enterococci the success
rate was about 30% [14]. This observation was confirmed
by other authors, also reporting higher success rates of
prosthesis-preserving operations in infections with penicillin-sensitive streptococci compared to other bacterial in-
16
fections [2, 14]. However, one has to consider, that most
periprosthetic infections are caused by staphylococci [7].
This was confirmed also by our data.
Tattevin et al. found, that a significantly better result
with regard to re-infection was achieved in patients with a
short interval (< 5 days) between symptom onset and surgical debridement of the infected endoprosthesis compared
to delayed therapeutic intervention [20]. In our five patients with progressive infection or re-infection the mean
time interval of seven days also exceeded that reported
limit.
The success achieved in two of four late infections in
our patient group is in contrast to other reports describing
successful prosthesis-preserving surgical debridements
only in early infections or acute hematogenic infections
[22]. Also Crockarell et al. reported about re-infection after treatment of late infections in total hip joint replacement operations [3]. This is consistent with our experience,
that preserving the prosthesis is more promising in early
infections [13]. The mean time interval between the implantation of the prosthesis and the onset of infection in
successfully treated late infections was nine months in our
investigation. This could point to germs with low grade virulence, which can be treated preserving the prosthesis in
some cases. The infection had been caused by Staphylococcus aureus in one case and Staphylococcus lugdunensis in
another. In 22 of the 23 patients the microbiologic culture
was negative at the time of the last revision prior to definite
wound closure. In one patient with a previously negative
microbiologic culture the result at the last operation was
positive in the enrichment culture showing Enterococcus
faecalis. In this case of an early infection of a total hip endoprosthesis a clinically apparent re-infection occurred at
two months after completion of the V.A.C. Instill® therapy
requiring an explantation of the endoprosthesis. Therefore
it seems desirable, to confirm a sterile microbiologic culture. However it must be considered, that enterococci and
enterobacter infections are difficult to treat. In two of the
four infections with these germs the endoprosthesis had to
be explanted in our investigation.
At the time of definitive wound closure the V.A.C.
Instill® therapy had resulted in a clean soft tissue surface
with high granulation activity, as achieved with V.A.C.therapy in soft tissue wounds [5, 21]. In three of the 14
patients a temporary superficial greyish discolouration of
the tissue showed up during the application of Lavasept®
representing a surface reaction to the applied antiseptic.
But no association with re-infection or delayed healing
could be demonstrated. As antiseptic agent for instillation
therapy other substances as alternatives to the Lavasept®
solution used by us can be administered. So far, Lavasept®
has shown good tissue tolerability, low systemic toxicity
and a broad antimicrobial spectrum [11]. As Schmidt-Neuerburg et al. demonstrated, Lavasept® induced a significant
and faster reduction of gram-positive bacteria in contaminated soft tissue wounds compared to Ringer solution with
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
similar tissue tolerability [18]. The well known potential for
cartilage damage of Lavasept® doesn’t apply to it’s use in
periprosthetic infections. Octenisept cannot be used in
combination with PVA-foam, because it does induce an
early plugging of the pores and foam formation. Basically,
also polyurethane-foams can be used. But these have two
main disadvantages: Due to their hydrophobic structure
the fluid retaining potential is reduced, and due to the large
pore size, there is a risk of soft tissue growing in, which can
lead to a breakaway of foam particles when removing the
foam (fig. 10). Furthermore, polyurethane-foams cannot
be used as visual indicators for an increased pore plugging
by protein-containing particles like this is the case with
PVA-foam showing a yellowish discoloration.
Conclusion
Periprosthetic infections in the hip joint can be treated successfully with V.A.C. Instill®. In our evaluation of the therapeutic value of V.A.C. Instill® 18 of 23 periprosthetic hip
joint infections could be treated successfully.
This primarily applies to early infections. But in selected cases also late infections can be treated this way, if
endoprosthesis explantation is contraindicated. It is important to confirm a negative microbiologic culture prior
to definite wound closure. However, this doesn’t exclude
re-infection. In addition to the V.A.C. Instill® therapy
each surgical revision has to include an extensive debridement.
5. Fleischmann W. In: Willy C (Hrsg). Die Vakuumtherapie. Ulm, 2005:
35–42.
6. Frommelt L. Orthopäde 2004; 33:822–826.
7. Fulkerson E, Valle CJ, Wise B, Walsh M, DiCesare PE. J Bone Joint
Surg Am 2006;88:1231–1237.
8. Gaine WJ, Ramamohan NA, Hussein NA, Hullin MG, McCreath SW.
J Bone Joint Surg Br 2000;82:561–565.
9. Haddad FS, Bridgens A. Orthopedics 2008; 31:907–908.
10. Herzog R, Morscher E. Orthopäde 1995;24:326–334.
11. Kalteis T, Lüring C, Schaumburger J, Perlick L, Bäthis H, Gifka J. Z
Orthop Ihre Grenzgeb 2003;141:233–238.
12. Kelm J, Anagnostakos K, Schmitt E. In: Willy C (Hrsg.). Die Vakuumtherapie. Ulm, 2005:117–121.
13. Lehner B, Suda A, Zeifang F. FMCH 2007;44–49.
14. Meehan AM, Osmon DR, Duffy MCT, Hanssen AD, Keating MR. Clin
Infect Dis 2003; 36:845–849.
15. Mella-Schmidt C, Steinbrink K. Stellenwert der Spül-Saug-Drainage bei der Behandlung des Frühinfekts von Gelenkimplantaten.
Chirurg 1989;60:791–794.
16. Moyad TF, Thornhill T, Estok D. Orthopedics 2008;31:581–588.
17. Ruchholtz S, Täger G, Nast-Kolb D. Die infizierte Hüftgelenksendoprothese. Unfallchirurg 2004;107:307–319.
18. Schmidt-Neuerburg KP, Bettag C, Schlickewei W, Fabry W, Hanke J,
Renzig-Köhler K, Hirche H, Kock HJ. Chirurg 2001;72:61–71.
19. Sofer D, Regenbrecht B, Pfeil J. Orthopäde 2005;34:592–601.
20. Tattevin P, Cremieux AC, Pottier P, Huten D, Carbon C. Clin Infect
Dis 1999;29:292–295.
21. Webb LX, Schmidt U. Unfallchirurg 2001;104:918–926.
22. Wodtke J, Löhr JF. Orthopäde 2008;37:257–269.
23. Wolvos T. Ostomy/Wound management 2004;50:56–66.
24. Zimmerli W, Ochsner PE. Infection 2002;31:99–108.
References
1. Bernard L, Hoffmeyer P, Assal M, Vaudaux P, Schrenzel J, Lew D.
J Antimicrobial Chemother 2004;53:127–129.
2. Brandt CM, Sistrunk WW, Duffy MC, Hanssen AD, Steckelberg JM,
Ilstrup DM, Osmon DR. Clin Infect Dis 1997;24:914–919.
3. Crockarell JR, Hanssen AD, Osmon DR, orrey BF. J Bone Joint Surg
Am 1998;80:1306–1313.
4. Fisman DN, Reilly DT, Karchmer AW, Goldie SJ. Clin Infect Dis 2001;
32:419–430.
Infection 37 · 2009 · Supplement I © Urban & Vogel
Correspondence address:
Dr. Burkhard Lehner
Head of the orthopedic oncology and septic orthopedic surgery unit
University hospital
Schlierbacher Landstr. 200a
69118 Heidelberg
Phone: +49 6221 96 63 08
E-mail: [email protected]
17
V.A.C. Instill® therapy – indications and technical applications
05
Management of early periprothetic infections in
the knee using the vacuum-instillation therapy
G. Köster
Introduction
An implant associated infection represents a severe complication following endoprosthetic knee joint replacement.
According to the literature, the incidence ranges from 1 to
3% [1, 4]. For the patient this complication is – at least
temporarily – associated with a remarkably reduced quality
of life. Often a relevant functional impairment of the extremity may persist.
Generally, there are several treatment options which
are used depending from the duration of the infection, the
causing bacteria, the extent of soft tissue involvement, the
comorbidity of the patient and the quality of the implant
anchorage. However, the duration of the infection is the
single most important factor for the decision, if the implant
can be left in place.
This study wants to answer the question, if the use of
the vacuum-instillation therapy combined with polyvinyl
foam (PVA) and antiseptic lavage is useful and feasible in
early periprosthetic infections (up to 8 weeks after the begin of infection) and is enhancing therapeutic safety and
success as well as reducing the number of surgical revisions,
while leaving the implant components in situ.
Patients and methods
Since January 2006, in our institution early periprosthetic
infections and acute hematogenic infections are treated
with a vacuum-instillation system while leaving the endoprosthesis in place. Early and acute infections are defined
as infections emerging not more than eight weeks earlier.
Basically, postoperative and hematogenic early infections
are differentiated. In postoperative early infection, the primary implantation respectively the surgical intervention in
patients with non-infected endoprosthesis is defined as the
time of infection initiation. Concerning hematogenic early
infections the emergence of an infection alio loco or the
first appearance of general or local clinical symptoms (fever, redness, increase of laboratory inflammation markers)
is defined as the starting point of the infection. Altogether,
between 2006 and 2008 ten implant associated infections
with a knee endoprosthesis remaining in place were treated
using the vacuum-instillation system (V.A.C. Instill®
Therapy System, KCI). Only patients with a positive result
of a bacterial standard culture after at least ten days of incubation were included. Patient characteristics are shown
in table 1 in more detail. Patients were followed 12 to 34
Table 1
Characteristics of the patients treated with the V.A.C. Instill® therapy
[H-TKR = hinged total knee replacement; NC-TKR = non constrained total knee replacement]
Nr.
Age
[years]
Type of
prothesis
Type of
infection
Duration of infection
[weeks]
Microbia
1
88
H-TKR
postop.
8
Staph. epidermidis
2
80
H-TKR
haematog.
4
Staph. aureus
3
77
NC-TKR
haematog.
4
Strep. mitis
4
71
H-TKR
postop.
1
Ent. faecalis
5
80
NC-TKR
haematog.
8
Staph. epidermidis
6
79
NC-TKR
postop.
2
Strep. [Gr. B]
7
61
NC-TKR
haematog.
6
Staph. aureus
8
68
NC-TKR
haematog.
2
MRSA
9
44
NC-TKR
haematog.
3
MRSA
10
69
NC-TKR
postop.
2
Strep. [Gr. B]
18
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
months (on average 21 months). Follow-up evaluations included a clinical, radiologic and laboratory examination.
In all patients standard operation procedures were followed. After excision of the skin scar an extensive soft tissue debridement with complete resection of the neo-synovialis and exchange of the polyethylene components were
performed. Thereafter, polyvinyl foam was applied amply
into the joint and the wound while one instillation and two
suction drains were inserted. The drains were led out percutaneously. The wound was closed completely or partially
and covered with a waterproof special foil. Then a
V.A.C.®-Instill pump [Kinetic Concepts, Inc., San Antonio, USA] was connected to and an intermittent vacuum
therapy was performed. Lavasept® 0,2% was used as antiseptic solution. Instillation time was 10 to 20 seconds, dwell
time 10 to 15 minutes and the suction or vacuum time 45 to
60 minutes. Altogether, the vacuum-instillation therapy
lasted for three to nine days. All patients received systemic
antibiotics according to microbial sensitivity testing results
for six weeks.
1a
Results
Between two and five surgical interventions (on average
3.4) per patient were performed for the reason of the infection. Only in one case, a skin transplantation was needed
as an additional intervention besides the installation respectively change and removal of the vacuum-installation
system. The foam was exchanged twice in five cases, once
in three cases; in two cases no exchange was performed
(see table 2). Besides one patient suffering from an infection caused by an MRSA no local or systemic re-infections
occurred (fig. 1a–1c). In that patient the implant was removed due to microbial persistence. At the last follow up examination, C-reactive protein levels were normal in all
patients but the one with the persisting infection. No method-associated or general complications were observed.
