Closure of a Complex Lower Extremity Wound With the Use of Multiple Negative Pressure Therapy Modalities

Complex lower extremity wounds can present challenges in healing due to the cause of injury or previous surgery, presence of infection or tissue necrosis, patient comorbidities, or a combination of these factors. Negative pressure wound therapy (NPWT) modalities play a major role in the perioperative management of patients with complex wounds and their adjunctive use continues to evolve with time. In this case study, we discuss the use of adjunctive NPWT with instillation and dwell time (NPWTi-d) and closed incision negative pressure therapy (ciNPT) to assist with the management of a complex lower extremity wound. The patient was a 25-year-old female who presented with an actively draining Morel-Lavallée lesion of the left lateral thigh that she had previously sustained after being struck by a motor vehicle as a pedestrian. She was initially evaluated and admitted for the avulsion injury approximately two weeks prior to this and had a drain placed at that time. However, due to issues with compliance, she had not been re-evaluated. She now presented with a suspected infection of her left lower extremity, and was thus admitted, placed on intravenous cefazolin and underwent several rounds of excisional debridement and irrigation. The patient was then managed operatively by the plastic surgery service. This care included three rounds of tissue advancement, followed by a seven-day course of NPWTi-d. Cycles consisted of normal saline instillation with a one-second dwell time, followed by six hours of continuous negative pressure at -125 mm Hg. The patient was then taken back for a final round of reconstruction with tissue advancement. A split-thickness skin graft was used at that time to cover the remaining area of the wound that the advancement could not close. A seven-day course of ciNPT (PREVENA RESTOR BELLA•FORM™ System; 3M + KCI, San Antonio, TX) was then applied to manage the incisions and bolster the graft. This was followed by simple dressing changes several times weekly for four weeks. In this case, we demonstrate how the adjunctive use of multiple NPWT modalities resulted in a completely healed wound within two months, without any major complications.