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  • 1. Introduction
  • 2. Preparation
  • 3. Removal of Foam and Sponges
  • 4. Irrigation and Wound Cleaning
  • 5. New Sponge Placement
  • 6. Stapling Sponge to Wound Edges and Protecting Skin with Plastic Dressing
  • 7. Application of Film Seal
  • 8. Foam Bridge Creation for Best Positioning of Vacuum Suction
  • 9. Application of Vacuum Suction
  • 10. Post-op Remarks
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Vacuum-Assisted Closure (VAC) Change for a Complex Right Hip Wound

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Joshua Ng-Kamstra, MD, MPH
Massachusetts General Hospital

Main Text

Hip joint infection is a serious health condition that can cause life-threatening septic complications and lead to death. Girdlestone arthroplasty is a well-established treatment option for severe hip joint infections in cases where functional outcomes are not the primary focus.12 Prolonged wound healing in such complex wounds is a major issue, especially among patients with comorbidities. Vacuum-assisted closure (VAC) is a method of wound management commonly employed as an adjunct to surgery that uses negative pressure to accelerate healing. VAC application involves a process of thorough debridement, sufficient hemostasis, and the use of sterile foam dressings.3 The foam is covered with a film dressing to achieve an air-tight closure, a hole is made in the film, and suction tubing is secured against the foam. The tube is connected to a vacuum pump, which is equipped with a fluid collection container. The machine provides either continuous or intermittent suction, with negative pressure ranging from 50–125 mmHg. The VAC dressings are usually changed every 2–5 days.4

This video is a comprehensive step-by-step demonstration of VAC change for a complex right hip wound. A male patient in his fourth decade, with a history of paralysis beginning in childhood due to a spinal tumor, was admitted to the hospital with a right hip joint infection complicated by methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Given his immobility at baseline, the patient was deemed a suitable candidate for a Girdlestone procedure, which involved resection of the femoral head and proximal aspect of the femur, resulting in a complex wound with exposed bone.

The complexity of the surgical procedure requires careful preparation, starting with a thorough review of previous operating room (OR) documentation. This preparatory phase is used to predict the nature of wounds, determine the need for additional interventions, and most importantly, count and eliminate the sponges placed during the previous VAC procedure. Failure to remove previously-placed sponges may result in long-term complications.56

The patient was positioned on his left side to ensure optimal access to the right hip. The procedure began with the systematic removal of external drapes and shaving the nearby skin to facilitate future dressing changes. Then, an iodine-based antiseptic solution was applied to prepare the surgical site. The wound was thoroughly inspected and palpated, with special care taken to ensure that all pieces of the black sponge were completely removed. In addition, wound swabs for culture and wound dimension measurements were carefully taken.

Subsequent steps focused on wound cleansing and debridement to optimize healing. Utilizing 3 L of normal saline solution, the wound was irrigated to eliminate clots and minimize the risk of infection. Tissue debridement using a curette and a surgical sponge were employed to remove devitalized tissue with the goal of exposing underlying healthy tissue for optimal healing. While the process may appear aggressive, the stimulation of edge bleeding has been shown to promote tissue perfusion and granulation tissue formation, both of which are important components of the wound healing process.7

After ensuring good hemostasis in the wound bed, a single large piece of sterile sponge was cut to an appropriate shape and size, with a tail passing deep to the femur to simplify future dressing changes. Careful measures were taken to ensure that the foam edges were precisely aligned with the subcutaneous tissue to avoid overlap with surrounding healthy skin, using a stapler to secure the foam. As direct contact with foam can damage healthy skin, the skin was further protected with a plastic film dressing after ensuring that the skin was perfectly dry.8 The appropriate use of plastic lining along the sponge's edges reinforces structural integrity and prevents leakage. Larger pieces of film were used to cover the black foam. Additional plastic strips were strategically placed to reinforce the seal and provide optimal coverage. The importance of applying the film to clean, perfectly dry skin cannot be understated. If the skin surface has any discernible moisture, the seal will be compromised.

The final step included the creation of a foam bridge to avoid having the suction connection under the patient’s hip when in the supine position, which can cause a pressure injury to the skin. VAC tubing was then applied to the foam dressing and connected to the vacuum suction machine. The VAC system has been demonstrated to reduce edema, improve tissue perfusion, and accelerate the process of healing in chronic and acute wounds.9 The decision to perform the VAC change in the OR, particularly for complex wounds or during the early stages of therapy, stems from a prioritization of therapeutic efficacy. The surgical team used the OR’s resources and controlled environment to maximize the therapeutic benefit of the intervention, in an attempt to move the patient closer to optimal wound healing and recovery.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

  1. Cordero-Ampuero J. Girdlestone procedure: when and why. HIP International. 2012;22(SUPPL.8). doi:10.5301/HIP.2012.9568.
  2. Oheim R, Gille J, Schoop R, et al. Surgical therapy of hip-joint empyema. Is the Girdlestone arthroplasty still up to date? Int Orthop. 2012;36(5). doi:10.1007/s00264-011-1351-2.
  3. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma. 2019;10(5). doi:10.1016/j.jcot.2019.06.015.
  4. El-Sabbagh AH. Negative pressure wound therapy: an update. Chinese J Traumatol - Eng Ed. 2017;20(2). doi:10.1016/j.cjtee.2016.09.004.
  5. Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ. 2012;184(11). doi:10.1503/cmaj.110900.
  6. McIntyre LK, Jurkovich GJ, Gunn MLD, Maier R V. Gossypiboma: tales of lost sponges and lessons learned. Arch Surg. 2010;145(8). doi:10.1001/archsurg.2010.152.
  7. Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K. Clinical approach to wounds: débridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg. 2006;117(7 SUPPL.). doi:10.1097/01.prs.0000225470.42514.8f.
  8. Baharestani M, Amjad I, Bookout K, et al. VAC Therapy in the management of paediatric wounds: clinical review and experience. Int Wound J. 2009;6(SUPPL. 1). doi:10.1111/j.1742-481X.2009.00607.x.
  9. Kelm J, Schmitt E, Anagnostakos K. Vacuum-assisted closure in the treatment of early hip joint infections. Int J Med Sci. 2009;6(5). doi:10.7150/ijms.6.241.

Cite this article

Ng-Kamstra J. Vacuum-assisted closure (VAC) change for a complex right hip wound. J Med Insight. 2024;2024(458). doi:10.24296/jomi/458.