The procedure was practicable in the clinical setting and
1b
Table 2
Number and type of surgical interventions, follow-up time and
therapeutic result
No.
Total number
of
interventions
Number of
V.A.C. Instill® changes
Followup
[months]
Reinfection
1
2
3
4
5
6
7
8
9
10
5
4
3
2
2
3
4
4
4
3
2
2
1
0
0
1
2
2
2
1
34
32
27
24
22
16
15
14
14
13
–
–
–
–
–
–
–
–
+
–
Infection 37 · 2009 · Supplement I © Urban & Vogel
1c
Fig. 1a–1c: Knee joint infection with total endoprosthesis in place [a].
Insertion of the polyvinyl foam and the drains after debridement [b].
Clinical result at 34 months after vacuum-instillation therapy [c].
19
V.A.C. Instill® therapy – indications and technical applications
easy to control due to the integrated monitoring system of
the device.
Discussion and conclusions
Treating a periprosthetic infection with debridement and
systemic antibiotics without removing the implant components is regarded to be adequate only in early infection [2,
7, 9]. Some authors recommend the installation of a suction-irrigation drain and the postoperative lavage of the
wound cavity with and without antiseptics [7]. However,
the conventional suction-instillation drainage generally is
associated with the problem, that only parts of the wound
cavity and the joint cavity are lavaged, whereby so-called
lavage tracks develop, while other parts are not rinsed.
With the vacuum-instillation therapy a new treatment option is available compensating for those disadvantages. The
wound cavity and the joint cavity can be rinsed thoroughly
through the PVA-foam. In addition, the ample vacuum effect favourably influences microcirculation and granulation
[11]. The success rate of the new therapeutic option was
high in relation to other procedures [3, 5, 6, 10].
The implant preserving treatment of a periprosthetic
early infection with surgical debridement, joint lavage, systemic antibiotic application and use of the vacuum-instillation therapy in the knee joint represents an alternative
application approach. The results achieved so far, justify
the future use of the method and its inclusion into the therapeutic algorithm.
20
References
1. Attar FG, Khaw FM, Kirk LM, Gregg PJ, J Arthroplasty. 2008;23:
344–9.
2. Barberán J, Aguilar L, Carroquino G, Giménez MJ, Sánchez B, Martínez D, Prieto J. Am J Med. 2006;119:993.e7–10.
3. Bengtson S, Knutson K. Acta Orthop Scand. 1991;62:301–11.
4. Chesney D, Sales J, Elton R, Brenkel IJ. J Arthroplasty. 2008;23:
355–9.
5. Deirmengian C, Greenbaum J, Lotke PA, Booth RE Jr, Lonner JH. J
Arthroplasty. 2003;18[Suppl 1]:22–6.
6. Dixon P, Parish EN, Cross MJ. J Bone Joint Surg Br. 2004:86:39–42.
7. Ochsner PE, Zimmerli W. In: Hendrich C., Frommelt, l, Eulert J
[Hrsg.]: Septische Knochen- und Gelenkchirurgie. Springer, Berlin,
Heidelberg 2004;234–246.
8. Marculescu CE, Berbari EF, Hanssen AD, Steckelberg JM, Harmsen
SW, Mandrekar JN, Osmon DR. Clin Infect Dis. 2006;15(42):471–8.
9. Mont MA, Waldman B, Banerjee C, Pacheco IH, Hungerford DS.
J Arthroplasty. 1997;12:426–433.
10. Silva M, Tharani R, Schmalzried TP. Clin Orthop Relat Res. 2002;
404:125–31.
11. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Am J Clin
Dermatol. 2005;6:185–194.
Correspondence address
PD Dr. Georg Köster
Chefarzt Orthopädie und Unfallchirurgie
Chirurgisch-Orthopädische Fachklinik Lorsch
Waldstraße 13
64653 Lorsch
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
06
First experience with the V.A.C. Instill® therapy in
the treatment of vascular prosthesis infections
Th. Karl
Introduction
The experience with V.A.C.® therapy in vascular prosthesis
infections are limited (table 1). There are no publications for
V.A.C. Instill® therapy for this indication. Possible indications are chronic and acutely infected wounds, especially
postoperative wound healing disturbances following femorodistal bypass implantation. Postoperative wound complications occur in up to 40% of the cases in vascular surgery;
a deep wound infection can be expected in 0,2 to 11% of all
vascular reconstructions depending from the localization. In
more than half of the cases prosthesis infections originate
from the inguinal region [1–5].
Especially with the use of alloplastic material, postoperative wound healing disturbances are of great importance, because they carry a substantial risk for the development of prosthesis infections. In almost every second
case, a femorodistal prosthesis infection will end in the loss
of the extremity [6–9].
Table 1
Published results with the V.A.C.® therapy in wound healing disturbances following vascular reconstruction
Year
Author
n
Allplastic/
autologous
Stage (Szilagyi)
Success
full (%)
Follow up
Majoramputations
Mortality
Therapy
Duration
2001
Demaria et
al. [20]
1
0/1
III
1 (100)
12
months
0
0
23 days
2003
Demaria et
al. [21]
4
0/4
Not
stated
4 (100)
0
0
16,7 days
2003
Heller et al.
[24]
36
8 / 24
I = 11
II = 12
III = 13
36 (100)
0
0
2003
Pinocy et
al. [22]
24
24 / 0
III = 24
24 (100)
12
months
0
0
14 days
2005
Dosluoglu et
al. [23]
4
4/0
III = 4
4 (100)
18,3
months
0
0
22,8 days
2007
Kotsis et al.
[26]
8
8/0
II = 2
III = 6
8 (100)
17,2
months
0
0
21,5 days
2007
Domingos
Hadamittzky
et al. [27]
11
11 / 0
III =11
9 (81,8)
13,1
months
1
1
16 days
2008
Svensson et
al. [25]
33
21 / 12
II =12
III =21
27 (81,8)
16
months
6
9
20 days
Own
results
25
25 / 0
III = 25
20 (80)
10,2
months
2
1
22 days
Sum
146
105 / 41
Not stated = 4
I = 11
II = 26
III = 105
133 / 146
(91,1%)
9
(6,2%)
11
(7,5%)
Range
3–119
days
Infection 37 · 2009 · Supplement I © Urban & Vogel
21
V.A.C. Instill® therapy – indications and technical applications
The aim of the therapy is to clear the focus of infection
and to maintain or restitute the arterial vascular bed. To
achieve that goal, either the graft can be explanted followed
by extra-anatomic or in-situ reconstruction, or a transplantpreserving strategy can be chosen. The disadvantages of
explantation include the considerable surgical trauma, an
inferior patency as well as higher mortality and re-infection
rate in extra-anatomic reconstructions and limited availability of homografts and autologous venous grafts [10–18].
A procedure able to heal the infection while preserving the
arterial reconstruction seems to be superior, because it
avoids a main problem induced by bypass explantation, i.e.
the restitution of perfusion in the affected extremity, if this
is achievable at all.
Data published so far about the use of the V.A.C.®
therapy in wound healing disturbances following vascular
surgery are promising with a overall success rate of 90%
[19–27]. Up to now, there is no data with V.A.C. Instill®
therapy in this indication. But it seems likely, that instillation therapy with antiseptic or antimicrobial solutions can
accelerate the infection healing process. Basically, a transplant-preserving therapy attempt can only be undertaken
in circumscribed infections without complications in the
stages I–IV (table 2).
If complications of the prosthesis infection occurred
already (stage V and VI), the prosthesis must be removed
completely and an extra-anatomic or in-situ reconstruction
must be performed. A transplant-preserving strategy is
contraindicated in this case. Although cases of a successful
treatment of postoperative prosthesis infections in peri-
pheral bypass surgery with the V.A.C. ® therapy have been
reported, the use in exposed vessels still remains a contraindication according to the manufacturer due to the bleeding risk. Taking this risk into account especially during
application in anastomoses, the entire medical personal
must be specifically instructed in order to be prepared, to
recognize anastomosis bleedings immediately and ensure
an prompt vascular surgical intervention.
Results
From May 2006 to July 2007 two patients with a prosthesis infection stage III resp. IV were treated with V.A.C.
Instill® as ultima ratio in our clinic. Both patients had already undergone multiple vascular reconstructions in the
affected extremity. In both patients an aortobifemoral
prosthesis and due to a shortage of autologous venous
material an alloplastic femoropopliteal infragenual bypass had been implanted to treat advanced peripheral
artery disease (Fontaine stage IV). The first patient postoperatively developed a prosthesis infection stage
IV (MRSA) accompanied by sepsis. During the V.A.C.
Instill® therapy femoral anastomosis bleedings occurred
twice. The patient finally died from septic multiple organ
failure after explantation of the bypass and hip joint exarticulation, which became necessary. In the second patient, the prosthesis infection first could be controlled and
a complete secondary wound closure was achieved by local skin flap coverage. But this patient also died three
months later from septic multiple organ failure following
bypass closure and re-infection.
Table 2
Stages of (peri-)prosthetic infections according to Szilagyi, Vollmar, van Dongen, Zühlke and Karl
Stage
(Karl)
Extent
Szilagyi
Vollmar
Van
Dongen
I
Superficial wound healing
disturbance without exposed
prosthesis material
II
I
II
II
Partially exposed prosthesis
without involvement of the
anastomosis
III
II
III
I
a) Transplant-preserving strategy with V.A.C.® therapy
b) Bypass explantation
III
II with (partial) exposition
of the sutures in the anastomosis region
III
II
IIIa
II
a) if anastomosis is intact,
V.A.C.® therapy attempt
b) Bypass explantation
IV
Completely exposed prosthesis/patch
III
II
IIIa
II
a) Bypass explantation
b) V.A.C.® therapy attempt
V
I–IV with septic arrosion
bleeding/suture aneurysm
III
II
IIIb
III
Bypass explantation
VI
I–IV with bypass thrombosis/septic embolisation
III
II
IIIc
III
Bypass explantation
22
Zühlke
Therapeutic
Options
a) Transplant-preserving strategy with V.A.C.® therapy
b) Bypass explantation
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
Conclusion
A transplant-preserving treatment attempt with V.A.C.®
therapy in postoperative wound healing disturbances or
periprosthetic infections following femorodistal bypass implantation seems also promising in cases with partially exposed prosthesis and might be superior over bypass explantation regarding mortality and major amputation rates.
Due to the risk of arrosion bleeding, immediate vascular
surgery and specifically instructed personal must be available at any time when treating deep postoperative wound
healing disturbances following peripheral bypass implantation with V.A.C.®. So far, no data exist about V.A.C.
Instill® therapy in this indications. Regarding our experience, there might be a theoretical advantage for the
V.A.C. Instill® therapy but we could not confirm this in our
results. So far, we don’t see an advantage of the V.A.C.
Instill® therapy over the V.A.C.® therapy for the treatment
of periprosthetic vascular graft infections.
References
1. Johnson JA, Cogbill TH, Strutt PJ, Gundersen AL. Arch Surg 1988
Jul;123(7):859–62.
2. Fleesenkaemper I. Gefäßchirurgie 2004 Nov 1;9(4):316–23.
3. Pounds LL, Montes-Walters M, Mayhall CG, Falk PS, Sanderson E,
Hunter GC et al. Vasc Endovascular Surg 2005 Nov;39(6):511–7.
4. Zuhlke HV, Lorenz EP. Langenbecks Arch Chir Suppl Kongressbd
1991;527–8.
5. Szilagyi DE, Smith RF, Elliott JP, Vrandecic MP. Ann Surg 1972
Sep;176(3):321–33.
6. Mertens RA, O’Hara PJ, Hertzer NR, Krajewski LP, Beven EG J Vasc
Surg 1995 May;21(5):782–90.
