Rotation Flap Closure of Pressure Injuries Following Negative Pressure Wound Therapy With Instillation for Wound Cleansing

PIs are characterized by damage to the integumentary system and/or underlying tissues resulting from persistent pressure or concomitant shearing forces. Stage III and IV PIs require multifactorial interventions implemented by health care professionals in various disciplines and specialties.^1,2 PIs represent the second most frequent complication among patients with SCIs and account for appreciable cost and resource use across the health care setting.¹ One study indicated that the annual cost of HAPIs in the United States may exceed $26.8 billion.³ According to the Agency for Healthcare Research and Quality, interventions to reduce PIs are among the integral strategies that health care systems are implored to adopt.^2,4

Early-stage wound cleansing is an essential aspect of wound therapy that allows transition to subsequent therapies to promote granulation tissue formation and epithelialization or provide wound coverage or primary closure or flap reconstruction. NPWT has become an integral part of wound bed preparation. In NPWTi-d, the instillation of topical wound solutions and negative pressure is used for wound cleansing and removal of infectious materials.^5-8

The plastic surgery reconstructive ladder is commonly referenced when reviewing options for closing a complex wound. The algorithm includes local and regional flap reconstruction for closure. With the increasing popularity of cellular tissue products, flap reconstruction typically is reserved for patients who require complex reconstruction and for whom less invasive options are inadequate. Postoperative complications such as infection, dehiscence, and recurrence following flap closure of chronic defects are relatively common, however.^9,10 Specifically, complications following PI flap reconstructive surgery have become an increasing concern for the reconstructive surgeon and in terms of health care economics. Reducing the risks of postoperative complications and optimizing surgical success can be challenging in this patient population.

Wound bed preparation is paramount for wound closure by either secondary intention or surgical intervention. While NPWT has been shown to be useful for chronic wound healing, NPWTi-d may assist with optimization of the wound bed prior to flap reconstruction and may help reduce the risks of postoperative complications. NPWTi-d is increasingly being used to assist in wound bed preparation prior to definitive closure.

This was a retrospective study of 5 patients (age range, 39–89 years) who were admitted to an acute care hospital and treated for PI. Three patients each presented with 1 PI. Two patients presented with multiple PIs, with 1 presenting with 2 PIs and the other presenting with 5 PIs. Surgical debridement was performed as an initial therapy for each wound, after which NPWTi-d (Veraflo Therapy; 3M Company) was initiated.

Topical wound solutions included either 40 mL to 80 mL of normal saline (0.9% solution) or HOCl wound solution (VASHE; Urgo Medical North America). The type of topical wound solution used was contingent on availability of the instillate. The topical wound solution was instilled into the defect with a dwell time of 20 minutes, followed by 2 hours of subatmospheric pressure (−125 mm Hg). The types of less hydrophobic ROCF dressings used for NPWTi-d—ROCF-V (V.A.C. Veraflo Dressing; 3M Company), ROCF-C (V.A.C. Veraflo Cleanse Dressing; 3M Company), and ROCF-CC (V.A.C. Veraflo Cleanse Choice Dressing; 3M Company)—were chosen based on wound etiology and the therapeutic objectives of the patient. NPWTi-d was applied for a total of 3 to 6 days, with dressing changes every 48 hours.

Systemic antibiotics were administered perioperatively as needed. Patients were maintained in the acute hospital setting until definitive closure was achieved. The surgical procedure was performed in the operating room by a single surgeon and with the patient under general anesthesia. In each patient, viable human amnion membrane allograft particulate material (AmnioBand Particulate; MTF Biologics) was placed in the cleansed defect to serve as a regenerative tissue matrix to stimulate cellular proliferation and optimize healing. In each case, surgical closure was achieved with a rotational flap advancement using a layered closure that included deep tissue suture closure and epidermal closure using skin staples.

Following closure, incision management was attained using ciNPT (Prevena Incision Management System; 3M Company). ciNPT was applied at −125 mm Hg for 5 to 7 days over the closed incisions of the flap margins. Patients remained in the acute hospital setting postoperatively for 3 to 7 days, after which they were discharged with ciNPT.

Average patient age was 63.2 years ± 21 standard deviation (range, 39–89 years) (Table). Comorbidities included paraplegia, diabetes, rheumatoid arthritis, and deep vein thrombosis. In 4 of the 5 patients, rotation flap closures were performed without immediate postoperative complications, and those patients were discharged from the hospital within 72 hours. One patient (case 2) was re-hospitalized for 7 days owing to nonadherence and secondary dehiscence. There was no evidence of infection, the wound was reclosed, and the wound healed without further incident by 6 weeks. In a different patient (case 5), an unrelated medical condition delayed closure of an ischial ulcer, and the patient underwent a colostomy to prevent further soilage and contamination. After the colostomy, the patient returned for flap coverage.

