Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_705_Библиотеки_им_академика_М_И_Перельмана
.pdf
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
abc
def
385
Fig. 26.18 Clinical images multiple views—sequential
cadaveric performance of the PT tendon transfer into the
cuboid bone via (a, b) four-incision approach, (c) with
harvesting of the PT tendon at its insertion, (d) passing of
the tendon to the deep posterior leg compartment, proximal to the exor retinaculum with placement of a passing
Procedure
The patient is placed in the supine position. A
thigh tourniquet and ipsilateral hip bump is generally used. As with most tendon transfers, general
anesthesia with paralysis is recommended. The
transfer of the posterior tibial tendon to the dorsum of the foot is generally performed through
four incisions. The rst incision made medial
directly over the insertion of the tendon on the
suture in the form of a whip style stitch to the distal ten-
don, (e) passing of the tendon to the anterior leg compart-
ment via and interosseous membrane approach, (f) nal
passing of the tendon to the dorsal foot with xation via a
biotenodesis screw
navicular tuberosity. This incision is generally
3–4cm in length. Dissection is carried down to
the tendon insertion, care is taken to preserve the
exor digitorum longus tendon. Preserving as
much of the PT tendon as possible, the tendon is
dissected off the navicular distally to proximally.
Using a 2-0 prolene a whip stitch is placed through
the distal tendon. A second 3cm incision is made
13–15cm proximal to the distal tip of the medial
386
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
J. S. Steinberg et al.
malleolus on the medial calf just posterior to the
medial aspect of the tibial crest. Dissection is carried down through the fascia, the rst tendon
encountered is the exor digitorum longus which
is retracted out of the way. Next the PT tendon is
encountered. The distal tendon stump is then
pulled proximally through the second incision. A
hemostat may be used to assist with retrieval.
Next using a large hemostat blunt, careful dissection is performed in distal and lateral direction on
the posterior tibia. Care must be taken to avoid the
neurovascular bundle as it resides in this area.
Once the interosseous membrane is encountered,
it is penetrated and the hemostat is advanced distally and laterally until the anterior skin is tented.
A third, 3 cm incision is made over the tented
skin. The hemostat is opened widely to enlarge
the interosseous window. Leaving the hemostat
open, a tendon passer is fed from the third incision to the second incision. The tendon is then fed
through the membrane anteriorly out through the
third incision. The fourth incision 3–4cm can be
placed over the lateral cuneiform or cuboid
depending on desired tendon function and length
(lateralizing the tendon insertion increased eversion force). The tendon is then passed deep to the
extensor retinaculum and out the fourth incision.
A drill hole is made through the bone and the
suture on a free needle is fed through the bone
tunnel and out the plantar foot. The foot is held at
neutral in the sagittal plane and/or slight eversion
when correcting for a varus deformity or lateral
column ulcers. The tendon is tensioned and the
biotenodesis screw is inserted. All incisions are
irrigated, and a layered closure is performed. The
patient is placed in a splint and non-weight-bearing for 6weeks. The surgeon should be mindful of
the length of the tendon when considering a PT
tendon transfer. Care must be taken to preserve as
much length as possible. The interosseous window should be wide enough to prevent any tethering of the tendon. It is also recommended to
address any equinus deformity with an Achilles
tendon lengthening or posterior ankle capsule
release when performing the PT tendon transfer.
If there is concern for medial column instability a
exor digitorum longus tendon transfer to the
navicular can be considered.
External Fixation forSurgical
Ooading
The use of external xation is a viable alterna-
tive or even primary treatment to the aforemen-
tioned ofoading strategies, especially when
strict ofoading or additional structural stability
is absolutely necessary (Fig.26.19). An external
xator may be applied either immediately fol-
lowing a denitive reconstructive closure attempt
or during an interim period where an open surgi-
cal site requires ofoading, structural support, or
immobilization. Patients with tenuous or fragile
grafts or aps or other procedures like joint
arthroplasty or fusion, osteotomy, and hardware
removal/exchange may benet from the weight-
relief and/or structural support provided by an
external xator. A wire or pin hybrid “frame”
Fig. 26.19 Clinical image AP ankle view—ringed (cir-
cular) external xator with hybridized skinny wire and
half-pin construct design. The use of external xation pos-
sesses a wide variety of constructs and uses in the com-
plex wound population from static ofoading,
immobilization, osseous compression, and dynamic mul-
tiplanar deformity correction
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
387
may be applied in innumerable construct fashions and several manufacturers provide circular
or “Ilizarov” frames, principally aimed at
ofoading or providing immobilization of a particular area about the foot and ankle. The primary shortcoming to this type of ofoading is
the morbidity associated with such a construct.