7. Chalmers RT, Wolfe JH, Cheshire NJ, Stansby G, Nicolaides AN,
Mansfield AO. Br J Surg 1999 Nov;86(11):1433–6.
8. Daenens K, Fourneau I, Nevelsteen A. Eur J Vasc Endovasc Surg
2003 Mar;25(3):240–5.
9. Samson RH, Veith FJ, Janko GS, Gupta SK, Scher LA. J Vasc Surg
1988 Aug;8(2):147–53.
10. Bandyk DF, Novotney ML, Back MR, Johnson BL, Schmacht DC.
J Vasc Surg 2001 Sep;34(3):411–9.
Infection 37 · 2009 · Supplement I © Urban & Vogel
11. O’Connor S, Andrew P, Batt M, Becquemin JP. J Vasc Surg 2006
Jul;44(1):38–45.
12. Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F, Bahnini A. J Vasc
Surg 2004 May;39(5):1009–17.
13. Zegelmann M, Guenther G, Eckstein H, Kreißler-Haag D, Langenscheidt P, Mickley V et al. Gefäßchirurgie 2006 Nov 17;11(6):402–7.
14. Hardman S, Cope A, Swann A, Bell PR, Naylor AR, Hayes PD. Ann
Vasc Surg 2004 May;18(3):308–13.
15. Goeau-Brissonniere OA, Fabre D, Leflon-Guibout V, Di C, I, NicolasChanoine MH, Coggia M. J Vasc Surg 2002 Jun;35(6):1260–3.
16. Hernandez-Richter T, Schardey HM, Wittmann F, Mayr S, SchmittSody M, Blasenbreu S et al. Eur J Vasc Endovasc Surg 2003
Nov;26(5):550–7.
17. Sacar M, Goksin I, Baltalarli A, Turgut H, Sacar S, Onem G et al.
J Surg Res 2005 Dec;129(2):329–34.
18. Schmacht D, Armstrong P, Johnson B, Pierre K, Back M, Honeyman
A et al. Vasc Endovascular Surg 2005 Sep;39(5):411–20.
19. Karl T, Modic PK, Voss EU. Zentralbl Chir 2004 May;129 Suppl 1:
S74–S79.
20. Demaria R, Giovannini UM, Teot L, Chaptal PA. J Wound Care 2001
Feb;10(2):12–3.
21. Demaria RG, Giovannini UM, Teot L, Frapier JM, Albat B. J Cardiovasc Surg 2003 Dec;44(6):757–61.
22. Pinocy J, Albes JM, Wicke C, Ruck P, Ziemer G. Wound Repair Regen
2003 Mar;11(2):104–9.
23. Dosluoglu HH, Schimpf DK, Schultz R, Cherr GS. J Vasc Surg 2005
Nov;42(5):989–92.
24. Heller G, Savolainen H, Widmer MK, Makaloski V, Menth M,
Schmidli J. Zentralbl Chir 2004 May;129 Suppl 1:S66–S70.
25. Svensson S, Monsen C, Kölbel T, Acosta S. Eur J Vasc Endovasc Surg
2008 Jul;36(1):84–9.
26. Kotsis T, Lioupis C. Acta Chir Belg 2007 Jan- Feb;107(1):37–44
27. Domingos Hadamittzky C, Schulte S, Horsch S. J Cardiovasc Surg
(Torino) 2007 Aug;48(4):477–83.
Correspondence address
Dr. Thomas Karl
Clinic for Vascular Surgery
Klinikum Offenbach
Starkenburgring 66
63069 Offenbach am Main
Phone: +49 69 840 50
E-mail: [email protected]
23
V.A.C. Instill® therapy – indications and technical applications
07
Instillation therapy and chronic osteomyelitis –
preliminary results with the V.A.C. Instill® therapy
M. Leffler, R.E. Horch, A. Dragu, U. Kneser
Summary
Background: Despite advances in diagnosis and treatment
bone infections remain a clinical challenge for the reconstructive surgeon. We present our experience with the
V.A.C.Instill® therapy in patients with subacute or chronic
bone infections in combination with a microsurgical flap
reconstruction. Patients and methods: Six patients with
subacute or chronic osteomyelitis were treated with the
V.A.C.Instill® therapy. Five patients presented with an osteomyelitis of the lower extremity whereas one was located
at the upper extremity. In all patients V.A.C.Instill ®
therapy was started directly after the first radical surgical
bone and soft tissue debridement and was continued until
surgical reconstruction was possible. Three patients
received a free latissimus dorsi muscle flap whereof two
were applied in combination with an autologous venous
bypass. One defect was reconstructed by the use of a medial gastrocnemius muscle flap, one defect was covered
with a combined free latissimus-dorsi- and serratus-anterior-muscle flap and one patient received a combined free
groin and iliac crest flap. Results: V.A.C.Instill® therapy
Introduction
Osteomyelitis is an infection of the bone in combination
with the bone marrow. The acute form is defined as an early
infection within the first six weeks and occurs after trauma
or iatrogenic after surgery. The chronic form is more frequent and occurs mainly after trauma but also after endoprothetic surgery. Osteomyelitis can also be causally differentiated. The haematogenous form is distinguished from a
transmitted infection and a posttraumatic form. The reason
for the development of osteomyelitis is a massive bacterial
colonisation of the bone in combination with an impaired
perfusion of the tissue and delayed wound healing [1]. The
patient usually presents with local infection signs like swelling, redness, tissue hyperaemia and pain. Frequently a fistula
or even a tissue defect is present. Sometimes the number of
white blood cells and the C-reactive protein are increased
[2]. However clinical symptoms are often rare and therefore
diagnosis especially of a chronic osteomyelitis can be rather
difficult. Standard X-Rays are often difficult to interpret and
24
was tolerated well in all patients. After initiation of
V.A.C.Instill® therapy tissue biopsies and superficial swabs
were collected during the following dressing changes and
surgical procedures. All bacterial cultures after initiation
of V.A.C.Instill® therapy were sterile. After surgical reconstruction in all patients stable wound coverage with no
signs of recurrence of osteomyelitis was achieved. Conclusions: In severe chronic osteomyelitis often complex
microsurgical reconstructions are necessary to cure the infection and achieve stable defect coverage. V.A.C. Instill®
therapy is a safe and easy to apply procedure to treat chronic osteomyelitis supportively besides a radical surgical
debridement, microsurgical flap reconstruction and an adequate long-term antibiotic therapy. However prospective
long-term studies are necessary to demonstrate a clear benefit of this procedure in terms of recurrence of osteomyelitis and predominance of the procedure especially in
contrast to negative pressure therapy alone.
Keywords: Instillation therapy – V.A.C.Instill® – bone infection – osteomyelitis – negativ pressure therapy
therefore a CT scan or MRI scan is necessary to detect the
disease [3]. Radionuclide imaging can be help-ful especially
in the diagnosis of haematogenous osteomyelitis and in
some cases of soft tissue infection. In the presence of osteosynthesis material artefacts in the CT or MRI scan can occur,
in these cases scintigraphy with labelled leucozytes is the
most reliable investigation [4]. Unfortunately the radiographic findings can be false negative and a bone biopsy for
histological and microbiological analysis is imperative. Complications of chronic osteomyelitis include spreading of the
infection into the bone marrow leading to a bone marrow or
soft tissue abscess. This can result in a systemic inflammatory response syndrome or even sepsis and death [5, 6].
Besides this fractures and bone sequesters can occur and
osteomyelitis can lead to a disturbance of growth in children.
Malignancy is also known to arise in a wound due to underlying osteomyelitis [7].
Despite advances in diagnosis and treatment bone infections remain a clinical challenge for the reconstructive
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
surgeon. Especially the chronic osteomyelitis is a severe
condition and leads to a long duration of treatment with a
multi-step surgical approach and adjuvant treatments such
as radical surgical debridements, complex reconstructive
operations, intravenous antibiotics and a sufficient postoperative rehabilitation [8]. Promising in-vitro results in tissue
engineering exist that may offer an alternative to standard
autologous free-flap transfer [9, 10]. However these approaches are currently under pre-clinical investigation in
animal models and do not represent the clinical standard
procedure today [11]. Although reports in the literature
exist that describe a single-staged approach for surgical
treatment of chronic osteomyelitis with free vascularised
bone grafts [12] usually the reconstructive surgical treatment is a multi-step approach [13, 14]. It includes multiple
steps of radical debridement of all infected tissues. In severe
cases a flap reconstruction of the injured soft tissue and
bone is necessary to achieve a stable bone situation and defect coverage. In between the operations frequently a vacuum dressing is applied to clean the wound and keep sterile
wound conditions until surgical flap reconstruction is possible [15–17]. The newly developed V.A.C. Instill® (Kinetic
Concepts Inc., Austin, Texas) is a technique that combines
a negative pressure therapy with the instillation of topical
agents into the wound to reduce bacterial contamination
[18]. Until now little is known in the literature about the
clinical application and outcome of V.A.C. Instill® therapy
[19]. We present our experience with the V.A.C. Instill® in
patients with subacute or chronic bone infections that underwent radical debridement and surgical reconstruction.
Patients and Methods
Six patients with chronic osteomyelitis were treated with
the V.A.C. Instill® therapy between September 2007 and
October 2008 (Table 1). The mean age was 59 years. Four
patients were male and two were female. Five patients
had an osteomyelitis on the lower extremity whereas one
was located at the upper extremity. Three patients presented with a posttraumatic chronic osteomyelitis, two
with an iatrogenic osteomyelitis after total hip or knee
endoprothesis and one patient had a chronic osteomyelitis with ulcera of the lower leg without any trauma. In all
patients V.A.C. Instill® therapy was started directly after
the first radical surgical bone and soft tissue debridement
and was continued until surgical reconstruction was possible. Two to four V.A.C. Instill® cycles were done (table
1). The mean time of Instillation was 20 seconds followed
by 20 minutes interaction of the topical solution (Lavasept®) with the tissue. The negative pressure cycle lasts
three to six hours depending on the wound condition.
Dressing changes were performed every three to seven
days. In all cases the black polyurethane foam (Granufoam®, Kinetic Concepts Inc., Austin, Texas) was used.
Three patients received a free latissimus dorsi muscle flap
whereof two were applied in combination with an autologous arterio-venous loop. In one patient a combined free
latissimus-dorsi- and serratus-anterior muscle flap was
carried out. One defect was reconstructed by the use of a
medial gastrocnemius muscle flap and one patient
received a combined free groin and iliac crest flap (table
1). In every patient superficial swabs and representative
Table 1
Characteristics of six patients with chronic osteomyelitis between September 2007 and October 2008
#
Age
Diagnosis
V.A.C.Instill®cycles
Surgical treatment
1
74
Chronic tibia osteomyelitis
after total knee endoprothesis
2
Medial gastrocnemius muscle flap
2
46
Posttraumatic osteomyelitis
after open fracture of the
ankle joint
2
Free latissimus-dorsi myocutaneus flap
3
70
Posttraumatic carpal, radial
and ulnar osteomyelitis after
radius fracture and Volkmann contracture
3
Free groin and iliac crest flap
4
74
Chronic osteomyelitis of the
upper and lower ankle joint
3
Combined free latissimus-dorsi- and serratus-anteriormuscle-flap
5
60
Chronic osteomyelitis after
total hip endoprothesis and
girdlestone situation
2
Free latissimus-dorsi-myocutaneus flap in combination
with an arterio-venous loop
6
30
Subacute osteomyelitis after
open tibia fracture
2
Free latissimus-dorsi-flap in combination with an arterio-venous loop
Infection 37 · 2009 · Supplement I © Urban & Vogel
25
V.A.C. Instill® therapy – indications and technical applications
Table 2
Microbiological germ characteristics in superficial swabs and tissue biopsies of six patients with chronic osteomyelitis before and
after treatment with the V.A.C. Instill® therapy
#
Swab prior to V.A.C. Instill®
Tissue biopsy prior to
V.A.C. Instill®
Swab after
V.A.C. nstill®
Tissue biopsy after
V.A.C. Instill®
1
Staphylococcus epidermidis
Staphylococcus epidermidis
Sterile
Sterile
2
Sterile
Sterile
Sterile
Sterile
3
Staphylococcus epidermidis
Staphylococcus epidermidis
Sterile
Sterile
4
Staphylococcus epidermidis,
acinetobacter baumanii
Staphylococcus epidermidis, acinetobacter baumanii
Sterile
Sterile
5
Staphylococcus epidermidis
Staphylococcus epidermidis
Sterile
Sterile
6
Staphylococcus epidermidis
Staphylococcus epidermidis
Sterile
Sterile
tissue biopsies were taken for microbiological analysis
prior to V.A.C. Instill® application during the first surgical debridement. Five patients presented with a staphylococcus epidermidis prior to V.A.C. Instill® therapy, in one
of these patients an additional acinetobacter baumanii
was detected (table 2). One patient had sterile wound
conditions prior to V.A.C. Instill® therapy. Tissue biopsies were also taken for histopathology examination during the first surgical debridement. All patients received
1a
1c
a germ directed antibiotic treatment for at least six weeks.
