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. 2021 Apr 23:18:82-87.
doi: 10.1016/j.reth.2021.04.001. eCollection 2021 Dec.

NPWTi allows safe delayed free flap repair of Gustilo IIIb injuries: A prospective case series

Hajime Matsumine  1 , Giorgio Giatsidis  2 , Hiroshi Fujimaki  1 , Nobuyuki Yoshimoto  3 , Yuma Makino  1 , Satoshi Hosoi  1 , Mika Takagi  1 , Mari Shimizu  1 , Masaki Takeuchi  1
Affiliations

NPWTi allows safe delayed free flap repair of Gustilo IIIb injuries: A prospective case series

Hajime Matsumine et al. Regen Ther. .

Abstract

Introduction: Free flap lower extremity repair is associated with a high complication rate (>31%); higher rates are observed in more severe patients. In cases requiring prior systemic/local stabilization, delayed repair increases complication rate (+10% at 7 days): Negative-pressure Wound Therapy (NPWT) decreases complications but only when applied for less than 7 days. Recent limited evidence suggests that augmentation of NPWT with instillation for wound irrigation (NPWTi) might safely extend such window. This study hypothesizes that, through the combined cleansing effect of NPWT and instillation, NPWTi allows safe (low complication rate) delayed free flap repair in severe patients with Gustilo IIIb injuries (GIIIb).

Methods: A prospective case series was designed (inclusion criteria: GIIIb requiring microsurgical repair, severe patient/injury condition preventing immediate/early repair; exclusion criteria: allergy to NPWTi dressing). Patients received NPWTi (suction: 125 mmHg continuous; irrigation: NaCl 0.9%) until considered clinically ready for repair. Preoperative/postoperative complications (dehiscence, wound infection, bone non-union, osteomyelitis, flap failure) were monitored with clinical signs, imaging, and serum markers (CRP, WBC).

Results: Four patients (male: N = 4, female N = 1; Age: 59 [44-75] years-old) were treated. NPWTi was applied for 15.2 [9-28] days. No complication (0%) was observed preoperatively or postoperatively. Delayed repair occurred by latissimus dorsi musculocutaneous flap (N = 3), and anterolateral thigh flap (N = 2). All patients walked weight-bearing 12 [6-20] weeks after injury.

Conclusions: NPWTi seems to allow safe delayed free flap repair in patients with severe lower extremity injuries unable to undergo immediate/early repair.

Keywords: Free flap; GIIIb, Gustilo IIIb injuries; Lower extremity; Microsurgery; NPWT, Negative-pressure Wound Therapy; NPWTi; NPWTi, Negative-pressure Wound Therapy with instillation for wound irrigation; Negative Pressure Wound Therapy.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Fig. 1
Fig. 1
Case#1: open fracture of the left tibia in a 72-year-old female. A. Wound on the day of injury, showing significant tissue necrosis and bone exposure. B. 3D-CT imaging showing a complex fracture of the tibial and fibula shafts. C. Injury after emergency debridement and management of the fracture by external fixation. D. NPWTi applied to the injury after debridement and bone fixation.
Fig. 2
Fig. 2
Case#1: open fracture of the left tibia in a 72-year-old female. A. Status of the wound after 9 days of NPWTi and a split-thickness skin graft: no signs of soft tissue infection or residual necrosis are observed, partial bone coverage is noted. B. Surgical design for a divided latissimus dorsi musculocutaneous flap. C. The two skin islands of the divided latissimus dorsi flap are sutured together to allow maximal coverage. D. Microsurgical repair with the free latissimus dorsi musculocutaneous flap.
Fig. 3
Fig. 3
Case#1: open fracture of the left tibia in a 72-year-old female. A. Six-month clinical follow-up showing complete healing of soft tissue injuries. B. Six-month 3D CT imaging follow-up showing complete healing of tibial bone injuries with full bone union and no sign of osteomyelitis.
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