The Hanikoda Method: 3-layered Negative Pressure Wound Therapy in Wound Bed Preparation

Ian Chik, MD; Enda G Kelly, BSc, MBBch BAO, MRCSI, MCh; Razman Jarmin, MD, MS; Farrah-Hani Imran, MB BCh BAO, MRCS, MS

Disclosures

Wounds. 2016;28(10):360-368. 

In This Article

Methods

Patients referred to the UKMMC Wound Care Team with wounds that required WBP to cover exposed structures, or with a high degree of fibrinous slough that required sharp surgical debridement, or concave wounds with soft tissue defects that met the criteria for NPWT were assessed for suitability for treatment with the HM.

The HM is a 3-layered system that includes the following: first layer, hydrogel; second layer, paraffin tulle dressing; and third layer, NPWT. A step-by-step illustration is shown in Figure 1. In order to standardize the NPWT element of the HM, the authors used an established commercially available NPWT for the subsequent cases presented in this case series.

Figure 1.

Step-by-step representation of the Hanikoda Method. (A) Hydrogel application on the wound after cleaning with normal saline; (B) paraffin tulle dressing placed over the hydrogel dressing; (C) sterilized foam cut in accordance to the wound shape with the suction tube placed within the foam; and (D) the wound sealed with transparent adhesive film.

Once WBP was complete, patients were listed for a split-thickness skin graft (STSG) procedure, or the wound allowed to contract and heal by secondary intention. The UKMMC uses Duoderm Hydroactive Sterile Gel hydrogel (Convatec, Greenboros, NC), BACTIGRAS paraffin gauze (Smith & Nephew, Hull, UK), and the RENASYS NPWT device (Smith & Nephew, Hull, UK).

Each cycle for wound treatment is 4 ± 1 days. The total number of NPWT cycles for each patient is determined by serial wound inspection (WI) throughout the WBP stage, with close monitoring and assessment at each WI.

Many patients have been treated with the HM since its initiation in the first quarter of 2014. In this case series, the authors report 8 different patients who were treated with the HM for a variety of wound types.

Case 1

A 32-year-old man was involved in a road traffic accident in which he was riding a motorbike and collided with a car (Figure 2). He sustained a right open midshaft femur fracture with a right open proximal tibia fracture with patellar tendon avulsion (Schatzker type VI). He was initially treated in a different hospital, and had initial wound debridement with a spanning external fixation applied before transferring to the authors' institution.

Figure 2.

Case 1: A 32-year-old man sustained a right open midshaft femur fracture with a right open proximal tibia fracture with patellar tendon avulsion following a motor vehicle accident. (A) Day 1 of treatment with the Hanikoda Method; and (B) the wound after 6 cycles of treatment.

The tibia-based wound measured 5 cm x 3 cm and had purulent discharge, which grew Pseudomonas spp and Staphylococcus aureus. No slough was evident but some granulation tissue could be seen over the wound. Due to the presence of infection, immediate open reduction internal fixation of the tibia was not possible, and definitive external fixation was embarked upon as an end goal. The planned gastrocnemius flap was initially delayed by wound bed infection and, ultimately, the patient did not consent to it.

The HM was initiated for this patient and changed every 4–5 days. He was also started on antibiotics concurrently. His wound closed after applying the HM for 6 cycles, approximately 25 days. (One cycle equates to the HM application until it is changed at the next WI.)

Case 2

A 76-year-old male with underlying diabetes mellitus and hypertension presented with a right gluteal swelling inflamed with purulent discharge and had associated fever (Figure 3). The swelling was diagnosed as a carbuncle, and saucerization of the wound had been performed, leaving a 10 cm x 10 cm crater wound. On initial inspection, there was still slough seen at the wound site and the wound bed was not ready for STSG to cover the wound.

Figure 3.

Case 2: A 76-year-old male presented with right gluteal swelling inflamed with purulent discharge and had associated fever. (A) Day 1 of treatment with the Hanikoda Method, the wound was 10 cm x 10 cm; and (B) after the 5 cycles of treatment, the wound had decreased in size to 6 cm x 6 cm.

The HM was initiated, and a notable decrease in the concavity of the wound could be seen after the technique was applied. After 5 cycles of treatment with the HM, the wound had decreased to 6 cm x 6 cm with healthy granulation and was ready for STSG coverage.

Case 3

A 53-year-old man with underlying diabetes mellitus type 2 and hypertension presented with left foot necrotizing fascitis, affecting the tendons and ankle joint (Figure 4). After debridement and application of an external fixator for the left foot, the patient was referred to the plastics team for wound management and closure. Initial assessment showed necrotic patches over the foot with exposed tendons and lateral malleolus. After 7 cycles of HM, the necrotic tissue was debrided without instrumentation, and granulation tissue comfortably covered the exposed bone and tendons. The wound was then ready for STSG which was performed and the end result is shown.