Follow-up was three to ten months.
Results
V.A.C. Instill® therapy was tolerated well in all patients.
After initiation of the V.A.C. Instill® therapy all bacterial
cultures were sterile (table 2). After surgical reconstruction
stable wound coverage with no evidence of flap loss or recurrence of osteomyelitis was achieved in all patients.
1b
1d
Fig. 1a, b, c, d: A 46 year old patient (#2) with a soft tissue defect and visible bone and osteosynthesis material in the wound after a distal
tibia and fibula fracture and chronic osteomyelitis of the upper ankle joint. C: X-Ray imaging after removal of the osteosynthesis plate, radical
surgical debridement and external bone fixation. D: After radical surgical debridement a V.A.C. Instill® dressing was applied.
26
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
Case #2:
A 46 year old male patient was admitted to our clinic with
a soft tissue defect of his left lower leg and a chronic osteomyelitis after distal tibia and fibula fracture five
months ago. Initially the fracture was treated with an internal fixation. Delayed union occurred and he developed
a pseudarthrosis of his left upper ankle. Therefore an arthrodesis of the left upper ankle was performed. Unfortunately delayed healing again occurred followed by a
soft tissue defect with visible bone and osteosynthesis material in the wound (fig. 1a, b). The c-reactive-protein was
increased (53 mg/l), the white blood count was normal.
Conventional X-Ray imaging showed a destruction of the
upper ankle joint and a delayed bone healing with inflammatory signs of the periosteum. MRI scan showed
strong suspicion of osteomyelitis of the left distal tibia and
fibula. Superficial swabs and bone biopsies from tibia and
fibula did not detect a bacterial colonisation. Radical
bone and soft tissue debridement was performed with removal of the osteosynthesis material. Afterwards external
fixation of the bone and V.A.C. Instill® dressing were applied (fig. 1c. d). After six hours of negative pressure
therapy Instillation therapy was started with 20 seconds;
instillation of Lavasept® followed by 20 minutes interaction of the wound and the solution. Four hours of negative pressure therapy were followed by the next V.A.C.
Instill ® cycle. Histopathology of the removed bone
showed typical morphological signs of a chronic osteomyelitis (fig. 2). The patient received intravenous antibiotics
(cefotiame) followed by an oral treatment for a total of
six weeks. V.A.C. Instill® dressing change was done after
six days. After another six days of V.A.C. Instill® therapy
the ankle joint arthrodesis was stabled by readjustment of
the external fixation. For defect coverage a latissimusdorsi muscle flap with a separate skin island based on a
thoracodorsal-artery-perforator (TAP) was applied with
a microsurgical anastomosis of the thoracodorsal artery
and vein to the anterior tibial vessels in an end-to-side
fashion (fig. 3, fig. 4 a, b). Three months postoperatively
the wound conditions were stable with minimal areas of
secondary healing (fig. 4c, d). Six months postoperatively
the wounds were healed completely, the external fixation
Fig. 2: Histopathology
of the removed bone
in patient #2 showed
typical morphological
signs of a chronic osteomyelitis (Hematoxillin/Eosin staining).
is planned to be removed eight months postoperatively.
Currently there were no signs for recurrence of osteomyelitis.
Case #4:
A 74 year old female patient presented with two chronic
ulcers of her right lower leg without any trauma or surgical procedure in the past (fig. 5a, b). Laboratory parameters like white blood count and CRP were normal. Conventional X-Ray imaging showed an inflammatory destruction of the upper and lower ankle joint (fig. 5c, d).
MRI-scanning showed typical signs of a chronic osteomyelitis of the upper and lower ankle joint (fig. 6). Radical
surgical debridement was carried out and tissue biopsies
were taken for microbiological and pathologic analysis.
A V.A.C. Instill® dressing was applied and instillation
therapy was started with 20 seconds; instillation (Lavasept®) followed by 20 minutes of interaction of the topical
solution with the wound. A negative pressure therapy
Latissimus dorsi
muscle
Thoracodorsal
artery perforator
Skin island
3a
Infection 37 · 2009 · Supplement I © Urban & Vogel
3b
Thoracodorsal
artery and vein
Fig. 3: Wound situation in
patient #2 after two cycles of
V.A.C.Instill® therapy (a).
A latissimus-dorsi muscle flap
with a separate skin island based
on a thoracodorsal-artery-perforator (TAP) was applied for defect
coverage (b).
27
V.A.C. Instill® therapy – indications and technical applications
4a
4b
4c
4d
Fig. 4: Initial postoperative result in patient #2; after defect coverage with a latissimus-dorsi muscle flap in combination with a separate skin
island (a). X-ray after readjustment of the external bone fixation (b). Three months postoperatively wound conditions were stable with minimal areas of secondary healing (c, d).
(125 mmHg) for four hours was followed by the next
instillation cycle. The superficial swabs and the tissue cultures showed staphylococcus epidermidis and acinetobacter baumanii. Germ-directed antibiotic treatment was
started intravenously with ceftazidime and fosfomycine
and was converted after three weeks into an oral treatment with cotrimoxazole and rifampicine for another
three weeks. After three days and another six days a
V.A.C. Instill® dressing change was carried out. Bacterial
cultures after the initial debridement were sterile and after a total of 18 days of V.A.C. Instill® therapy the patient
received a combined free latissimus-dorsi- and serratusanterior-muscle-flap for reconstruction (fig. 7a–7d).
Three months postoperatively stable defect coverage was
obtained and the patient was planned for an arthrodesis
of the ankle joint six months after flap reconstruction.
There were no signs of recurrence of osteomyelitis.
Discussion
Chronic osteomyelitis is still difficult to treat and remains
a challenge for the clinician. It is often difficult to diagnose
because laboratory parameters as well as radiological and
microbiological findings can be false negative. The positive
bone histology is obligatory to confirm the diagnosis of
chronic osteomyelitis. The treatment consist of a radical
surgical debridement usually followed by a temporary defect coverage (e.g. with a vacuum dressing) and intravenous
antibiotics for four to six weeks. In most cases sequential
surgical debridements are necessary in order to remove all
affected tissue. After sufficient debridement of the wound
without any signs of bacterial colonisation the defect is reconstructed mostly using free flap transfer. In severely affected extremities with a large zone of injury or pre-existing vascular occlusive disease autologous venous bypasses
might be utilized as recipient vessels [20].
Because multiple operative steps prior to reconstruction are necessary, application of a vacuum dressing has
become a standard procedure in the treatment of osteomyelitis with soft tissue defects [21–23]. It has a high patient
comfort, helps cleaning the wound and keeps the wound
sterile. Besides this it leads to removal of exudates, improvement of tissue perfusion and formation of granulation
5a
5b
28
5c
5d
Fig. 5: A 74 year old female patient
(#4) presented with two chronic ulcers
of her right lower leg (a, b). Conventional X-Ray imaging showed an inflammatory destruction of the upper
and lower ankle joint (c, d).
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
Fig. 6: MRI-scanning in patient #4
showed typical signs of a chronic osteomyelitis of the upper and lower ankle
joint.
tissue [17, 24]. There is also evidence for neoangiogenesis
in the wound which can be supportive in the patient’s defence of the infection [25].
The introduction of the V.A.C. Instill® therapy is a
promising approach to increase the chances of success in
the treatment of patients with chronic osteomyelitis. It
was first described by Fleischmann et al. in 1998 [26]. In
2005 and 2006 Labler and Trentz reported an in vitro model which analysed the commercial V.A.C. Instill® therapy
settings [27, 28].
Until now little is known in the literature about the
clinical application and outcome of V.A.C. Instill ®
therapy. A few case reports and retrospective clinical studies exists that describe a positive effect of the instillation
7a
7c
Infection 37 · 2009 · Supplement I © Urban & Vogel
therapy in combination with negative pressure therapy in
infected hip and knee joint endoprotheses [19, 29] and
posttraumatic osteitis and osteomyelitis [30]. Besides this
Gabriel et al. reported their experience with the V.A.C.
Instill® compared to standard moist wound dressing in
complex infected wounds in a prospective pilot study [31].
Our experience with the V.A.C. Instill® therapy confirms
these preliminary reports. It is easy to apply and has a
high patient comfort. In our series all tissue biopsies and
superficial swabs were negative after V.A.C. Instill®
therapy was initiated. Until now no recurrence of osteomyelitis was detected. However long-term follow-up and
prospective clinical trials are needed to verify these preliminary results.
7b
7d
Fig. 7: Wound situation in patient #4
after a total of 18 days of V.A.C. Instill®
therapy (a, b). A combined free latissimus-dorsi- and serratus-anterior
muscle flap for reconstruction of the
lower leg was carried out (c ). Three
months postoperatively stable defect
coverage was obtained (d).
29
V.A.C. Instill® therapy – indications and technical applications
Conclusion
V.A.C. Instill® therapy is a safe and easy to apply procedure to treat osteomyelitis supportively besides a radical
surgical debridement, surgical reconstruction and an
adequate germ-directed antibiotic therapy. However prospective long-term studies are necessary to demonstrate
a clear benefit of this procedure in terms of recurrence of
osteomyelitis and predominance of the procedure
especially in contrast to negative pressure therapy alone.
References
1. Concia E, Prandini N, Massari L, Ghisellini F, Consoli V, Menichetti F,
Lazzeri E. Nucl Med Commun 2006;27:645–660.
2. Wilson ML, Winn W. Clin Infect Dis 2008;46:453–457.
3. Umans H, Haramati N, Flusser G. Magn Reson Imaging 2000;
18:255–262.
4. Palestro CJ, Torres MA. Semin Nucl Med 1997;27:334–345.
5. Al-Nammari SS, Gulati V, Patel R, Bejjanki N, Wright M. J Orthop
Surg (Hong Kong) 2008–16:54–57.
6. Davidovich T, Rimbroth S, Chazan B, Colodner R, Markel A. Isr Med
Assoc J 2008;10:653–654.
7. Bauer T, David T, Rimareix F, Lortat-Jacob A. Rev Chir Orthop Reparatrice Appar Mot 2007;93:63–71.
8. Patzakis MJ, Zalavras CG. J Am Acad Orthop Surg 2005;13:417–427.
9. Bach AD, Arkudas A, Tjiawi J, Polykandriotis E, Kneser U, Horch RE,
Beier JP. J Cell Mol Med 2006;10:716–726.
10. Kneser U, Stangenberg L, Ohnolz J, Buettner O, Stern-Straeter
J, Mobest D, Horch RE, Stark GB, Schaefer DJ. J Cell Mol Med
2006;10:695–707.
