Novel Closed-System Combination of Surgical Drains and Incisional Negative Pressure Wound Therapy in Management of Upper Extremity Infections

Infections in the upper extremity can cause significant morbidity and management of these infections can often cause significant burdens on the health care system.1 Infections related to the upper extremity may be caused by direct inoculation of the soft tissues, bone, or joint, and the complex anatomy of the upper extremity may pose challenges in management for hand surgeons.2 The use of negative pressure wound therapy (NPWT) in the management of upper extremity infections has significantly broadened the armamentarium of coverage options for hand surgeons, allowing for incisional NPWT, more time for tissue granulation, and opening up options for staged reconstructions.3 Further, closed suction surgical drains have been used for surgical management of infections as a way to prevent postoperative seromas and hematomas and theoretically reduce risk of wound dehiscence, complications, and recurrent infection.4 However, insufficient evidence exists for routine use of closed suction drainage in orthopedic surgery, particularly for intra-articular placement of the drain with concern of intra-articular bacterial inoculation through the drain track.4 While some have described the use of both closed-suction surgical drains and NPWT, using both on the same wound can cause vacuum leaks through the drain tracks, causing frequent leak alarms and reducing the efficacy of the negative pressure therapy.5 Therefore, this report describes a novel technique that incorporates closed-suction surgical drains directly into the incisional NPWT dressing to create a sterile, closed-system environment in the management of upper extremity infections. This combines the benefit of deeper surgical drains with the NPWT wound vacuum-assisted closure (VAC) system, creating a sterile environment without external drain tracks that could prevent closure of the dead space, and decrease the burden of patient care during recovery with only one external line to manage. TECHNIQUE After the operative intervention indicating the use of closed suction drains or negative pressure wound therapy is completed, 2 deep closed-suction surgical drain tubes (or one tube cut in half) are placed on either end of the incision and cut to the desired length (Fig. 1A). Any diameter of drains may be used, depending on the size of the space available—larger drains are recommended given less risk of clotting off. The drain ends with the holes or slit openings depending on the tube type, should be seated fully within the deep surgical wound. The tubes exit at opposite ends of the surgical incision, and the surgical incision is closed in a typical layered fashion, generally with a deep dermal interrupted layer and a running subcuticular suture with external tails that allow for incision reapproximation once the drains are removed (Fig. 1B).FIGURE 1: A 61-year-old male patient with chronic right elbow septic arthritis and associated distal humerus osteomyelitis. Elbow aspiration confirmed Methicillin-Resistant Staphylococcus Aureus infection. He was brought to the operating room for elbow irrigation and debridement. A, demonstrates placement of 2 deep surgical drains in the elbow joint, at either end of the incision. B, After layered incision closure, the drains at either end of the incision are checked to ensure they are freely mobile. C, After placement of a nonadherent dressing, a black wound VAC foam is placed with 2 slits at either end to allow the drains to lay on top of the foam in a semi-constrained manner. D, The drains are cut obliquely at the center of the black foam where the lily pad will be placed. An adhesive wound vac dressing is then placed to cover the dressing, and a hole is made for lily pad application per the manufacturer’s instructions. E, The lily pad is applied over the foam and drains, and suction is turned on to ensure adequate suction, address any leaks, and confirm that the drains are patent and working.A nonadherent dressing is placed over the surgical incision, followed by the wound vacuum black sponge. A vertical slit is cut at both ends of the black sponge (Fig. 1C) to allow for the drains to fit into the sponge. The drain tubes are then laid over the top of the sponge, and cut in an oblique fashion at the center of the incision where the vacuum lily pad will be placed (Fig. 1D). This allows for increased surface area during negative pressure therapy to best draw out fluid. These drains are intentionally placed overlying the sponge to allow visual confirmation that the drains are actively evacuating fluids. The final adhesive dressing is then placed, and the lily pad is applied over the 2 drain ends (Fig. 1E). Appropriate padding may be placed between the skin and the tubing to prevent pressure injury if needed. The wound VAC suction may then be turned on at the desired settings to confirm that the suction seal is holding and that the drains are drawing out fluid from the deep wound. The authors utilize 125 mm Hg, medium continuous suction at the initial postoperative period and while the patient is in the hospital. On discharge, the patient may be transitioned to the smaller and more mobile incisional wound VAC machine (3M Prevena, Solventum, Saint Paul, MN) or may remain on the larger wound VAC machine per the discretion of the managing physician. The