Vacuum-Assisted Closure and Muscle Flap as An Alternative Modality for Infected Wound After Orif of Tibial Fracture: Case Report
Background: The blood supply of a bone can be decreased due to the use of an implant, leading to wound-bed bacterial colonization and the development of the SSI. The principle of vacuum-assisted closure (VAC) is to use a negative pressure environment in the wound to promote increased wound healing. The case shows that VAC application and muscle flap therapy provide the definitive healing of infected wounds after ORIF.
Case Report: A 45 years-old male presented with a close comminuted proximal third right tibia fracture and tense skin. The fracture was openly reduced and internally fixated with plate fixation and a skin flap on the fracture area. Still, the wound could not be closed due to difficulty covering the wound, so a counter incision was made. After four days, the patient developed necrosis in the post-operation wound and subsequently underwent debridement and muscle flap with VAC application.
Discussion: SSI can be treated by applicating of appropriate antibiotic and surgical procedures. In this case, the infection was treated using third-generation cephalosporin antibiotic, debridement, dissection, and re-elevation of gastrocnemius muscle flap covering the exposed plate area in inferior, split skin graft above the muscle flap and VAC above skin graft with 75 mmHg pressure.
Conclusion: Debridement with muscle flap and application of VAC in the deep infected wound of open reduction and internal fixation was found to be successful methods in minimizing complications and obtaining an optimal outcome. This finding was associated with accompanying morbidities or a good wound healing process.
Doshi P, Gopalan H, Sprague S, Pradhan C, Kulkarni S, Bhandari M. Incidence of infection following internal fixation of open and closed tibia fractures in India (INFINITI): a multi-centre observational cohort study. BMC Musculoskelet Disord. 2017;18:156.
Swart E, Lasceski C, Latario L, Jo J, Nguyen U-SDT. Modern treatment of tibial shaft fractures: Is there a role today for closed treatment? Injury. 2021;52:1522–8.
Schlatterer DR, Hirschfeld AG, Webb LX. Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures? Clin Orthop Relat Res. 2015;473:1802–11.
Bonnevialle P. Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures). Orthop Traumatol Surg Res. 2017;103:S67–73.
Bhandari M, Jeray KJ, Petrisor BA, Deveraux PJ, Heels-Ansdell D, Schemitsch EH, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med. 2015;373:2629–41.
Nsaful KO, Paintsil AB, Dakubo JCB, Nsaful J. Appiah-Labi K, Nartey E. An Evaluation of Bacterial Infection of Split Thickness Skin Grafts: At the Korle Bu Teaching Hospital. Lap Lambert Academic Publishing; 2020:9(1):259-65.
Tetreault MW, Della Valle CJ, Hellman MD, et al. Medial gastrocnemius flap in the course of treatment for an infection at the site of a total knee arthroplasty. JBJS Essent Surg Tech. 2017;7(2):e14.
Fang C, Wong T-M, To KKW, Yong SSY, Lau TW, Leung F. Infection after fracture osteosynthesis–Part II: Treatment. J Orthop Surg. 2017;25(1):1–11.
Ploumis A, Mpourazanis G, Martzivanou C, Mpourazanis P, Theodorou A. The role of vacuum assisted closure in patients with pressure ulcer and spinal cord injury: a systematic review. World J Plast Surg. 2019;8:279.
Jiang Z-Y, Yu X-T, Liao X-C, Liu M-Z, Fu Z-H, Min D-H, Guo G-H. Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials. Burns. 2021;47:747–55.
Raducha JE, Swarup I, Schachne JM, Cruz A, Fabricant, P. Tibial Shaft Fractures in Children and Adolescents. JBJS Rev. 2019;7(2):e4.
Henkelmann R, Frosch K-H, Glaab R, Lill H, Schoepp C, Seybold D et al.Infection following fractures of the proximal tibia–a systematic review of incidence and outcome. BMC Musculoskelet Disord. 2017;18:1–8.
Karbalaeikhani A, Dehkhoda S, Saremi H. Gastrocnemius Muscle Flap and Its Application in Lower Extremity Reconstruction. Ann Mil Heal Sci Res. 2015;13:154-6.
Le Nen D, Hu W, Liot M, Moineau G, Gerard R. Gastrocnemius medial flaps. Interact Surg. 2007;2:118–27.
Norris R, Chapman AWP, Krikler S, Krkovic M. A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings. Ann R Coll Surg Engl. 2013;95:118–24.
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