Coupling Negative Pressure Wound Therapy with Instillation and Split-thickness Skin Graft for a Large Chronic Venous Leg Ulceration: A Case Report

VLUs are a late sequela of chronic venous insufficiency and are becoming more prevalent worldwide. These ulcers are not only an economic burden but can cause disability and detrimental consequences to affected patients. VLU is the most common type of ulceration and affects 1% to 3% of the United States population.¹ The high prevalence of VLU in the population helps explain the $1.5 billion to $3 billion spent annually in the United States to address such wounds.² Larger ulcerations add to the severity, because they are associated with longer healing time and worse quality of life.³

Compression therapy is considered the standard of care for VLU.⁴ However, such therapy is not successful in treating all wounds. Milic et al⁵ found that VLU larger than 20 cm² was a risk factor for failure of compression therapy. Other studies have shown that larger wounds of longer duration (>10 cm² and >12 months, respectively) have a 20% chance of healing by the 24th week of wound care, while smaller wounds with a shorter duration have a 70% chance of healing by the 24th week of wound care.⁶ New treatments are needed to address larger VLUs that are more challenging to heal.

STSG is an option for covering large VLUs. Not only is STSG a rapid and efficient treatment option, but it also provides patients with better health-related quality of life and self-esteem compared with compression therapy.⁷ Success with skin grafting relies on the condition of the recipient bed, prevention of graft contraction, and appropriate coverage of the donor site.⁷

NPWT has undergone technological advancements since its inception, and NPWTi has recently gained popularity. Studies have shown better results in patients treated with NPWTi compared with those treated with NPWT.⁸ In fact, many studies demonstrated decreased hospital length of stay, decreased number of surgical interventions, decreased time to final reconstructive surgery, and decreased average time to wound closure with NPWTi versus NPWT.⁸ NPWTi uses the same mechanisms as standard NPWT but has the added benefits of cyclic cleansing that dilutes and solubilizes wound debris.⁹ NPWTi has also shown promise as an adjunct to STSG.

Raad et al¹⁰ described 5 patients with venous stasis ulcers who were treated with NPWTi for 10 days before STSG. Complete healing was achieved at 1 year. Llanos et al¹¹ found that use of NPWT for closure of STSG diminishes the loss of STSG and shortens the hospital stay. In addition, Yang et al¹² found NPWTi preceding STSG to be a somewhat more economical approach for treating large complex VLUs over a 6-month period compared with compression therapy.

The present case report highlights a patient with a chronic VLU located on the anteromedial ankle that healed in 2 months using NPWTi and STSG.

A 62-year-old female with a history of chronic venous insufficiency and varicose veins presented with a wound on the right medial ankle that extended to the subcutaneous tissue, with severe malodor and periwound erythema. The wound was of 2 years’ duration; prior outpatient treatment, including compression therapy, had been unsuccessful. The patient had previously undergone vein stripping. The wound originated as a traumatic injury caused by using a wheelchair and gradually worsened. In the weeks prior to the patient presenting to the authors of this case report, the wound had significantly worsened in size, pain, erythema, and edema. On presentation, the patient was started on levofloxacin and was admitted to the hospital for further treatment.

Upon admission, specialists in infectious diseases and vascular surgery were consulted. The patient was placed on intravenous piperacillin/tazobactam 3.375 g every 6 hours, per the recommendation of the infectious diseases specialist. A vascular surgeon found no arterial disease and deferred venous testing as an outpatient procedure. A radiograph of the right ankle did not show signs of osteomyelitis or soft tissue emphysema.

On admission, the wound measured 9.5 cm × 6.5 cm × 0.3 cm (Figure 1). The wound base was fibrotic and necrotic, and the wound bed extended through the subcutaneous tissue. Malodor and periwound erythema were present. The patient had diminished arterial pulses and pitting edema of the bilateral lower extremties. Sensations to the lower extremities were intact to touch. There was pain on palpation of the lower extremity wound. Wound culture revealed Pseudomonas aeruginosa and Streptococcus agalactiae (group B). The decision was made to apply NPWTi with hypochlorous acid for wound cleansing, removal of infective material, and wound bed preparation. The NPWTi unit was set for continuous cycling of hypochlorous acid instillation, 10 minutes of solution dwell time, and 1 hour of suction at 125 mm Hg. NPWTi with hypochlorous acid was continued for 2 days while the patient awaited surgical debridement in the operating room.

Initial surgical debridement included hydrosurgery, biopsy of 4 quadrants to rule out carcinoma, and application of NPWTi (Figure 2). The patient was placed in the supine position on the operating table. A local block was performed at the site of the ulceration on the right lower extremity. The right lower extremity was prepped, scrubbed, and draped according to the usual aseptic technique. The right medial leg ulcer measured 9.5 cm × 6.5 cm × 0.3 cm and was fibrogranular. Four excisional biopsies were performed (1 each at the 3-, 6-, 9-, and 12-o’clock positions) to rule out vasculitis and squamous cell carcinoma. Hydrosurgery was used for debridement of fibrogranular tissue to achieve a good bleeding, granular base. The postexcisional wound measurements were 10 cm × 7 cm × 0.3 cm. The wound was cleansed with saline; no tendon or bone was exposed. NPWTi with hypochlorous acid was applied in preparation for STSG. The NPWTi unit was again set for continuous cycling of  hypochlorous acid instillation, 10 minutes of solution dwell time, and 1 hour of NPWT without instillation.

