Complex Infections in the Hand Managed by Irrigating Wound VAC-NPWT
Gregory Borah, MD FACS
West Virginia University, Morgantown, WV
Introduction: Management of major infections of the upper extremity and hand is predicated on effective reduction of the infectious agents, adequate debridement and optimization of the wound bed for subsequent reconstruction. While VAC-NPWT with an irrigating component has been widely described in trunk, groin and lower extremity wounds it has not been reported (PubMed) in the hand and forearm. We present effective wound treatment with irrigating NPWT for a variety of severe infections of the hand, wrist and forearm.
Materials and Methods: From February 2015 to June 2017, almost six hundred patients (591) presented to the hand surgery service at our Level 1 Trauma Center with early or late infections of the hand, wrist or forearm requiring admission. Various infectious sources such as traumatic lacerations, animal bites, subcutaneous injection of illegal substances (IVDA) and idiopathic sources led to hand infections severe enough to require intravenous antibiotics. Twelve (12) patients had severe open wounds from avulsion, necrotizing infections, IVDA, and osteomyelitis of the carpal bones that were considered extensive and raised concerns for adequate infection control with conventional protocols. Eight (8) dorsal hand and forearms, and five (5) palmar and volar wound patients were treated with NPWT. After aggressive intraoperative surgical incision and drainage, an assessment was made regarding suitability for placement of irrigating wound VAC dressings. These patients were started with intermittent antibiotic fluid irrigation and NPWT at 125mm Hg continuously. Once wound control was achieved definitive reconstruction was undertaken with acellular dermal matrix (ADM) and skin graft or flap closure.
Results: From February 2015 to June 2017, all twelve (12) NPWT patients achieved complete resolution of infection and had stable wound coverage upon discharge. The carpal osteomyelitis patient underwent 6 weeks of outpatient intravenous antibiotics with no detectable residual bone infection. Five (5) of the NPWT patients had placement of ADM (Integra) over exposed tendons and muscles with complete granulation which accepted FTSG and STSG.
Conclusions: 1) Complex hand infections with exposed tendons, muscles, and bones can be treated with a high degree of success using irrigating NPWT. 2) Complex hand infections can be reconstructed with a combination of acellular dermal matrix and skin grafts on NPWT prepared upper extremity wounds.
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