Well-known potential complications associated
with external xation frames include pin or wire
site irritation and/or infection, pin or wire failure, pin or wire associated fracture as well as
external xator associated psychosis or “cage
rage.” Certainly, not every patient is considered a
candidate for this type of ofoading and those
under consideration should be properly counseled about the realistic expectations, the benets of such a construct, and the potential for
complication. Although not infallible, one may
minimize the potentiation for the aforementioned and associated complications of external
xation by minimizing the patients collective
time within the xator, by providing as rigid and
stable a construct as the tissues will tolerate, and
by providing for inherent contingency of the
internal component parts so that, should a pin or
wire experience breakage or irritation/infection,
a simple removal in ofce or bedside may be utilized, sparing the patient unneeded operative and
anesthesia intervention for wire or pin exchanges.
The authors prefer to plan utilization of external
xation for a maximum time period of
4–8 weeks, when possible, utilize a four-ring
construct (two tibial rings, one talus ring, and
one footplate ring), utilize a hybridized skinny
wire and half- pin combination of xation at the
tibial rings, and utilize the narrowest ringed construct amenable to the patient’s anatomy. In
these ways, the possibility of many of the most
common complications of external xation can
be minimized.
Prophylactic Surgery inLimb
Salvage
In the high risk patient population, it may be
benecial to prophylactically correct a pedal
deformity which has the potential to insite
ulceration, prior to wound formation.
Deformities such as hammertoes, bunions, hal-
lux rigidus, tailor’s bunions, pes planus, pes
cavus, and ankle equinus are the most common
pathologies that can lead to ulcerations in the
neuropathic foot [48, 49]. When custom shoes
or inserts fail to properly accommodate poten-
tial sites of ulcerations, surgical correction
should be necessary.
When performing an elective surgical procedure on a high risk patient, the surgeon must
understand the increased risk of wound healing
complication and infection compared to a
healthy individual. The authors recommend a
thorough vascular work-up including arterial
studies with vascular surgery consultation, glycosylated hemoglobin A1c of 7.9 or lower, fasting glucose level of less than 200mL/dL on day
of surgery, smoking/nicotine cessation greater
than 6weeks prior to surgery on any high risk
surgical patient. It is also recommended to limit
the amount of absorbable suture used and consider using antibiotic powder or biodegradable
antibiotic delivery device on hardware and incisions. Following surgical correction of a pedal
deformity, it is strongly encouraged patients
receive custom inserts/shoes after they have
completely healed. Patients should be followed
routinely indenitely after surgery for preventative care.
Summary
The diabetic foot and ankle is a complex structure with multiple intrinsic and extrinsic factors.
Surgical ofoading and prophylactic surgery performed at the appropriate time can be critical in
preventing amputation. Identifying high pressure
areas and selecting the appropriate surgical procedure is of paramount importance. Insufcient
surgical ofoading or unnecessary surgical procedures increase the risk of amputation. However,
when performed appropriately, surgical ofoading and prophylactic surgery can be a power tool
in treating and preventing ulcers in the high risk
diabetic foot.
388
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
J. S. Steinberg et al.
References
1. Beaulieu RJ, Grimm JC, Lyu H, Abularrage CJ,
Perler BA.Rates and predictors of readmission after
minor lower extremity amputations. J Vasc Surg.
2015;62:101–5.
2. Hobizal KB, Wukich DK. Diabetic foot infections: current concept review. Diabet Foot Ankle.
2012;3(1):18409.
3. Armstrong DG, Frykberg RG. Classifying diabetic
foot surgery: toward a rational denition. Diabet Med.
2003;20:329–31.
4. Edmonds ME, Sumpio BE. Limb salvage of the
diabetic foot: an interdisciplinary approach. Berlin:
Springer; 2019.
5. Raspovic KM, Hobizal KB, Rosario BL, Wukich
DK. Midfoot Charcot Neuroarthropathy in patients
with diabetes: the impact of foot ulceration on
self-reported quality of life. Foot Ankle Spec.
2015;8:255–9.
6. van Schie CHM. A review of the biomechanics of the diabetic foot. Int J Low Extrem Wounds.
2005;4:160–70.
