A comparative study between vacuum assisted wound closure vs conventional dressing in non-healing ulcers

In a surgical ward, acute and continual wounds have an effect on a minimal of 1% of the population. Vacuum-assisted wound closure (VAC) is a technique of Negative pressure in the wound to improve the healing process. To study the advantage of a vacuum assisted closure over conventional dressing in the management of chronic non-healing diabetic ulcers. To study the difference in the rate of amputation, hospital stays in case and control groups. Group1-case group – vacuum associated closure therapy. Group 2-Control group -conventional dressings. Most of the patients in the study population was in the age group of 41 -60 years. 82% of the study population was within the age group of 41-60 years. The two groups are comparable with their baseline characteristic of age, and the P-value is less than 0.05. Wounds were more common in males than females. Out of the 44 patients, 26 were male, i.e. 57% of the study population were males. About 68% of wounds occurred in the foot. About 50% of the culture showed staphylococcus. Nearly 27% of study participants had no growth. The hospital stay is less in VAC dressing when compared to the conventional dressings, who have an average hospital stay of 28 days and the relation is statistically significant (p-value<0.05). Mean hospital stay in Vacuum is 21 compared to stay of 28 in conventional dressings group. Patients in Vacuum had 12 SSG,9 discharge and 1 amputation. There is no statistically significant association in terms of grade of ulcer between the two groups(P =0.23). There is a statistically significant association between VAC and conventional in terms of the results of the Doppler study. (P<0.01). From the study results, it is obvious that VAC dressing has many advantages in terms of Low no of amputation, Earlier discharge, Minimal infection, Lesser complications, Healing in a better way.

A In a surgical ward, acute and continual wounds have an effect on a minimal of 1% of the population. Vacuum-assisted wound closure (VAC) is a technique of Negative pressure in the wound to improve the healing process. To study the advantage of a vacuum assisted closure over conventional dressing in the management of chronic non-healing diabetic ulcers. To study the difference in the rate of amputation, hospital stays in case and control groups. Group1case group -vacuum associated closure therapy. Group 2-Control groupconventional dressings. Most of the patients in the study population was in the age group of 41 -60 years. 82% of the study population was within the age group of 41-60 years. The two groups are comparable with their baseline characteristic of age, and the P-value is less than 0.05. Wounds were more common in males than females. Out of the 44 patients, 26 were male, i.e. 57% of the study population were males. About 68% of wounds occurred in the foot. About 50% of the culture showed staphylococcus. Nearly 27% of study participants had no growth. The hospital stay is less in VAC dressing when compared to the conventional dressings, who have an average hospital stay of 28 days and the relation is statistically signi icant (p-value<0.05). Mean hospital stay in Vacuum is 21 compared to stay of 28 in conventional dressings group. Patients in Vacuum had 12 SSG,9 discharge and 1 amputation. There is no statistically signi icant association in terms of grade of ulcer between the two groups(P =0.23). There is a statistically signi icant association between VAC and conventional in terms of the results of the Doppler study. (P<0.01). From the study results, it is obvious that VAC dressing has many advantages in terms of Low no of amputation, Earlier discharge, Minimal infection, Lesser complications, Healing in a better way.

INTRODUCTION
In a surgical ward, one of the most common cause for frequent admission is a non-healing ulcer; among them, diabetic foot ulcer is the most common cause. In many cases, stay in a medical institution for many weeks is required for treatment. In many instances, they result in amputation. Acute and chronic wounds have an effect on a minimal of 1% of the population. Certain predisposing factors like diabetes interfere with the process of wound healing.
Vacuum-assisted closure would possibly be a uni-

Procedure
Any dressings from the wound was removed and discarded. A culture swab for microbiology was taken before wound irrigation with normal saline. Surgical debridement was done and adequate haemostasis achieved. Application of negative pressure.

Two groups
Group1 received -vacuum associated closure therapy.
1. Before and after procedure-culture taken 2. Doppler taken before and after application of Vacuum procedure. 3. X ray-to inds osteomyelitis.

Outcome variables
1. Mean duration of hospital stay 2. Organisms before and after VAC The study is approved by an Institutional ethical committee, and written informed consent obtained from patients.

