Use of Negative Pressure Wound Therapy in the Management of Extreme Crush Abdominopelvic Injuries: An In-Depth Case Study and Literature Review

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The advent of NPWT revolutionized the management of contaminated acute wounds, with NPWT being widely accepted and used globally.¹ Introduced in 1997 by Argenta and Morykwas, NPWT—more specifically, V.A.C. Therapy (Solventum)—has significantly advanced wound care management.^2,3 The therapy makes use of a hydrophobic, reticulated open cell foam dressing to manage extensive wounds that prove unresponsive to conventional treatments.⁴

As estimated by WHO, injuries resulted in the death of approximately 4.4 million people globally in 2021.⁵ Yet the death toll captures only a fragment of the impact of traumatic injuries caused by devastating incidents such as road traffic accidents, which can result in blunt trauma, penetrating trauma, burns, and, as in the current case report, catastrophic crush injuries.^6-8

Crush injuries present an intricate therapeutic challenge because they often lead to widespread damage extending from soft tissue to bone and internal organs. The severity and complexity of these wounds necessitate the use of multimodal interventions to achieve effective management and ultimate healing. NPWT has gained substantial recognition in the treatment of patients with crush injury, accelerating healing, reducing cost, and enhancing patient satisfaction.^9,10

As a key intervention in wound care, NPWT expedites healing by stimulating granulation tissue formation and new capillary growth through the application of negative pressure to the wound bed.¹¹ By removing wound exudate that harbors inflammation-promoting enzymes, NPWT contributes to reducing the bacterial burden in the wound and decreasing edema.¹²

However, the use of NPWT requires careful patient selection and evaluation of the wound. The use of and indications for NPWT vary based on the patient's age and comorbidities, the contamination of the wound, the condition of the wound bed, and the exposure of vascular and nervous structures. Additionally, managing potential complications and infections is crucial. Therefore, it is essential to adopt a personalized treatment plan tailored to the specific needs of the patient.¹³

This case report centers upon a 16-year-old male who sustained catastrophic crush injuries from a vehicle run-over event involving a farm vehicle. The patient presented with an extensive wound in the left gluteal region, necrosis of the gluteus maximus muscle, exposed femur, perforation of the rectosigmoid junction, a membranous urethral injury, and a large anal laceration that communicated with the left inguinal and ischiorectal fossa. This intricate trauma was managed with NPWT combined with progressive tension sutures for wound management.

This case report aims to underscore the efficacy of NPWT, in association with damage control resuscitation and surgery, in managing complex crush injuries and demonstrate its potential as the primary therapeutic tool in similar scenarios.

A 16-year-old male, weighing 105 kg and measuring 1.80 m in height, was admitted to the ICU after a road traffic accident involving a farm vehicle which led to crushing and rolling injuries. The accident occurred on a public roadway at the exit from a private farm.

The patient was hospitalized for a total of 181 days, with 100 days spent in intensive care, 50 days in general surgery, and 31 days in rehabilitative medicine. During his hospitalization, the patient underwent 24 surgical procedures under general anesthesia for issues related to general surgery, plastic surgery, urology, and orthopedics.

Upon admission to the ICU, the patient exhibited a plethora of injuries, including a burst injury of the rectosigmoid junction, ruptures of the bladder and membranous urethra, acute kidney and liver failure, and splenic contusions. Additional presenting injuries included perineal crush injury, extensive wounds of the left gluteal region, and necrosis of the gluteus maximus muscle alongside femoral bone exposure, as well as a bilateral lumbosacral plexus injury and dislocation of the left sacroiliac joint (Figure 1).

Immediately following admission, a damage control resuscitation and damage control surgery approach was adopted to address the rectosigmoid junction rupture. A Hartmann procedure and epicystostomy were performed as part of the intervention. Due to the extensive soft tissue injuries and stability concerns, at that time orthopedic interventions were deemed to be contraindicated.

