Main principle of infection surgery has always been radical debridement. “Ubi pus, ibi evacua”, often cited by surgeons is not enough. All necrotic and infected tissue should be resected in case of limb or life threatening infections. Surgical and sharp debridement has become the gold standard, especially in complicated skin and soft tissue infections, whereas in chronic wounds alternative techniques (mechanical, enzymatic, autolytic and biological debridement, honey) may be more appropriate.

Wound irrigation can be helpful, but has no effect on remaining pathogens. HPPL may be deleterious by causing bacterial penetration into depth of tissues, while instillation of antiseptic fluids into a wound has an ongoing effect, when it´s used for a longer time, and when the antiseptic agent remains in the wound for at least 20 minutes. For more than seventeen years the V.A.C.® Therapy System has been used succesfully 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 hardware, 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 V.A.C. 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 total debridement and MDR bacteria.

Prof. Dr. Michael Schintler
Department of Plastic and Reconstructive Surgery
University Clinic Medical School Graz, Austria

Qualifications
2008-date Head of Burns Team, University Clinic of Surgery,
Department for Plastic and Reconstructive Surgery
2000 to date Head of Outpatient Clinic for Diabetic Foot Patients
University Clinic of Surgery,
Department for Plastic and Reconstructive Surgery
2000-2001 Consultant for Trauma Surgery
1995-2000 Consultant for Plastic and Reconstructive Surgery
Clinical Department for Plastic Surgery
Medical University Graz, Austria
1988-1992 General Practitioner, District Hospital Klagenfurt, Austria
1981-1988 M.D., Medical University Graz, Austria

Employment History
Jan 1998-date Staff Surgeon, Department of Plastic and
Reconstructive Surgery, Medical University Graz
Jan 1995-Dec 1997 Surgical Residency
Department of General Surgery, Medical University Graz
1992-1995 Surgical Residency , Department of Trauma Surgery,
Regional Hospital Hermagor
1988-1992 General Practitioner Training, District Hospital Klagenfurt
Teaching
1998-2007 Courses and Seminars; Certified Woundmanager, Austria,
Germany, Switzerland; Kammerlander Consulting.
2003-date AO- Courses, University Clinic of Trauma Surgery,
Flap – Courses with Cadaver dissections, Institute of Anatomy,
Medical University Graz
2000-to date Theoretical, practical and clinical teaching to the
postgraduate students at the University Clinic of Surgery

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

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 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.

According to the International Consensus’ Guidelines for DF, the cornerstone of ulcers’ management are the control of infection, revascularization, offloading, systemic and local care; all of the issues must be addressed to cope with this complex and evolutive pathology, in an integrated model of care.

Infection should be managed as aggressively as possible, both surgically, with an early and aggressive debridement, and with systemic antibiotic therapy, which should be aggressive as well.

The possibility of restoring an adequate blood supply to the foot, by means of endovascular, surgical or combined techniques changed the prognosis of DF in the last ten years, since more than 50% of the patients have an underlying lower limb ischaemia.

Offloading is the cornerstone of therapy for the ulcers located on plantar side, and its application is per se sufficient to heal pure neuropathic lesions.

Local care is the aspect of the DF management that faced the most impressive progress in the last five years: V.A.C.® Therapy demonstrated to be highly effective in the management of both chronic and acute post-surgical lesions in DF, reducing healing time and secondary amputations and, combined with new and promising bio-engineered products and surgical reconstructive techniques changed the scenario for many patients which were otherwise candidated to major amputations.

Material and Methods: The V.A.C. Instill® enables a 3 stage-working cycle. Vacuum therapy / instillation of antiseptic fluids / hold time. We have always been using Polyhexanid (Lavasorb®) for instillation. 15 patients with severe diabetic foot infections were treated with V.A.C. Instill®. All patients presented with limb or even life-threatening infections. Debridement and following plastic surgical procedure seemed to be insufficient for infection control, or time to closure seemed to be to early. Instillation time directly depended on wound size. Time of therapy lasted at least 6 days, at most 12 days. Dressing changes were performed every two to four days. Surgical closure was performed by direct secondary suture, skin grafting or flap surgery.

Results: In all cases infection control and complete healing was achieved, despite of incomplete debridement and even long lasting open Charcot joints.

Conclusion: We believe the V.A.C. Instill® to be a useful tool for infection control and limb salvage in severe diabetic foot infections and in case of impossibility of totally debridement. Early defect coverage and hospital discharge could be cost-effective.