The management of complex wounds remains a challenge, and although there have been many promising advances, patients often undergo a morbid and lengthy process to obtain sufficient, satisfactory healing. Sarcoma patients are especially vulnerable to soft tissue wound-healing complications. These patients are often treated with neoadjuvant radiation and/or chemotherapy and have compromised local vascularity to healing tissue. The advent and refinement of wound vacuum-assisted closure technology have been shown to have a tremendous impact. This article reviews the benefits of some novel technologies currently undergoing investigation in orthopedic oncology that will likely have applications in wound management from other causes.
Key points
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Using a multifactorial approach to the management of massive wounds will likely facilitate healing of massive, complex wounds as a result of tumor, trauma, and/or infection.
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The combination of hyperbaric oxygen treatment, wound vacuum-assisted closure therapy, and silver dressings has great potential and seem to reduce the morbidity and cost of wound management.
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Future randomized studies are needed to understand the impact of each modality better.
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Studying sarcoma patients and the complexity associated with wound care due to soft tissue loss, prior radiation exposure, and immunosuppression from chemotoxicity will likely lead to future improvements and the development of other modalities to improve wound care.
Wound complications in sarcoma treatment
For most sarcoma patients, limb-sparing surgery is the standard of care. Functional outcome and quality of life are major concerns when considering surgical resection and reconstruction. Radiation is an effective means to reduce the incidence of recurrence, particularly in high-grade soft tissue sarcoma. However the combination of radiation and limb salvage has created its own set of complications in terms of wound complications. Pelvic and sacral resections remain a challenge for wound complications. A multidisciplinary approach is often needed to optimize the patient’s functional and cancer outcome successfully; early referral to a sarcoma center is important ( Fig. 1 ).
Radiation administered in conjunction with surgery is designed to eliminate tumor recurrence from close or positive margins. The risk of recurrence can be substantially reduced by using either preoperative or postoperative adjuvant radiation. The traditional method of providing radiation in conjunction with surgery is to begin radiation after surgery once postoperative wound healing is completed. However, postoperative radiation treatment requires that the entire surgical wound be radiated. The field size is much larger than the field size that would be provided with preoperative radiation. In addition to the larger field size, the poorly oxygenated postoperative field requires a higher dose of radiation than the well-oxygenated tumor before surgery. In contrast, the use of preoperative radiation is associated with lower total radiation dose and lower volume of tissue exposed to radiation ( Fig. 2 ). The reason for the decreased field size is that the radiation can be contoured to the tumor itself, maximizing treatment of the viable peripheral cells that can implant in the wound, rather than treating the entire postoperative wound. Because the dose and field size are reduced, preoperative radiation may be associated with better functional outcomes and a lower fracture risk, especially if the periosteum is removed to obtain a negative surgical margin.
However, giving radiation before surgery is associated with a higher risk of wound-healing complications after surgery ( Fig. 3 ). Intensity modulated radiotherapy has the potential to reduce the surgical complication rate following preoperative radiation by protecting the superficial tissues that heal the wound as well as the underlying bone. However, intensity modulated radiotherapy requires a collaborative team of surgeons, radiation oncologists, and physicists to permit precise targeted radiotherapy delivery to very select volumes. This review covers the application of wound vacuum-assisted closure (VAC), silver-plated dressings, and hyperbaric oxygen treatment (HBOT) in the orthopedic oncology patient with a complex open wound.
Wound complications in sarcoma treatment
For most sarcoma patients, limb-sparing surgery is the standard of care. Functional outcome and quality of life are major concerns when considering surgical resection and reconstruction. Radiation is an effective means to reduce the incidence of recurrence, particularly in high-grade soft tissue sarcoma. However the combination of radiation and limb salvage has created its own set of complications in terms of wound complications. Pelvic and sacral resections remain a challenge for wound complications. A multidisciplinary approach is often needed to optimize the patient’s functional and cancer outcome successfully; early referral to a sarcoma center is important ( Fig. 1 ).
Radiation administered in conjunction with surgery is designed to eliminate tumor recurrence from close or positive margins. The risk of recurrence can be substantially reduced by using either preoperative or postoperative adjuvant radiation. The traditional method of providing radiation in conjunction with surgery is to begin radiation after surgery once postoperative wound healing is completed. However, postoperative radiation treatment requires that the entire surgical wound be radiated. The field size is much larger than the field size that would be provided with preoperative radiation. In addition to the larger field size, the poorly oxygenated postoperative field requires a higher dose of radiation than the well-oxygenated tumor before surgery. In contrast, the use of preoperative radiation is associated with lower total radiation dose and lower volume of tissue exposed to radiation ( Fig. 2 ). The reason for the decreased field size is that the radiation can be contoured to the tumor itself, maximizing treatment of the viable peripheral cells that can implant in the wound, rather than treating the entire postoperative wound. Because the dose and field size are reduced, preoperative radiation may be associated with better functional outcomes and a lower fracture risk, especially if the periosteum is removed to obtain a negative surgical margin.