7. Besse J-L, Leemrijse T, Deleu P-A. Diabetic foot:
the orthopedic surgery angle. Orthop Traumatol Surg
Res. 2011;97:314–29.
8. Wu SC, Crews RT, Armstrong DG.The pivotal role
of ofoading in the management of neuropathic foot
ulceration. Curr Diab Rep. 2005;5:423–9.
9. Finestone AS, Tamir E, Ron G, Wiser I, Agar
G. Surgical ofoading procedures for diabetic foot
ulcers compared to best non-surgical treatment: a
study protocol for a randomized controlled trial. J
Foot Ankle Res. 2018;11:6.
10. Armstrong DG, Lavery LA, Vazquez JR, Short B,
Kimbriel HR, Nixon BP, Boulton AJM. Clinical
efcacy of the rst metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes. Diabetes
Care. 2003;26:3284–7.
11. Scott JE, Hendry GJ, Locke J.Effectiveness of percutaneous exor tenotomies for the management and
prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res. 2016;9:25.
12. Fontaine JL, Crisologo PA, Lavery L.Current concepts in curative surgery for diabetic forefoot ulcers.
Foot. 2019;39:37–44.
13. Bonanno DR, Gillies EJ.Flexor tenotomy improves
healing and prevention of diabetes-related toe ulcers: a
systematic review. J Foot Ankle Surg. 2017;56:600–4.
14. Frykberg RG, Bevilacqua NJ, Habershaw G.Surgical
off-loading of the diabetic foot. J Am Podiatr Med
Assoc. 2010;100:369–84.
15. Yammine K, Kheir N, Assi C.A meta-analysis of the
outcomes of metatarsal head resection for the treatment of neuropathic diabetic foot ulcers. Adv Wound
Care. 2021;10:81–90.
16. Molines-Barroso RJ, Lázaro-Martínez JL, AragónSánchez J, García-Morales E, Beneit-Montesinos
JV, Álvaro-Afonso FJ. Analysis of transfer lesions
in patients who underwent surgery for diabetic foot
ulcers located on the plantar aspect of the metatarsal
heads. Diabet Med. 2013;30:973–6.
17. Henry J, Besse JL, Fessy MH, AFCP. Distal osteotomy of the lateral metatarsals: a series of 72 cases
comparing the Weil osteotomy and the DMMO percutaneous osteotomy. Orthop Traumatol Surg Res.
2011;97:S57–65.
18. Tamir E, Tamar M, Ayalon M, Koren S, Shohat N,
Finestone AS.Effect of mini-invasive oating metatarsal osteotomy on plantar pressure in patients with
diabetic plantar metatarsal head ulcers. Foot Ankle
Int. 2021;42:536–43.
19. Lipsky BA, Kuss M, Edmonds M, Reyzelman A,
Sigal F.Topical application of a gentamicin-collagen
sponge combined with systemic antibiotic therapy for
the treatment of diabetic foot infections of moderate
severity: a randomized, controlled, multicenter clinical trial. J Am Podiatr Med Assoc. 2012;102:223–32.
20. Elmarsa T, Oliver NG, Steinberg JS, Evans KK,
Attinger CE, Kim PJ.Long-term outcomes of permanent cement spacers in the infected foot. J Foot Ankle
Surg. 2017;56:287–90.
21. Moon KC, Son JW, Han SK, Kim JY. Risk factors for major amputation for midfoot ulcer in
hospitalized patients with diabetes. Foot Nail Care.
2021;48(2):163–8.
22. Lu Q, Wang J, Wei X, Wang G, Xu Y.Risk factors
for major amputation in diabetic foot ulcer patients.
Diabetes Metab Syndr Obes. 2021;14:2019–27.
23. Laborde J.Midfoot ulcers treated with gastrocnemiussoleus recession. Foot Ankle Int. 2009;30(9):842–6.
24. Wieman T, Grifths G, Polk H.Management of diabetic midfoot ulcers. Ann Surg. 1992;215(6):627–32.
25. Siddiqui N, LaPorta G.Midfoot Charcot reconstruction. Clin Podiatr Med Surg. 2018;35:509–20.
26. Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier
P, Friscia DA, Hansen ST, Schaser K, Ljungqvist J,
Sands AK.Tibiotalocalcaneal fusion using the hindfoot arthrodesis nail: a multicenter study. Foot Ankle
Int. 2013;34(9):1245–55.
