Vacuum-assisted closure for the treatment of complex chest wounds

Background. Destruction of chest wall musculature from trauma, empyema, or local infection limits closure options, especially with muscle flaps. While the vacuum-assisted closure system (VAC; KCI International, San Antonio, TX) has been used for wounds in other anatomic locations, we have found no series for chest wounds. Methods. This is a retrospective review of trauma registry data from the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine from 2000 to 2003. Results. Seventeen patients were identified and divided into two groups. Group I consisted of seven patients with primary chest wall processes: four necrotizing soft-tissue infections and three with thoracic trauma resulting in significant loss of chest wall musculature. Group II consisted of ten patients with empyema and varying levels of chest wall extension. Six were postpneumonic and four postoperative. Wound size averaged 16 × 7 cm (range, 7 × 3 cm to 21 × 11 cm). The VAC duration averaged nine days (range, 3 to 21 days) and changed every two to three days. Fourteen wounds were culture positive; nine staphylococcus aureus, two alpha hemolytic streptococcus, and one each with enterococcus, Citrobacter, and anaerobes. Eight were polymicrobial. There were no deaths. All wounds healed without rotational muscle flaps. Ten underwent delayed primary closure, four split-thickness skin graft, and three healed by secondary intention. There was one significant complication: a wound infection after delayed primary closure which required reoperation. Conclusions. Closure of complex chest wall wounds can present significant technical challenges. The VAC system is a simple, useful, and novel alternative to conventional wound care even with large, infected wounds.