soft tissue infection often occurs after injuries , which , if not treated appropriately , could slow wound healing and further deteriorate the patient s condition [ 13 ] . thus , prevention and treatment of infection remains a major challenge for clinical surgeons . vacuum sealing drainage ( vsd ) has been increasingly recognized as a valid treatment approach in the management of various types of tissue injuries . it facilitates complete suction of seepage , necrotic tissues , and pus from the wound area by using a negative - pressure device . emerging studies have demonstrated that vsd treatment can speed wound healing and reduce incidence of infection [ 68 ] recent evidence indicates that if antibiotic is added to bone cement , infected joint arthroplasties can be prevented and treated . it has been suggested that prophylactic use of antibiotic - impregnated bone cement decreases the deep infection rate in total joint arthroplasty . these findings suggest that antibiotic - impregnated bone cement may be a promising therapy for prevention of soft tissue infections . to the best of our knowledge , the effect of antibiotic - impregnated bone cement on soft tissue defects and infection has not been reported before . we conducted a prospective randomized study to compare the combination of vsd therapy and antibiotic - impregnated bone cement versus the single vsd therapy for the therapeutic effect in patients with soft tissue defects and infection . to the best of our knowledge , this is the first study to test whether open flesh wounds benefit from the combined treatment of vsd therapy and antibiotic - impregnated bone cement . the treatment appeared to speed wound healing and prevent infection . the study might shed new light on clinical treatment of soft tissue defects and infection . this prospective randomized non - blinded study enrolled 46 cases with soft tissue defects and infection in our hospital between january 2010 and may 2014 . the study included 24 males and 22 females , who were aged 3572 years with a mean age of 53 years . their wound causes were : diabetic foot in 16 cases , postoperative infection following fracture internal fixation in 6 cases , sacral decubitus in 10 cases , and post - traumatic limb infection in 14 cases . these patients were randomly divided into 2 groups by random numbers generated by computer : the experimental group was treated with vsd combined with antibiotic bone cement , while the control group received vsd treatment only . in order to avoid bias due to different injury causes , the cases with the same injury cause and similar size of tissue defect were randomly divided into 2 groups . therefore , both groups ( n=23 ) included 8 cases with diabetic foot , 3 cases with postoperative infection following fracture internal fixation , 5 cases with sacral decubitus , and 7 cases with post - traumatic limb infection . bacterial culture results were pseudomonas aeruginosa - positive in 13 cases ( sensitive to cefoperazone plus sulbactam ) , escherichia coli - positive in 6 cases ( sensitive to gentamicin ) , and staphylococcus aureus - positive in 27 cases ( sensitive to vancomycin ) ( table 1 ) . the following antibiotic - laden polymethyl - methacrylate bone cements ( heraeus , beijing landmover medical company , beijing , china . ) were used in the study based on our previous experiences : vancomycin bone cement ( 15% vancomycin ) , cefoperazone bone cement ( 10% cefoperazone ) , and gentamicin bone cement ( 1.6% gentamicin ) . other materials used in our study were : vsd sponge , seaweed salt hydration alcohol polyethylene foam with pore diameter of 0.21.0 mm , and built - in multi - side holes and drainage pipes were purchased from beijing hongren ningrui technological company ( beijing , china ) ; semipermeable membranes comprised of polyurethane and acrylic acid were provided by beijing hongren ningrui technological company ( beijing , china ) . after thorough debridement , the wound was veiled by the tailored vsd sponge sutured with surrounding natural skin in the control group . in case of a deep wound , vsd dressing was used to fill the wound cavity , leaving no dead space . it was appropriate that the vsd dressing was attached within 2 cm of the drainage tube fringe . when treating large wounds , drainage tubes in cascading series were required . then , the skin around the wound was cleaned with 75% alcohol and a semipermeable membrane was used to seal the wound and the vsd dressing . all the drainage tubes were connected to a 3-way stopcock connected to a negative - pressure device ( beijing hongren ningrui technological company , beijing , china ) . presence of sunken vsd dressing and absence of fluid accumulation under the membrane was a reflection of effective negative pressure status . prior to the vsd treatment , prepared pillar- or pie - shaped antibiotic - laden bone cement was placed in the bone or soft tissue cavities in the experimental group . in case of large cavities , bone cement beads were used . the vsd treatment was performed again until a clean , red , granulating wound bed was achieved (  ready for surgery  ) . if much scar tissue remained and suturing was not suitable , free flap transplantation or skin grafting was chosen . the following variables of the experimental and control groups were compared to evaluate the outcome of different treatment measures : length of hospital stay , the time needed until the wound was ready for surgery , speed of wound closure , duration of antibiotic administration , and the number of vsd dressing renewals . student s t - test was used to compare the difference of each variable between the 2 groups . this prospective randomized non - blinded study enrolled 46 cases with soft tissue defects and infection in our hospital between january 2010 and may 2014 . the study included 24 males and 22 females , who were aged 3572 years with a mean age of 53 years . their wound causes were : diabetic foot in 16 cases , postoperative infection following fracture internal fixation in 6 cases , sacral decubitus in 10 cases , and post - traumatic limb infection in 14 cases . these patients were randomly divided into 2 groups by random numbers generated by computer : the experimental group was treated with vsd combined with antibiotic bone cement , while the control group received vsd treatment only . in order to avoid bias due to different injury causes , the cases with the same injury cause and similar size of tissue defect were randomly divided into 2 groups . therefore , both groups ( n=23 ) included 8 cases with diabetic foot , 3 cases with postoperative infection following fracture internal fixation , 5 cases with sacral decubitus , and 7 cases with post - traumatic limb infection . bacterial culture results were pseudomonas aeruginosa - positive in 13 cases ( sensitive to cefoperazone plus sulbactam ) , escherichia coli - positive in 6 cases ( sensitive to gentamicin ) , and staphylococcus aureus - positive in 27 cases ( sensitive to vancomycin ) ( table 1 ) . the following antibiotic - laden polymethyl - methacrylate bone cements ( heraeus , beijing landmover medical company , beijing , china . ) were used in the study based on our previous experiences : vancomycin bone cement ( 15% vancomycin ) , cefoperazone bone cement ( 10% cefoperazone ) , and gentamicin bone cement ( 1.6% gentamicin ) . other materials used in our study were : vsd sponge , seaweed salt hydration alcohol polyethylene foam with pore diameter of 0.21.0 mm , and built - in multi - side holes and drainage pipes were purchased from beijing hongren ningrui technological company ( beijing , china ) ; semipermeable membranes comprised of polyurethane and acrylic acid were provided by beijing hongren ningrui technological company ( beijing , china ) . the vsd dressing was tailored according to the size of the wound . after thorough debridement , the wound was veiled by the tailored vsd sponge sutured with surrounding natural skin in the control group . in case of a deep wound , it was appropriate that the vsd dressing was attached within 2 cm of the drainage tube fringe . when treating large wounds , drainage tubes in cascading series were required . then , the skin around the wound was cleaned with 75% alcohol and a semipermeable membrane was used to seal the wound and the vsd dressing . all the drainage tubes were connected to a 3-way stopcock connected to a negative - pressure device ( beijing hongren ningrui technological company , beijing , china ) . presence of sunken vsd dressing and absence of fluid accumulation under the membrane was a reflection of effective negative pressure status . prior to the vsd treatment , prepared pillar- or pie - shaped antibiotic - laden bone cement was placed in the bone or soft tissue cavities in the experimental group . in case of large cavities , bone cement beads were used . the vsd treatment was performed again until a clean , red , granulating wound bed was achieved (  ready for surgery  ) . if much scar tissue remained and suturing was not suitable , free flap transplantation or skin grafting was chosen . the following variables of the experimental and control groups were compared to evaluate the outcome of different treatment measures : length of hospital stay , the time needed until the wound was ready for surgery , speed of wound closure , duration of antibiotic administration , and the number of vsd dressing renewals . student s t - test was used to compare the difference of each variable between the 2 groups . there was no significant difference between the 2 groups in gender , age , average area of tissue defect before treatment , or the delay between infection and treatment ( p>0.05 ) . in the experimental group , the wound was healed in 23 cases within 4 weeks postoperatively , of which direct suture was performed in 12 cases , and additional free flap transplantation or skin grafting was performed in 6 cases and 5 cases , respectively . notably , vsd treatment was performed only once in 6 cases in the experimental group and the drainage tube remained unobstructed for 14 days . function of the injured limbs of the patients and their vocational abilities recovered well ( typical cases : figures 1 , 2 ) . for the control group ( n=23 ) , the wound was healed in 15 cases within 6 weeks postoperatively . among the 15 cases , the wound was directly sutured in 8 cases , and additional free flap transplantation or skin grafting was performed in 3 cases and 4 cases , respectively . the wound was ruptured in 3 cases within 2 months following vsd treatment , and these were re - admitted to the hospital . the experimental group was compared with the control group for the number of vsd dressing renewals ( times ) , the time needed until the wound was ready for surgery ( days ) , the speed of wound closure ( cm / week ) , the duration of antibiotic administration ( days ) , and the length of hospital stay ( days ) ( table 3 ) . statistical analyses revealed that the experimental group had significantly fewer vsd renewals , shorter time needed until the wound was ready for surgery , shorter duration of antibiotic administration , faster speed of wound closure , and shorter hospital stay compared with the control group ( p<0.01 ) . there was no significant difference between the 2 groups in gender , age , average area of tissue defect before treatment , or the delay between infection and treatment ( p>0.05 ) . in the experimental group , the wound was healed in 23 cases within 4 weeks postoperatively , of which direct suture was performed in 12 cases , and additional free flap transplantation or skin grafting was performed in 6 cases and 5 cases , respectively . notably , vsd treatment was performed only once in 6 cases in the experimental group and the drainage tube remained unobstructed for 14 days . function of the