The accelerating effect of negative pressure wound therapy with Prevena™ on the healing of a closed wound with persistent serous secretion

Abstract

Negative pressure wound therapy has been lately used on closed incisions in the immediate postoperative period to accelerate wound healing. However, there are no data in the literature regarding the use of this type of therapy for wounds with persistent secretion in the early postoperative care. We present the first report of persistent postoperative serous wound secretion in a patient after femoral nailing treated successfully with Prevena™ (KCI), a closed incision negative pressure management system (CINPWT).

Patient history and methods

A 76‐year‐old male patient was brought to the emergency room with pain in the right hip after a fall. Clinical examination revealed a local tenderness over the right hip with a shortened and externally rotated right leg. There were no changes in the skin over the right hip. Radiological evaluation with X‐rays showed a pertrochanteric femoral fracture of the right side. Past medical history of the patient was significant for type 2 diabetes, diabetic nephropathy, arterial hypertension, chronic obstructive lung disease as well as end‐stage liver disease (Child C) with persistent pleural effusions and ascites. Because of the unstable fracture pattern, a closed reduction and internal fixation of the fracture with a proximal femoral nailing was performed on the same day. There were no intraoperative complications. Postoperatively the patient was admitted to the gerontotraumatology facility for mobilisation and early rehabilitation. Wound inspections with dressing changes were performed starting on the first postoperative day. All wounds were clean and without erythaema during the entire postoperative period. There was only haematoma around the incisional site. The Redon drains (pfm medical mepro GmbH, Nonnweiler‐Otzenhausen, Germany) were placed before suturing the skin at the end of the surgical intervention and were removed on the second postoperative day. Beginning from the third postoperative day a copious serous drainage from the incisions and the drain site was noted. The initial dressing (compresses attached to the skin) was changed regularly but the serous secretion persisted over the next 12 days. It was interpreted mainly as a result of the hypoproteinaemia of the patient due to his liver cirrhosis and not as a result of deep wound infection. So it was decided to use a closed incision negative pressure wound therapy (CINPWT) system, Prevena™ [KCI (Kinetic Concepts, Inc.), San Antonio, TX], to accelerate wound healing. The dressing was applied on the closed incision according to the manufacturer's instructions. The dressing covered the entire wound (Figure 1). During the first day of the therapy, the canister had to be changed as it was full of serous fluid. Owing to the fast drainage more than the capacity of the canister, which can take a maximum amount of 45 ml, a modification was made in the system to avoid changing the canister multiple times a day. In order to achieve this, the dressing was cut in the middle aspect, sealed with a T.R.A.C. pad (KCI) and connected to ActiV.A.C. Therapy Unit (KCI) with the same negative pressure of 125 mm Hg. The original tube had to be clamped in order to avoid leaks in the system. With the modified system, the total amount of drained fluid was 300 ml in the first day. On the second day, it declined to a 100 ml and after the third day it was only minimal. After 5 days, the system was removed to assess the wound. The incision was clean and without any local infection signs. No more serous drainage from the wound or the former Redon site was observed until the patient was discharged from the hospital.

Figure 1.

Application of the Prevena™ (KCI) system to the wound.

Discussion

NPWT of open wounds is a well‐established therapy employed to increase wound granulation, increase tissue perfusion and reduce oedema. Lately, there is increasingly more data available on the positive effects of NPWT on closed incisions immediately after the initial operation. 1, 2, 3

In the primary wound management after hip arthroplasty, CINPWT showed a statistically significant volume reduction of seroma 1. Furthermore, a reduction of deep infection and wound dehiscence could be seen in fractures of the lower extremity with the use of CINPWT 2, 3. Although good results have been achieved with the intraoperative application of CINPWT, there have been no reports regarding use of CINPWT in the postoperative period. So this report describes for the first time the off‐label successful treatment of persistent serous wound secretion after an orthopaedic surgery with the help of the CINPWT Prevena™.

Persistent wound secretion in elderly patients with liver cirrhosis can be attributed to numerous reasons such as increased capillary leakage, malnutrition accompanying concomitant hypoproteinaemia with seroma and decreased healing rate. Many different mechanisms of action have been debated since the initial use of CINPWT. Although there are no studies on patients with uninfected wounds having persistent secretion. One possible mode of action is described in a recently published study that showed that CINPWT increases the lymphatic drainage in the deep tissue 4.

In wounds with persistent serous fluid collection beneath the incision, the opening in the wound allows drainage of the fluid. We expected that the collection will subside and the wound would heal. In cases (such as in this study) where this is not the case after 12 days because of the permanent fullness of the subcutaneous dead space, it is not possible to achieve approximation of the deep wound edges resulting in dehiscence and wound healing problems. We addressed this problem by applying CINPWT on the wound. Animal studies have shown that both the subincisional haematoma and seroma are reduced under CINPWT therapy 1, 3, 5. As a result, we hypothesise that the combination of the reduction in subcutaneous fluid collection and tissue oedema with the NPWT result in accelerated wound healing.

This report shows that CINPWT is a promising new tool for treating prolonged secretion in the early postoperative period. Further prospective randomised studies are needed to prove whether the CINPWT therapy can be used as a standard method for non‐septic wounds with persistent drainage.