Fix and flap in the era of vacuum suction devices: What do we know in terms of evidence based medicine?

INTRODUCTION

The concept of immediate or early fixation and soft tissue coverage of open fractures is frequently referred to as 'fix and flap,' and negative pressure wound therapy (NPWT) has had a major impact in this area. This article aims to review concepts and evidence relevant to the use of NPWT in open fractures.

REVIEW OF OPEN FRACTURE MANAGEMENT

Muscle flaps in open fractures do well in part because they improve blood supply to the underlying fracture. Outcomes of muscle flaps are best when done acutely, before bacterial colonisation. The colonised subacute wound is managed with 'open-wound techniques' until it becomes a chronic localised wound, when flap coverage is again indicated. NPWT provides a useful adjunct in this process as the zone of injury is determined. VACUUM-ASSISTED CLOSURE: REVIEW OF BASIC AND CLINICAL SCIENCE LITERATURE: Proposed mechanisms of action of NPWT include: increased blood flow, decreased oedema, cytokine release induced by mechanical stretch and increased lactate and oxygen tension in the tissue with induction of collagen transcription and angiogenesis. VACUUM-ASSISTED CLOSURE IN OPEN FRACTURES: NPWT to open fractures caused early appearance of healthy granulation tissue, a reduction in wound area and allowed simpler soft tissue procedures for wound closure. NPWT also improved clinical survival of muscle flaps despite occluded flap venous outflow.

SUMMARY

The aim in open fractures is to stabilize the fracture and achieve soft tissue coverage before infection develops. NPWT, applied as a temporizing dressing, simplifies soft tissue coverage on the 'reconstructive ladder.' The only Level-I data on that topic showed a significant decrease in infections. However, NPWT does not allow delay in soft tissue coverage. NPWT increases the 'take rate' of skin grafts, skin substitutes and composite skin grafts and allows quicker graft incorporation.