Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat a Complex Open (Terrible Triad) Injury of the Elbow: A Case Report

Complex elbow injuries are challenging for most orthopedic surgeons.¹ In managing such injuries, bone lesions cannot be considered independently from the soft-tissue lesions.² The main clinical objective is to restore joint stability, carefully addressing soft tissue around the elbow joint,³ and to ensure adequate soft tissue coverage to reduce the probability of long-term complications.⁴ Several studies⁵ have shown a successful use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) in open fractures.⁵ Herein, the authors describe the management of a complex elbow injury in a 75-year-old male that resulted in a good clinical and functional outcome at 6 months, with no adverse effects.

A 75-year-old male with a history of high blood pressure was admitted to the authors’ department after an accident involving agricultural equipment that resulted in open trauma of the left elbow. The initial clinical examination identified a type IIIA (Gustilo-Anderson dislocation classification) open fracture with extensive loss of skin and soft tissue of the upper extremity (Figure 1). The neurovascular assessment revealed ulnar nerve palsy. Initial radiographs noted a triad injury of the left elbow: a posterolateral dislocation combined with fractures of the radial head (Mason-Johnson Type II) and ulnar coronoid process (Morrey Type 1) (Figure 2A).

Treatment protocol for open fractures was initiated in the emergency department: 2 g amoxicillin-clavulanic acid was administered with a tetanus toxoid booster, the wound was covered with sterile dressing, and the fracture was immobilized. The patient was moved to the operating room for surgical debridement and wound irrigation. Surgical exploration found extensive soft tissue injury involving the lateral aspect of the distal arm, the proximal forearm, and the elbow associated with a rupture of the triceps tendon and both elbow collateral ligaments. A contusion of the ulnar nerve also was noted. The bone was stabilized using a screw fixation of the radial head and the coronoid process; subsequently, the lateral radial collateral ligament was repaired by anchoring it to the lateral epicondyle. Although the elbow remained unstable, the lateral ulnar collateral ligament was repaired (Figure 2B). Finally, the triceps tendon was repaired, and the authors were able to preserve a local skin flap to provide adequate soft tissue coverage. A hinged external fixator was applied to maintain elbow alignment and allow early mobilization (Figure 3A).

Traditional NPWT was started postoperatively and applied to the remaining skin defects to promote wound healing (Figure 3A). Once the dressing was applied, a standard negative pressure of  -125 mm Hg was administered to the wound, with a dressing change every 48 hours. After 3 days of this treatment, the patient developed necrosis of the local skin flap with a septic arthritis of the elbow (Figure 3B). Subsequently, all nonviable tissue was excised in combination with an open irrigation and debridement of the elbow. Culture and sensitivity results of the elbow drainage revealed Methicillin-sensitive Staphylococcus aureus that then was treated with rifampicin (900 mg daily) and ofloxacin (600 mg daily) for 12 weeks, with blood control every 2 weeks. Given the clinical trajectory, NPWTi-d (VAC VERAFLO; 3M + KCI) was initiated. A foam dressing (V.A.C. VERAFLO Dressing;3M + KCI) was placed on the wound directly over the soft tissue defect and sealed with a semi-occlusive dressing (Cavilon No Sting Barrier Film; 3M). Negative pressure of -125 mm Hg was applied, and 50 mL of normal saline solution (0.9%) was instilled for 20 to 30 seconds and left to dwell for 10 minutes. The dressing was changed every 3 days. After 2 weeks, a local rotational flap was used for partial elbow reconstruction (Figure 3C). Once a viable wound bed was obtained (ie, all tissue viable with healthy wound edges, no visible sign of infection, and a correct moisture balance), a split-thickness skin graft was performed to provide total coverage (Figure 3D).

All wounds and fractures were healed within 8 weeks, at which point the external fixator was removed (Figure 4A). Free elbow joint mobilization was allowed. At 3 months, the authors obtained 100°/30°/0° of elbow range of motion with a DASH 3 at 30 out of 100. At 6 months, the elbow range of motion reached 120°/20°/0° with a clear improvement of DASH score (DASH 6 at 14.2 out of 100). The patient was happy with the results and able to return to their job and daily activities (Figure 4B).

