Surgeons from a wide variety of specialities including: Thoracic, General, Cardiac, Colorectal, Plastic, Vascular, Orthopaedic, Abdominal, Gastroenterology, Visceral, Trauma, Emergency and Oncology participated in the ISWF to discuss and debate.

Wound management topics raised by the attending surgeons¹ during the two-day forum included:

 
• The rationale for, and benefit of, Open Abdomen (OA) treatment provided the device used for temporary abdominal closure not only manages the local defect but also actively manages the inflammatory contents of the exudate. A classification system for the OA that illustrates the various structural situations that can be encountered was presented.

• The option to use vacuum assisted closure in combination with instillation offers new possibilities for the healing of infected wounds. For instillation purposes, various solutions were effectively used such as polyhexidine. A new patented acetic acid solution was presented to combat bacteria encapsulated in biofilm with initial promising results.

• An approach using external fixation and acute shortening to initially close the wound of open fractures after radical debridement in an attempt to reduce infections was presented. After closure gradual lengthening is undertaken.

• Initial results of a new therapy in which Topical Negative Pressure is applied on closed incisions. Examples and early experiences from Plastic and Orthopedic surgeons indicated beneficial effects such as better and longer lasting increased perfusion and lower complication rates after abdominoplasties. Also, shorter drainage duration and hospital length of stay when applied on closed incisions over high energy fractures was experienced.

• Beneficial effects of vacuum assisted closure in terms of cost effectiveness were shown for treating deep sternal wound infections and in terms of reduction of bacterial load for traumatic soft tissue defects.

¹ _{Any opinions, findings, and conclusions or recommendations expressed are those of the attending surgeons, not necessarily those of KCI.}
 

Following that, we will discuss the results of three different Level I studies that have evaluated incisional NPT on patients following trauma. The first study that will be presented is an evaluation of NPT in patients following open reduction and internal fixation of calcaneus, pilon, and tibial plateau fractures. This large multi-center study indicated that incisional NPT helps prevent both infection and wound dehiscence following these high energy lower extremity fractures. The second study was an evaluation of the use of NPT to treat patients with draining hematoma’s following orthopaedic trauma surgery. This study did not demonstrate significant differences in resolution of the drainage between those treated with NPT and those treated with a compression dressing. However, there was a trend suggesting that NPT may help prevent the development of an infected hematoma. The final study that will be presented is an ongoing prospective randomized study on incisional treatment following the posterior approach to the hip following acetabulum fractures. This is a small study that is currently ongoing.

The final segment of the presentation will demonstrate some case examples of the use of incisional NPT to treat miscellaneous conditions in skeletal trauma patients. Examples will include fracture blisters, open fractures that are closed following surgical fixation, and fasciotomy wounds following compartment syndrome.

James Patrick Stannard, M.D.
Professor of Surgery with Tenure
Chairman, Department of Orthopaedic Surgery
J. Vernon Luck Sr. Distinguished Professor of orthopaedic Surgery
University of Missouri, USA

Methods
From November 2001 to December 2009, 330 patients (age range from 10 days to 86 years) received a vacuum assisted closure system for the treatment of sternal wound infection.
Treatment consisted of opening of the entire wound with removal of all sternal wires, surgical debridement and implantation of a V.A.C.® Therapy System with a black foam or a silver-coated foam use trademarked and registered marks for Granufoam and Silver foam. Thereafter, the patients underwent a dressing change every third day until the swabs were negative and the inflammation parameters were in the normal range or when requested by treating physician..

Results
In 65%, cases there was a deep infection with involvement of the sternal bone and mediastinitis; 35% had a superficial infection. Secondary sternal closure after V.A.C.® Therapy was possible in 76% of the patients, whereas 24% proceeded to plastic surgery reconstruction with muscle flaps due to destruction of the sternal bone. In those cases where sternal closure was possible, we used three techniques of sternal closure, depending on the quality of the sternal bone: normal sternal wires, the sternal talon system or plate osteosynthesis. In all patients, Triclosan-coated sutures were used for secondary infection prevention.

Discussion
The key to successful management of sternal wound infection is with early recognition, enabling preservation of the sternal bone and facilitating secondary sternal closure, which in turn reduces hospital stay and costs. As we have gained a wide experience in using NPWT therapy, we developed certain guidelines for the treatment of sternal wound infections in order to ensure the best outcome.reference to those guidelines here.