injured limbs of the patients and their vocational abilities recovered well ( typical cases : figures 1 , 2 ) . for the control group ( n=23 ) , the wound was healed in 15 cases within 6 weeks postoperatively . among the 15 cases , the wound was directly sutured in 8 cases , and additional free flap transplantation or skin grafting was performed in 3 cases and 4 cases , respectively . the wound was ruptured in 3 cases within 2 months following vsd treatment , and these were re - admitted to the hospital . the experimental group was compared with the control group for the number of vsd dressing renewals ( times ) , the time needed until the wound was ready for surgery ( days ) , the speed of wound closure ( cm / week ) , the duration of antibiotic administration ( days ) , and the length of hospital stay ( days ) ( table 3 ) . statistical analyses revealed that the experimental group had significantly fewer vsd renewals , shorter time needed until the wound was ready for surgery , shorter duration of antibiotic administration , faster speed of wound closure , and shorter hospital stay compared with the control group ( p<0.01 ) . this study compared the combination of vsd and antibiotic - impregnated bone cement with vsd only in management of soft tissue defects and infection . to the best of our knowledge , this is the first study to evaluate the impact of the combined treatment on soft tissue defects and infection . our results showed that 23 cases in the experimental group were healed within 4 weeks postoperatively , and no infection recurrence was reported in 1-year follow - up . in contrast , only 15 of the 23 cases in the control group were healed within 6 weeks postoperatively and infection recurrence was reported in 3 cases in the follow - up . we found that the combined treatment might be useful for accelerating wound healing and preventing infection recurrence in patients with soft tissue defects and infection . vsd is a negative - pressure technique that drains out seepage , pus and necrotic tissues . it has been widely used for treatment of skin defects , soft tissue defects , and complicated wounds [ 1517 ] . however , the vsd sponge could not kill microorganisms by itself . in case of severe infection , large amounts of pus might be produced , which might clog the pores of the vsd and inhibit its normal functioning . polymethyl methacrylate bone cement has been widely recognized as one of most stable antibiotic carriers . it aids in maintaining long - term and high concentrations of antibiotics for infected wounds . topical antibiotics have been increasingly used for prevention and treatment of various types of infections . it has been suggested that perioperative topical prophylaxis is beneficial for several different surgical procedures . topical use of antibiotics has several potential advantages over systemic administration of antibiotics , such as limiting the possibility of systemic toxicity , sustaining high concentrations of antimicrobials locally , and reducing the potential development of antibiotic resistance . antibiotic - impregnated cement has been revealed to be similar to systemically administered antibiotics , and is independent and additive in combination with other prophylactic measures . in the present study , the combined use of antibiotic - impregnated cement and vsd achieved better outcome than the vsd treatment only , as evidenced by significantly fewer vsd dress renewals , shorter time needed until the wound was ready for surgery , short duration of antibiotic administration , faster wound healing , shorter hospital stay , and lower incidence of infection recurrence in the experimental group . the better outcome may be explained by strong postoperative local resistance of the antibiotic - impregnated cement to infection because of elution of antibiotics . notably , the vsd dressing was used only once in 6 cases of the experimental group , and the drainage pipeline remained unobstructed for 14 days . one possible explanation for this is that topical antimicrobials from the antibiotic - impregnated bone cement might kill microorganisms or inhibit their growth , thereby leading to reduced production of secretions . it reveals that use of antibiotic - laden bone cement might a complementary measure to vsd in the prevention and treatment of soft issue defects and infection . moreover , a sealed , effective and negative pressure status , and unobstructed pipelines are required during the surgery . topical application of antibiotics might cause adverse effects such as local hypersensitivity , contact dermatitis reactions , and possible disturbance of the wound - healing process . there are also concerns with regard to higher cost of antibiotic - laden bone cement than plain bone cement and possible development of antibiotics resistance [ 2832 ] . unlike systemic antibiotics , rigorous trials to accurately determine the dose of topical antibiotics are not available , thus the dose of topical antibiotics is difficult to determine . in this study , based on the results of bacterial culture and drug sensitivity test , vancomycin bone cement ( 15% ) , cefoperazone bone cement ( 10% ) , and gentamicin bone cement ( 1.6% ) were used . the ratios of antibiotics in bone cement were determined based on previous clinical experiences of our surgeons in the present study . this is a preliminary study with some limitations . the small sample size and short - term follow - up limit the power of the study . more studies are required to address these concerns and to validate the findings regarding the 2 treatments . compared to application of vsd only , combination of vsd and antibiotic - laden bone cement accelerated wound healing , shortened hospital stay , and decreased infection recurrence in the management of soft tissue defects and infection . this combined therapy might be a better approach to speed wound healing and prevent infection .