Elbow dislocation with fracture of the radial head and the coronoid process (the terrible triad⁶) is difficult to treat and requires surgical intervention.⁷ Over the years, treatment has resulted in long-term complications, including stiffness, pain, joint instability, and secondary arthrosis.⁸ The elbow injury combined with severe soft tissue trauma is an example of complex elbow injury as defined by Regel et al⁹ that challenges orthopedic surgeons and can lead to permanent disabilities¹ and poor functional outcomes¹⁰ if soft tissue reconstruction is inadequate.

In the case described, two fundamental and connected objectives had to be achieved: restoring joint congruency and stability to reduce the probability of long-term complications⁴ and achieving adequate soft tissue coverage. As described in the literature¹¹ and based on the principles of open fracture management, the wound first was irrigated and debrided. Next, the wound was explored surgically, identifying nerves and vessels before performing skeletal stabilization. Elbow primary and secondary stabilizers together provide stability to the joint^12-14; to restore this stability, the authors needed to repair all elbow stabilizers, using the same systematic approach described by Pugh and McKee¹⁵; this comprised osteosynthesis or arthroplasty of the radial head; repair of the coronoid, if possible, and/or the joint capsule; and repair of the lateral ligament complex of the elbow, along with making repairs to the medial collateral ligament. Using the same systematized approach, several authors reported good and excellent results in 77% to 84% of patients, with a revision rate of 15% to 25%.^16-18

Most orthopedic surgeons favor external fixation in open trauma because of the fear of infection,^17,18 but in the current case, it was determined that surgical management was fast enough (optimal surgical timing for management of open fractures) to use internal fixation. Using an external fixator in elbow trauma may not always be the best treatment option because of the risk of complications, such as pin tract infections and nerve problem, but it can be necessary in cases involving soft tissue damage.¹⁹ In the current case, an external fixator was determined to be a safe treatment method and was utilized for 8 weeks until all wounds were healed. Opinions differ regarding the duration of an external fixator: Tan et al²⁰ suggest 2 months, von Knoch et al²¹ suggest 6 or 7 weeks, and Zeiders et al²² suggest 6 weeks.

The authors were able to preserve skin for a local skin flap to provide adequate soft tissue coverage. The use of NPWT is supported in deep wounds with exposed structures to provide temporary wound cover and prepare the wound bed for closure; NPWT should be discontinued when surgical closure is possible.²³ However, given the evolution of the wound and the development of a septic arthritis of the elbow, NPWTi-d was determined to be a worthwhile option²⁴ in order to facilitate wound cleansing and dilution as well as solubilization of infectious materials and wound debris.²³ Brinkert et al²⁵ employed NPWTi-d with sterile saline when traditional NPWT did not offer good outcomes, and they obtained wound closure in 98% with an observed increased granulation and reduced wound volume compared with standard NPWT. Fluieraru et al²⁶ achieved successful wound closure after application of NPWTi-d in 24 patients who either were unsuccessfully treated with NPWT or presented with complex wounds.

Negative pressure wound therapy with instillation and dwell time has been shown to improve wound bed preparation and have a positive effect on wound granulation.²³ Patients may experience less pain and discomfort,²³ and the treatment duration is shorter.²⁷ In a comparative retrospective study of 27 patients, Schreiner et al²⁷ reported that NPWTi-d leads to a shorter care time for the wound (P = .075 and P = .217).

With the literature in mind, the authors’ level 1 trauma center manages severe degloving or high-energy soft tissue injury combined with or without open fracture with the NPWTi-d protocol described in this case. Depending on the wound condition and the discomfort of the patient, negative pressure is applied for 4 to 12 hours. Once granulation tissue is obtained, a skin graft is used to cover the defect.

In the current case, the NPWTi-d protocol allowed the authors to achieve a good result, despite the large degloving injury and the severe elbow fracture-dislocation.

A complex triad elbow injury was successfully managed using NPWTi-d. An elbow flexion-extension range of motion of 120° to 20° was achieved in 6 months, allowing for most daily activities. Negative pressure wound therapy with instillation and dwell time allowed the authors to ensure coverage of extensive losses of skin and soft tissue without a great deal of pain for the patient. This approach offers a promising treatment that provides clinical benefit from the perspectives of the patient and surgeon. Additional research and larger prospective studies are warranted before recommendations can be made unequivocally.

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