Management of a High-Energy Soft Tissue Injury of the Lower Extremity Using Negative Pressure Wound Therapy With Instillation and Dwell Time and a Reticulated Open Cell Foam Dressing

Soft tissue injuries of the lower extremity are the result of high-energy trauma, such as road accidents.¹ These injuries remain challenging for most orthopedic surgeons in decision-making and treatment.² Negative pressure wound therapy (NPWT) has improved complex wound treatment since 1997, as it improves local perfusion, decreases edema, and stimulates granulation.³ However, like other treatment strategies, NPWT has its limitations. Here, the authors present the case of a 21-year-old male with an extensive soft tissue injury of the right lower extremity managed with NPWT with instillation and dwell time (NPWTi-d) and a reticulated open cell foam dressing when the limits of traditional NPWT were reached.

A 21-year-old male was brought to the Department of Orthopedic Surgery and Trauma at the Regional Hospital of Orleans (Orleans, France) after a high-energy trauma (road accident). The patient suffered from trauma to the right lower limb and multiple injuries to the head, chest, and abdomen. Initial clinical examinations revealed an extensive soft tissue injury of the lateral side of the right knee and leg. The bones, muscles, and joints were exposed as a result of the extensive loss of skin and soft tissue. The wound was contaminated, and risk of infection was high (Figure 1A). Radiographs were normal, and the Mangled Extremity Severity Score was less than 6, consistent with a salvageable limb. The patient underwent wound irrigation and debridement in the operating room. Inspection of the wounded area revealed a single-plane degloving injury of the anterolateral aspect of the right leg. Necrotic and nonbleeding tissues were excised, and the wound was closed without tension with a remaining small skin defect on the lateral aspect of the knee (Figure 1B). The patient was admitted to the intensive care unit (ICU). Prior to the start of surgery, 2 g of cefazolin was administered—1 g after 4 hours and 1 g every 8 hours for 2 days. Cultures were collected and were negative.

After 3 days, local necrosis was noted on the medial side of the right thigh and the lateral side of the right knee and leg (Figure 2A, B); consequently, surgical debridement was done and traditional NPWT alone (without instillation) was initiated. Two weeks later, wound healing had not progressed, and the bone remained exposed (Figure 2C, D). Given the failure of traditional NPWT, further surgical debridement would have been considered but could not be performed because of the patient’s other recent multiple surgical procedures involving the head, chest, and abdomen. Alternatively, the authors decided to utilize NPWTi-d (V.A.C. VERAFLO Therapy; 3M + KCI) with a reticulated open cell foam dressing (ROCF-CC; V.A.C. VERAFLO CLEANSE CHOICE Dressing; 3M + KCI) (Figure 2E). A negative pressure of -125 mm Hg was applied with instillation of normal saline solution (0.9% NaCl) with a 10-minute dwell time and a cycle frequency of 4 hours.

After 9 days, granulation tissue had grown with healthy wound edges, even over the exposed bone (Figure 3A), so NPWTi-d was discontinued; traditional NPWT was applied for 3 days until a viable wound bed was obtained (Figure 3B). Next, a split-thickness skin graft was used to cover the defects. Finally, 4 weeks following the accident, all wounds of the right lower extremity were completely healed (Figure 4).

Soft tissue injuries of the lower limb often result after a high-energy trauma, such as that seen with road accidents.¹ Reconstructing the soft tissue is crucial to preserving the architecture of the lower limb. The preparation for wound closure is essential, and surgical debridement is needed to remove devitalized soft tissue and other negative factors that influence wound healing.⁴ Additionally, the subcutaneous hematoma and dead fat need to be removed, followed by drainage and pressure dressing.⁵ The principal goal of using NPWT in soft tissue traumatic wounds is to ensure temporary wound cover following debridement and before definitive closure.⁶ It can also prevent bacterial contamination, reduce edema, and facilitate wound drainage to improve the success of future closure procedures.⁶

In the present case, after 2 weeks of surgical debridement and NPWT, wound healing had not progressed, and the bone remained exposed. Because surgical debridement was not possible and the use of NPWT was not recommended by the French high authority for health, the authors utilized NPWTi-d with ROCF-CC, which had been previously shown to be effective in other complex cases.^7,8 Thanks to this strategy, growth of granulation tissue was extraordinarily fast (9 days), even over the bone, without any surgical debridement and despite the presence of nonviable and fibrinous tissue.

Recent research suggests that NPWTi-d with ROCF-CC improves wound healing by removing the thick exudate and nonviable tissue from the wound when complete surgical debridement is not possible or when nonviable tissue remains present. The present case shows the advantage of this therapy over traditional NPWT, which cannot replace surgical debridement and cannot be used in the presence of necrotic tissue requiring debridement.

In the authors’ experience, NPWTi-d with ROCF-CC allowed them to ensure coverage of an extensive loss of soft tissue when the traditional NPWT limits were reached (surgical debridement was not possible but necrotic tissue was present). Growth of granulation tissue, even over the bone, was extraordinarily fast (9 days), without any surgical debridement and despite the presence of nonviable and fibrinous tissue. While surgical debridement remains the preferred treatment, NPWTi-d with ROCF-CC might be the next best alternative when debridement is not feasible.

This is a case report, so additional research and larger studies are required before a strict recommendation can be given.

Authors: Mazen Ali, MD¹; Fekhaoui Mohammed Reda, MD²; Hichem Issaoui, MD¹; Hatem Abbassi, MD¹; Mahdi Gargouri, MD¹; and Fredson Razanabola, MD¹

Affiliations: ¹Department of Orthopedic Surgery and Trauma, Regional Hospital of Orleans, Orleans, France; and ²Department of Trauma and Orthopaedic Surgery, Ibn Sina University Hospital, Faculty of Medicine, Mohammed V University of Rabat, Rabat, Morocco

Correspondence: Fekhaoui Mohammed Reda, MD, Resident, Ibn Sina University Hospital, Faculty of Medicine of Rabat - Mohammed V University of Rabat, Rabat, 10100 Morocco; rfekhaoui@icloud.com

Disclosure: The authors disclose no financial or other conflicts of interest.