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Notes on Practice: Healing a Wound with an Exposed Herrington Rod: A Case Study
The development of chronic wounds in spinal cord patients represents a particularly challenging dilemma because of the high rate of wound recurrence. Initial surgical management limits the options for operative treatment of the recurrent wound. Traditional nonoperative management can preserve options for future surgery but requires frequent dressing changes.
The vacuum-assisted closure (VAC, KCI Medical, San Antonio, Tex.) system may offer an alternative to treating these difficult wounds. The VAC technique uses continuous-cell foam dressing, which is attached to a subatmospheric pressure device. Although the mechanisms of action are still being fully delineated, subatmospheric pressure decreases bacteria count, removes serous fluid, reduces tissue edema, improves blood flow, and maximizes granulation tissue formation.1,2 Although this technique has been effective in a large number of patients with a variety of wounds, vascularized soft tissue remains the preferable treatment choice in wounds with exposed hardware.3
When chronic wounds result in exposure of hardware, management can be quite difficult. Typically, these wounds require vascularized soft tissue to obtain satisfactory coverage, either with local flaps or with free-tissue transfers. This article presents a single case of a patient who underwent placement of vacuum-assisted dressing to cover exposed spinal hardware. Complete wound and hardware coverage was achieved nonoperatively without any evidence of recurrent wound breakdown.
Patient History
A 25-year-old female with spina bifida, paraplegia, and autoimmune deficiency presented with a large pressure ulcer on her back, right of the midline, at the T-10 level. The wound, measuring approximately 20 cm x 15 cm, was in the area of a previous reconstruction. Eight years before, following a severe case of necrotizing fasciitis, the patient required reconstruction of a large thoracic wound. Soft tissue coverage was obtained using a combination of skin grafts, local flaps, and free-tissue transfer. Vein grafts were used to create an arteriovenous loop from the iliac, and free-tissue transfer was performed using the right rectus abdominus muscle. The wound was stable for 10 years until a traumatic injury led to a recurrent breakdown with exposure of Herrington rod spinal stabilization hardware.
The previous surgeries had severely limited the options for surgical coverage. Use of local flaps left significant scarring around the area and transected the local blood flow available for local flaps. Because the inflow vessels of the groin had been used, free-tissue transfer would require multiple vein grafts from the contralateral groin and was likely to be unsuccessful. The hardware at the base of the wound made the use of antibiotics alone unlikely to address the chronic bacterial load. In addition, the proximity of the hardware to the spine presented a significant potential threat for osteomyelitis.
Treatment
To stabilize the wound, a VAC dressing was placed in anticipation of a repeat free-tissue transfer. Two weeks later, evaluation demonstrated good granulation tissue that covered the hardware completely. Treatment with the VAC dressing was continued for an additional 3 months until the defect filled completely and epithelial coverage was noted at the wound edge.
Discussion
Multiple factors affect the ability of a chronic wound to heal. Particularly in the paraplegic patient, factors such as neurovascular alterations, nutritional status, and skin integrity can inhibit proper healing.4 Bacterial colonization is typical in chronic wounds, making healing even less likely when a foreign body is present. Frequently extensive debridement, wound stabilization, and vascularized tissue coverage are needed to avoid removal of hardware, if present. Unfortunately, this necessitates hospitalization, surgery, and postoperative care.
Using a VAC dressing has several advantages. First, it obviates the need for hospitalization as well as complications from a surgical procedure.5 Also, the VAC system can be applied on an outpatient basis and dressings can be performed by home health nursing staff two to three times a week. Nonoperative management preserves the options for surgical coverage if future wounds develop.6
The VAC's disadvantages include the need for continued nursing care and the potential for prolonged healing. Although VAC dressing changes are less frequent, they can be more difficult than traditional dressings and are also more expensive. Often, the use of the vacuum device is not covered by third-party reimbursement, which can be a significant burden to the patient. Placement of the VAC may impair mobility when the suction device is connected to the wound unless a portable suction device is employed.
Surgical coverage is the primary management for spinal cord injury patients with chronic wounds, despite a significantly increased recurrence rate.7,8 However, in selected patients the VAC dressing may offer a nonoperative alternative and preserve limited surgical options. If the wound heals with the VAC, local flaps or free-tissue transfer can be used for recalcitrant wounds. VAC can be used to successfully obtain wound coverage in difficult patients, as illustrated in this case, where suitable wound healing in the face of chronic bacterial load and a foreign body was achieved.
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2. Hartnett JM. Use of the vacuum-assisted wound closure in three chronic wounds. JWOCN. 1998;25:281-290.
3. Argenta LC, Morkwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563-576.
4. Rodriquiez DJ, Benzel EC, Clevenger FW. The metabolic response to spinal cord injury. Spinal Cord. 1997;35:599-604.
5. Goodman CM, Cohen V, Armenta A, et al. Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients. Ann Plast Surg. 1999;42:665-672.
6. Deva AK, Buckland GH, Fisher E, et al. Topical negative pressure in wound management. Med J Aust. 2000;173:128-131.
7. Disa JJ, Carlton JM, Goldberg. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg. 1992;89:272-278.
8. Niaza ZB, Salzburg CA, Byrne DW. Recurrence of initial pressure ulcer in persons with spinal cord injuries. Advances in Wound Care. 1997;10:38-42.
