Flap plus sub-flap irrigation and negative pressure therapy for infected extremity wounds

• Main Authors: David E. Kurlander, Marco Swanson, Corinne Wee, Rebecca Knackstedt, James Gatherwright
• Format: Article
• Language: English
• Published: Elsevier 2020-12-01
• Series: Orthoplastic Surgery
• Subjects: Free flap; Negative pressure wound therapy; Negative pressure wound therapy with instillation and dwelling; Lower extremity trauma; Lower extremity wound
• Online Access: http://www.sciencedirect.com/science/article/pii/S2666769X20300026

Background: Infected wound reconstruction risks persistent infection and potential flap loss. Taking advantage of negative pressure wound therapy with instillation's ability to decrease bioburden, we introduce a novel paradigm “flap plus sub-flap irrigation” for treatment of infected lower extremity wounds. Methods: This is a retrospective review of all patients over a 2-year period who underwent wound reconstruction with flap plus sub-flap irrigation. After flap inset, irrigation tubing is placed under the flap and foam sponge placed superficial to the flap edges, with pressure set to −100 mmHg. Fifty milliliters of 0.5% sodium hypochlorite solution instills every 4 h with 15 min of soak time. Sub-flap irrigation is discontinued post-operative day #5. Results: Eight patients with mean age of 47 years and mean follow up time of 21 months were identified. Seven patients (88%) had multidrug resistant infections, six (75%) had polymicrobial infections, and five had exposed hardware (63%). Wound etiology was most commonly motor vehicle collision (50%). Flaps included free ALT, (38%), radial forearm (25%), and latissimus dorsi (25%), as well as pedicled rectus femoris (13%). There were no flap losses or persistent infections. Two patients had delayed wound healing, one treated with skin grafting and the other with flap advancement. Conclusion: This series demonstrates successful treatment of high-risk infected wounds with flap plus sub-flap irrigation. This strategy may mitigate risk of persistent infection and flap loss. Larger studies and comparative studies are required to elucidate indications and assess relative benefits of this treatment paradigm.