VAC Therapy
NPWT applies sub atmospheric pressure (continuous or intermittent), or suction, to the wound bed  (Singh and Sharma, 2017) 41.2 58.9 (Vaidhya et al., 2015) 17.2 34.9 (Blume et al., 2008) -43.2 28.9 (Paola et al., 2010) Better graft acceptance rate and the association is statistically signi icant.              through a computerized vacuum pump attached to a foam sponge that is placed in the wound and secured with an adhesive semi occlusive dressing. Fluids from the Wound are evacuated by a tubing system placed on the foam at one end and connected to a disposablecanster in the therapy unit on the other end ( Figure 1) (Yang et al., 2006) The major indications for the powered VAC are (Morykwas et al., 1999;von Goßler and Horch, 2000;Miller et al., 2007) Acute wounds  4. Fistulas to organs or body cavities 5. Do not place V.A.C.dressing over exposed arteries or veins 6. Freshly anastomosed blood vessels because it may cause disruption of anastomoses (Kalaskar and Butler, 2016).

Proliferative Phase
The third phase-starts after 2 -3days and continue for several weeks. The important changes during this phase, Migration of cells, Multiplication of Cells, Formation of new blood vessels -Angiogenesis & Additional Cellular Matrix Formation (Fentem and Matthews, 1970).
Fibroblast secretes ibrous & non-ibrous parts of additional Cellular Matrix results in damaged tissue regeneration. An enzyme matrix metalloproteinases (MMPs) degrade the damaged protein to form New ECM. Endothelial cells, which form new blood vessels also helpful in tissue regeneration. The epithelial layer is formed by the migration of multiplying epithelial cells over the newly developed granulation tissue (Figure 2).

Remodelling
The fourth Phase -is often the ultimate stage, the transforming stage, in which intact skin is replaced by scar tissue. Characterized by the formation of cellular component and the connective tissue degradation by the proteases (Fabian et al., 2000).
Wound attain maximum strength within 1 year. Collagen deposition is sustained for an extended period, but after 3 weeks, internet rise in plateaus of collagen deposition. The healing process is halted in chronic ulcer and shows continues in lammation or proliferation. Debridement temporarily accelerates the healing process, but the healing process stopped (Figure 3). Negative pressure wound therapy in a patient after amputation for wet gangrene and in a patient with enterocutaneous istula (Figure 4) (Greg et al., 2015) Figure 5 shows the Age Distribution of wounds. 41-60 years of age is more in both cases and controls. Figure 6 shows the Sex distribution of wounds in case and control patients. In cases, female predominance is more whereas, in controls, male predominance is high. Figure 7 Shows About 68% of wounds occurred in foot followed by leg(27%), sole 1(2%) and forearm 1(2%). Figure 8 shows the organisms cultured from the wound. Staphylococcus showed 11%, pseudomonas 2%, Proteus 2%, Klebsiella 1% No growth showed 6% Figure 9 shows the organism cultured from wound 16% of study participants had showed no growth in cases. Figure 10 shows that organisms cultured from wound (cases) organism before the procedurestaphylococcus was seen in most of the cases 11% psudomonoas4% proteus2% klebsiella 1% no growth 4% Figure 11 shows the Organisms cultured from a wound (cases) after the procedure-no growth was seen in most of the cases 20% Figure 12 shows the Hospital stay in days cases and control-reduced in cases with vacuum therapy 21.52% Figure 13 shows the Patients in the case group had 12 SSG,9 discharge and 1 amputation. Figure 14 shows the Results of control at the end of treatment. Discharge 11% Amputation 6% SSG 5% Figure 15 igure showing cases at the end of treatment SSG 12% DISCHARGE 9% AMPUTATION 1% Figure 16 shows the Grade of ulcer both males and females in cases and control Figure 17 shows the Results of Doppler study

DISCUSSION
The present study is a randomized control trial. All patients admitted with a clinical diagnosis of "Diabetic or Non Healing ulcers or traumatic ulcers" under General Surgery care in SRM medical college hospital and research centre are randomized into two groups.