However, giving radiation before surgery is associated with a higher risk of wound-healing complications after surgery ( Fig. 3 ). Intensity modulated radiotherapy has the potential to reduce the surgical complication rate following preoperative radiation by protecting the superficial tissues that heal the wound as well as the underlying bone. However, intensity modulated radiotherapy requires a collaborative team of surgeons, radiation oncologists, and physicists to permit precise targeted radiotherapy delivery to very select volumes. This review covers the application of wound vacuum-assisted closure (VAC), silver-plated dressings, and hyperbaric oxygen treatment (HBOT) in the orthopedic oncology patient with a complex open wound.
Risk factors for poor wound healing
A problem wound is one that fails to progress normally through the typical stages of healing. It demonstrates poor granulation, persistent exudates, retarded or failure of/or failure of neo-epithelialization. Skin flaps and grafts fail to integrate with the underlying tissue, leading to retraction and death of the flap or graft and re-exposure of the original wound in its initial or a worsened state. In some cases, the overt cause of a problem wound is a surgical procedure in tissue that is intact but compromised. Multiple factors can contribute to the failure of a wound to heal. Low tissue oxygenation, caused either by decreased systemic oxygenation or by poor tissue perfusion, is foremost among these factors. Others include inflammation; infection; nutritional deficiencies; repetitive trauma; poor glucose and lipid control; hematologic, rheumatologic, and autoimmune disorders; use of certain medications; and social and economic concerns, such as alcohol and tobacco use, poverty, and homelessness. Therefore, treating any wound that is not healing properly must involve identification of all contributing factors and a focused attempt to eliminate or ameliorate each one.
Tobacco use bears special mention because it is common and avoidable. Tobacco contributes to the development of wounds, delays in healing, wound dehiscence, and infection. Nicotine causes vasoconstriction, resulting in local tissue hypoxia. Vasoconstriction in the microcirculation has been demonstrated within 5 to 10 minutes of smoking one cigarette, and microvascular flow is reduced by 30% to 38% after 2 cigarettes. Nicotine substitutes have the same effect. Smoking also appears to be correlated with long-term endothelial vasomotor alterations, endothelial dysfunction, accelerated atherosclerosis, platelet activation, and decrements in collagen synthesis, all of which contribute to poor wound healing in current and former smokers.
Wound vacuum-assisted closure technology
As a negative margin is important to optimize local tumor control, resection of musculoskeletal tumors may result in large soft tissue defects that cannot be closed primarily and which may require prolonged dressing changes and complex surgical interventions for wound coverage. Adequate wound debridement of necrotic tissue is essential, while preserving vital structures when possible. Soft tissue coverage may be performed at the same setting as the debridement or may be delayed after an interval period of wound VAC treatment ( Fig. 4 ). The VAC is helpful to reduce soft tissue swelling and encourage the growth of vascularized granulation tissue. The disadvantages of wound VAC application include poor patient compliance because of discomfort, the need for frequent changes that may be uncomfortable, a foul smell, and difficulty with application in some anatomic areas. Although patient compliance has been improved with the development of mobile VAC units, areas such as the adductor compartment of the thigh and perineum remain a challenge.
The wound VAC is generally applied to the surgical bed with the sponge in direct contact with muscle and/or fascia. An interposed synthetic covering is often helpful if neurovascular structures or bone are exposed in the wound. The author uses a petroleum gel–impregnated dressing to protect structures that may be compromised by direct sponge contact. The skin surface may be coated with Mastisol or benzoin to help with dressing adherence. The sponge is contoured to fit the soft tissue defect without contact with the skin. In difficult areas such as the proximal adductor area, the sponge may be stapled to the skin at the periphery and stoma paste used under the sealant dressing for extra adherence. The device is set to 125 mm Hg on continuous pressure; alternatively an intermittent pressure may be used. The dressing is changed 3 times per week until the wound has healed enough for either a further surgical procedure such as skin grafting or soft tissue flap, or dressing changes alone. Wounds with prior radiation exposure may reopen after initial closure and require long-term follow-up ( Fig. 5 ).
