A Non-healing Sinus of the Lower Leg 5 Years After Vacuum-assisted Closure Therapy Due To a Gossypiboma

Since its introduction, vacuum-assisted closure (V.A.C.^® Therapy^™, KCI, San Antonio,Tex) therapy has proven to be an adequate and noninvasive method in the treatment of complicated wounds.^1,2 Vacuumassisted closure can be used in the treatment of many types of chronic wounds, such as venous stasis ulcers, pressure ulcers, dehisced surgical wounds, arterial and diabetic ulcers, and a wide variety of miscellaneous, long-existing wounds.^3–5 Although complications related to its use are rare; localized superficial skin irritation is the most common complication reported in the literature.⁶ Further complications involve pain, infection, bleeding, and fluid depletion.² Although rare, severe complications, such as toxic shock syndrome, anaerobic sepsis, or thrombosis have been reported.^7–9 This case report presents an unusual complication of vacuum-assisted closure therapy, which to the authors’ knowledge has only once been reported in the literature.¹⁰

Case Report

A 55-year-old woman was admitted to the surgical ward for exploration of a persistent sinus on the lower left leg. Patient history included a traumatic posterior knee luxation 5 years and 10 months prior to presentation with no fracture visible on x-ray examination. Due to vascular injury and a lesion ofthe peroneal nerve, she was surgically treated with reposition, fasciotomy, vascular reconstruction, and an external fixture. After surgery, the wound was treated with a vacuum-assisted closure therapy system to promote wound healing. Dressings were changed twice per week, and initially the wound was healing nicely. Two weeks after the vacuum-assisted closure therapy was stopped the patient experienced pain in her knee. An ultrasound examination showed a cavity suspected to be an abscess, which was then explored and drained. Following both exploration and drainage, the fistula continued to produce serous fluid. A small fluid collection was visible on the ultrasound examination that had drained onto the fistula. Osteomyelitis was not visible on the x-ray exam. Bacteriological examination found Escherichia coli in the fluid, which was treated with antibiotics. The patient was discharged with 2 skin defects. Six months after the initial accident, these 2 defects were still present.
Five years later, the patient returned with an infection of the fasciotomy wound. At the time of this presentation, there was no indication of fistula or sinus complication. Over the next 5 years she returned several times as an outpatient with serous fluid leakage from the prior wound site. Although the wound managed to heal most of the time, it would resume leaking serous fluid in 3 to 4 months.
Five months prior to her admission to the surgical ward, a MRI scan showed a 4.5-cm sinus tract. In the center of the sinus a roughly shaped structure was identified and suspected to be a foreign body (Figure 1).The fistula and sinus were then opened and explored. A foreign body was found in the cavity and it appeared to be a polyurethane V.A.C.^® dressing, which was completely removed (Figure 2A, 2B). Pathological examination of the specimen showed signs of a chronic infection with multinucleated giant cells together with extensive fibrosis and large quantities of foreign body material (Figure 3A, 3B).
After the surgery, the wound was treated with vacuum- assisted closure therapy. Almost 2 months after the surgery the wound is nearly closed (Figure 4).The vacuum- assisted closure therapy was terminated and the wound is currently being treated with 0.2% polyhexamethylene biguanide impregnated antimicrobial dressings (Kerlix^™ AMD^™, Tyco Healthcare, Zaltbommel, The Netherlands) to prevent infection and promote final closure of the wound.

Discussion

A retained piece of surgical dressing, also known as a gossypiboma (gossypium: Latin, cotton; boma: Swahili, place of concealment),^10–12 is a complication that can easily occur; however, the number of publications about this complication in the literature is limited. Gossypibomas are uncommon and are rarely reported.The true incidence of retained dressings is unknown,but has been reported as 1 in 3000 surgical intervention cases.¹³ No data is available in the literature regarding the incidence in postsurgical wounds.
The problem of retained dressings during vacuum-assisted closure therapy is a complication that can easily occur due to the numerous dressing changes, especially when using multiple pieces of foam dressing and/or using vacuum-assisted closure therapy on deep wounds.The percentage of problems with using multiple pieces of retained vacuum-assisted closure dressings is around 20% (15 of 74 cases reported).¹⁴ Nevertheless,the retaining of a vacuum-assisted closure dressing has only been reported once (to the authors’ knowledge) by Fox et al.¹⁰ They describe a case in which the vacuum-assisted closure dressing remained in a nonhealing sacral pressure ulcer for 18 months and advise to ensure a meticulous count, annotation, and documentation of the materials placed in and subsequently removed from a wound to prevent this complication. Furthermore, they advise that thorough inspection of the wound cavity should also be carried out during dressing changes. In their case, the retained dressing was likely to have been responsible for the foreign body reaction and the wound’s failure to heal, which led to a surgical investigation. In the present case, the retained dressing most likely elicited a fibrinous response and became apparent as a result of fistulation.¹¹
The author’s wound center regularly treats patients with vacuum-assisted closure therapy. The therapy is used on nonhealing wounds in admitted patients as well as on nonhealing wounds on the extremities within the home care setting.The recommendations made by Fox et al¹⁰ were integrated into the wound center’s vacuumassisted closure therapy protocol. Additionally, clinicians at the wound center are advised to count the pieces of foam dressing and to attach separated pieces to each other either by stapling or stitching. By using this method, the loss of foam dressings will be reduced to a minimum since it is impossible to remove 1 dressing piece without removing the other. The staples or stitches can be removed when changing foam dressings; however, not before all pieces of the dressing are identified.

Conclusion

Despite the complication described above, vacuumassisted closure therapy remains one of the most reliable methods for the management of difficult, chronic, nonhealing wounds. The patient described in this case suffered avoidable morbidity, both physically and psychologically, due to the retaining of a piece of vacuum-assisted closure dressing for 5 years. By combining the counting of pieces of vacuum-assisted closure dressing, thorough inspection of the wound cavity, and attaching the pieces of dressing to each other, the authors hope to minimize the number of complications with gossypibomas.