Management of Lower Extremity Orthopedic Wounds With Exposed Hardware Using Negative Pressure Wound Therapy With Instillation

Surgical wounds with orthopedic hardware can be difficult to manage. Rates of post-surgical complications can be as high as ~16% in patients that underwent open reduction and internal fixation (ORIF) for tibial fractures.1 One of the most common complications following the use of orthopedic hardware is infection, which can lead to amputation or death.2 Common treatment for orthopedic hardware infection includes use of antibiotics, debridement, and in some cases removal of the hardware.

Negative pressure wound therapy with instillation and dwell time (NPWTi-d*), which provides wound cleansing to help remove debris, infectious materials, and exudate, has been reported to help manage patients with infected wounds with orthopedic hardware without complications.3 We present our experience using NPWTi-d to help manage non-healing lower extremity wounds with exposed orthopedic hardware in two patients. Two females (69 and 81 years old) presented for care with non-healing orthopedic wounds 4 weeks after ORIF. Patient comorbidities included previous surgery, previous fracture, diabetes, hypertension, and opioid use. Intravenous antibiotics were given, followed by surgical debridement of non-viable tissue. NPWTi-d was initiated to cleanse the wound bed.

A hypochlorous topical wound solution was instilled into the wound with a 20-minute dwell time, followed by 2 hours of continuous negative pressure wound therapy at -125 mmHg. Dressings were changed every 3 days. After 3 days of NPWTi-d, patients either underwent surgical closure, or surgical debridement followed by 3 days of negative pressure wound therapy† and surgical closure with split-thickness skin graft placement. Closed incision negative pressure therapy‡ was applied over the closed surgical incisions and left in place for 7 days. The wounds remained closed without complications 2.5 to 4 weeks after surgical closure. In these 2 patients, the use of antibiotics and NPWTi-d successfully prepared the wound for surgical closure.

Trademarked Items (if applicable): *V.A.C. VERAFLO™ Therapy with V.A.C. VERAFLO CLEANSE™ Dressing or V.A.C. VERAFLO CLEANSE CHOICE™ Dressing; †V.A.C.® Therapy; ‡PREVENA™ Incision Management System; KCI, now part of 3M Company, San Antonio, TX

References (if applicable): 1. Gaunder CL, Zhao Z, Henderson C, McKinney BR, Stahel PF, Zelle BA. Wound complications after open reduction and internal fixation of tibial plateau fractures in the elderly: a multicentre study. Int Orthop. 2019;43(2):461-465.
2. Kaufman MG, Meaike JD, Izaddoost SA. Orthopedic prosthetic infections: diagnosis and orthopedic salvage. Semin Plast Surg. 2016;30:66-72.
3. Dettmers R, Brekelmans W, Leijnen M, van der Burg B, Ritchie E. Negative pressure wound therapy with instillation and dwell time used to treat infected orthopedic implants: a 4-patient case series. Wound Manage Prevent. 2016;62(9):30-40.