27. Burns PR, Dunse A. Tibiotalocalcaneal arthrodesis
for foot and ankle deformities. Clin Podiatr Med Surg.
2017;34(3):357–80.
28. Lee BH, Fang C, Kunnasegaran R, Thevendran
G. Tibiotalocalcaneal arthrodesis with the hindfoot arthrodesis nail: a prospective consecutive
series from a single institution. J Foot Ankle Surg.
2018;57(1):23–30.
29. Wukich DK.Pantalar arthrodesis for post-traumatic
arthritis and diabetic neuroarthropathy of the ankle
and hindfoot. Foot Ankle Int. 2011;32(9):924.
30. Herscovici D, Sammarco GJ, Sammarco VJ, Scaduto
JM. Pantalar arthrodesis for post-traumatic arthritis
and diabetic neuroarthropathy of the ankle and hindfoot. Foot Ankle Int. 2011;32(6):581–8.
31. Langan T, Lalli TAJ, Smith CN, Wukich
DK. Talectomy as part of chronic foot and ankle
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
389
deformity correction procedure: a retrospective study.
J Foot Ankle Surg. 2020;59(1):16–20.
32. Hintermann B, Knupp M, Barg A. Supramalleolar
osteotomies for the treatment of ankle arthritis. J Am
Acad Orthop Surg. 2016;24(7):424–32.
33. Chopra V, Stone P, Ng A.Supramalleolar osteotomies.
Clin Podiatr Med Surg. 2017;34(4):445–60.
34. Walcher MG, Fraissler L, Konrads C, Plumhoff P,
Hoberg M, Rudert M.Distale tibiaosteotomien [osteotomies of the distal tibia]. Oper Orthop Traumatol.
2018;30(4):253–75.
35. Horn DM, Fragomen AT, Rozbruch
SR.Supramalleolar osteotomy using circular external
xation with six-axis deformity correction of the distal tibia. Foot Ankle Int. 2011;32(10):986–93.
36. Siddiqui NA, Millonig KJ, Mayer BE, Fink JN,
McClure PK, Bibbo C.Increased arthrodesis rates in
Charcot neuroarthropathy utilizing distal tibial distraction osteogenesis principles. Foot Ankle Spec.
2022;15:394.
37. Lavery LA, Armstrong DG, Boulton AJM, Diabetes
Research Group. Ankle equinus deformity and its
relationship to high plantar pressure in a large population with diabetes mellitus. J Am Podiatr Med Assoc.
2002;92:479–82.
38. Silfverskiold N. Reduction of the uncrossed twojoints muscles of the leg to one-joint muscles in spastic conditions. Acta Chir Scand. 1924;56:315–30.
39. Hoke M.An operation for the correction of extremely
relaxed at feet. J Bone Joint Surg. 1931;13:773–83.
40. Firth GB, McMullan M, Chin T, Ma F, Selber P,
Eizenberg N, Wolfe R, Graham HK. Lengthening of
the gastrocnemius-soleus complex: an anatomical and
biomechanical study in human cadavers. J Bone Joint
Surg Am. 2013;95:1489–96.
41. Herzenberg JE, Lamm BM, Corwin C, Sekel
J.Isolated recession of the gastrocnemius muscle: the
Baumann procedure. Foot Ankle Int. 2007;28:1154–9.
42. Garceau GJ. Anterior tibial tendon transposition in
recurrent congenital club-foot. J Bone Joint Surg Am.
1940;22:932–6.
43. Kuo K, Wu KW, Krzak J, Smith P. Tendon transfers
around the foot: when and where. Foot Ankle Clin N
Am. 2015;20:601–17.
44. Mulhern J, Protzman N, Brigido S. Tibialis anterior tendon transfer. Clin Podiatr Med Surg.
2016;33:41–53.
45. Cates NK, Bunka TJ, Kavanagh AM, Wynes J.Split
anterior tibial tendon transfer to dorsal lateral foot for
cavovarus deformities with neuropathic ulcerations: a
case series. J Foot Ankle Surg. 2022;61:189–94.
46. Ober FR.Tendon transplantation in the lower extremity. N Engl J Med. 1933;209:52–9.
47. Watkins MB, Jones JB, Ryder CT, Brown
TH.Transplantation of the posterior Tibial tendon. J
Bone Jt Surg. 1954;36:1181–9.
48. Frykberg R, Bevilacqua N, Habershaw G.Surgical
ofoading of the diabetic foot. J Vasc Surg.
2010;52:44s–58s.
