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Simplified VAC Application with External Orthopedic Hardware

Allison J. Derrick *, Mark W. Kiehn*

* University of Wisconsin School of Medicine and Public Health,Madison, WI

Address for Correspondence:

Mark Kiehn, M.D.
Department of Surgery
Plastic and Reconstructive Surgery
G5/356 Clinical Science Center
600 Highland Avenue
Madison, WI  53792-3236


The utility and efficacy of VAC therapy has led to its use in wound management among many specialties.  Challenges may be encountered, however, when the VAC device is applied to irregular surfaces.  The technique presented in this case report illustrates an efficient and effective method for the circumferential placement of the VAC device around external orthopedic hardware that provides a reliable seal and reduces the difficulty of dressing changes.

J.Orthopaedics 2007;4(2)e35


The use of vacuum-assisted closure (VAC) for wound management is a widely accepted and utilized practice.  This device has been shown to decrease local edema and bacterial loads, increase blood flow, and remove excess fluid from the wound, promoting the formation of granulation tissue and accelerating healing by secondary intention (1-4).  

The clinical applications for this therapy are vast and include treatment of traumatic wounds, diabetic ulcers, venous stasis ulcers, diabetic foot ulcers, and wounds with exposed bone and hardware (5).  In the typical application of the VAC dressing (Kinetic Concepts, Inc; San Antonio, TX), a foam sponge is applied to the wound, covered with an occlusive film dressing, and uniform negative pressure is applied (4,6).  Challenges are encountered with application of the VAC device in proximity to external orthopedic hardware (Fig. 1).  When there is inadequate skin between the wound and fixator, the adhesive film can be applied to the hardware itself.  Wrapping the entire frame is a solution to the problem (7), though it too presents challenges.  Tenting and tearing of the occlusive film can occur.  Moreover, the adhesive film dressing can be difficult to remove from the fixation device and tends to leave a residue of adhesive.  We present an efficient and effective technical adaptation for the placement of VAC therapy around external orthopedic hardware.

Figure 1:  Distal tibia and fibula fractures with soft-tissue loss after debridement and reduction with an external fixator.

A 54 year old male involved in a motorcycle accident presented with a grade 3B open fracture with concurrent dislocation of his left ankle with extensive soft tissue damage.  The ankle was reduce and stabilized with a combination of internal and external fixation techniques.  Clinical instability prevented early flap coverage of the wound.  The presence of an external fixator in proximity to this extensive wound made application of the VAC by conventional means quite difficult.   The technique of VAC application was adjusted to accommodate this challenge.  

As with other techniques, the polyurethane foam is cut to the dimension of the wound.  A non-adherent dressing is usually applied to the wound base to facilitate sponge removal during subsequent dressing changes.  Mepilex (Mölnlycke Health Care; Norcross, GA), a silicone backed foam dressing, can be applied to the surrounding skin to prevent maceration of the intact skin by serving to wick fluid from the system.  The silicone backing of the Mepilex allows it to stick to intact skin and maintain its position without adhesive.  The foam sponge can be stapled to the Mepilex to secure its position directly over the wound bed and prevent shifting with suction application.  This avoids stapling the sponge to the skin in patients for whom the dressing change is performed without anesthesia.  Prominent points of the fixator can be padded to reduce the risk of leaking, particularly in areas that are subjected to pressure (Fig. 2).

Figure 2:  Foam sponge dressing is place over the open wounds and the surrounding skin is protected with a non-adherent dressing.