11. Kneser U, Schaefer DJ, Polykandriotis E, Horch RE. J Cell Mol Med
2006;10:7–19.
12. Rhomberg M, Frischhut B, Ninkovic M, Schwabegger AH, Ninkovic
M. Plast Reconstr Surg 2003;111:2353–2361; discussion 2362–2353.
13. Kneser U, Bach AD, Polykandriotis E, Kopp J, Horch RE. Plast Reconstr Surg 2005;116:1910–1917.
14. Pelissier P, Boireau P, Martin D, Baudet J. Plast Reconstr Surg
2003;111:2223–2229.
30
15. Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. Ann Plast Surg
2007;58:397–404.
16. Schipper J, Leffler M, Maier W, Kopp J, Bach AD, Horch RE. Zentralbl
Chir 2006;131 Suppl 1:S141–145.
17. Horch RE. Zentralbl Chir 2004;129 Suppl 1:S2–5.
18. Riepe G, Schneider M. Zentralbl Chir 2006;131 Suppl 1:S157–159.
19. Kirr R, Wiberg J, Hertlein H. Zentralbl Chir 2006;131 Suppl 1:S79–82.
20. Cavadas PC. Plast Reconstr Surg 2008;121:514–520.
21. Loos B, Kopp J, Hohenberger W, Horch RE. Eur J Surg Oncol
2007;33:920–925.
22. Horch RE, Dragu A, Lang W, Banwell P, Leffler M, Grimm A, Bach AD,
Uder M, Kneser U. J Cutan Med Surg 2008;12:223–229.
23. Strecker T, Rosch J, Horch RE, Weyand M, Kneser U. Heart Surg Forum 2007;10:E366–371.
24. Horch RE. Zentralbl Chir 2006;131 Suppl 1:S44–49.
25. Grimm A, Dimmler A, Stange S, Labanaris A, Sauer R, Grabenbauer
G, Horch RE. Strahlenther Onkol 2007;183:144–149.
26. Fleischmann W, Russ M, Westhauser A, Stampehl M. Unfallchirurg
1998;101:649–654.
27. Labler L, Trentz O. Biomed Tech (Berl) 2005;50:413–418.
28. Labler L, Trentz O. Biomed Tech (Berl) 2006;51:30–37.
29. Lehner B, Bernd L. Zentralbl Chir 2006;131 Suppl 1:S160–164.
30. Brem MH, Blanke M, Olk A, Schmidt J, Mueller O, Hennig FF, Gusinde J. Unfallchirurg 2008:111:122–125.
31. Gabriel A, Shores J, Heinrich C, Baqai W, Kalina S, Sogioka N, Gupta
S. Int Wound J 2008:5:399–413.
Correspondence address
Dr. Mareike Leffler
Department of Plastic and Hand Surgery
University Hospital Erlangen-Nürnberg
Krankenhausstrasse 12
91054 Erlangen
Germany
Phone: + 49 9131 853 32 96
Fax: +49 9131 853 93 27
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
08
The impact of V.A.C. Instill® in severe soft tissue
infections and necrotizing fasciitis
M.V. Schintler, E.-Ch. Prandl, G. Kreuzwirt, M.R. Grohmann, S. Spendel, E. Scharnagl
Introduction
Primary goal of infection surgery is clinically securing
diagnosis [1] and saving bacterial agents for culture. Main
principle of infection surgery has always been radical
debridement. “Ubi pus, ibi evacua” (fig 1), the old dictum
of Celsus, often cited in medicine is not enough at all. All
necrotic and infected tissue should be resected to healthy
tissue in case of limb or life threatening infections, better
said in all complicated skin and soft tissue infections (criteria approved by the FDA [2]).
In case of necrotizing fasciitis quite a sizable incision is
necessary and amounts of tissue loss and huge defects can
result. In time of minimal invasive surgery those different
approaches cannot be brought in harmony. Till now there
isn’t any alternative action to aggressive debridement [1],
quite apart from prevention and early treatment. In case of
inestimable extent of infection, planned redebridements
[1,3] are essential every 12–24 hours.
Deep tentative incision
Radical debridement
Amputation
Intensive care
Programmed
redebridement
Antibiosis
Fig. 1: Deep femoral
abscess, inguinal fistula
one year after necrotising fasciitis, probing
leads to evacuation of
700 ml pus.
Only in case of early diagnoses and radical surgical
debridement survival of patients is possible [4]. Total resection of necrotic tissue, including disintegrated toxic bacterial products can intercept perpetuation of systemic sepsis.
Limited surgical debridement leads to jump in fatality rate
up to 75–100 % [4]. According to Kujath’s algorithm systemic antimicrobial agents and intensive care together with
surgical therapy are the key to infection control and survival (fig. 2).
For more than ten years the V.A.C.®-device is successfully used in trauma wounds, as well in chronic wounds
and in wound infections [5]. Preparing wounds for closure
means to clean wounds, to achieve wound retraction and
decrease bacterial load to minimize following surgical
procedures and enable premature wound closure. Infection control can be difficult or even impossible in case
of insufficient debridement or persistence of bacteria
[6].
Stage-adapted wound therapy (e.g. vacuum assisted closure)
Material und methods
Meshed split thickness skin graft
Secondary sutures
Flap surgery
Mobilisation and discharge
Fig. 2: Kujath´s algorithm for treatment of complicated skin and soft
tissue infection (cSSTI) [1].
Infection 37 · 2009 · Supplement I © Urban & Vogel
The V.A.C. Instill® enables a 3 stage-working cycle: vacuum therapy – instillation of antiseptic fluids – time to
reaction. We have always been using Polyhexanid (Lavasorb®, Lavasept®) for instillation. From 10/2007–10/2008
15 patients were treated by V.A.C. Instill®. In all cases
radical debridement was preceding. Surgical debridement
alone followed by flap coverage or skin grafting seemed
to be not suitable for infection control. In eight patients
exposed bone or septic arthritis with doubtful eradication
31
V.A.C. Instill® therapy – indications and technical applications
ing changes were performed every two to four days (fig.
4). White foams as well as black foams and combinations
of both were used (fig. 5). Surgical closure was performed
by direct secondary suture, skin grafting or flap surgery.
Results
Fig. 3: After evacuation
and limited debridement (abscess membrane including femoral
vessels, widely branched between adductor
muscles) application of
VAC-instill.
Fig. 4: Dressing change
every 48–72 hours,
combination of white
foam, deeply positioned
to the femoral vessels,
including instillation
drain, black foam with
suction drain.
In all cases infection control and complete healing was
achieved, despite of incomplete debridement in cases of
open joints and exposed bone, and leaving prolene mesh in
situ in two cases.
Conclusion
We believe the V.A.C. Instill® to be a useful tool for
infection control in difficult anatomical regions and in case
of impossibility of totally debridement in complicated skin
and soft tissue infections. We propose earlier wound
closure could be possible when using the V.A.C. Instill®
device. The preservation of implants, already successfully
described in orthopaedic surgery, seems possible.
Controlled randomised studies to compare V.A.C. Instill®
treatment versus open moist wound care in complicated
skin and soft tissue infections are necessary.
References
Fig. 5: Secondary wound
closure after ten days,
complete infection control and healing.
of infection in case of flap coverage justified the application of V.A.C. Instill®. Two cases of necrotizing fasciitis
and one case of full chest thoracic wall defect with multiresistant Acinetobacter baumanii infection following immunsuppressive therapy of pyoderma gangrenosum after
breast reconstruction required V.A.C. Instill ® treat ment for control and healing of life-threatening infection.
Instillation time directly depended on wound size (fig. 3),
time of reaction was 20 minutes in all cases. Time of
therapy lasted at least four days, at most 18 days. Dress-
32
1. Kujath P, Eckmann C, Bouchard R, Esnaashari H. Zentralbl Chir
2007;132:411–418·
2. Uncomplicated and complicated skin and skin structure infections-developing antimicrobial drugs for treatment. Guidance for
Industry : Center for Drug Evaluation and Research (CDER). 1998.
Available at: http://www.fda.gov/cder/guidance/2566dft.pdf.
3. Kaiser RE, Cerra FB. J Trauma 1981;21:345–355.
4. Eckmann C, Soetbeer F, Schroeder M, Kujath P. Surg Infect 2005;6:
159.
5. Argenta LC, Morykwas MJ. Ann Plast Surg 1998;38:563–577.
6. Kujath P. In: Kujath P (Hrsg). Haut- und Weichgewebsinfektionen.
2. Auflage. Uni-Med, Bremen, London, Boston 2004;81–83.
Correspondence address
Ass. Prof. Dr. Michael Valentin Schintler
Clinical Department of Plastic Surgery
Auenbruggerplatz 29
A 8036 Graz
Medical University Graz
Phone: +43 316 385 81904
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
09
Vacuum-assisted closure and instillation dressing
(V.A.C. Instill®) in the treatment of open fractures
G. Amtsberg, M. Frank, J. Lange, M. Gondert, A. Kramer, A. Ekkernkamp, P. Hinz
Introduction
Open fractures with severe contamination (Grade II–III)
remain a therapeutic challenge [1]. Despite the use of modern antimicrobials, bacteria in deep wound areas are difficult to eradicate. If managed inefficiently, progressive
soft tissue loss and uncontrolled inflammation may result
in major amputation [2, 3].
Radical debridement and pulsatile lavage are key components of early treatment [2]. Foreign bodies and necrotic
tissue predispose to infection and must be removed.
Fractures need to be stabilized by external fixation, with
screws placed safely away from the injury site. Wound
swabs or tissue samples should be collected prior to and
after surgery to adapt the antibiotic strategy [4].
Vacuum dressings have emerged as an important treatment option for complicated and deep traumatic soft tissue
defects [8]. The V.A.C. Instill® system allows for intermittent application of antiseptics like polihexanid (Lavasept®)
[6, 9], thus clearing and decontaminating the wound [5–8].
This forms the basis for definitive internal fixation and later wound closure by a skin flap or split skin graft. We herein present a case report stressing a potential indication for
the V.A.C. Instill® in the setting of orthopaedic trauma.
Case report
A 43 year old motorcyclist sustained a grade III open,
multi-level fracture of the left lower leg as part of multiple
trauma. The lateral lower leg showed a wound of 12 x 8 cm,
contaminated with mud (fig. 1). The fracture was stabilized
by external fixation, followed by extensive wound debridement, lavage, and soft tissue coverage by a vacuum dressing.
Despite continuous suction, the patient developed a
massive soft tissue infection with putrid secretion. E. coli
was identified as the causative germ by multiple wound
swabs. The initial coverage was replaced by the V.A.C.
Instill® polyurethane foam, and 100 ml of Lavasept® 0.1%
were instilled seven times daily for 20 minutes. Continuous
suction with a negative pressure of 150 mmHg over two
hours was applied thereafter (fig. 2). Instillation therapy
was interrupted during the night.
The wound was surgically revised every three days until macroscopic improvement, and later inspected every
six days. The patient received 500 mg of Tavanic®, which
Infection 37 · 2009 · Supplement I © Urban & Vogel
could be stopped after three days because of significantly
improved local conditions. At day 10, the wound was clean,
and the lower leg fracture was stabilized by intramedullary
nailing. The defect was covered with a split skin graft on
day 16 (fig. 3).
Discussion and outlook
In the presented case with massive microbial contamination, the combination of vacuum sealing and antiseptic
cleansing provided ideal conditions for intramedullary
Fig. 1: Contaminated wound on the lateral lower leg.
Fig. 2: V.A.C. Instill® dressing of the wound on the lateral lower leg.
33
V.A.C. Instill® therapy – indications and technical applications
References
Fig. 3: Defect coverage of the wound on the lateral lower leg with
split skin.
fixation and limb salvage. The V.A.C. Instill® system did
not only assist in eradicating bacteria, but induced wound
granulation as well. It is likely that other attempts of
wound conditioning would have failed in the particular
setting, and that the combination of V.A.C. Instill® and
proper surgical management helped to preserve the
injured extremity. A randomized trial comparing V.A.C.