49. Smith D, Barnes B, Sands A, Boyko E, Ahroni
J. Prevalence of radiographic foot abnormalities in patients with diabetes. Foot Ankle Int.
1997;18(6):342–6.
Negative Pressure Wound Therapy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
PaulJ.Kim
27
Introduction
Negative Pressure Wound Therapy (NPWT) has
been utilized in wound care and limb salvage/
limb function preservation for almost 30years.
This technology is considered an adjunctive standard of care treatment modality utilized in both
the inpatient and outpatient settings. Imparting
negative pressure onto the surface of wounds
optimizes the wound bed by promoting the generation of granulation tissue, neovascularization,
enhancing venous and lymphatic drainage, reduction of bacteria, and decreasing wound size. The
device consists of a porous interface (foam or
gauze material), drape, tubing, canister, and a
pump. Further, NPWT is used over closed incisions to decrease incision-related complications.
There have been many innovations in the original
device design that include improvements in the
software, hardware interface, the addition of
instillation, foam and drape construct. Other
innovations include increasing portability
through smaller devices as well as mechanically
and not electrically powered pumps (Fig.27.1)
(Table27.1).
Author Disclosure: 3M.Inc.
P. J. Kim (*)
Department of Plastic Surgery, University of Texas
Southwestern, Dallas, TX, USA
Department of Orthopedic Surgery, University of
Texas Southwestern, Dallas, TX, USA
e-mail: Paul.Kim@UTSouthwestern.edu
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_27
391
392
P. J. Kim
Fig. 27.1 There are a
variety of innovations
that have branched from
the traditional NPWT
device
Instillation
NPWT
Waffle Design
Portable
NPWT
Table 27.1 Advantages and disadvantages to NPWT
systems
Advantages Disadvantages
Standard
NPWT
Mechanically
powered
portable
NPWT
Incisional
NPWT
NPWT with
instillation
NPWT negative pressure wound therapy
Mechanism ofAction
There are multiple proposed mechanisms of
action for NPWT.The base device of NPWT provides multiple positive effects on the wound bed
beyond that of decreasing overall wound dimensions and exudate removal (Fig. 27.2). Some
believe that the primary clinical goal for the use
of NPWT is to promote the growth of granulation
tissue. Morykwas etal. in a porcine study exam-
Promotes wound
bed conversion
to a healthier
state
Mobility Limited for the use
Decrease in
incisional
complications
Clearance of
bacteria
Has battery backup
but still needs
electricity for
recharge
of smaller,
minimally
exudative wounds
No direct
visualization of the
incision
Higher cost than
traditional incision
dressings
Potential for leaks
and maceration
Can only be
utilized in the acute
setting or some
long-term acute
care settings
Incisional
NPWT
Novel Drape
NPWT
Open Abdomen
NPWT
ined the effect of different pressures on granulation tissue growth [1]. This study may have been
erroneously extrapolated to suggest that granulation tissue growth is the goal of NPWT.However,
it is important to understand that granulation tissue should be viewed simply as a sign of wound
bed health and not necessarily the clinical end
goal. The presence of granulation tissue indicates
adequate perfusion and low bioburden (bacteria
and nonviable tissue). Granulation tissue is
essentially a bed of capillaries imbedded in a collagen matrix. This environment increases the
likelihood of epithelization or provides a base to
receive and incorporate a split-thickness skin
graft, allograft, or xenograft.
NPWT can be programmed for continuous
application of negative pressure or intermittent
application of negative pressure. The evidence
suggests that the intermittency (periods of lower
or no negative pressure) is the preferred method
in stimulating the wound bed. Morykwas etal.
report that there is a 40% greater granulation tissue growth with intermittent negative pressure as
compared with continuous negative pressure [2].
The intermittency appears to stimulate a greater
response in cell proliferation and angiogenesis
[3]. The engagement and disengagement of
negative pressure provides the stimulus to the
wound bed to react in response to tissue stress.