Group1 received -vacuum associated closure therapy
Before and after procedure-culture was taken, Doppler taken before and after application of Vacuum procedure and X ray-to ind osteomyelitis.

Group 2-Control group -conventional dressings
Most of the patients in the study population were in 41-60 years of age. 82% of the study population was within the age group of 41-60yearsThe two groups are comparable with their baseline characteristic of the age, and the P-value is less than 0.05 Wounds were more common in males than females. Out of the 44 patients, 26 were male, i.e. 57% of the study population were males. About 68% of wounds occurred in the foot, followed by leg (27%), sole 1(2%) and forearm 1(2%). About 50% of the culture showed staphylococcus, and 9% showed organism pseudomonas. Nearly 27% of study participants had no growth. Study participants with sterile pre-vac culture were not turning non-sterile after VAC. The hospital stay is less in VAC dressing when compared to the conventional dressings, who have an average hospital stay of 28 days and the relation is statistically signi icant (p-value<0.05). Mean hospital stay in cases is 21 compared to stay of 28 in control group Patients in the case group had 12 SSG,9 discharge and 1 amputation. There is no statistically signi icant association in terms of grade of ulcer between the two groups(P =0.23). There is a statistically signi icant association between cases and control in terms of the results of the Doppler study. (P<0.01) Table 1. Table 2 In our study, the majority of the study population belonged to the age group 41-60 years. The two groups are comparable with their baseline characteristic of the age and the P-value is less than 0.05 Table 3 shows that, Majority of the study population are males(61%), and females constitute 39%. There is a statistically signi icant association between cases and controls in terms of sex. Table 4 shows that, Distribution of location of wounds, statistically association between location and frequency of wounds. Table 5 About 50% of culture showed staphylococcus and 9% showed organism pseudomonas. Nearly 27% of study participants had no growth. Table 6 shows that, Organisms cultured from a wound (controls) 5% showed staphylococcus 1% showed pseudomonas. Nearly 16% of study participants had no growth. Table 7 About 50% of culture showed staphylococcus, followed by pseudomonas 18.2%, Nearly 18.2% of study participants had no growth. Table 8 shows that, Organisms cultured from a wound (Cases) after the procedure. In cases, nearly 91% of study participants had no growth after the procedure. Table 9 shows that, Study participants with sterile Pre VAC culture and sensitivity is not turning nonsterile after VAC, anyway 90% non-sterile turns sterile after VAC, and the relationship is not statistically signi icant. Table 10 shows that, Mean hospital stay in cases is 21 compared to the stay of 28 in the control group, which is signi icant in control. Table 11 shows that, End of treatment SSG is increased compared with control. Incidence of Amputation increased in control, whereas in cases 1. Table 12 shows that, Results of control at the end of treatment. The discharge rate showed 50%, followed by the amputation rate showed 27.28% in the control group. Table 13 shows that, Results of cases at the end of treatment. Incidence of SSG showed 54.54% Amputation rate in patients showed 4.55% Table 14 shows that, Chisquare-1.437 P VALUE 0.23 There is no statistically signi icant association in terms of grade of ulcer between the two groups (P =0.23) Table 15 shows that, Chisquare-1.437 P Value<0.01-Signi icant In a study conducted by atefetal (Al-Mallah et al., 2018), 24% were females and 76% were males. The mean duration of hospital stay in the VAC group is 22.87, and in conventional dressing, it is 32.53, and the association is statistically signi icant.

CONCLUSION
The present study is a Randomised controlled trial involved 44 wound cases. Patients affected were most commonly in 41-60 age group. There was a male preponderance. The majority of the study population are males (61%), and females constitute 39%. There is a statistically signi icant association between cases and controls in terms of sex. About 68% of wounds occurred in the foot, followed by leg (27%), sole 1(2%) and forearm 1(2%). About 50% of the culture showed staphylococcus, and 9% showed the organism Pseudomonas. Nearly 27% of study participants had no growth. Patients in the case group had 12 SSG,9 discharge and 1 amputation. From the study results, it is obvious that VAC dressing has many advantages in terms of Low no of amputation, Earlier discharge, Minimal infection, Lesser complications and Healing in a better way. It could be an appropriate new technology in treating a variety of wounds.