An impervious stockinette (Convertors, Allegiance Healthcare Corp; El Paso, TX), used in surgical draping, is used to provide the occlusive covering for the system.  The cloth portion of the stockinette is removed and one of the corners is cut off of the sealed end.  The stockinette is placed over the extremity and fixator and the toes or foot is passed through the hole created in the end.  The stockinette is then unrolled over the frame and cut to the appropriate length.  A strip of the adhesive film is placed over the distal end of the stockinette, sealing it to the intact skin.  The proximal end is sealed by applying traction to the anterior aspect of the stockinette and the sides and posterior aspect of the stockinette is sealed to the leg with occlusive dressing.  The free edges of the stockinette are then sealed to one another and the anterior aspect of the leg.  A slight offset of the edges near the leg facilitates sealing.  The suction interface is then applied to a part of the stockinette that overlies the polyurethane sponge.  The stockinette is then tucked into the interstices of the external fixator and suction is applied.  In the event of tenting of the stockinette, suction can be released and the stockinette can be repositioned.  The VAC then conforms to the leg and external fixation device (fig. 3).   

Figure 3:  Completed VAC application.  The stockinette is sealed on both the proximal and distal edges with adhesive and conforms to the fixator. 

In the event of dressing change, removal of a VAC device applied using this technique is quite simple.  Adhesive must only be removed from two small areas of the lower extremity, rather than from both the external fixator and skin.  This makes for rapid dressing changes that are well tolerated by patients and surgeons alike.  In the case presented in this report, the wound improved remarkably with reduced edema and granulation tissue growth.  The surrounding skin was well preserved (Fig. 4). 

Figure 4:  Lower extremity wound after 18 days of VAC therapy utilizing the stockinette technique

Discussion :

With extremity wounds found in association with external hardware, one of the main limitations to the effective use of VAC therapy is the ability to establish and maintain an adequate seal (8).  The technique presented here reduces this difficulty by shifting the points that are sealed away from the hardware and wound.  The stockinette does not adhere to the fixator, which allows greater flexibility in conforming to the contour of the limb and hardware.  This technique reduces the amount of adhesive film in contact with the skin and external hardware, allowing for more tolerable dressing changes and preventing the deposition of adhesive residue on the fixator.  The extremity distal to the VAC dressing can easily be monitored for perfusion by assessing distal pulses, capillary refill and sensation.  The technique outlined in this paper provides a safe, effective and efficient means of applying the VAC dressing in the setting of challenging wounds with associated external orthopedic hardware. 

Reference :


  1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: Clinical experience. Annals of Plastic Surgery. 1997 Jun;38(6):563-76.

  2. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment: Animal studies and basic foundation. Annals of Plastic Surgery. 1997 Jun;38(6):553-62.

  3. Argenta LC, Morykwas MJ, Marks MW, DeFranzo AJMolnar JA, David LR. Vacuum-Assisted Closure: State of Clinic Art. Plastic and Reconstructive Surgery. 2006 Jun;117(7 Suppl):127S-142S.

  4. DeFranzo AJ, Argenta LC, Marks MW,  Molnar JA, David LR, Webb LX.. The use of vacuum-assisted closure therapy for the treatment of lower extremity wounds with exposed bone. Plast Plastic and Reconstructive Surgery. 2001 Oct;108(5):1184-91.

  5. Geller SM, Longton JA. Ulceration of pyoderma gangrenosum treated with negative pressure wound therapy. Journal of the American Podiatric Medical Association. 2005 Mar-Apr;95(2):171-4.         

  6. Herscovici D, Sanders RW, Scaduto JM., Infante A, DiPasquale T. Vacuum-assisted wound closure (V.A.C. therapy) for the management of patients with high-energy soft tissue injuries. Journal of Orthopedic Trauma. 2003 Nov-Dec;17(10):683-8.

  7. Ozer K. Smith WA. Simple Technique for Applying Vacuum-Assisted Closure Therapy Over the Circular Type External Fixation Device. Annals of Plastic Surgery. 2006 Jun;56(6):693-4.

  8. Greer SE, Duthie E, Cartolano B, Koehler KM, Maydick-Youngberg D, Longaker MT.  Technique for applying subatmospheric pressure dressing to wounds in difficult regions of anatomy.  Journal of wound, ostomy, and continence nursing. 1999 Sep;26(5):250-3.


This is a peer reviewed paper 

Please cite as :Allison J. Derrick : Simplified VAC Application with External Orthopedic Hardware

J.Orthopaedics 2007;4(2)e35





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