The thesis is dedicated to research the important issue in contemporary traumatology and orthopedics which is related to the application of negative pressure wound treatment (Vacuum Assisted Closure, VAC) in early period after admission of patients with ballistic trauma, including a comprehensive analysis of VAC effectiveness regarding the clinical data, bacterial load, VEGF level changes, WBC count, ultrastructural, cytological and histological changes in wound bed comparing with the conventional method of wound treatment in patients with severe gunshot wounds of the upper and lower extremities. We also investigated the impact of negative pressure wound therapy on quality of life of the patients with the gunshot injuries.
Thirty-four patients, who were admitted to diagnostic department of the Dnipropetrovs’k Regional Hospital named after Élie Metchnikoff with severe gunshot wounds of the limbs, were included in this study. Eighteen patients (52.9 %) were included into investigated group with VAC. The conventional wound treatment with antiseptics and gauze saline-soaked dressings was applied for 16 patients (47.1 %) of control group. Evaluation of edema, wound hyperemia, development of granulations and marginal epithelization as well as a comparison of the bacterial load (the amount of colony forming units per gram of tissue) were carried out, too. The concentration of vascular endothelial growth factor VEGF in the blood serum was determined using ELISA. The WBC count together with calculation of integral WBC indices was performed. Quality of life parameters were assessed using the accepted methods. All clinically investigated parameters together with cytological, histological, immunohistochemical, transmission electron microscopy, morphometric evaluation and statistical analysis of specimens were evaluated at 0, 3 and 7 day-checkpoints in both investigated subgroups.
According to the results of the study, it has been found that our proposed VAC method for treatment of through and through of the limbs provides conditions for the creation of uniform negative pressure (-125 mm Hg) accelerates the evacuation of the tissue debris throughout the wound bed. The gross examination of wounds demonstrated that on day 3 in VAC group edema was extinguished in 94.4 % of patients as well as hyperemia disappeared in 88.9 % of them; whereas in the subgroup with the wound bandages, these features were declined in 62.5 % and 68.8 % of patients, respectively. On the 7th day in 100 % of patients with VAC granulation tissue was completely formed, as well as a marginal epithelization was observed in all patients of this subgroup. In the subgroup with wound dressings these features were found in 68.8 % and 81.3 % of patients, respectively.
The total bacterial load for the negative pressure wound treatment was significantly lower than that for the conventional wound treatment at each observing time after application. Hematological assessment showed the decrease of overall WBCs level in VAC group. On day 7 in VAC group the WBC values approached the normal WBC values.
Morphological evaluation demonstrated reduction of inflammatory infiltration by 31.9 % (p < 0.05), advance in wound re-epithelisation and support of negative pressure wound therapy in collagen matrix remodeling due to early proliferation of fibroblasts, elevated collagen production and myofibroblasts differentiation. Immunohistochemical labeling of vascular endothelial marker CD34 revealed significantly enhanced angiogenesis in the wound by 75,9 % (p <0,05) that occurs as formation of more developed and functioning microvessels on day 3 of negative pressure wound therapy comparing to control group and its reduction on 7 day of treatment (on 35.1 %, p < 0.05).
It was clearly demonstrated that application of negative pressure for treatment of ballistic injuries can improve mobility, relieve the feeling of pain or discomfort, as well as anxiety and depression in patients, thereby improving their quality of life. Method of VAC accelerates the normalization of WBC count due to reducing of necrotic changes; sustains a high concentration of VEGF in the serum; significantly reduces the percentage of septic complications; shortens the time of wound preparation for surgical closure in patients with VAC by 5.2 ± 0.8 days. Therefore, vacuum assistance wound closure is a more effective method of severe combat wounds healing, than application of gauze bandages. Negative pressure wound therapy benefits a wound repair by enhancing angiogenesis, diminishing inflammation, and contributing to early connective tissue development.