Instill® to the standard of care is needed to prove its
effectiveness.
1. Frank M, Matthes G, Bauwens K, Hinz P, Ekkernkamp A. Eur J
Trauma Emerg Surg 2007;33(Suppl II):82.
2. Hinz P, Boenigk I, Ekkernkamp A, Wolf A, Kramer A. Tägl. prax
2008;49:73–81.
3. Ostermann PA, Hahn MP, Henry SL, Seligson D. Zentralbl Chir
1996;121:990–993.
4. Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Lancet
Infect Dis 2001;1:175–188.
5. Kramer A, Hinz P, Maier S, Hübner NO, Assadian O. Medizin & Praxis 2008;5:27–32.
6. Kramer A et al. Hyg Med 2004;29(5):147–157.
7. Fleischmann W, Russ M, Westhauser A, Stampehl M . Unfallchirurg
1998;101:649–654.
8. Dedmont BT, Kortesis B, Punger K, Simpson J, Argenta J, Kulp B et
al. J Orthop Trauma 2007;21:11–17.
9. Kramer A, Roth B. Polihexanid. In: Kramer A, Assadian O (Hrsg.)
Wallhäußers Praxis der Sterilisation, Desinfektion, Antiseptik und
Konservierung. Thieme, Stuttgart, 2008;789–93.
Correspondence address
Dr. Gerlind Amtsberg
Ernst Moritz Arndt University Greifswald
University Hospital Greifswald
Unit for traumatologic and reconstructive surgery
Ferdinand-Sauerbruch-Straße
17475 Greifswald
E-mail: [email protected]
10
Optimizing the microbiologic diagnostics
in septic orthopedics
M. Kommerell, S. Brunner, O. Nolte, B. Lehner
Summary
Periprosthetic infection remains a main complication in
arthroplasty. Diagnosis is a challenge and has to include a
variety of investigations. Precise definition of the infectious
origin is essential. Optimal microbiological diagnostics
using aspirates and tissue samples can optimize microbio-
Septic arthritis and TEP infections
Infections of total endoprothetics (TEP’s) are a common
problem in the orthopaedic setting, because local immune
response is suppressed which enhances susceptibility of
the joint for infections further. The risk for periprosthetic
34
logical results. Care has to be taken to find out whether
biofilm formation is the reason for the infection. New
diagnostic procedures can lead to better results.
Keywords: Periprosthetic infection – microbiology – biofilm – blood culture bottle
infection is 1–3% and increases in the case of revision
arthroplasty [1, 2].
While the fate of an individual TEP infection may not
be influenced in every case by medical intervention, precise
clarification of the infectious origin by optimal microbio-
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
logic diagnostics enables the clinician to provide the best
available treatment for the individual patient.
The best individual treatment for every periprosthetic
infection therefore is a result of interdisciplinary diagnosis
as a combination of clinical, radiological, histological and
microbiolocal findings.
Premises of optimal diagnostics
Improvement of diagnostics
Early postoperative infections are most often caused by
staphylococcus aureus with substantial numbers of coagulase negative staphylococci and gram-negative bacilli. The
majority of chronic infections are caused by staphylococci
with coagulase negative staphylococcus being the most
common species. gram negative bacilli, streptococcus and
enterococcus species and rarely anaerobes are also seen in
chronic infections. Also acute hematogenous infections are
caused by Staphylococcus aureus.
A number of factors are critical to achieve optimal
microbiological diagnostic results. One main issue is the
choice of the most appropriate sampling method. As a matter of fact, simple swaps from the site of infection are inadequate if not useless. Optimal specimens are obtained
either via puncture or – if sampling is done during joint
surgery – by scraping off tissue or debris from the infected
site or implant. Samples of tissue also should be transferred
to histological investigation.
Since the discrimination from contaminating flora and
the correct identification of the infection causing microorganism is a prerequisite, specimens for microbiologic
investigation have to be sampled under the most achievable sterile conditions (fig. 1).
In order to obtain optimal results, tissue samples as
well as aspirates should be transferred into a small volume
of sterile, physiologic saline (NaCl) (fig. 2). However, the
sample must not be put into formaldehyde since this inhibits not only downstream processing by means of culture
but may also inhibit analysis by molecular methods.
Even with this optimal approach the sensitivity of the
culture is moderate (estimated to be 65%) since in TEP
infections bacteria may either be covered in organic slime
Fig. 1: Aspiration of
synovial fluid under
aseptic conditions.
Infection 37 · 2009 · Supplement I © Urban & Vogel
(biofilms) or the actual amount of bacteria may be very
low. Furthermore, even sterile obtained samples are at risk
of secondary contamination. While potential contaminating germs may overgrow the pathogen, the latter may suffer from long transportation times, reducing sensitivity
even more.
In our previously published study [5] we have shown that
sensitivity of the culture can be increased with the use of
blood culture bottles (PEDS bottles), which are commercially available from different suppliers (e.g. Becton
Dickinson). In fact these systems have a number of advantages over conventional diagnostics because the detection
of pathogen growth is extremely sensitive while automated.
This means that if routinely applied in the diagnostics of
TEP infections the overall diagnostics can be improved.
Optimal use of PEDS Bottles requires 1–3 ml of sterile
obtained puncture aspirate, injected under maximum sterility into the sealed flasks (fig. 3). Remaining aspirate can be
used for further downstream analysis (i.e. synovial analysis).
The inoculated blood culture bottles are kept at room temperature until transport to the laboratory. A previously published study demonstrated the usefulness of this approach.
Ninety-seven samples were analysed of which eleven or 32%
remained sterile by conventional culture while yielding
growth of a pathogen in the blood culture system.
The time of bacterial culture still should be prolonged
up to 13 days because organisms indicating infection could
be found up to 13 days whereas after seven days the detection rate via culture was only 73% [3]. The longer the time
of culture the higher the risk of contamination should be
estimated. Early detection of infection is more valid.
Perspectives
Failure to detect a pathogen in cases of septic arthritis or
TEP infections can be a result of inappropriate sampling or
of factors like biofilm formation, sparse distribution of
micro-organisms in the specimen or simply non-culturable
micro-organisms. To improve results of microbiologic dia-
Fig. 2: Collection of
tissue in NaCl.
35
V.A.C. Instill® therapy – indications and technical applications
diagnostics, at least in those cases which fail to deliver a
culture based diagnostic result despite a septic origin of the
disease.
However, molecular based methods (i.e. PCR) are
highly sensitive and therefore even more vulnerable to
contamination. A further constraint is that susceptibility
testing is not possible using nucleic acid amplification and
sequencing. The knowledge of antibiotic resistances is
however substantial for one stage revision surgery with
specially prepared bone cement.
Conclusion
Optimal diagnostic in cases of TEP infection is a result of
interdisciplinary collaboration between clinician and diagnostician. Use of optimal specimens in combination with
advanced methods (blood culture system for detection or
enrichment, molecular detection and identification) were
necessary.
Fig. 3: Injection of synovial
fluid into PEDS bottle.
gnosis sonication of removed hip and knee prostheses for
diagnosis of infection can be performed [4]. Culturing sonicate fluid improved the number of proven infections. In
comparison to conventional culture of periprosthetic tissue
samples sensitivity increased from 60.8% to 78.5% and
specifity was comparable (98.8% vs. 99.2%). However this
technically demanding technique only can be performed in
specialized laboratories.
In recent times, molecular methods have moved into
focus, providing an interesting perspective for the future.
Of particular interest is the amplification of the prokaryotic 16S rDNA or 16S-21S rDNA intergenic region with
subsequent sequence determination. Although not routinely available at this time (and if available, very costly)
this method provides an additional chance for accurate
36
References
1. Gaine WJ, Ramamohan NA, Hussein NA, Hullin MG, McCreath SW J
Bone Joint Surg Br 2000;82:561–565.
2. Ruchholtz S, Täger G, Nast-Kolb D. Unfallchirurg 2004;107: 307–319.
3. Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Clin
Infect Dis 2008;47:1403–1409.
4. Trampuz A, Piper KE, Jacobsen MJ, Hanssen AD Patel R. N Engl J Med
2007; 357:654–663.
5. Weiss S, Geiss H, Kommerell M, Simank HG, Bernd L, Henle P. Orthopäde 2006; 35(4):456,458–62.
Correspondence address
Dr. Mechthild Kommerell
Medizinisches Labor Brunner
Mainaustr. 48 a/b
78464 Konstanz
Phone: +49 7531 81 73-0
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
11
First experiences with the vacuum-instillation
therapy in plastic surgery
J.P. Stromps, G. Kolios, C.Y. Choi, C.C. Cedidi
Since many years, the traditional vacuum therapy is an
established method for wound conditioning in plastic surgery [1]. We wanted to find out, if the vacuum-instillation
therapy [2] offers an additional benefit in plastic surgery.
Since December 2007 our hospital is participating in a
clinical trial evaluating V.A.C. Instill®.
Up to now, twelve patients (three women, nine men;
average age 52,5 years) have been treated with V.A.C.
Instill® in this study. The indications this technique was used
for, included infected, chronic or deep wounds as well as
wounds associated with exposed functional structures.
We decided, to set a standardized program for the
application (table 1).
In figure 1 we present an example of a patient with an
extensive decollement of the right heel and soft tissue damage grade III due to an accident caused by a forklift. The
wound was debrided, and an instillation therapy was
initiated.
After five days of V.A.C. Instill® treatment the wound
was clean and showed good granulation (fig. 2). Therefore
a micro-surgical coverage with a myocutaneous latissimusdorsi flap could be performed (fig. 3).
In some of our cases we encountered several technical
problems:
1) Depending from the localization of the defect the instillation fluid sometimes was distributed unevenly in
the wound.
2) The application of the system requiring two TRACpads® represents a challenge in small wounds.
3) In patients mobilized completely sometimes leakiness
was observed, because the foil came off dangling parts
of the body due to the pressure induced by the soaked
through foam.
4) It was very difficult to mobilise elderly patients carrying the relatively large device (compared to the traditional V.A.C.® system).
Our overall impression is, that the instillation therapy is
increasing the options for wound clearing and conditioning
and therefore represents an useful addition to the traditio-
Fig. 1: Defect prior to instillation therapy.
Table 1
Program setting for the VAC-Instill® therapy
Suction
125 mmHg
Instillation cycle
6 hours (4x daily)
Instillation hold
8 minutes
Instillation time
Depending from the wound size (5-20 seconds)
Instillation solution
0,04% Polyhexanide-Ringer solution
Foam
V.A.C.-Granu-Foam® (black)
Infection 37 · 2009 · Supplement I © Urban & Vogel
37
V.A.C. Instill® therapy – indications and technical applications
Fig. 2: Wound situation after five days of instillation therapy.
Fig. 3: Early postoperative result.
nal V.A.C. therapy in plastic surgery. The humidity created
in the wound area seems to protect exposed functional
structures like tendons from exsiccating and undergoing
necrosis. However, it must be further investigated, if the
number of debridements, V.A.C. dressing changes or the
length of hospital stay [3] can be reduced by the V.A.C.
Instill® therapy.
2. Jerome D. J Wound Ostomy Continence Nurs 2007:34(2):191–4.
3. Gabriel A, Shores J, Heinrich C et al. Int Wound J 2008:5(3):399–
413.
Literatur
1. Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta
J. Plast Reconstr Surg 2006:117(7 Suppl):121S–6S.
Correspondence address
Dr. med. Jan-Philipp Stromps
Klinik für Plastische Chirurgie
Klinikum Bremen-Mitte
St.-Jürgen-Straße 1
D-28177 Bremen
Phone: +49 421 497 38 46
E-mail: [email protected]
12
V.A.C. Instill® technology in
spinal column surgery
R. Neef, M. Planert, K. Brehme
The bacterial infections of the spinal column can be divided
into a primary and secondary group.