As the patient's clinical progression continued, he developed septic shock, which was marked by an elevated white blood cell count (>40,000/µL), fever (>39°C), and elevated polymerase chain reaction, presepsin, and procalcitonin levels. An abscess of the left ischiorectal fossa was observed; this was caused by an injury of the membranous urethra, which led to urinary leakage in this area. This clinical scenario was urgently treated with abscess drainage in addition to a double percutaneous nephrostomy to divert urinary transit and manage the acute abdominal condition. The intestinal and urinary diversions remained in place for 80 and 100 days, respectively. No complications were reported following the colostomy, whereas the nephrostomy led to recurrent urinary sepsis, requiring early recanalization.

Approximately 10 days after the trauma, extensive necrosis was observed in the left gluteal region. The crush wound in this area measured approximately 25 cm × 10 cm. The wound bed was contaminated due to trauma involving a farm vehicle and urine loss from the membranous urethra. The gluteal wound was treated with a wide debridement, including the completely necrotic left gluteus maximus muscle. This intervention led to exposure of the femoral head, which left the patient susceptible to osteomyelitis. In response to this critical condition, NPWT was applied to the gluteal and perineal region simultaneously with a single suction source provided by the NPWT device (V.A.C. Therapy; Solventum).

The patient was subsequently transferred from the OR to the ICU. He was mechanically ventilated through endotracheal intubation. Then he underwent hemodialysis, which was continued over a period of 2 months. Hemodialysis was implemented to ensure optimal maintenance of the patient's renal function, thereby compensating for any immediate or potential impairments.

In light of the patient's precarious respiratory status, a proactive stance was undertaken to establish a more stable and accessible airway. This necessitated performing a tracheostomy, which was effectively retained for an additional period of 2 months. This intervention served dual purposes—ensuring unobstructed respirations and facilitating future weaning from mechanical ventilation—thereby fostering the patient's steady progression toward recovery.

NPWT was initiated, applying a continuous pressure of −125 mm Hg, with dressings changed methodically every 48 to 72 hours. The exposed femoral head was covered with V.A.C. Whitefoam dressing (Solventum) due to the risk of osteomyelitis and necrosis (Figure 2). The negative pressure allowed for granulation tissue deposition, enabling closure of the large wound.

The approach used for the application of NPWT was a meticulously planned strategy involving a multifaceted, progressive technique. This method was primarily characterized by debridement of nonviable tissue coupled with the application of tensioned sutures on the wound margins.

Concomitant with NPWT, sutures were meticulously tensioned and placed loosely over the wound dressings, thereby facilitating a tentative approximation of the healthy skin margins without exerting undue pressure that might hamper the burgeoning granulation tissue (Figure 3). Subsequent NPWT dressing changes provided an opportunity to allow the granulation tissue at the base of the wound to approximate further via carefully progressive tensioning sutures.

This stepwise suturing method was the linchpin that allowed the step-by-step alignment of the wound edges. Initially, it allowed the inferior granulation tissue, which thrived under the NPWT sponge, to integrate seamlessly with the contralateral tissues. Aided by progressive union and elevation of the wound bed, the distance between the skin edges of the wound was systematically reduced. This iterative process showed a slow, steady, but significant progression, creating a virtuous cycle of wound healing, where negative pressure worked in tandem with progressively tensioned sutures.

The negative pressure facilitated the growth of robust granulation tissue that efficiently enveloped the exposed femur, thus averting potential bone and soft tissue infections, while simultaneously promoting closure of the subcutaneous and skin wounds. Notably, the use of NPWT alone resulted in complete wound closure, thus eliminating the need for alternative closure methods such as skin grafting or flap coverage (Figure 4).

During his 4-month stay in the ICU, the patient developed multiple gastrointestinal ulcers and had recurring episodes of hematemesis and melena due to stress-induced duodenal ulcer. This was initially managed endoscopically, then with an interventional radiology approach, and subsequently by surgical ligation of the gastroduodenal artery and suture repair of the post-duodenotomy ulcer.

After 4 months following the crush event, removal of nephrostomies, reconstruction of the ureter, and resumption of urination was achieved. However, the patient experienced recurrent urinary infection, necessitating a left radical nephrectomy in July 2023.

As of this writing, the patient is following an intense rehabilitation program, despite traumatic outcomes with paraparesis and saddle hyposthenia.

