This project is designed as a prospective, randomized, comparative study evaluating the use
of a negative pressure vacuum device in treating traumatic wounds sustained associated with
an open fracture.
Soft tissue injury following an open fracture is a significant problem following surgical
treatment of traumatic skeletal injuries. The soft tissue injury results from a combination
of the initiating trauma and additional tissue injury during surgery. Current treatment
includes open reduction and internal fixation versus external fixation, irrigation and
debridement following admission, decreased activity (non weight bearing status on the
injured extremity), maintaining the patient as an inpatient in the hospital, repeated
irrigation and debridements (36-72 hours following the initial trauma) with concomitant
wound culturing until which time it is determined that either delayed primary closure, or
skin grafting with/without flap coverage should be attempted.
All patients in the study will be treated with the appropriate empiric antibiotic regimen
until wound culture results justify modification for antibiotic sensitivity/resistance
reasons. In general, barring patient allergy, the empiric antibiotic regimen will adhere to
the Gustilo and Anderson classification as follows:
Grade I : Ancef Grade II : Ancef and Gentamicin or Zosyn Grade III : Ancef, Gentamicin or
Zosyn, and add a Penicillin for grade IIIB open fractures.
All wounds will be assessed initially at admission following the Gustilo and Anderson
classification for open fractures. Subsequent wound assessments in the operating room will
be graded according to the following descriptive scale:
Type A wound: Abundant granulation tissue, ready for closure. Type B Wound: Granulation
tissue present but inadequate for closure, Wound is clinically clean appearing. Type C
Wound: No granulation tissue, no gross purulence. Type D Wound: Gross purulence/infected
wound, no granulation tissue.
The outcome variables consist of the intraoperative and postoperative adverse device effects
recorded in the medical record and on the study data collection form, time to wound closure,
intraoperative and postoperative complications recorded in medical record and on the study
data collection form. Clinical photographs of the wounds will be taken with a digital camera
at the time of admission to the study, and during each subsequent trip to the operating room
(every 48-72 hours). We will also record the injury severity score for all multiple trauma
patients recorded at the time of injury in the medical record and on the study data
collection form, and soft tissue score according to Gustillo and Anderson for open injuries
in the medical record and on the study data collection form. Baseline serum albumin and
total lymphocyte counts will be taken on admission to evaluate baseline nutritional and
immunologic status at the time of injury. All patients in the Intensive Care Units will
have daily weights, fluid balances, and nutritional intake documented. Resuscitation data
will also be recorded from the trauma room, including fluids, blood, and base deficit. The
effects will be measured by clinical examination and will be augmented with culture data for
any wounds that require surgical intervention.
Patients who have an open fracture and who give informed consent to enter the study will be
randomized into two groups. Group A will be patients treated with a return to the operating
room approximately 48 hours following the initial trauma, and approximately every 48 hours
thereafter, for irrigation and debridement and concomitant wound cultures (qualitative and
quantitative) until which time the wound is judged by the surgeon to be ready for either
delayed primary closure or flap/skin graft coverage. Group B will be patients treated with a
VAC negative pressure device following the initial surgical irrigation and debridement.
Group B patients will return to the operating room approximately 48 hours following the
initial irrigation and debridement for VAC removal, wound cultures (qualitative and
quantitative), repeat irrigation and debridement, and wound evaluation by the surgeon for
possible delayed closure versus reapplication of the VAC device. Group B patients will also
be returned to the operating room approximately every 48 hours thereafter for irrigation and
debridement and concomitant wound cultures (qualitative and quantitative) until the wound is
judged ready for coverage or closure by the surgeon.
- Patient who has sustained an open fracture that requires surgical irrigation and
- No gross clinical evidence of infection.
- A grossly infected open wound. Infection will be defined by clinical signs and
symptoms of infection that include increasing drainage, increasing pain, purulent
drainage, and increasing erythema. Any wounds that are thought to be infected will
be cultured to confirm the diagnosis.
- A surgical incision that can not be covered with VAC sponges and a water impermeable
sheet (such as Ioban or Tegaderm) to achieve a closed vacuum environment over the
- Wounds associated with the surgical incision that are intentionally left open to heal
with either a delayed primary closure or secondary granulation
- Abnormal coagulation leading to an expanding hematoma that will require surgical
- Pregnant women.
- Inability or unwillingness to comply with protocol.
- Patients or family members who are unable or unwilling to sign study informed