The first one includes spondylodiscitis with an
incidence rate of 1 : 250 000 inhabitants/year. This destructive inflammatory disease therefore makes up 2–7% of all
osteomyelitis cases [2]. The unspecific form is primarily
caused by staphylococcus and streptococcus, while mycobacteria tuberculosis and treponema pallidum cause the
majority of the specific form [5]. Although even today
many spondylitis patients are conservatively treated with
great success, abscess formation, failure of conservative
therapy, neurological complications/transection, septicaemia, instability, the reduction of a progressive spinal column deformity or a desired quick mobilisation make operative procedures necessary.
38
Diagnostic-therapeutic manipulations preceded many
other primary infections of the spinal column. These iatrogenic causes include facet infiltrations, intrathecal injections, spinal and peridural anaesthetic as well as kyphoplasty and vertebroplasty. Another form of vertebral infection is the spinal epidural empyema. This arises due to direct
extension of paravertebral centres of infection or as local
metastasis in bacteraemia during systemic infections. The
incidence of key spintomographically secured diagnoses is
estimated at two cases/10.000 hospital admissions [4].
The group of secondary infections includes implant
associated bacterial inflammations after spinal column
operations. The main indications of these intrusions are
provided by degenerative illnesses such as spondylosis or
mechanical spinal disc destructions and injuries of the ver-
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
tebral bodies and lacerations of spinal discs and vertebral
ligaments due to accidents.
In the case of poly traumatised patients the percentage
of spinal injuries is 20%. According to the figures of the
trauma register half of these are to be allocated to serious
and the most serious vertebral body fractures [7].
Principally for a vacuum treatment on the spinal column the post operative circumstances need to be revised:
infection of access ways and puncture channels and very
rarely infected soft tissue defects after open spinal column
injuries. Therefore the operative procedure must be differentiated according to the surgical access ways. Both with
degeneratively and traumatically induced interventions the
operations of the lumbar region of the spine and the vertebral column outweigh those on the cervical vertebral column.
Therefore it seemed to the authors that treatments
with V.A.C. Instill® to sanitise deep vertebral infections
after transperitoneal and retroperitoneal as well as transthoracal entries, are too uncontrollable and therefore too
risky for patients.
The infection of dorsally brought in implants like the
fixture of internal systems for example is a good indication
for vacuum therapy [8]. It is postulated that instillation vacuum therapy can also be carried out when using conventional vacuum treatment. In this way the same characteristics as with the remaining implant associated infections in
orthopaedics and accident surgery can arise in other body
regions, primarily the formation of bio films which inhibits
therapy.
Therefore the known requirements on the instillation
fluids used apply as in other surgical specialist areas and/or
anatomical regions. Therefore hydrogen peroxide, alcohol
based solutions, Octenisept and acetic > 3% are not eligible due to foam formation, cytotoxitiy, soapy character
or corrosive potential on the dressing bandage. On the
other hand commercially available instillation media polyhexanide (Lavasept®) < 0.2% is very suitable for clinical
use, as well as Ringer lactate and physiological natrium
chloride solution. Liquid antibiotic supplements are also
used.
If the primary operation included a laminectomy or it
came to exposure of the Dura mater spinalis and/or other
neural structures in the scope of the necessary extensive
surgical debridements, some exceptions must necessarily
be taken into account. On one hand these relate to the
general procedure of vacuum sealing. Therefore in this
case a white foam made of polyvenylalcohol is to be preferred to black polyurethane foam. The danger of lesions
in sensitive tissues when removing the polyurethane foam
(PU foam, V.A.C. GranuFoam®) is higher due to the stronger vascularisation of granulation tissues compared to
polyvenylalcohol foam (PVA foam) where the danger of
lesions is lower, as much as is the granulation stimulus
itself. Inspite of using the PVA foam (V.A.C. VersaFoam®)
it is recommended to cover the dura, for example with
Infection 37 · 2009 · Supplement I © Urban & Vogel
Fig. 1: Debridement.
Fig. 2: Deep instillation via GranuFoam®.
Fig. 3: Completely wounddressing with sandwich-technology.
39
V.A.C. Instill® therapy – indications and technical applications
DuraGuard® (Synovis). Equally vacuum sealing should not
be carried out on dura leakages which have been freshly
sewn or patched.
Furthermore the selection of an instillate after a
laminectomy should be critically regarded.
The application of polyhexanide is not recommended,
as the manufacturer has made a contraindication against
use on the central nervous system. Equally there is no final
information regarding the reabsorption behaviour and the
complication possibilities which arise from a systemic acceptance [3]. Therefore lactated Ringer’s solution or physiological saline solution at 0.09% can be used as a rinsing
solution. The resulting reduction in germs can then lead to
infection sanitation when combined with surgical debridement, adapted systemic antibiotic dosage and if necessary
further measures.
Maurer and Kunz [4] published good treatment success of the spinal epidural empyema with a rinse drainage
after fenestration and a Robinson outlet drainage. A
drainage loss of a maximum of 100 ml/12 hours was estimated as danger free. Ringer lactate with nebacetin was
used for instillation.
For the technical use of V.A.C. Instill® placed on the
dorsal spinal column there are regional differences to other
localisations which need to be adhered to. In order to treat
the deep infections effectively, the instillation solution
should ascend from the deepest point of the wound. For
this reason the patient should lie on their stomach during
the instillation and acting phase. For patients with a high
compliance the time sequence set out in the treatment protocol can be carried out without a problem by using an
alarm clock. To ensure the necessary sleep phases the
instillation frequency can be reduced at night or changed
to a continual suction. Only by lying on the stomach can
the individual time interval which is dependent on gravitational pull be exactly defined visually and palpably.
Due to the lower pressure of the fluid against the wound
foil which arises in this way, leakage is minimised.
In our clinic instillation vacuum therapy has been used
on the dorsal spinal column for two years with great
success. An example case should clarify the usage.
During a traffic accident a 58 year old obese patient
suffered a lumbar vertebral body one fracture which was
provided with an internal cross stabiliser due to a bi-seg-
40
mental fixture. Subsequently there was an early infection
with staphlococus aureus.
The series of photos (fig. 1–3) show the operation site
at the first change of the vacuum sealing.
After three germ free tissue probes in a row the wound
was able to be closed by secondary stitches. A total of
seven revision interventions were necessary.
The local usage of silver sponges may provide
prospects for situations in which no instillation therapy is
possible or have to be interrupted for wound and implant
infections with multi resistant bacteria stems due to the
wound characteristics or lack of compliance. Alt et al. [1]
were able to show that bone cement loaded with silver
particles with a particle size of 5–50 nm was more effective
than PMMA containing gentamycine for the tested MRSE
and MRSA stems. With the therapy of infected spinal
column implants, however, the toxicity of high silver
concentrations for neighbouring sensitive nerve tissue is to
be taken into account [6].
Instillation vacuum technology is an enrichment of the
treatment of infected wounds. It can even be used successfully on the spinal column. The aim is infection sanitation
while leaving implants.
References
1.
2.
3.
4.
5.
6.
7.
8.
Alt V et al. Orthop 2004;33:885–892.
Frangen TM et al. Unfallchirurg 2006;109:743–753.
Kramer A et al. ZfW 2004;3:110–120.
Mauer UM, Kunz U Unfallchirurg 2007;110:250–254.
Scheffer D et al. Orthop 2008;37:709–720.
Schierholz JM et al. Orthop 2004;33:397–404.
Schinkel C et al. Unfallchirurg 2007;110:946–952.
Willy C, Bergenthal G, Ziegler U. Die Vakuumtherapie 2005;
1. Auflage:127–130.
Correspondence adress:
Dr. Rüdiger Neef
Universitätsklinik und Poliklinik für Unfall- und Wiederherstellungschirurgie
Ernst-Grube-Straße 40
06120 Halle/Saale
Phone: +49 345 557 71 36
Fax: +49 345 557 70 76
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
13
The application of instillation combined
with vacuum therapy in visceral surgery
H.B. Reith
Introduction
Numerous indications for vacuum therapy are known in
daily routine of visceral surgery so far. Vacuum therapy is
applied together with modern therapeutic principles in the
treatment of wound healing disturbances, as well as in the
abdomen and retroperitoneum [1].
In addition to the well known advantages of vacuum
application, instillation therapy is targeting at the reduction of germs by desinfection and removal of necrotic tissue.
Solutions for instillation
Clinical application
The available disinfecting agents differ in tissue tolerability, foam formation, toxicity and onset of action. Regarding tissue tolerability first, it is very clear, that taurolidine
is superior over polihexanide and povidone iodine solution.
1
The same is true for foam formation. Already taking these
criteria into account, some agents can be excluded for
clinical use. Furthermore, taurolidine represents the least
toxic agent followed by polihexanide, povidone iodine
solution and octenidine solution [2].
In table 1, the reaction times of the different agents are
shown. Following the described properties and our clinical
experience, we use taurolidine for instillation. However,
we set the instillation time to at least 30 minutes, to allow
for the necessary chemical reaction and disinfection time.
2
There are three main application areas for instillation
therapy:
1. Treatment of deep wound infections of the abdominal
wall with and without synthetic foreign bodies.
3
Fig. 1–3: Deep wound infection after stomal hernia repair and restoration of bowel continuity (patient with M. Crohn, recurrent fistulas and
bowel pouch), complete dehiscence of the fascia, intraperitoneal fat is covering the abdominal organs, reconstruction of fascia with augmentation throughout a polypropylene mesh, starting an instillation therapy with the white foam as an indicator for the upcoming wound revision.
Infection 37 · 2009 · Supplement I © Urban & Vogel
41
V.A.C. Instill® therapy – indications and technical applications
Table 1
Desinfection time listed for different usable medical liquids
PVP-Jod
Octenidin/PE
Chlorhexidin
Polihexanid
Taurolidin
> 30 s
< 5 min
> 5 min
5–20 min
min. 30 min., throughout a chemical reaction the time can be prolonged to 6–24 h
2. intraperitoneal necrosis and peritonitis and
3. in some cases with retroperitoneal necrosis, for instance
after pancreatitis.
Concerning the first application: As an example we present
the management of a stoma requiring reconstruction of the
abdominal wall following incisional hernia with deep
wound infection accompanied by an involvement of the
fascia. The prevalent mixed flora (gram+ and gram-) and
the meshgraft could be reduced by the instillation therapy,
and the wound could be healed following secondary suture
(fig. 1–3). At first glance, nothing unusual could be seen.
But in the depth, the fascia was completely absorbed (burst
abdomen), so that a reconstruction with synthetic meshgraft and simultaneous infection therapy (disinfection) had
to be performed. After six days of instillation therapy and
one exchange of foam the defect could be closed by
secondary suture.
The second example presented refers to the classical
peritonitis therapy. In the past, cycles of so called „low-tide
high-tide lavage“ used to be performed in the open or temporarily closed abdomen. Together with the use of vacuum
instillation therapy this procedure can be adopted again.
But the following modifications are necessary: the instillation drains are placed in that way, that the abdominal cavity can be filled up at the deepest points. A volume of
42
about 500 to 1000 ml is instilled (depending from the size
of the abdomen). Therefore, the instillation time must be
longer, and the reaction time and the duration of vacuum
therapy therefore shorter. Also in this case we use taurolidine, because it was developed and approved specifically
for intraperitoneal application in peritonitis.
The third, however rare option of use is the retroperitoneal application of foams in infected necrosis, for
instance in pancreatitis. The goal of cleaning and decontaminating retroperitoneal wound cavities can be perfectly reached. However, the potential risk of generating
fistulas by the unprotected use of foam (in contrast to foil
protected abdominal dressings must be considered carefully.
