Title : Low-cost negative pressure wound therapy for gunshot traumatism in developing countries
Abstract:
Wounds from gunshots and other explosive devices are a source of loss of substances directly or secondary to a well-conducted debridement. In addition, these types of wounds are by definition contaminated. The major challenge in this context for any surgeon remains filling of the cavity. The use of flap-type plastic surgery is one of the options if feasible. Another option is the use of vacuum dressing with reproducible results.
VAC therapy delivers better results than sugar and honey because of its proven benefits. In a humid environment, it ensures the drainage of exsudates. It causes an increase in local blood flow by stimulating neoangiogenesis, it stimulates cell proliferation and also the granulation tissue. It leads to a decrease in bacterial colonization and tissue edema.
Four observations are presented to illustrate the feasibility of this treatment in developing country and to show its beneficial effects.
Keywords: Gunshot wound, vacuum assisted closure, VAC therapy
Cases report (4 cases)
Case 1:
A 30-year-old patient with no prior history of injury was admitted for an open Gustillo-IIIb-fracture of the 2 bones of the right leg one week after trauma. He underwent debridement, removing necrotic soft tissue leaving the medial half of the tibial bone exposed (Fig. 2). In addition to external fixation (Hoffman 2), he was placed under a vacuum dressing for 12 days with a change every two days. He underwent one additional bone debridement. The evolution was a total coverage of the bone and a filling of the cavity after 12 days, followed by a skin graft (Fig.2). A Sarmiento cast was placed after removal of the external osteosynthesis material.
Case 2:
A 55-year-old patient with an open Gustillo-IIIb-fracture of the right olecranon by bullet. In emergency, a debridement of all wounds was performed and after 5 days, a tension band wiring was performed to maintain active elbow extension.
The post-operative course was marked by the lack of coverage of the cerclage wires and part of the olecranon, which led to the use of a vacuum dressing. The evolution after 12 days (change every 2 days) was favourable and a simple skin graft was performed.
Case 3:
An 18-year-old patient with an open Gustillo-IIIb right cervico-trochanteric fracture was admitted in hemorrhagic shock. All wounds were debrided. The evolution was a septic necrosis of the femoral head needing resection of the femoral head and of the trochanteric area and debridement of the surrounding soft tissue.
The sugar dressing was tried without success due to the stagnation of serosity in the pseudo-articular cavity. The vacuum dressing after sixteen days (changed every 2 days) allowed not only the filling of the cavity but also the reduction of the wound surface and a simple skin graft was performed at the end.
Case 4:
A 21-year-old patient with a right gluteocrural transfixing gunshot wound, with a right Gustillo-IIIb gunshot iliac wing fracture. Surgical debridement was performed removing all necrotic tissue and leaving a large wound with a huge cavity (about 10 cm long axis). After 16 days of VAC therapy (changed every 2 days), the cavity was filled and surface was reduced. The wound was ready to receive a simple skin graft afterwards.