The effect appears to be on small vessels in promoting a more organized, more dense vascular
structure [4, 5]. Despite the evidence to suggest
that intermittency is superior, many clinicians
Well Aligned
27 Negative Pressure Wound Therapy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 27.2 There is good
alignment between the
goals of wound healing
and the mechanism of
NPWT
Goals of Wound Healing
• Remove exudate
• Promote granulation tissue
• Increase local perfusion
• Decrease bacteria and
contamination
Goals of Wound Healing
Novel Foam
NPWT
with Instillation
393
Mechanism of NPWT
• Remove exudate
• Promote granulation tissue
• Increase local perfusion
• Decrease bacteria and contamination
NPWT
Fig. 27.3 This gure conceptualizes the combination of
the innovations of NPWT.NPWT is the foundation of the
house, while NPWT with instillation is its walls, the novel
utilize the continuous setting for pragmatic reasons including the reduced likelihood of leaks
and alarms, and for greater patient comfort. A
more recent porcine study by Lessing et al.
reports no difference in granulation tissue thickness between continuous and intermittent negative pressure [6]. Further, they report that the use
of NPWT with instillation promotes greater granulation thickness than either continuous or intermittent negative pressure.
The mechanical forces imparted by negative
pressure provides for both macrodeformation and
microdeformation [7]. Macrodeformation is
essentially the centripetal forces that shrink the
overall wound dimensions when negative pressure
is applied. The decrease in overall wound dimen-
foam is the roof, and the novel drape is the shingles. The
innovations build on the fundamental benets of standard
NPWT
sions decreases the strain across the wound bed
and provides laxity in the tissue. Thus, the type of
tissue or anatomical location of the wound dictates
the degree of macrodeformation [8]. For example,
indurated tissue will have less ability for macrodeformation. Microdeformation is imparted through
the perforations in the porous foam. This type of
force is responsible for protein activation and the
cellular effects that promote cell migration and
neovascularization [3]. The variants of NPWT
including Negative Pressure Wound Therapy with
Instillation (NPWTi) and incisional NPWT provide additional and different effects on tissue.
The most widely used NPWTi device utilizes
a solution that is programmed to intermittently
bathe the surface of the wound (Fig.27.3). There
394
P. J. Kim
are other NPWTi devices that provide continuous
ow of solution across the wound bed. Essentially,
NPWTi combines the benets of negative pressure and wound irrigation. The proposed
mechanism of action of NPWTi is to provide a
medium, through the instillate, to hydrate, solubilize, and evacuate the nonviable tissue as well as
provide a medium for the bacteria to be removed
and perhaps decrease the likelihood of reattachment. NPWTi has been demonstrated to not only
reduce planktonic bacteria amounts but also
destroy mature biolm in invivo and exvivo porcine models [9, 10]. Yang etal. report in chronic
human wounds a 48% reduction of bacterial
amount utilizing NPWTi as compared with a
14% increase in bacterial amount with the use of
standard NPWT [11]. Some have postulated that
the reduction of bacteria may simply be the effect
of an antimicrobial solution on the wound bed
and has little to do with the NPWTi device itself.
Kim etal. report in a randomized controlled trial
of NPWTi in infected wounds; no difference in
various surrogate clinical outcomes (e.g., length
of hospitalization, number of surgeries) utilizing
normal saline as compared with polyhexanide
with betaine [12]. Kim etal. reported in a retrospective study on infected wounds a signicant
decrease in the number of operations, length of
hospitalization, and shorter time to nal surgical
procedure utilizing NPWTi with normal saline as
compared with standard NPWT [13]. This study
suggests that there is an additive positive effect
for the use of NPWTi beyond that of solely utilizing an antiseptic solution or standard NPWT.
A variety of solutions have been utilized with
NPWTi. To date there is no robust data to suggest
one type of solution is clearly superior to another.
Antiseptics may have a role in highly infected or
contaminated wounds. However, there may be
cytotoxic effects on healthy tissue that prohibit
its prolonged use. Normal saline is a viable alternative in many cases due to its wide availability
and its tolerability. The instillate can also serve to
moisturize the wound surface, thereby hydrating
the underlying tissue and reduce desiccation.
This is especially important for tissues such as
ligament, tendon, and joint capsule. Another
potential advantage is that NPWTi requires inter-
mittency of negative pressure which the evidence
suggests is superior to that of a continuous negative pressure setting as discussed above.
Incisional NPWT decreases the initial tensile
forces experienced along the incision line by
50% by distributing the forces over a wider surface area [14]. Further, incisional NPWT has
been reported to decrease edema through relieving venous congestion and enhancing lymphatic
drainage [15–17]. This may have 2 consequences:
(1) the decrease in edema decreases the tension
along the incision, (2) expedite healing by more
rapidly removing inammatory factors. Incisional
negative pressure is not designed to directly
remove the underlying uid in the incisional area.
