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

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.

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.

The St Vincent Declaration (1989) agreed to reduce worldwide diabetic amputation rates by half and a Hi-Lo amputation ratio was suggested as an additional quality measure (High Amputation was defined as an amputation above the ankle).

This session will enable practioners to look at the impact of ‘high cost’ wound care therapies to a health economy. The cost of care is changed with savings realised but masked in differing budgets.
It will provide evidence for further local discussions and will allow you to look at your own data for quality indicators to see whether this can also have an significant impact on quality of life for patients as well as reduce cost of care and amputation rates.

This literature review will discuss the clinical outcome of diabetic foot ulcers treated with vacuum assisted closure therapy, its implication in the transition from acute care to home care, factors that might influence clinical outcome in home care, and the quality of life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multidisciplinary collaboration to provide comprehensive wound care. It is critical for limb-preservation in this most high-risk population to have available a versatile, efficacious wound healing modality that can easily transition from acute care to home care. Finally, combining vacuum assisted closure therapy with other wound healing resources in a collaborative and synergistic fashion allows patients to continue with daily living activities, while receiving all the potential benefits of an advanced wound healing modality.