Danijela Semenič, Kliment Dajoski, Ljupcho Gjorshevski, Miloš Macura, Tomaž Kastelec, NadjaAlikadič, Jana Wahl, Andrej Lapoša, Igor Frangež
Introduction: Negative-pressure wound therapy with instillation for complex soft tissue and bone infections is an important therapy in daily surgical practice. With addition of the topical antiseptic solution bacterial load is reduced and growth of the granulation tissue increased.
Methods. A 55-years old male patient with pseudogout suffered joint, bone and soft tissue infection of the right foot (Fig1). X-ray, CT and MRI (Fig 2) diagnostics have been done. On the day of admission debridement of the infected necrotic soft tissue was performedand repeted on the 3th and 7th day. Followed by arthrotomy, synovectomy and bone resection with external fixation (Fig3) and negative pressure wound therapy with instilationon with Veraflo cleanse at the 14th day (Fig4). From the bone andsoft tissue biopsies and hemocultures S.aureus was isolated. Patient was treated with two different systemic antibiotics Flucloxacillin and Clindamycin. Pathohistological examinations of bone revealed osteitis. The VAC Ulta device was set to -125 mmHg for 8 hours of NPWTi-d followed by instillation with hypochloride antiseptic solution, set to dwell time of 20 minutes. Systemic hyperbaric oxygen therapy was also indicated and performed. Granulation tissue and clean appearance of the wound were leading to closure with musculo-cutaneus lattisimus dorsi flap from the right side of the back on the 28th day. There were complicationswith occurrence of artery and vein thrombosis at the site of anastomosis and subsequent flap necrosis. Debridement was done on the 36th day. NPWT was reapplied.
Results. On the 56th day re-cover with musculo-cutaneus lattisimus dorsi flap from the left side of the back and split thickness skin graft were performed (Fig 5). The closure was successful (Fig 6). On the 149th day external fixator was removed. On the 166th day the patient began walking with support of crutches and progressively loading his right foot. Movement in the right ankle and foot is restricted.
Discussion. NPWTi-d stimulates granulation tissue, removes infectious debris, and manages bacterial bioburden. It is especially valuable in treating complex, contaminated or infected wounds. It allows faster healing and greater proportion of completely healed wounds. With the above mentioned multiple surgical procedures the patient retained the right lower limb and avoid amputation, nevertheless, the flexibility and movement is not yet completely full.
Conclusion. The goal in complex wound management is to optimize clinical outcome, reduce time to wound closure and to achieve fast functional recovery as far is possible. NPWTi-d is an important additional therapy in the management of complex and infected wounds.
Fig1: Infection on the foot
Fig3: debridement, external fixation
Fig 4: NPWTi-d
Fig5: musculo-cutaneous flap and skin graft
Fig 6: final closure