incisional NPWT wound VAC dressing and drains remain in place for at least 7 days, and no longer than 14 days, at which point the patient is seen in clinic and the dressing and drains are removed. A dry sterile dressing is then applied, and regular wound care may be anticipated at this time. This technique may be utilized in various other settings about the upper extremity, including a clavicle nonunion from infection (Fig. 2), or a longer forearm incision (Fig. 3). Further, if an incision is unable to be closed or there is a plan for a staged closure, this technique may still be used as a wound VAC and later be transitioned to an incisional NPWT. If this is the case and there are more vulnerable structures within the wound, a white foam may be used to protect structures such as the neurovascular bundles and tendons.FIGURE 2: Clavicle nonunion from Propionibacterium acnes infection status post removal of hardware and irrigation and debridement as well as placement of vancomycin impregnated calcium sulfate beads. A, The drains were placed on either end of the incision. B, The incision was closed with subcuticular 4-0 monocryl with the drains on either end. C, Adaptic nonadherent dressing was placed on top of the incision. D, The sponge was placed and the drains were cut in an oblique fashion in the middle of the sponge where the lily pad will be placed.FIGURE 3: Status post irrigation and debridement of multiloculated abscesses about the elbow and forearm from intravenous drug use. The vac was removed on postoperative day 7 without return of collection and a well-healed incision. The patient was discharged on oral antibiotics after consultation with Infectious Diseases and speciation/sensitivity results of the cultures obtained in the operating room.Expected Outcomes With the combination of both the NPWT wound VAC and the surgical drains, dead space reduction is optimized, reducing the risk of seroma/hematoma formation, wound dehiscence, and reinfection. Incisional NPWT has been shown to improve tissue edema, perfusion, and assist in wound healing by reducing wound edge tension but does not address the deeper dead space. The addition of the sterile wound VAC dressing over the drains creates a closed sterile environment, which addresses the concern of closed-suction surgical drains as potential tracks for infection into the deeper spaces, particularly if used within joints. This relatively low cost and easy application of NPWT and surgical drains may combine the benefits of each individual intervention in an additive way, while addressing the limitations of both modalities when used independently. Representative cases are reported in Table 1. TABLE 1 - Representative Table of Select Cases Utilizing the Drain/VAC Technique Patient Age/sex Location Indication Procedure 1 61 M Elbow Septic arthritis and distal humerus osteomyelitis Irrigation and debridement of the elbow and distal humerus with drain/incisional VAC placement 2 41 M Clavicle Nonunion from Propionibacterium acnes infection Removal of hardware and irrigation and debridement with drain/VAC placement. Had a repeat irrigation and debridement and drain/incisional VAC placement 3 53 F Elbow/forearm Recurrent abscesses from intravenous drug use Irrigation and debridement and drain/incisional VAC placement 4 4 M Humerus/elbow/ forearm Diffuse abscesses and disseminated infection from missed infection Multiple irrigation and debridements with drain/wound VAC placements after each surgery before definitive closure 5 49 M Proximal humerus Open proximal humerus fracture with extruded humeral head Irrigation and debridement and open reduction internal fixation of the proximal humerus with drain/incisional VAC placement 6 64 M Wrist Infected dorsal spanning plate Irrigation and debridement and removal of hardware, drain/incisional VAC placement Complications Contraindications of this technique would include patients in whom use of a VAC would not be considered safe or patients who cannot manage the VAC machine in the hospital or at home. There may also be situations where surgeons may prefer to monitor the output of the drain and the VAC separately or may want to remove them at different timepoints, in which case this technique would not be recommended. While this technique in itself does not have any significant associated complications, the established complications of the NPWT wound VAC and drains should be noted. The NPWT wound VAC can lead to complications with skin maceration and pain if excessive moisture and pressure remains on the skin around the incision. Both the NPWT and surgical drains can also cause blood loss, particularly if the patient is on anticoagulant therapy or significant hemorrhage under the incision has not been addressed. They both can also be a source of infection if the foam dressing and the drains are kept in for long periods of time, allowing for bacterial colonization and possibly even deeper infections through the drain tracks. Finally, if the drains are inadvertently sewn in while suturing or get caught in a fracture, the drain may break during extraction, which may result in a portion of the drain being retained in the body necessitating operative intervention to remove the piece. Therefore, it is recommended that before dressing placement, the surgeon checks the mobility of the drains to ensure that the drain has not been sutured or is not caught on any deeper structures.