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 Table of Contents  
Year : 2021  |  Volume : 54  |  Issue : 6  |  Page : 234-237

Use of negative pressure wound therapy with simultaneous instillation for treatment of Gustilo type IIIC tibia-fibula fracture during COVID-19 pandemic

1 Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital; Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
2 Department of Orthopedics, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan; Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
3 Department of Surgery, Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
4 Department of Orthopedics, Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan

Date of Submission12-May-2021
Date of Decision23-Jun-2021
Date of Acceptance03-Nov-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Chin-Jung Lin
Department of Orthopedics, Kinmen Hospital, Ministry of Health and Welfare, No. 2, Fuxing Rd., Jinhu Township, Kinmen County 891
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_96_21

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Since the coronavirus disease (COVID-19) outbreak at the end of 2019, there have been changes in human habits, customs, and patient management. Conventional wound treatments may not be performed in certain cases due to the risk of COVID-19 transmission, and alternative methods should be thus considered. Negative pressure wound therapy (NPWT) is a well-established and widely applied dressing alternative for acute and chronic wounds. Meanwhile, the continuous irrigation associated with simultaneous instillation (NPWTi) is thought to achieve better cleansing and lower infection rates. Although NPWTi is still controversial with regard to flap reconstruction, this report presents a successful management of Gustilo type IIIC tibia-fibula open fracture using NPWTi as a bridge dressing to endure the 14-day quarantine period in a district hospital with insufficient medical staff and resources.

Keywords: Coronavirus disease, Gustilo, instillation, negative pressure wound therapy, open fracture

How to cite this article:
Chen CE, Chen YC, Chen YR, Chuang YH, Lin CJ. Use of negative pressure wound therapy with simultaneous instillation for treatment of Gustilo type IIIC tibia-fibula fracture during COVID-19 pandemic. Formos J Surg 2021;54:234-7

How to cite this URL:
Chen CE, Chen YC, Chen YR, Chuang YH, Lin CJ. Use of negative pressure wound therapy with simultaneous instillation for treatment of Gustilo type IIIC tibia-fibula fracture during COVID-19 pandemic. Formos J Surg [serial online] 2021 [cited 2022 Nov 26];54:234-7. Available from: https://www.e-fjs.org/text.asp?2021/54/6/234/331640

  Introduction Top

The coronavirus disease (COVID-19) outbreak has spread globally since December 2019 and is still causing problems, irrespective of human health and economic conditions. Several countries have issued public health policy to prevent the spread of this disease. In Kinmen, a 151 sq km2-area island which is 277 km from Taiwan with no confirmed COVID-19 cases until May 2021, international travelers have been requested to undergo a 14-day quarantine period, as recommended by the Center for Disease Control, given that the incubation period of COVID-19 is thought to be up to 14 days after exposure. It is, however, difficult for medical staff to maintain the treatment quality during this time, especially for critical patients and those with major trauma.

Negative pressure wound therapy (NPWT) has been used for treatment of open fractures of the lower limb, owing to its beneficial effects in lowering the infection rate and improving granulation tissue growth.[1],[2],[3],[4] Furthermore, NPWT with instillation (NPWTi) is more effective in avoiding infection in complex wounds, due to its ability to provide an optimal environment for wound-healing by removing debris, exudate, and metabolic waste.[1],[5] Patients suffer less pain and need for fewer dressing changes. In this case, with NPWTi, we were able to reduce exposure between staff and patients, who were in a 14-day quarantine period, as well as to create an opportunity for further reconstruction.

  Case Report Top

A 60-year-old man living abroad, with an uncertain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contact history, was sent to the emergency room for a Gustilo type IIIC tibia-fibula open fracture of his left leg [Figure 1]. Although the first SARS-CoV-2 test revealed negative, surgery was still performed in an isolated operation room where all the staff wore personal protective equipment kit. During the operation, the tibial arteries were found completely transected. Muscles, with the exception of those in the superficial posterior compartment, were ruptured. After revascularization and external fixation of tibia, a large wound from the middle to the distal third of the leg was left open for wet dressing. The patient was then transferred to an isolation ward for postoperative care.
Figure 1: Gustilo type IIIC tibia-fibula open fracture of the left leg (left); radiograph (right)

