Wounds of the upper and lower extremities provide a constant challenge for orthopaedic and plastic surgeons. Complex severe injuries involving bone and soft tissue demand major reconstructive procedures. Less severe injuries exposing tendon, bone, and joints also demand innovative surgical approaches. Many patients with injured extremities have been the victim of multiple traumas and may have major associated injuries involving head, chest, and abdomen. Major blood loss, disseminated intravascular coagulopathy (DIC), high intracranial pressure, acute respiratory distress syndrome (ARDS), septicemia, and renal failure frequently complicate the treatment of these patients. Vacuum-assisted closure (VAC) has provided a way to effectively manage these wounds until definitive reconstruction can be performed. Vacuum-assisted closure has also greatly simplified reconstruction in many of these patients. Skin grafts are performed in many cases that would have otherwise required major rotational flaps or free flaps prior to the advent of VAC therapy.

The mechanics of the VAC system are straightforward. The system consists of an open cell polyurethane ether foam sponge sealed by an adhesive drape. All pores in the sponge communicate so that negative pressure applied to the sponge is applied equally and completely to the entire wound surface. The effects of the VAC on the wound are multiple. The application of negative pressure causes the sponge to collapse toward its center. Traction forces are thus applied to the wound perimeter pulling the wound edges together progressively making the wound smaller. The VAC sponge should be cut to fit inside the wound to maximize traction forces on the wound edges. The sponge should not overlap intact skin, as skin maceration may occur. In addition, the VAC removes wound edema, appears to increase circulation and decrease bacterial counts, and significantly increases the rate of granulation tissue formation (1,6).

All wounds are thoroughly debrided prior to VAC placement. No clinical infection, purulence, or suspected osteomyelitis should be present prior to VAC placement. Grossly contaminated wounds are a contraindication for VAC placement. The VAC sponge should not be applied directly over major exposed blood vessels in the extremity status posttrauma, especially if the vessel wall has been damaged or a vessel repair has been performed. A protective interface such as Adapticw may be used. Exposed, repaired, or damaged major vessels should be covered with flaps such as muscle flaps or fasciocutaneous flaps. The VAC may be applied over intact nerves if muscle flap or adequate soft tissue coverage is not possible. A layer of Adaptic may help prevent pain caused by VAC traction especially when VAC sponges are changed. Nerve repairs should also be protected by an interface layer such as Adaptic placed under the VAC sponge. Adequate soft tissue or flap coverage of major peripheral nerves is preferred for final long-term management. The VAC may frequently allow secondary closure of wounds over major peripheral vessels or nerves by pulling together adequate soft tissue as edema is removed. Split-thickness skin grafts placed directly over major exposed vessels or nerves is possible with VAC therapy after granulation tissue occurs, but not preferred.

The VAC sponge may be placed directly on bone if the bone surface bleeds following sharp debridement by an osteotome or low-speed power burr. Occasionally, desiccation of bone may occur
with the VAC. If desiccation occurs, further debridement to punctuate bone surface bleeding with the immediate placement of Integraw Dermal Regeneration Template and then VAC placement directly over Integra may be tried. This technique has provided Integra take over bone allowing subsequent skin graft coverage. The Integra must be meshed or holes cut in the outer silicone layer before VAC sponge placement. Relatively small areas of bone have been successfully treated in this manner. Large areas of exposed bone are better treated with pedicle muscle flaps, pedicle fasciocutaneous flaps, or free flaps. The VAC should not be placed over desiccated bone with questionable viability without punctuate bone surface bleeding.

Wounds should be thoroughly debrided before VAC application. Once the wounds are clean, VAC therapy may be initiated. VAC sponges can initially be applied in the operating room following definitive debridement.

To illustrate the application of the VAC device to wounds of the extremities, case studies will be shown to illustrate degloving injuries, gunshot wounds, and a variety of avulsion injuries with exposed tendons, bones, and joints. VAC treatment of traumatic wound complications such as infection and hematoma is also illustrated.