For more than seventeen years the V.A.C.® Therapy System has been used successfully in treating wound infections. Preparing wounds for closure means to clean wounds, to achieve wound retraction and minimize following surgical procedures. When infection is under control, the wound should be closed at the earliest time possible. Sometimes a simple split-thickness skin graft may be suitable for wound closure. In case of exposed bone, orthopaedic harware the use of local, pedicled and free flaps including microsurgical procedures is essential not only for wound closure but also for infection control. Well perfused tissue of the flap serves as carrier of systemic antimicrobial agents, which are absolutely necessary to kill remaining pathogens at the site of infection. Infection control can be difficult or even impossible in case of insufficient debridement, persistence of bacteria, and insufficiency of antimicrobial agents in case of multidrug-resistant (MDR) bacteria like MRSA and Acinetobacter Baumannii.

Instillation technology is able to combine and optimize the effects of permanent elimination of bacteria by NPWT and to kill and wash out pathogens by cyclic instillation of antiseptic fluids. The V.A.C.-instill® System enables a 3 stage-working cycle. Vacuum therapy / instillation of antiseptic fluids / hold time. Our experiences of treatment of infected wounds include chronic wounds with local infection, acute infections originating from chronic wounds as well as limb- and lifethreatening infections caused by MDR bacteria. In some patients NPWT and Instillation Technology were used as a salvage procedure following failure of multiple plastic surgical procedures. One thing was equal in all patients. Debridement and subsequent plastic surgical procedure seemed to be insufficient for infection control, or time to closure seemed to be to early. We have always been using Polyhexanid (Lavasorb®) for instillation. Instillation time directly depended on wound size. Time of therapy lasted at least 4 days, at most 18 days. Dressing changes were performed every two to four days. Surgical closure was performed by direct secondary suture, skin grafting or flap surgery. In all cases infection control and complete healing were achieved, despite of incomplete debridement and leaving prolene mesh® in situ in two cases. We believe the VAC-instill® Wound Therapy System to be a useful tool for infection control in difficult anatomical regions, (e.g. open wrist and talocrural joint) in case of impossibility of totally debridement and MDR bacteria.

The recognition of bacterial biofilm in chronic wounds may give us the opportunity to explain many of the characteristics of the chronic wound. It may explain why a chronic wound doesn’t heal despite adequate treatment of underlying condition.

The bacterial biofilm interfere with the human immune system in numerous ways. This may cause inflammation and necrosis in the chronic wound and may prevent healing. It is tempting for the clinician to start antibiotic treatment, but in case of established, mature biofilm, this treatment often has only a temporary effect on both inflammation and healing. The bacteria in biofilm are up to 1000 times less susceptible to antibiotics(2). Even silver treatment, as incorporated in several wound dressings, has limited effect in biofilm in vitro(3).
Our research group have developed and recently filed a patent on buffered acetic acid for the treatment of bacterial biofilm. It has shown a remarkable effect on even mature bacterial biofilm in vitro and promising results in early clinical trials. We will present the in-vitro results and some clinical case stories.

Reference List

(1) Hoiby N, Bjarnsholt T, Givskov M, Molin S, Ciofu O. Antibiotic resistance of bacterial biofilms.
Int J Antimicrob Agents 2010 Feb 8.
(2) Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms.
Lancet 2001 Jul 14;358(9276):135-8.
(3) Bjarnsholt T, Kirketerp-Moller K, Kristiansen S, Phipps R, Nielsen AK, Jensen PO, et al.
Silver against Pseudomonas aeruginosa biofilms. APMIS 2007 Aug;115(8):921-8.

Dr. Klaus Kirketerp-Møller
Consultant
Orthopaedic department
Køge University Hospital
Lykkebækvej 1
DK-4600 Køge

July 1989 Medical Doctor - Copenhagen University, Denmark
March 2001 - Speciality of Ortopaedic Surgery
January 2005 -  Consultant Surgeon, Copenhagen Wound Healing Center
June 2007 - Clinical Head, Copenhagen Wound Healing Center
December 2009-present  - Consultant, Orthopaedic dept. Køge University Hospital

Medical society:
   
Chair of Danish Association of The Diabetic Foot (2007-2008)
Membership:
- Danish Orthopaedic Society
- Diabetic Foot Study Group
- European Bone and Joint Infection Society
- Danish Wound Healing Society   