This case report presents a complex journey to recovery of a 16-year-old male who sustained an abdominopelvic traumatic crush injury in a road traffic accident involving a farm vehicle. Crush injuries are a serious concern with road traffic accidents, with a global study conducted by WHO reporting that approximately 20% to 50% of traffic accidents result in soft tissue injuries, including crush injuries.¹⁴

Road traffic injuries are the leading cause of death for persons 5 to 29 years of age, according to WHO data.¹⁵ Notwithstanding the elevated risk of life-threatening complications and fatality within 24 hours postinjury, the persistent rate of death due to sepsis and multiorgan failure resulting from severe trauma remains the prominent concern in patients who sustain road traffic injuries.^16,17

Studies of blast-related injuries have also shown NPWT to be an effective adjunctive treatment. Hinck et al¹⁸ reviewed the efficacy of NPWT with reticulated open cell foam in managing open soft tissue wounds in wartime conditions, emphasizing its role in preventing infection and facilitating complex wound care under challenging conditions. Similarly, Maurya et al¹⁹ reported that NPWT significantly aided in managing mine blast injuries of the foot, finding it to be helpful in preventing proximal amputations and enabling satisfactory reconstruction, ultimately allowing injured soldiers to return to their units.

The complexity and severity of the injuries sustained by the young patient in the current report necessitated a multidisciplinary approach for comprehensive case management. This approach involved confronting the significant issues posed by both primary wounds and secondary complications,^20,21 specifically, the necrotic gluteal tissue resulting in femoral bone exposure and accompanying genitourinary infection.

The complexity of the current case mirrors the often daunting challenges routinely encountered by trauma surgeons. The management of this patient's traumatic injuries was further complicated by the development of an abscess in the left ischiorectal fossa. Promptly addressing this acute condition was paramount to prevent further complications. Therefore, the authors of the current report implemented intensive care measures, which included draining the abscess and performing a double percutaneous nephrostomy, a critical procedure to divert urinary flow from the abscess site to the external environment.

Both the intestinal and urinary diversions proved to be effective procedures in this case. Ostensibly, they lasted for more than 2 to 3 months and, notably, no complications were reported with the colostomy. The nephrostomy, however, led to recurrent urinary sepsis, requiring early recanalization, which highlights the complexity of managing such a severe wound scenario and the importance of monitoring the patient for unforeseen complications.

Despite meticulous adherence to these treatments, this patient's condition remained precarious, prompting a revision of the therapeutic approach—most importantly, the implementation of NPWT.

Concerning the catastrophic wound in the left gluteal region, which was extensive and contaminated, with large amounts of devitalized tissue, the authors of the current report opted for NPWT to manage the wound. The theory behind NPWT is to promote wound healing through macrodeformation, which brings the edges of the wound closer together, and microdeformation, which stimulates granulation tissue formation.

Since the early 2000s, NPWT has emerged as an important option for managing large soft tissue defects.^22-24 This treatment reduces the risk of pathogenic infection, removes dirty exudate, encourages the formation of healthy granulation tissue, reduces the wound area, and effectively speeds healing times.^25-27 Using NPWT after removal of necrotic tissue converts the open wound into a controlled closed environment, thereby curtailing the chances of cross-infection while simultaneously promoting an improved local blood supply.^28-31

Throughout treatment of the current case, sutures were meticulously tensioned and placed loosely over the wound dressings, effectively encouraging approximation of the skin margins without compromising the development of granulation tissue. This procedure paved the way for perfect alignment of the wound edges, permitting an iterative wound closure procedure, made possible by the presence of vast granulation tissue facilitated by NPWT.

Addressing the various considerations made during care of the patient in the current case, it is important to discuss the thought process behind not performing a free flap surgery to manage the extensive wound. Free flaps are often considered in cases of extensive tissue damage^32-37; however, the unique parameters of this case directed the medical team toward a different route.

Initially, the patient's critical condition was a determining factor in not performing free flap surgery. Numerous complications demanded immediate attention and stabilization, including septic shock. The condition was not conducive for an extensive procedure such as free flap surgery, which involves significant surgical stress and risk.