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Four days later, after confirming the distal perfusion, NPWTi was applied to the wound. The setup was similar to that mentioned by Kiyokawa et al.[6] A hard and rough sponge was placed with a nasogastric tube for washout and a Foley catheter with side holes for vacuum insertion. The wound was then maintained in a completely airtight environment with a polyethylene film covering and negative pressure at −50 cmH2O by wall suctioning [Figure 2]. Approximately 2–3 L of normal saline was used for a fluid irrigation each day.
Figure 2: Four days after revascularization (left); NPWTi was performed with a nasogastric tube (arrowhead) at the cephalic aspect for saline instillation, and a Foley catheter with side holes (arrow) was used at the caudal aspect as a vacuum (right)

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NPWTi setting was renewed in the isolated operation room on Day 11 when external fixation was shifted to internal fixation in order to maintain a further week to endure the 14-day quarantine period. However, due to lack of materials for NPWTi in Kinmen, we had no choice to shift the dressing to standard wet dressing after the exposed tibia was covered by a hemisoleus muscle rotational flap on Day 19. Wound cultures yielded staphylococcus epidermidis initially, but all the successive cultures were negative. Due to severe contusion, tissue necrosis was identified at the trauma zone in the following days. Therefore, a scheduled free anterolateral thigh (ALT) flap, sizing 20 × 8 cm2, was performed after preparation for microsurgery for the exposed tendons and vessels on Day 42. A 20 cm great saphenous vein (GSV) graft was first harvested from the contralateral leg to setup an arteriovenous (A-V) loop with end-to-side anastomosis at the posterior tibia artery, proximal to the trauma zone, and end-to-end anastomosis to the residual GSV beyond the trauma level. Transferal of free ALT flap was then accomplished based on the blood supply from the A-V loop [Figure 3]. Areas covered with granulation tissue were finally resurfaced with split-thickness skin graft. The patient was finally discharged with a satisfactory outcome 68 days after his injury, as the first successful free tissue transfer case in Kinmen [Figure 4]. At one-year follow-up, the patient could walk with a single-handed walker [Supplement Video 1].[Additional file 1]
Figure 3: Exposed tendons and few necrotic muscles (upper); Free ALT flap was transferred through a 20 cm great saphenous vein graft for extension of recipient's vessels (lower). ALT: Anterolateral thigh; GSV: Great saphenous vein; PTA: Posterior tibial artery

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Figure 4: The outcome with definite soft tissue coverage before the patient was discharged

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  Discussion Top

Infection is one of the critical topics when managing contaminated open lower limb fractures with a lack of skin or soft tissue coverage. Previous reports have shown that nosocomial infections are common, ranging from 15% to 45%. Debridement followed by early soft tissue coverage is a well-recognized recommendation. Therefore, an adequate dressing method that lowers dressing-frequency, pain, and infection rate, and enhances local neovascularization and tissue growth, should be considered as a bridge to the definite soft tissue coverage. NPWT is a well-established dressing method for the wounds of high-energy soft tissue injuries with open fractures[4] and showed lower infection rate, wound coverage time, duration of wound healing, hospital stay, and amputation rate than those with conventional wet dressings. However, there were no significant differences with regard to flap surgery and the flap failure rate.[3] In spite of a recent study showed no significant differences in a 12-month outcome between NPWT and conventional dressings for lower limb open fractures, it was noted that a slight increase in the 30-day deep infection rate with conventional dressings. Nevertheless, most of the cases in this study were Gustilo type IIIA fractures, and the wounds were commonly managed by delayed primary closure.[2]

In contrast, NPWTi is associated with a high proportion of complete healing. With the addition of a closed irrigation system, NPWTi could overcome the limitation of NPWT to successfully reduce the bacterial load.[1] Previously, NPWTi has been applied to infected or complex wounds, where wound closures have been delayed in preparation for reconstruction, for cleansing and/or granulation tissue formation.[1] An animal study conveyed that wound healing rate and the final outcome was not significantly different in NPWTi than that in NPWT alone. But with simultaneous irrigation therapy, NPWTi showed further reduction of bioburden.[7] These results were similar to those of Omar et al. which showed shorter hospital stay and accelerated lower limb wound healing in the NPWTi group, but no difference in the outcome.[5] A randomized study showed an opposite result, with no significant difference in wound healing and length of hospital stay between the two groups; it also showed no significant improvement in outcome.[8]