Case 2: multiple pressure injuries

A 39-year-old female with paraplegia presented with multiple PIs (sacrum, bilateral ischium, and bilateral hips), including an extensive left hip ulcer with complete exposure of the femoral head (Figure 1). The acute progression of the left hip ulceration resulting in exposure of bone was identified during preoperative workup for scheduling elective surgery.

The patient underwent orthopedic surgery, including excision arthroplasty of the hip using the Girdlestone procedure owing to acute and chronic osteomyelitis of the femoral head. The patient developed a postoperative hematoma (Figure 2A) and returned to the operating room 2 days later for hematoma evacuation (Figure 2B). The remaining ulcers were addressed at that time and were treated in stages. While there was no evidence of acute infection, the procedures were staged because of the extent of the ulcers. Stage 1 included surgical debridement, specifically, excision of the ulcer and a partial ostectomy. NPWTi-d using ROCF-V dressings and instilling HOCl was initiated immediately postoperatively (Figure 2C).

Following 48 hours of NPWTi-d, the patient was returned to the operating room (Figure 2D). The ulcers were clean, with no evidence of infection or necrotic debris. The surgeon elected to proceed with definitive closure of the remaining defects using rotational flap advancement (Figure 2E). Prior to closure using rotational flap advancement, viable human amnion membrane allograft particulate material was placed to stimulate cellular proliferation and optimize healing. After flap closure, ciNPT was applied and initiated immediately (Figure 2F).

After 48 hours of ciNPT, the patient was discharged to a long-term care facility, where she was to be on strict bed rest for 6 weeks. ciNPT was reapplied at the long-term care facility. After 7 days, ciNPT was discontinued and the ciNPT dressing removed. The incisions were intact upon ciNPT dressing removal; however, there was evidence of postoperative incisional dehiscence due to patient nonadherence with treatment (Figure 3A). Although the patient had been instructed not to elevate the head of the bed more than 30°, she elevated the head of the bed to 90° during meals on multiple occasions. The patient nonadherence with treatment was unfortunate; however, when she was returned to the operating room the surgical sites were noted to be quite healthy in appearance and remained free of infection. The areas of previously exposed bone where the allograft particulate was distributed displayed healthy tissue. Consequently, the open surgical sites were reclosed with rotational flap advancements (Figure 3B) and the flap margins were managed with ciNPT during hospitalization and following discharge (Figure 3C). After 7 days, ciNPT was discontinued and removed.

At the 6-week follow-up appointment, the patient had healed without further incident (Figure 4).

In this small series of 5 patients with 10 PIs, staged procedures that included surgical debridement followed by NPWTi-d to assist with wound bed preparation and transition to rotational flap closure were associated with a successful surgical outcome. No postoperative infections occurred. In the representative case (case 2), postoperative incisional dehiscence occurred owing to treatment nonadherence by the patient; because there was no infection, surgical closure was performed, with a successful outcome. In another patient, an unrelated medical issue preempted closure of an ischial ulcer, and a stoma was created to prevent further soilage and contamination. After the colostomy, the patient returned for flap coverage.

Since it was first described by Morykwas in 1997, NPWT has altered the treatment of wounds and has become an innovative modality in the armamentarium of medical practitioners.¹¹ In 2011, Suissa et al¹² published a meta-analysis of randomized trials of NPWT versus standard wound care. Their results suggest that NPWT appears to be effective in the management of chronic wounds. Modifications and advances have expanded the use of NPWT, specifically within the field of plastic surgery.¹³

While wound bed preparation with conventional NPWT has been shown to be beneficial in the management of chronic wounds, NPWTi-d has shown even greater promise in terms of granulation tissue growth and expedited time to closure in hospitalized patients, including economic benefits compared with traditional NPWT.^6,14 Multiple studies have been published citing the benefits of NPWTi-d.^6,7,14-17 NPWTi-d is designed to cleanse the wound through instillation of topical wound cleansers that can help soften and loosen wound debris. This modality has been used to assist in wound bed preparation for secondary healing as well as definitive surgical closure. Additionally, NPWTi-d can promote granulation tissue formation, which can help prepare the wound for closure and promote healing in wounds that may be unresponsive to conventional NPWT.^6,7,14-17 Although NPWTi-d was initially largely used as a last-resort therapy, it is increasingly being used to promote wound healing by combining the mechanisms of action of standard NPWT (eg, draw wound edges together, promote perfusion and granulation tissue formation, remove exudate, reduce edema) with the benefits of cyclic cleansing that dilutes and solubilizes wound debris.

