Since its introduction, vacuum-assisted closure (V.A.C.^® Therapy^™, KCI, San Antonio,Tex) therapy has proven to be an adequate and noninvasive method in the treatment of complicated wounds.^1,2 Vacuumassisted closure can be used in the treatment of many types of chronic wounds, such as venous stasis ulcers, pressure ulcers, dehisced surgical wounds, arterial and diabetic ulcers, and a wide variety of miscellaneous, long-existing wounds.^3–5 Although complications related to its use are rare; localized superficial skin irritation is the most common complication reported in the literature.⁶ Further complications involve pain, infection, bleeding, and fluid depletion.² Although rare, severe complications, such as toxic shock syndrome, anaerobic sepsis, or thrombosis have been reported.^7–9 This case report presents an unusual complication of vacuum-assisted closure therapy, which to the authors’ knowledge has only once been reported in the literature.¹⁰

Case Report

A 55-year-old woman was admitted to the surgical ward for exploration of a persistent sinus on the lower left leg. Patient history included a traumatic posterior knee luxation 5 years and 10 months prior to presentation with no fracture visible on x-ray examination. Due to vascular injury and a lesion ofthe peroneal nerve, she was surgically treated with reposition, fasciotomy, vascular reconstruction, and an external fixture. After surgery, the wound was treated with a vacuum-assisted closure therapy system to promote wound healing. Dressings were changed twice per week, and initially the wound was healing nicely. Two weeks after the vacuum-assisted closure therapy was stopped the patient experienced pain in her knee. An ultrasound examination showed a cavity suspected to be an abscess, which was then explored and drained. Following both exploration and drainage, the fistula continued to produce serous fluid. A small fluid collection was visible on the ultrasound examination that had drained onto the fistula. Osteomyelitis was not visible on the x-ray exam. Bacteriological examination found Escherichia coli in the fluid, which was treated with antibiotics. The patient was discharged with 2 skin defects. Six months after the initial accident, these 2 defects were still present.
Five years later, the patient returned with an infection of the fasciotomy wound. At the time of this presentation, there was no indication of fistula or sinus complication. Over the next 5 years she returned several times as an outpatient with serous fluid leakage from the prior wound site. Although the wound managed to heal most of the time, it would resume leaking serous fluid in 3 to 4 months.
Five months prior to her admission to the surgical ward, a MRI scan showed a 4.5-cm sinus tract. In the center of the sinus a roughly shaped structure was identified and suspected to be a foreign body (Figure 1).The fistula and sinus were then opened and explored. A foreign body was found in the cavity and it appeared to be a polyurethane V.A.C.^® dressing, which was completely removed (Figure 2A, 2B). Pathological examination of the specimen showed signs of a chronic infection with multinucleated giant cells together with extensive fibrosis and large quantities of foreign body material (Figure 3A, 3B).
After the surgery, the wound was treated with vacuum- assisted closure therapy. Almost 2 months after the surgery the wound is nearly closed (Figure 4).The vacuum- assisted closure therapy was terminated and the wound is currently being treated with 0.2% polyhexamethylene biguanide impregnated antimicrobial dressings (Kerlix^™ AMD^™, Tyco Healthcare, Zaltbommel, The Netherlands) to prevent infection and promote final closure of the wound.