Scientific Work
Reference List

 1.  Thomsen, T. R., Aasholm, M. S., Rudkjobing, V. B., Saunders, A. M., Bjarnsholt, T., Givskov, M., Kirketerp-Moller, K., and Nielsen, P. H. (2010) The bacteriology of chronic venous leg ulcer examined by culture-independent molecular methods. Wound.Repair Regen. 18[1], 38-49
 2.  Fazli, M., Bjarnsholt, T., Kirketerp-Moller, K., Jorgensen, B., Andersen, A. S., Krogfelt, K. A., Givskov, M., and Tolker-Nielsen, T. (2009) Nonrandom distribution of Pseudomonas aeruginosa and Staphylococcus aureus in chronic wounds. J.Clin.Microbiol. 47[12], 4084-4089
 3.  Kirketerp-Moller, K. and Gottrup, F. (2009) [Bacterial biofilm in chronic wounds]. Ugeskr.Laeger 171[13], 1097
 4.  Kirketerp-Moller, K., Jensen, P. O., Fazli, M., Madsen, K. G., Pedersen, J., Moser, C., Tolker-Nielsen, T., Hoiby, N., Givskov, M., and Bjarnsholt, T. (2008) Distribution, organization, and ecology of bacteria in chronic wounds. J.Clin.Microbiol. 46[8], 2717-2722
 5.  Bjarnsholt, T., Kirketerp-Moller, K., Jensen, P. O., Madsen, K. G., Phipps, R., Krogfelt, K., Hoiby, N., and Givskov, M. (2008) Why chronic wounds will not heal: a novel hypothesis. Wound.Repair Regen. 16[1], 2-10
 6.  Laurinaviciene, R., Kirketerp-Moeller, K., and Holstein, P. E. (2008) Exostectomy for chronic midfoot plantar ulcer in Charcot deformity. J.Wound.Care 17[2], 53-58
 7.  Bjarnsholt, T., Kirketerp-Moller, K., Kristiansen, S., Phipps, R., Nielsen, A. K., Jensen, P. O., Hoiby, N., and Givskov, M. (2007) Silver against Pseudomonas aeruginosa biofilms. APMIS 115[8], 921-928
 8.  Kirketerp-Moller, K., Balslev, N., and Lohmann, M. (1996) [Accidents caused by inflatable bouncers in 0-19 year-olds in Denmark in 1993]. Ugeskr.Laeger 158[16], 2251-2253
 9.  Blond, L., Kirketerp-Moller, K., Sonne-Holm, S., and Madsen, J. L. (2002) Exsanguination of lower limbs in healthy male subjects. Acta Orthop.Scand. 73[1], 89-92
 10.  Boel, J. and Kirketerp-Moller, K. (1993) [Clinical result after Leeds-Keio reconstruction of the anterior cruciate ligament]. Ugeskr.Laeger 155[26], 2049-2052
 11.  Kirketerp-Moller, K. (1991) [Acute compartment syndrome after a brief march]. Ugeskr.Laeger 153[29], 2071-2072

The treatment of open fractures relies on debridement, inadequate debridement leads to a high complication rate, however adequate debridement frequently requires complex plastic surgical reconstructive techniques to fill the resultant defect.

Standard protocols for debridement use longitudinal wound extensions along or parallel to standard fasciotomy incisions. When debridement is planned allowing for the use of acute shortening following bony debridement, transverse orientation of the incisions in contrast to the normal longitudinal wound extensions may allow direct closure of defects which if treated traditionally would require complex reconstruction, or provide local muscle which following shortening may be mobilised beyond normal limits, to allow simple techniques for soft tissue coverage rather than free tissue transfer. Subsequent use of circular fixators allows correction of the longitudinal defects, essentially using distraction histiogenesis to provide both bony and soft tissue reconstruction.

Methods
Medline-, hand-search for NPWT literature. Used filter were “randomized”, “future” (what about NPWT as a filter?). Analysis of the literature for recently produced evidence according to the criteria of evidence-based medicine (EbM). Additionally, literature, dealing with the experimental basis of NPWT was analysed. Survey 2006 and 2008 at the “3-Länder”-congresses (Nürnberg, Graz) dealing with the application methodology of NPWT. Furthermore some reflections about future necessities for the development of importance of NPWT in wound treatment were added.

