A novel intervention for wound bed preparation in severe extremity trauma: Highly concentrated carbon dioxide bathing

Abstract

Introduction: In severe extremity trauma involving large tissue defects, early closure (e.g., free-flap surgery) of the defects is an essential step for good functional reconstruction; however, in some cases, early closure may be difficult. Highly concentrated carbon dioxide bathing, used to improve blood flow in ischemic limbs and skin ulcers, can also be applied in wound bed preparation for severe limb trauma.

Patients and methods: The three cases in this study required an average of 13 weeks of highly concentrated carbonated bathing, which led to significantly better wound bed preparation, even in the exposed bone and tendon regions.

Results: We successfully achieved good functional limb reconstruction in patients with deep burns and severe open fractures by reducing wound infection and facilitating good wound bed preparation.

Conclusions: Highly concentrated carbon dioxide bathing was sufficient to prevent frequent wound infections, even in severe extremity trauma involving large soft-tissue defects such as deep crush burns and Gustilo Anderson classification ≥3b open fractures of the extremities. To our knowledge, such interventions have not been reported in the past and are valuable as new procedures for wound bed preparation in severe extremity trauma from both cost and wound infection control perspectives.

Keywords: Acellular dermal matrices; Carbon dioxide bathing; Negative-pressure wound therapy; Severe extremity trauma; Wound bed preparation.

Figure 1

The palmar skin was severely indurated due to deep burn damage, and the active motion of the fingers was severely limited.

Figure 2

A 15-min hand bath in highly concentrated carbon dioxide bathing at 37°C (AS Care®; Asahi Kasei Medical Co., Ltd., Tokyo, Japan) was performed daily to gradually eliminate necrotic tissue and continue finger rehabilitation

Figure 3

Four weeks after the injury, the patient underwent skin grafting using plantar glabrous skin grafts.

Figure 4

One year after the injury, the intrinsic muscles and mechanisms of the fingers functioned normally without any residual damage.

Figure 5

The patient sustained an open fracture of the left calcaneal region with degloving skin while riding a motorcycle in a traffic accident.

Figure 6

Four weeks after injury, a 15-min foot bath in highly concentrated carbon dioxide bathing (AS Care®) at 37°C was performed daily to gradually eliminate necrotic tissue.

Figure 7

Twenty-two weeks after injury, the removal of necrotic tissue was completed, and sufficient granulation tissue had formed around the calcaneal base; therefore, a distally based sural flap was used to reconstruct the heel area.

Figure 8

Ten months after the injury, the patient walked with normal shoes, although sensory disturbance in the sole of the foot remains.

Figure 9

The patient had bone defects of the lateral epiphysis of the humerus and neck of the radius and an extensive soft-tissue defect on the outer side of the elbow, approximately 40 cm in diameter.

Figure 10

Large tissue defects were packed using a right latissimus dorsi muscle flap and a right pectoral skin flap, and external fixation of the right upper extremity was performed. Two weeks after injury, wound irrigation was continued with a highly concentrated carbonated spring bathing (AS Care®) at 37°C for 15 min once daily.

Figure 11

Twelve weeks after the injury, sufficient granulation tissue had developed around the elbow, and full-thickness skin grafts were performed on the skin defect at the elbow.

Figure 12

Six months after the injury, the patient still had a limited range of motion of the right elbow joint, but the hand function had been fully preserved.