Biopsies of the right lower extremity showed no signs of a tumor. The NPWTi with hypochlorous acid was applied for a total of 3 days postoperatively. The wound was properly prepped for STSG placement, and general surgery was consulted for application of STSG the next day (Figure 3).

Recommended treatment consisted of STSG of the right lower extremity, placement of cryopreserved placental membrane on the donor site, and NPWT without instillation at the recipient site. The patient was brought to the operating table and placed in the supine position. General anesthesia was administered. The right lower extremity was prepped, scrubbed, and draped following usual aseptic technique. The recipient site was debrided with a curette to a good granulating base. The wound appeared clean, with no signs of infection. An STSG approximately 5 cm wide was harvested from the upper thigh, after which it was placed in a mesher and the graft was meshed. The mesh was then placed on the wound site and secured in place with multiple staples. Cryopreserved placental membrane was placed at the donor site to adequately cover the wound, and dressing was applied. The graft at the recipient site was kept in place with staples, and NPWT was applied along with Adaptic (3M) for adherence of the STSG to the wound.

The patient was discharged from the hospital with a 5-day course of cephalexin 500 mg tablets to be taken 3 times a day, per the recommendation of the infectious diseases specialist. The patient followed up with a podiatrist weekly (Figure 4). Complete wound healing was achieved in 2 months (Figure 4). As of the time of this writing, the patient continues to follow up with a podiatrist and has had no wound complications 12 months after initial presentation.

VLUs are a huge burden to patients and the health care system. The goal of advanced wound care should be to achieve wound closure and to prevent infection, recurrence, sepsis, loss of limb, and loss of life. Although compression therapy is the standard of care for VLU, it is not always effective. In the case reported in the present study, a chronic VLU was treated using NPWTi, hydrosurgery, and STSG. The patient was discharged from the hospital within 9 days of arrival to the emergency department, and the ulceration healed in 2 months.

The patient in this case report presented with an acutely infected chronic wound. Wound culture revealed P aeruginosa and S agalactiae (group B). Although there is debate about whether NPWT can be used in the setting of infection, a review article published in 2011 showed that NPWTi with antiseptics may be beneficial in managing infected wounds.¹³ In addition, Phillips et al¹⁴ found that NPWTi was effective in reducing colony-forming units by increasing destruction and removal of biofilm bacteria on P aeruginosa biofilm on porcine skin explants. Formation of biofilm that is resistant to antibiotic therapy can impede healing. The authors of the present study chose the particular instillation solution noted previously because it is non-cytotoxic and has a skin-friendly pH with the highest concentration of hypochlorous acid of any such solution. In the case reported in the present study, NPWTi was used as an adjunct to antibiotic, not a replacement for it. To further prep for STSG placement, biopsy was performed, followed by surgical debridement using hydrosurgery and application of NPWTi. Biopsy was performed to rule out tumor. Hydrosurgery was used to further remove nonviable tissue. NPWTi with hypochlorous acid was reapplied and placed on the wound for 3 days to ensure the wound bed was adequately prepped for STSG placement. Finally, the patient was returned to the operating room for STSG placement. NPWT without instillation was applied to promote adherence of the STSG to the wound.

Although NPWTi and STSG are both well documented individually for the management of VLU, few studies report coupling these 2 modalities.^10-12 The present case report differs from previously published studies because hydrosurgery was used to further prep the wound bed in addition to NPWTi. The patient discussed in the present case report was discharged 9 days after admission and achieved wound healing in 2 months. No new wounds have occurred since healing of the right medial ankle wound.

To the knowledge of the authors of the present study, no previously published case report has coupled NPWTi, hydrosurgery, and STSG for the management of chronic VLU. This method of treatment showed promising results in the case reported herein. Further studies are warranted to evaluate the value of this treatment method.

This case report has potential limitations. The current case is limited by the number of patients studied. Although this case report is limited to a single patient, the authors do believe that this management technique could be used to treat patients with similar, challenging wounds. Currently, venous wounds are very challenging to treat and manage. Discussion on this type of method is lacking in literature.

VLUs are difficult to heal, and large ones are particularly challenging. It may take months to achieve closure, and such ulcers can drastically affect a patient’s quality of life. Possible benefits of STSG include good rates of ulcer healing, pain reduction, earlier time to mobilization, decreased outpatient visits, and reduced need for dressings. NPWTi increases granulation tissue, improves tissue oxygenation, and clears wound debris. Furthermore, NPWTi has shown promise in wound preparation prior to STSG. The authors of the present case report believe that the combination of surgical debridement with NPWTi and STSG is a viable method to manage VLUs.