Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat a Deep Foot Abscess With a Small Plantar Surface Incision.

INTRODUCTION: Deep soft tissue wounds have a significant volume of dead space that often delays healing. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) used as an irrigation channel to manage deep cavity wounds with a tunneled opening has yet to be described to the authors' knowledge. CASE REPORT: The patient presented with pain and swelling of the left foot along with fever, elevated inflammatory markers, and signs of infection. Antibiotics were initially provided. Surgical debridement with a minimally invasive incision revealed a deep midfoot plantar abscess and resulted in a 2.2 cm wound with a cavity extending 5 cm from the second to fourth metatarsophalangeal joints, initially managed with topical dressings. At postoperative day 5, NPWTi-d (-125 mm Hg) with instillation of betadine-polyhexanide solution and dwell time of 10 minutes was initiated and provided twice weekly for 2 weeks. Clinicians created a foam dressing irrigation channel that enabled cleansing of the entire wound and reduced the volume of dead space within the cavity. A hydrocolloid dressing was used to protect wound edges. The type of NPWT system was changed as healing progressed. No repeat surgical debridement was required, and inflammatory markers down trended over the course of the 3-week hospital admission. The deep cavity wound demonstrated good progress with healing, and eventually healed completely by 2 months from initial surgical debridement. CONCLUSIONS: In a deep cavity wound with a small tunneled opening, NPWTi-d used as an irrigation channel is effective in reducing dead space and removing debris, in addition to avoiding the need for multiple surgical debridements and minimizing dressing change frequency.

Negative Pressure Wound Therapy With Instillation and Dwell Time Modifications for Lower Limb Wounds With the Waterfall Technique: A Case Series.

BACKGROUND: Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is an integrated system that combines conventional NPWT with an irrigation feature. Wound size and location of diabetic foot wounds may make NPWTi-d utilization difficult, commonly resulting in leakages and blockages. OBJECTIVE: This study evaluates the effectiveness of a novel waterfall technique, a modification of the usual bridging used during NPWTi-d application, to facilitate the channeling of instillation fluid into diabetic foot wounds with small entry points. MATERIALS AND METHODS: A literature review of NPWTi-d use in the treatment of infected diabetic foot wounds and a case series of 9 patients with infected diabetic foot wounds who were admitted to a tertiary health care institution from September 2019 to May 2020 were carried out. RESULTS: Six patients were male and 3 were female, with a median age of 56 years (range, 45-67 years). All patients underwent a surgical procedure of the infected foot wounds (7 minor ray amputations, 2 wound debridements). All resultant wounds were ray amputation wounds over the metatarsals, except for one wound over the plantar midfoot. Wound sizes ranged from 2 cm x 4 cm x 4 cm to 11 cm x 4 cm x 8 cm. Median duration from surgery to initialization of NPWTi-d was 2 days (range, 1-22 days). Only 1 case reported a leak in NPWTi-d, which was resolved with minor adjustments and without changing the dressing in its entirety; no incidents of blockage were encountered. None of the patients required repeat surgical debridement during index hospitalization, and full epithelialization was achieved in 88.9% of patients. CONCLUSIONS: The waterfall technique ensures placement of the NPWTi-d tubing pad in a dependent position to improve flow of instillation fluid with minimal risk of leakage or blockage.

Paget-Schroetter syndrome as a result of 1st rib stress fracture due to gym activity presenting with Urschel's sign - A case report and review of literature.

BACKGROUND: Paget-Schrotter Syndrome (PSS) also known as "effort thrombosis" is a form of primary thrombosis in the subclavian vein at the costoclavicular junction is usually seen in younger patients after repeated strenuous activity of the shoulders and arms. When occurring in younger patients, PSS presents itself with predisposing factors such as unilateral dull, aching pain in the shoulder or axilla and swelling of the arm and hand. CASE PRESENTATION: We report a rare case of unusual left axillo-subclavian vein thrombosis following narrowing of thoracic outlet due to stress injury of rib fracture likely during gym activity in absence of other clear risk factors and a negative hypercoagulable workup in a 27-year-old man who was admitted as left deltoid rupture 5 days after his usual gym. Subsequently he was transferred under vascular surgery for thrombectomy. CONCLUSION: In addition to the unusual location in the left upper extremity in our case, the absence of common etiologic factors makes our case of Paget-Schroetter Syndrome a very unique one. This case report aims to discuss the common causes of PSS in order to raise a high index of suspicion in certain groups of patients. This will allow early identification and avoidance of catastrophic outcomes such as pulmonary embolism and stroke.