Results
Between 2007 and 2010 eight randomized controlled trials (RCT) were published. Medical progression could be shown in patients with open fractures (surgical site infection rate: minus 80%) and with diabetic foot syndrome (DFS; time to granulation: minus 40%, wound closure: plus 50%, faster healing). Generally, a tendency to shorter duration of therapy could be demonstrated in wounds. An economical progression was calculated for DFS patients. Unfortunately some RCT’s were based on very small patient groups or on a secondary analysis of patients enrolled in other RCT. In order to develop wound treatment further, it is important to create an Excellence Center of Wound Therapy giving support to clients (patients or customers?) by constantly evolving guidelines, technical advices, algorithms. E.g., against the background of the results of both above mentioned surveys, it is necessary to teach an individualized (what does this mean?) adaptation of the negative pressure value. There is a need to reduce the pressure particularly in those tissues sensitive to hypoxia like subcutaneous tissue, tissue after microcirculation injury, wounds after fasciotomy, DFS. Additionally, algorithms to define the beginning and the end of NPWT integrated into the wound therapy, have to be formulated for all indications. To further develop wound treatment it is important to use a multidisciplinary approach to future R&D activities. In an Invention Center, all components of NPWT have to be considered scientific challenges. For example, the avital synthetic foam has to be transferred to a biologically active interface; for home treatment a 24h surveillance using wireless-technology (principle: “never alone“) could be implemented and wound therapy data and images can be transferred online and in real time to all players like physicians surgeons in the hospital, Health-Technology-Assessment (HTA)-institution and caregivers. Beyond the scalpel and the wound, , new technologies to communicate and to spread out the knowledge need to be developed.
In order to progress with wound treatment it is important to be responsible in contributing with high evidence of new inventions according to the criteria of EbM. There is a need to cooperate very early in a deep collaborative relationship with HTA-centers to provide earliest proof of high evidence of the new invention.

Conclusions
The latest RCT’s showed medical and economical progression by NPWT only within two indications (which ones?). Even if literature and empiric knowledge show that NPWT created a paradigm shift in many indications of wound treatment, today’s low evidence of NPWT is a great deficit. Nevertheless, there is no doubt that NPWT and its modificationssuch as instillation therapy, will play an important role in the innovation of wound treatment. If we want to widen the scope, it is necessary not to respond to trends (technical, medical, social, statistical, …) but to shape and lead them. Support by modern knowledge, safety features, realization of results of multidisciplinary research and self-motivated HTA activity allow it to surprise patients, surgeons and care-givers with innovations that create a benefit for both the patients and the society. 

LtCol Prof. Christian Willy, MD
Professor of Surgery
Military Hospital Ulm
Federal Armed Forces of Germany
Oberer Eselsberg 40
89075 Ulm

Chairman Surgical Center
General Surgeon,Trauma Surgeon

 
Clinical main topics:
- Healing of complex wounds
- Acute and chronic compartment syndrome
- Pelvic trauma
- Spine trauma
- Surgery under military and catastrophic conditions

Organisational main topics:

- Surgical training programs (Medical service Federal Armed Forces, German Society of Surgery)
- Quality Management
- Students
- Coordination Surgical Research
- Speaker Advisory Board Surgery (Ministry of Defense)
- Coordination Deployment Surgery Germany

Scientific main topics:

- Wound healing
- Vacuum-assisted therapy
- Acute and chronic surgery
- Wound drainages
- Soft tissue injuries
- Pathophysiology of extremity injuries
- Importance of Non-Linear Dynamics in Surgical Research
- Epidemiology of Deployment Surgery

 
Born 06 Oct 1962

1981   University of Ulm
1987   Approbation as a medical doctor
  MD-Thesis: Outcome of lysis therapy (Urokinase) of chronic peripheral arterial occlusive disease
 
1987 – 1996 Resident Time in Surgery

1990 – 1993 Military Service

1992 – 1993 University of Munic (Studies in Theory of Science, Logic and Philosophy)

1998  Senior Consultant in Surgery

1999 – 2000 Fellowship TraumaCenter University of Zurich, Switzerland

2000  PhD Thesis: ICP Monitoring in Chronic Compartment Syndrome

2003  Fellowship TraumaCenter University of Victoria, Melbourne, Australia

2007  Professor of Surgery

2008  Speaker Advisory Board Surgery (Ministry of Defense)

1997 – 2009 Missions in Sarajewo / Bosnien-Herzegowina (SFOR) Prizren / Kosovo (KFOR) Kabul, Kunduz, Fayzabad and Mazar-e-Sharif / Afghanistan (ISAF)

Member German Society of Surgery (DGC)
Member German Society of Trauma Surgery (DGU)
Member German Society of Military Medicine and Pharmacy (DGWMP)