Several points should be noted regarding the setting up of NPWTi. First, the skin perfusion pressure should be considered in setting the suction pressure range. Owing to variations in the suggested optimal settings for NPWTi, an international, multidisciplinary panel of expert clinicians has indicated that the consensus guideline for a NPWTi dressing is-125 mmHg. However, in this case, we followed the setting (-50 cmH2O) as Kiyokawa et al. on managing open fractures for that we had no commercialized vacuum system on hand instead of wall suction.[4] Second, regarding continuous or intermittent pressure, Sano et al. exhibited optimal intermittent negative pressure by means of side holes on the tubes could reach almost 100% of the wash-out area in an ulcerative wound model, even at a low-flow irrigation volume (100 mL/h).[9] Irrigation volume is another factor that should be considered. Despite no standard formula recommendation for irrigation volume, some authors have applied 15−30 mm/h on wounds less than 100 cm2 in size.[7] Kiyokawa et al. suggested 2000−7000 mL/d of normal saline for irrigation, depending on wound size, location, and condition.[1] Additionally, studies recommend prophylactic use of antiseptic-instilled topical solutions, such as polyhexanide (0.01%) and acetic acid (0.25%–1%) for 20 min, four to eight times daily, especially for trauma wounds with an expected infection rate of >40%.[10] Last, by minimizing the frequency of dressing changes (twice to thrice per week), NPWTi provides better pain relief than conventional dressings. In brief, NPWT is useful as a suitable temporary dressing for contaminated wounds in preventing occult infections, especially with the addition of continuous irrigation though NPWTi may not actually lower the need for flap surgery or achieve better long-term outcomes than NPWT alone.

For the present case, NPWTi with simultaneous normal saline irrigation was applied throughout the 14-day quarantine period. Contact between the staff and the patient for wound dressing was lowered from twice per day to once per week. Although there was still some necrotic tissue and muscle around the trauma zone, NPWTi indeed improved tissue growth and avoided local infection, thus preparing the wound and offering the opportunity for definitive reconstruction.

  Conclusion Top

In summary, NPWT provides a bridge from trauma to definite coverage and may thus be an ideal method for isolated patients, such as having uncertain SARS-CoV-2 contact or having a history of infectious disease. Despite the inclusion of irrigation treatment remains controversial in terms of long-term outcomes, the authors would like to share the experience of NPWTi in a successful management of Gustilo type IIIC open fractures, and in reducing the exposure between staff and patients in the time of COVID-19 pandemic.

Ethical considerations

In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rikimaru H, Rikimaru-Nishi Y, Yamauchi D, Ino K, Kiyokawa K. New alternative therapeutic strategy for Gustilo type IIIB open fractures, using an intra-wound continuous negative pressure irrigation treatment system. Kurume Med J 2020;65:177-83.  Back to cited text no. 1
Tahir M, Chaudhry EA, Zimri FK, Ahmed N, Shaikh SA, Khan S, et al. [RETRACTED] Negative pressure wound therapy versus conventional dressing for open fractures in lower extremity trauma Bone Joint J 2020;102-B: 912-7.  Back to cited text no. 2
Liu X, Zhang H, Cen S, Huang F. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis. Int J Surg 2018;53:72-9.  Back to cited text no. 3
Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta J, Kulp B, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma 2007;21:11-7.  Back to cited text no. 4
Omar M, Gathen M, Liodakis E, Suero EM, Krettek C, Zeckey C, et al. A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing. J Wound Care 2016;25:475-8.  Back to cited text no. 5
Kiyokawa K, Takahashi N, Rikimaru H, Yamauchi T, Inoue Y. New continuous negative-pressure and irrigation treatment for infected wounds and intractable ulcers. Plast Reconstr Surg 2007;120:1257-65.  Back to cited text no. 6
Davis K, Bills J, Barker J, Kim P, Lavery L. Simultaneous irrigation and negative pressure wound therapy enhances wound healing and reduces wound bioburden in a porcine model. Wound Repair Regen 2013;21:869-75.  Back to cited text no. 7
Davis KE, La Fontaine J, Farrar D, Oz OK, Crisologo PA, Berriman S, et al. Randomized clinical study to compare negative pressure wound therapy with simultaneous saline irrigation and traditional negative pressure wound therapy for complex foot infections. Wound Repair Regen 2020;28:97-104.  Back to cited text no. 8
Sano H, Kajikawa A, Ueda K. Study of continuous irrigation negative-pressure treatment using an original ulceration model. J Plast Surg Hand Surg 2013;47:175-9.  Back to cited text no. 9
Back DA, Scheuermann-Poley C, Willy C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions – When, where and how to use: What does the evidence show? Int Wound J 2013;10 Suppl 1:32-42.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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