Conclusion
Instillation therapy in combination with vacuum therapy
represents an improvement for clinical routine. This modern therapeutic option also can be used favourably in visceral surgery. Among the available disinfectant solutions,
taurolidine is preferable, because of positive experience
with the clinical use in the abdomen.
References
1. Bourrée M, Kozianka J. Zentralbl Chir 2006;131:100.
2. Hübner NO, Assadian O, Kramer A. GMS Krankenhaushyg Interdiszip 2007;2:60.
Correspondence address
Prof. Dr. H. Bernd Reith
Klinik für Viszeral-, Kinder- und Gefäßchirurgie
Klinikum Konstanz
Luisenstr. 7
78464 Konstanz
Phone: +49 7531 801 11 01
E-mail: [email protected]
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
14
First experience using V.A.C. Instill® therapy In
pediatric surgery
A. Fette
Summary
According to the positive experiences out of our case
series, the management of complex and infected wounds
or local infections in childhood by emerging new technologies like eg the wound instillation/V.A.C. Instill®
therapy is constantly increasing. Similar to the classic
Introduction
Modern wound management still poses a considerable
challenge for clinicians, especiallly surgeons, while on the
other hand this modern wound management traditionally
demonstrate surgeon's expertise and proficiency as well.
Orientation of such a progressive wound management is
usually based on stage and phase-adapted wound healing
and have to benefit from innovative technologies, like the
instillation technique. However, for special use in children
the applied technique needs to be child-friendly, childsafe and child-adapted. And last but not least, in front of
limited health care resources efficient and (cost-)effective
as well.
Patients and Methods
The V.A.C. instill® technique is based in principle on the
classical suction/irrigation drainage described by Willeneger recently. Recommended parameter settings for topical
negative pressure (TNP) and dressing change intervals for
adults are summarized in table 1 and 2. Initially forming the
base for use in children, too. Later on, comparable parameter settings for TNP in children could be fixed accordingly,
while dressing change intervals could be widely extended.
So far, normal saline at room temperature was the irrigation fluid exclusively used. No specific antiseptic or antibiotics were added. Therefore our routine key parameter
settings are: instill 10 s, acting 10 min, V.A.C.® 60 min, 125
mmHg, continous.
For sensitive, less exudating wound surfaces the
original white foam (Polyvinylalcohol) was prefered,
while the black Polyurethan foam was favorite for extensively discharging and severely infected wounds.
Based on our previous V.A.C.® experience the prefered
form of application for the upper limb was the “V.A.C.®
glove”, the “V.A.C.® boot” for the lower one (fig. 1), re-
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C.® therapy more and specific indications for the
V.A.C. Instill® therapy will be developed in the near future.
Key words: V.A.C. Instill® therapy – wound management
– pediatric surgery
spectively the “V.A.C.® scarf” for the upper thoracic region (fig. 2).
Individual diagnosis, given treatment and specific
problems of our patient sample are summarized in
table 3.
Results
In all patients the local infection focus could be treated
successfully with the V.A.C. ® instill technique. The
V.A.C.® dressing could be fixed properly and thight on all
involved body parts. No device-related complications
could be notified. The principles of minimal access surgery (MAS) could be followed in the majority of cases. In
the majority of patients delayed secondary wound closure
was feasible without complications in a short time. Several
infected foci located on the same body could be treated
Fig. 1: V.A.C. Instill® applicated as a “boot” in the poplitea in parallel
to a second application to the contralateral hip joint.
43
V.A.C. Instill® therapy – indications and technical applications
Table 1
Parameter set up "negative topical pressure"
50–75 mmHg to 125 mmHg for chronic ulcers
50–125 mmHg for skin grafts
125 mmHg for all other wounds, polyurethan foam
125–175 mmHg, for all other wounds, polyvinylalcohol foam
(48 h continous, than intermittend)
Table 2
Recommended dressing change intervals
• 48 h than 4–5 days for most of the wounds
• 48 h or less for all infected wounds
• 4–5 days for all non infected wounds
successfully with one system in parallel (fig. 1 and 2).
No local tumor infiltration could be observed during
(incidental) use in a malignancy case. Sufficient odour
control and better personal hygiene was appreciated by a
desperate teenager giving him back a new social life. In
addition, when managing him part time as an outpatient,
he was able to join his vocational school again. Problems
arising, first with dissolution and subsequent loosening of
the original glue fixation stripes (V.A.C.® Gel, KCI), or
the second one with intermittend blockage of the
T.R.A.C.® pad by small bony pieces could be solved by
either change of the product or the kit itself more frequently.
Discussion
In the management of infected and complicated wounds
debridement and cleansing is well established and not
debated [1, 2]. Other essentials are wound bed preparation,
supporting re-epithelisation and wound protection throughout the entire healing process [2–4]. For best preparation
of the wound bed, conditioning of the wound floor by improving tissue granulation, angioneogenesis and exudate
management best support by the applied technique is
essentiell [2–4]. For best re-epithelalisation all wound healing factors had to be adjusted and cell proliferation and
collagen synthesis optimized, too. In addition, bacterial
load must be well controlled and wound margins activated
[2–7]. According to our personal experience the basis technique of V.A.C.® and V.A.C. instill® [5, 8, 9] provides
significant advantages throughout the entire wound
management and wound healing process.
All open and MAS surgical accesses could be treated
well which competitive results by V.A.C.® alone. However,
due to the small total amounts of irrigation fluid volumes
administered in pediatric osteomyelitis therapy through
MAS accesses, future indications need to be specified,
44
Fig. 2: V.A.C. Instill® applicated as a “scarf” on a tumorous-inflammed
scapula.
since our results with the conventional V.A.C.® therapy
alone are already competitive. This point is competitive for
the type of irrigation fluid as well, since pure fluids (eg
Ringer’s solution) alone achieved comparable good results,
too.
If a MAS access is appropriate, definitive wound closure by secondary suture in children with or without
V.A.C.® is nearly always possible. Comparable to a tissue
expander device, the ongoing discontinuation of topical
negative pressure during any V.A.C.® therapy in inter-
Table 3
Diagnoses, treatments and specific problems summarized
5 y, male
Swelling left clavicle, subperiostal abscess,
dressing fixation/water tightness, MAS,
dissolution of the glue fixation stripes
7 y, female
Painful right heel after minor trauma,
osteomyelitis, dressing fixation/water tightness,
MAS, pluged T.R.A.C.® pad
8 y, female
"Scapula tumor" right-side, persistent shoulder
pain, suspected osteo-myelitis, but OSTEOSARCOMA, malignancy, tumor-induced pain, dressing
fixation/water tightness
10 y, female Salmonella osteomyelitis, fistulas right hip and
left poplitea, dressing fixation/water tightness,
clearance of the infected focus, parallel treatment
of multiple foci
15 y, male
Inguinal hernia surgery as toddler, recurrent osteofascio-cutaneous fistula network, recurrences and
revisions, odour control, personal hygiene, dressing fixation/water tightness, permit for visiting
vocational school
Infection 37 · 2009 · Supplement I © Urban & Vogel
V.A.C. Instill® therapy – indications and technical applications
mittent mode, achieves a preferable skin stretching effect.
Even pronounced, if the wound margins are temporarily
fixed, eg by staples, to the well moulded foam margins [3,
14, 15]. Using the V.A.C. Instill® therapy the increase and
decrease of the wound volume by the alternating in- and
outflow of the irrigation fluid respectively the interchanging amount of tissue edema might act even synergistically.
Focusing on the simple property “wound dressing”
the applied dressing must be capable to protect wound
surface and margins simultaneously and bound odourous
smell [10–12]. The applied technique should not lead to
tissue or vessel arrosions with uncontrolled hemorrhage
[2–6, 13]. If the appropriate foam was used, no such
device-related complications were seen with any of our
V.A.C.® or V.A.C. Instill® applications during clinical
use. In addition, the V.A.C.® dressing always provided
sufficient protection of the wound without restricting mobility or personal hygiene of the children. Nor restricting
their social life due to odourous smell. Thus, the V.A.C.®
dressing technique is well accepted by all of our patients
and their parents.
To be considered as child-friendly the entire treatment
must be as painless and horrorless as possible for the little
patients to offer the best quality of life [11, 13–15]. Here
the V.A.C.® device is equally successful in theatre or emergency room, the (N)ICU or a bedside setting. However, no
more invasive anesthesia or analgesia is needed, if compared to the classical dressing technique.
Since routine clinical use of the V.A.C.® technology in
pediatric surgery started, either in an in- or outpatient setting, treatment time and costs decreased with even an increase in our patients’ comfort and care [11, 16–19]. For the
diagnoses, eg osteomyelitis or abdominal wall infections,
already discussed in the previous paragraphes proceeds
within 10 000 and 25 000 Euro could be gained, if the brand
new multiple procedures - DRG - 2008 codes were applied
[20]. (Cost-)effectiveness and efficiency would be increased
even more, if kit size and package could be miniaturized
for further use in children.
Despite best marks for KCI customer services and support (company customer survey, personal experience) and
despite the numerous other advantages, no reimburse-
Infection 37 · 2009 · Supplement I © Urban & Vogel
ment from the inpatient to the outpatient setting for any
pediatric surgical case by any of the German health
insurance companies was feasible so far [11, 16, 19].
Conclusion
According to our limited experience V.A.C. Instill®
technique is a handsome and child-friendly method for
treatment of complex and infected wounds in children.
References
1. Heister. Wund=Artzney/Chirurgie 1719; Reprint-Verlag Leipzig.
2. Téot et al. Surgery in Wounds 2004; Springer Verlag Berlin, Heidelberg, New York.
3. Willy. Die Vakuumtherapie: Grundlagen, Indikationen, Fallbeispiele, praktische Tipps 2005; Kösel Verlag.
4. Banwell et al. 1 st international topical negative pressure (TNP)
therapy, Focus group meeting proceedings 2003; London UK.
5. Mullner et al. Br J Plast Surg 1997;50:195–199.
6. Swan et al. Oxford Wound Healing Society (OWHS) 2003;Sonderdruck.
7. O’Kaine. J Wound Care 2002; 11:29–299.
8. Morykwas et al. Ann Plast Surg 1997;38:553–562.
9. Fleischmann et al. Eur J Orth Surg and Trauma 1995;5:37–40.
10. Bundesverband Medizintechnologie (BVMed) e.V.: Gesundheitspolitik. Der Einsatz moderner Wundversorgungsprodukte, 2000.
11. Fette. Journal of Plast Surg Nursing 2006;26(No. 4):184–188.
12. Turner. Health Soc Service J 1979;4(89):529–531.
13. Mooney et al. Clin Orthop 2000;376:26–31.
14. Fette et al. Direct-fmch 2007, Supplement zum 3-Länder-Kongress
in Luzern/Schweiz.
15. Fette. European Surgery (Acta Chirurgica Austriaca) 2008; Suppl
222/08;Vol 40:58–62.
16. Nord. Schriftensammlung 2002.
17. Fette et al. Journal of Wound Healing (ZfW) 2003;5:180–184.
18. Fette et al. Zeitschrift für Wundheilung (ZfW) 2005;VAC®-Wundtherapie:38–40.
19. Fette et al. Zeitschrift für Wundheilung (ZfW) 2005;2:235.
20. Schroeders von et al. Kodierhilfe chronische Wunden 2008, Druck
le Roux GmbH, Erbach.
Correspondence address
Dr. Andreas Fette
Drosselstr. 4
D-71554 Weissach im Tal
E-mail: [email protected]
45
V.A.C. Instill® therapy – indications and technical applications
Imprint Infection • Vol. 37 • 2009 • Supplement I
Coordinating Manager: Dr. Melanie Leshel
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KCI Medizinprodukte GmbH
Cover:
R. Neef: Completely wounddressing with sandwich technology
Director Medical Communication:
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Infection 37 · 2009 · Supplement I © Urban & Vogel