Implant Salvage in Patients With Severe Post-Fracture Fixation Surgical Site Infection Using Negative Pressure Wound Therapy With Intramedullary and Subcutaneous Antibiotic Perfusion

Keisuke Shimbo, MD, PhD; Tatsuhiko Saiki, MD; Haruka Kawamoto; Isao Koshima


Wounds. 2022;34(6):e47-e51. 

In This Article

Case Report

The use of NPWT with intramedullary and subcutaneous antibiotic perfusion is a 2-stage procedure that consists of surgical debridement and flap reconstruction. Written informed consent was obtained from both patients presented in this report.

Surgical Debridement

The previous skin incision is reopened and, if necessary, the incision is enlarged to expose the infected site. Infected tissues are debrided to preserve the orthopedic implant, and the wound is irrigated with copious saline. A double-lumen tube (16 Fr Salem Sump Silicone Tubes; Cardinal Health) is placed as deep as possible into the wound, near the implant. A 2.4-mm Kirschner wire is used to create a hole in the cortical bone along the implant fixation area, after which 2 bone marrow needles (Tohoku University bone marrow puncture needle; Senko Medical Instrument Manufacturing Co. Ltd.) are inserted. Antibiotics should be selected in accordance with the results of bacterial culture. For instance, gentamicin solution (50 mL total [60 mg of gentamicin per milliliter of 0.9% saline solution]) is continuously administered at a rate of 2 mL per hour through the bone marrow needles and double-lumen tubes as intramedullary and subcutaneous perfusions, respectively. A black foam sponge is placed within the wound and then connected to an NPWT device (RENASYS TOUCH; Smith + Nephew) through a Y-connector, in conjunction with the double-lumen tube (Figure 1A). Continuous negative pressure is set at −80 mm Hg.

Figure 1.

Illustrations of the serial technique. (A) NPWT with intramedullary and subcutaneous antibiotic perfusion after surgical debridement. (B) Incisional NPWT with intramedullary and subcutaneous antibiotic perfusion after flap reconstruction.
Abbreviation: NPWT, negative pressure wound therapy.

The aforementioned procedure is similar to that described by Himeno et al.[10] The black foam sponge and double-lumen tube are replaced after approximately 5 days. The patient undergoes NPWT with intramedullary and subcutaneous antibiotic perfusion for approximately 1 to 2 weeks, until granulation tissue forms in the wound and inflammation subsides, as confirmed with a blood test (eg, C-reactive protein level).

Flap Reconstruction

After wound debridement, a free musculocutaneous or fasciocutaneous flap is transferred to the wound. After microvascular anastomosis is performed, the double-lumen tube is placed under the flap and the bone marrow needles are inserted into the bone marrow. The black foam sponge is placed along the edges of the flap and connected to the NPWT device through the Y-connector, in conjunction with the other double-lumen tube (Figure 1B). The double-lumen tube and bone marrow needles are removed approximately 5 days postoperatively.


The authors of this case report applied surgical debridement and flap reconstruction followed by NPWTi-d to 2 patients with abscess collections due to SSI after either tibial or calcaneal open fracture fixation using titanium plates. The infected wound of the lower leg involved a deep dead space that reached the crural interosseous membrane, whereas the heel wound was accompanied by a subcutaneous pocket. The debrided wounds of the lower leg and heel were reconstructed with free latissimus dorsi musculocutaneous and anterolateral thigh fasciocutaneous flaps, respectively, to preserve the titanium plates. In both patients, the wounds healed without complications and remained healed after more than 7 months following treatment. Figures 2, 3, and 4 show photographs of the lower leg wound in a 59-year-old male before and after treatment.

Figure 2.

A 59-year-old male presented with severe SSI after tibial fracture fixation. (A) Preoperative photograph taken 27 days after initial fracture fixation. The wound was necrotic, with an abscess at the incision site. (B) Photograph taken after surgical debridement. The yellow arrows point to bone marrow needles. (C) Preoperative anteroposterior radiograph of the right leg; the radiograph was obtained at the same time as the panel A photograph was captured.

Figure 3.

Eleven days after the first surgical debridement. (A) Photograph taken before flap reconstruction. (B) Photograph taken after free latissimus dorsi musculocutaneous flap reconstruction. In both panels, the yellow arrow points to the double-lumen tube.

Figure 4.

Seven months after the flap reconstruction procedure. (A) Postoperative anterior photograph of the lower legs. (B) Postoperative lateral photograph ofthe right leg. (C) Postoperative anteroposterior radiograph of the right leg.