It is recommended that drains be used to serve
this purpose. These drains should be placed at a
distance from the foam/drape or gauze/drape
construct to prevent interference with the device.
Some have proposed that there are long-term
benets that include an increase in tensile
strength across the incisional area and more organized scarring [17].
Indications
NPWT is utilized for soft tissue defects in all
areas of the body. It is not indicated in areas such
as inside the abdominal or thoracic cavities, spinal cord or brain, directly over identiable vessels or nerves. NPWT can promote granulation
tissue over less vascular structures such as bone,
capsule, ligament, or tendon. However, the area
must have adequate perfusion in order for this to
occur. Thus, noninvasive or invasive vascular
studies and/or intervention should be conducted
prior to treatment onset. NPWT should be
reserved for wounds that are not progressing, for
complex wounds, or in compromised patients.
Historically, NPWT was utilized to promote
wound healing over time in a relatively clean
wound bed. Armstrong etal. in the pivotal study
in post-amputation foot wounds report a faster
time to granulation with the use of NPWT compared with standard gauze dressing (42 vs.
84days) [18]. The technology has evolved as an
adjunctive therapy in wounds that are infected/
27 Negative Pressure Wound Therapy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
395
contaminated, and for closed surgical incisions in
high-risk populations. Each NPWT platform has
unique properties and characteristics that require
proper application in order to maximize its benets (Table27.2).
Chronic Wounds
NPWT should be considered for wounds that are
not healing as demonstrated by wound volume or
surface area reduction. Further, the quality of the
tissue in the wound bed may also benet from
NPWT by promoting the growth of granulation
Table 27.2 Tips and pearls for the use of NPWT
systems
Tips and pearls
Standard NPWT • Establish a denitive treatment
goal (terminal epithelization,
wound bed preparation for a graft)
• Use bridging techniques away
from weightbearing or boney
prominences
Mechanically
powered portable
NPWT
Incisional
NPWT
NPWT with
instillation
NPWT negative pressure wound therapy
• Use only on small, minimally
exudative wounds
• Should be reserved for outpatient
to maximize its portability
• Utilize drains as necessary away
from the incision line
• If utilizing the traditional black
foam (not the prefabricated
construct), cut the width that
expands at least 2cm on both sides
of the incision line
• Do not use large volumes of
solution per dwell cycle
• The volume of instillate may need
to be adjusted at each dressing
change with changing dimensions
of the wound
• Use of ostomy rings or paste may
be helpful to maintain a seal
utilizing the traditional polyvinyl
drape, but do not use these
products with the silicone
composite drape
• The novel foam should only be
used with NPWT with instillation
and not with traditional NPWT
tissue over deeper exposed structures. In the
lower extremity the fundamental principles of
optimized perfusion, medical management and
optimization of comorbidities, nutritional
enhancement, serial sharp excisional debridement, and ofoading/immobilization should be
adhered to along with NPWT.There should be an
ultimate treatment goal when utilizing
NPWT.This includes: (1) terminal epithelialization, (2) creation of a wound bed that will support
a split-thickness skin graft or other grafts, (3) as
part of staged approach for a local ap or free tissue transfer. NPWT should not be used for a
lengthy period without regular wound evaluation
to assess that NPWT has had positive effects on
the wound. If NPWT has demonstrated little or
no change to the wound bed, other treatment
options should be considered.
Traditional NPWT should not be used if there
is an active infection or necrotic tissue in the
wound bed. The infection should be treated and
the necrotic tissue removed prior to application
of NPWT.If the patient is not a surgical candidate or the patient refuses surgical intervention,
NPWTi with the novel foam with the large perforation may be an option for wounds that have
areas of necrotic and brotic tissue. This foam
will be discussed in further detail below.
NPWT has also been utilized as a bolster for
grafts [19, 20]. The foam or gauze is applied over
an autologous graft, allograft, or xenograft and
negative pressure is applied. The proposed benet
for this approach is to reduce seroma or hematoma
formation that could otherwise lift the graft off the
wound bed surface by evacuating uid. The other
proposed benet is to afx the wound bed and the
graft together to prevent graft drift or oating of
the graft. There have been multiple reports of this
technique in the literature; however these have
been relegated to case studies/case series and
underpowered comparative studies, thus the ultimate benet remains unclear [21–25].
Closed Incisions
NPWT has been demonstrated to decrease complication in high-risk populations across all sur-
Соседние файлы в папке Библиотека им академика М.И. Перельмана