INTRODUCTION: An open fracture, if severe enough, has the potential to threaten the viability of the limb. Standard protocol for the treatment of open tibial fractures includes initial wound debridement and lavage, stabilization of the fracture and early wound closure or soft tissue coverage. Current standards also suggest definitive closure should occur within a 5 day time frame in order to provide optimal closure and prevent long term sequela. A method to refine this treatment protocol using Vacuum Assisted Closure (V.A.C.) therapy as a bridge between initial debridement and delayed definitive closure is described and compared to both the treatment of open tibia fractures with the traditional method of prompt soft tissue coverage and published historical controls. METHODS: A retrospective review of a series of 105 patients with open tibial fractures from 1996 through the end of 2002. Patients were divided into groups by the severity of fracture using the Gustilo grading system. Of the 105 patients, 59 (56%) were treated with the VAC wound treatment system between initial debridement and definitive closure, while 46 (44%) were not treated with the V.A.C. system. Fracture classification is as follows: Gustilo Grade I, n = 4 (3 VAC/1 traditional); Grade II, n = 6 (3 VAC/3 traditional); Grade IIIA, n = 53 (28 VAC/27 traditional); Grade IIIB, n = 34 (20 VAC/14 traditional); and Grade IIIC, n = 8 (5 VAC/3 traditional). An analysis of the number of days between initial debridement and closure, number and types of flaps, and the presence of long term infection rates was performed. RESULTS: The two groups were similar regarding age, sex, and types of injuries. For Gustilo Grade I fractures, no flaps were required in either group. For Grade II fractures, no flaps were required in either group, although historically 20% required flaps. Grade IIIA: 2/26 (8%) VAC treated wounds required flaps (0 free laps); 1/27 (4%) traditionally treated wounds required flaps (0 free laps). Grade IIIB: 8/20 (40%) VAC treated wounds required flaps (3 free laps (15%)); 10/14 (71%) traditionally treated wounds required flaps (4 free laps (28%); 3 amputations); and historically 30% required free flaps. Grade IIIC: 2/5 (40%) VAC treated wounds required flaps; and 0/3 traditionally treated wounds required flaps (2 amputations). Regarding infections rates: Grade I; no infections in either group; historically 8.3% become infected. Grade II: 0/3 VAC treated wounds became infected; 2/3 (67%) traditionally treated wounds became infected; and historically 14% become infected. Grade IIIA: 2/26 (7.7%) VAC treated wounds became infected; 5/27 (18.5%) traditionally treated wounds became infected; and historically 12.3% become infected. Grade IIIB: 3/20 (15%) VAC treated wounds became infected; 6/14 (42.6%) traditionally treated wounds became infected; and historically 13.3% become infected. Grade IIIC: 1/5 (20%) VAC treated wounds became infected; 1/3 (33%) traditionally wounds became infected; and historically 14.6% become infected. Regarding time to closure, Grade I: 8.3 days VAC; 3 days traditional. Grade II: 14 days VAC; 10.5 days traditional. Grade IIIA: 12.3 days VAC; 11.3 days traditional. Grade IIIB: 13.3 days VAC; 19.3 days traditional. Grade IIIC: 14.6 days VAC; 18.3 days traditional. CONCLUSIONS: The use of V.A.C in the treatment of open tibia fractures provides an effective bridge between initial debridement and definitive closure. The VAC decreases the need for flap coverage, particularly in the IIIB category where 40% of patients required flaps (15% free flaps) compared to 71% flap rate (28% free flaps) for the traditional group which historically requires 30% free flaps for coverage. Infection rates were lower in the VAC treated group. Time to closure was comparable between the groups.
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