Another important distinguishing feature of NPWTi-d is the use of specialized ROCF dressings relative to conventional ROCF dressings used in NPWT. The specialized dressings (eg, ROCF-V, as described by Gabriel et al¹⁴) for NPWTi-d possess fewer hydrophobic properties, which aids in the uniform delivery of topical wound solutions within the wound bed. The use of either ROCF-V, ROCF-C, or ROCF-CC is predicated on wound etiology, wound location and topography, and the respective therapeutic objectives of the patient.¹⁸ Additionally, ROCF dressings for NPWTi-d also demonstrate a higher tensile strength than conventional ROCF dressings for NPWT to facilitate thorough removal during dressing changes.^16,18 Select ROCF dressings for NPWTi-d are designed with different specifications to accommodate the location and complex topography of wounds. For example, ROCF-C foam dressings for NPWTi-d are coiled and cylindrical and are designed for use on wounds with tunneling or undermining and/or that require circumferential applications, whereas ROCF-CC foam dressings for NPWTi-d are multilayered to accommodate varied wound depths and contain a layer with through holes for use on wounds with thick wound exudate for the purpose of disruption, solubilization, and removal.^16,18 Conversely, foam dressings composed of PVA are designed for use with NPWT but not with NPWTi-d applications. While less adherent than conventional ROCF dressings for NPWT, PVA foam dressings demonstrate elevated tensile strength to facilitate placement on and removal from wounds with tunneling and undermining; however, they also have increased density to preempt granulation tissue in-growth in instances of hypergranulation. PVA foam dressings are not designed for NPWTi-d using topical wound solutions; however, they may be pre-moistened with sterile water per the instructions for use.

Per the 2019 International Consensus Guidelines update, NPWTi-d may be used as an adjunct therapy in traumatic wounds; surgical, including dehisced, wounds; diabetic wounds; venous leg ulcers; pressure injuries/ulcers; wounds with exposed intact bone; wounds with treated, underlying osteomyelitis; infected or contaminated wounds in the presence of orthopedic fixation hardware; full-thickness burns after excision; wounds resulting from evacuation of a hematoma and when hemostasis is achieved; and wounds that are a bridge between staged/delayed amputation.¹⁹ The delivery of antiseptic or antimicrobial topical wound solutions can help manage bacterial bioburden while diluting and solubilizing wound debris and removing exudate and devitalized tissue.¹⁹

Postoperative complications following PI flap reconstructive surgery have become an increasing concern for the reconstructive surgeon. Preoperative techniques to enhance outcomes may include patient optimization, such as modulation of factors including nutritional status and comorbidities; however, preoperative wound management and preparation are critical to a successful surgical outcome.

PIs generally have a high bioburden and an elevated risk of postoperative infection. Kamradt et al²⁰ reported that neither the bacterial strain nor the extent of bacterial bioburden of deep tissue cultures is predictive of flap failures. Further, those authors suggested that the insufficient administration of prophylactic antibiotics was associated with elevated rates of flap failure. No postoperative infections occurred in the current study.

In 4 of the 5 patients treated in the current study, no complications occurred immediately postoperatively after rotation flap closures. Biglari et al²¹ noted that rotational flaps had the lowest rate of complications (11.5%) relative to 8 other types of skin flap. Suture line dehiscence was the most common complication (6.1%) of rotational flaps in that study. In a retrospective study of 276 patients who underwent flap coverage for PI between 1997 and 2015, wound dehiscence was the most frequent complication (31.2%).¹⁰ Preoperative osteomyelitis and PIs associated with the ischium were independent risk factors for dehiscence. The single postoperative dehiscence in the current study occurred in a patent who was readmitted for 7 days owing to nonadherence with treatment. That issue was resolved without further complication.

More data are needed on the effectiveness of NPWTi-d in early-stage wound cleansing prior to flap closure; however, a small reduction in the postoperative complication rate of rotational flap surgery for PI would result in a significant benefit in this patient population. A report from the Agency for Healthcare Research and Quality has previously estimated that the costs to manage PIs reportedly ranged between $9.1 billion and $11.6 billion per year in the United States.⁴ However, a 2019 study noted that the costs of HAPI in the United States may exceed $26.8 billion.³ Another benefit of NPWTi-d prior to flap closure would be a putative reduction in economic burden associated with these patients given the prevalence of PIs and high incidence of recurrence.

The limitations of this study include its retrospective nature, the small sample size, lack of a control group, and the absence of economic data for these patients.

Wound bed preparation is an integral step prior to wound closure. Early-stage wound cleansing is an essential part of wound therapy that allows transition to subsequent therapies to promote granulation tissue formation and epithelialization, or provide wound coverage, primary closure, or flap reconstruction. NPWTi-d can be particularly beneficial in contaminated wounds, specifically PIs, to aid in the transition to rotational flap closure. In all PI surgeries performed in this series, a successful outcome was achieved with definitive surgical closure within 3 to 6 days with no postoperative infection. In the experience of the authors of this study, facilitating wound bed preparation with NPWTi-d may assist with wound bed optimization prior to flap reconstruction, specifically in PI surgery, given the high bacterial burden and high risk of postoperative infection.