Figure 4.

Case 3: A 53-year-old man with underlying diabetes mellitus type 2 and hypertension presented with left foot necrotizing fascitis, affecting the tendons and ankle joint. (A) Day 1 of treatment with the Hanikoda Method; (B) the wound after 7 cycles of treatment; and (C) the wound at 8 weeks postpresentation, following a split-thickness skin graft.

Case 4

A 69-year-old man presented with swelling of the left hand he had for 5 years that was subsequently diagnosed as basal cell carcinoma (Figure 5). Excision of the tumor included excision of tendons along with a segment of the first metacarpal bone. The tendons were reconstructed and internal fixation wires were placed. Following resection of the tumor, the wound bed comprised an exposed radial artery, reconstructed tendons, and internal fixation wires. The patient was immediately started on the HM following histopathological clearance of the tumor. After 6 cycles of the treatment over a 3-week period, the structures were covered by healthy granulation tissue and STSG was performed.

Figure 5.

Case 4: A 69-year-old man presented with swelling of the left hand he had for 5 years that was subsequently diagnosed as basal cell carcinoma. (A, B) The wound at presentation and following tumor resection; (C) appearance of the wound after 6 cycles of treatment with the Hanikoda Method; and (D) the wound after application of the split-thickness skin graft.

Case 5

A 69-year-old woman with underlying diabetes mellitus type 2 with peripheral neuropathy, hypertension, valvular heart disease, and a history of breast cancer, presented with an infected wound of the right leg secondary to a 1% partial-thickness burn (Figure 6). She had applied a hot water bottle overnight to ease soreness in her legs, and replaced the hot water 3 times. Due to her neuropathy, she did not notice the noxious stimulus, and the burn was detected by her daughter who noticed it the next morning. Due to her comorbidities and poorly controlled diabetes, she refused formal surgical debridement, requesting conservative measures. She was started on the HM for 6 cycles over 24 days. Prior to discharge, the infection had resolved and the wound had contracted in size.

Figure 6.

Case 5: A 69-year-old woman presented with an infected wound of the right leg secondary to a 1% partial-thickness burn. (A) The wound at presentation; and (B) after 6 cycles of treatment with the Hanikoda Method.

Case 6

A 20-year-old man was involved in a motor vehicle accident resulting in comminuted fracture of the right acetabulum and left superior and inferior pubic ramus fracture (Figure 7). The patient had developed an infected Moralle-Lavalle lesion of the right hip/gluteus, and the wound was debrided. He was referred to the plastics team to manage the deep cavities in the upper and lower portions of his wound, then was started on HM, and the cavities closed after 7 cycles. The wound bed was then ready for STSG.

Figure 7.

Case 6: A 20-year-old man presented with a comminuted fracture of the right acetabulum and left superior and inferior pubic ramus fracture following a motor vehicle accident. (A) The appearance of the wound at presentation; (B) day 1 of treatment with the Hanikoda Method; (C) after 6 cycles of treatment; and (D, E) following application of a split-thickness skin graft.

Case 7

A 16-year-old girl sustained a crush injury of the left lower limb following a motor vehicle accident (Figure 8). She was treated for acute limb ischemia with underlying displaced fracture of the proximal third of the left fibula and left lateral malleolus. She underwent fasciotomy for compartment syndrome and subsequent debridement. Due to previously noted nonopacification of the anterior tibial artery with poor wound healing and dusky muscle, the patient was referred to the authors' medical center for a second opinion. The patient underwent revascularization and was started on treatment with the HM. The initial wound had a deep, large cavity proximally, which is shown in Figure 8A. After 2 cycles of the HM, the cavity had approximated and was ready for STSG. The dimensions of the wound had also reduced in size, requiring a smaller graft area.

Figure 8.

Case 7: A 16-year-old girl sustained a crush injury of the left lower limb following a motor vehicle accident. (A) The wound appearance upon presentation; (B) after 2 cycles of treatment with the Hanikoda Method; and (C) following application of a split-thickness skin graft.

Case 8

A 35-year-old man with underlying diabetes mellitus type 1 and hypertension presented with pain and purulent discharge from the left leg (Figure 9). It was diagnosed as necrotizing fasciitis, and the wound was debrided. Post debridement, there were exposed bones, and he was referred the authors' medical center for wound coverage. The HM was initiated for 4 cycles. Prior to STSG, tendon and bone were covered with healthy granulation tissue with the cavities approximated.

Figure 9.

Case 8: A 35-year-old man with underlying diabetes mellitus type 1 and hypertension presented with pain and purulent discharge from the left leg, which was diagnosed as necrotizing fasciitis. (A) The appearance of the wound at presentation; (B) after 4 cycles of the Hanikoda Method; and (C) following application of a split-thickness skin graft.

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