Additionally, the infection resulting from urinary leakage was a pivotal concern in this case. Urinary leakage led to contamination of the wound area, creating a substantial risk for failure had a free flap been attempted. Additionally, such a procedure would introduce the risk of seeding the infection to a wider area or even of systemic dissemination, potentially leading to severe, life-threatening complications such as sepsis or endocarditis.³⁸

Lastly, the ongoing progress resulting from the use of NPWT was another determinative factor. The decision to bypass free flap surgery was significantly influenced by the positive wound response seen after each change of NPWT. NPWT is a less invasive treatment course, carrying fewer risks for the patient compared to surgical intervention. The beneficial outcomes achieved in this case, as evidenced by the wound's positive recovery trajectory, underpinned the decision not to perform a free flap surgery.

The current case demonstrates the effectiveness of NPWT in managing extensive wounds in patients in extremely critical condition.³⁹ The combination of NPWT with careful suturing techniques led to proper wound closure outcomes. This outcome is particularly significant in the current case, in which injury severity, location, and complications presented diverse medical challenges.

Ultimately, despite the unquestionable triumph of saving a life and successfully leading this patient through an intricate labyrinth of surgical challenges such as rectal and genitourinary complications, management of bone exposure, and complex wound closure, challenges remain in the post-recovery period. Specifically, this patient's experience highlights a crucial point often emphasized in the field of trauma surgery: a positive outcome is not simply about survival; it is also about ensuring quality of life after recovery.

This patient demonstrated impressive resilience despite the challenges he faced following the farm vehicle run-over event. However, despite the substantial progress made, as of this writing, the patient struggles with neurological recovery related to walking.

Neuromuscular and functional rehabilitation focusing on improving the patient's knee flexion, foot drop, and overall walking ability is ongoing. This underlines the importance of a multidisciplinary approach extending beyond immediate medical intervention, with the need for the prolonged involvement of physiotherapy and neurorehabilitation specialists who can guide post-recovery neurological improvement.

NPWT is a well-established technique, and this case highlights its use in an exceptionally complex life-threatening scenario in which the use of alternative surgical techniques was not feasible.

While this case report provides valuable insights into the successful application of NPWT, it is important to acknowledge its limitations. As a single case report, the findings may not be generalizable to all patient populations. Furthermore, the long-term outcomes of this approach in similar severe crush injuries remain unclear.

The current case underscores the severe sequelae that can ensue from road traffic accidents, particularly those involving heavy machinery. It highlights the complexity of managing extensive wounds, muscle necrosis, and bone exposure, emphasizing the primary need for well-coordinated multidisciplinary care. Immediate intervention and the use of advanced therapy such as NPWT were instrumental in managing this patient's complicated injuries. The effectiveness of NPWT in managing comprehensive wounds reaffirms it as a viable option in the management of extensive injuries resulting from road traffic accidents.

Authors: Giuseppe Massimiliano De Luca, MD, PhD¹; Pasquale Tedeschi, MD²; Michele Maruccia, MD, PhD¹; Silvia Malerba, MD¹; Giuliana Rachele Puglisi, MD¹; Francesco Paolo Prete, MD, PhD¹; Francesco Vittore, MD¹; Giuseppe Giudice, MD, PhD²; and Mario Testini, MD, PhD²

Affiliations: ¹Department of Precision and Regenerative Medicine and Jonica Area (Dimepre-J), U.O.C. of General Surgery University V. Bonomo, University of Bari Aldo Moro, Bari, Italy; ²Department of Precision and Regenerative Medicine of the Ionian Area, Division of Plastic and Reconstructive Surgery, University of Bari Aldo Moro, Bari, Italy

Author Contributions: Drs Massimiliano De Luca and Tedeschi contributed equally and are considered co-senior authors of this work.

Disclosure: The authors disclose no financial or other conflicts of interest.

Correspondence: Pasquale Tedeschi, MD; Department of Precision and Regenerative Medicine of the Ionian Area, Division of Plastic and Reconstructive Surgery, University of Bari Aldo Moro, Piazza Giulio Cesare, 11, Bari 70124, Italy; Pasquale.tedeschi93@gmail.com

Manuscript Accepted: July 12, 2024