A Novel Approach for Primary Closure of Deep Tissue Pressure Injuries by Combining the TopClosure® Tension Relief System and Regulated Oxygen-enriched and Irrigation Negative Pressure-assisted Wound Therapy in a Simplified Surgical Procedure

Moris Topaz1, Oren Barzel2, Sigal Ezra2, Egozi Dana3, Tervala Tomi4, Menachem Motiei5, Guy Topaz6, Tamar Sadan5, Rona Katzengold7, Amit Gefen7, Rachela Popovtzer5, Itzhak Ziev-Ner2,

1. Plastic Surgery Unit, Hillel Yaffe Medical Center, Hadera, Israel
2. Rehabilitation Center, Haim Sheba Medical Center, Ramat Gan, Israel
3. Plastic Surgery Department, Kaplan Medical Center, Rehovot, Israel
4. Kuopio University Hospital, Finland
5. Faculty of Engineering & the Institute of Nanotechnology and Advanced Materials, Bar-Ilan University, Israel
6. Department of Internal Medicine G, Meir Medical Center Kfar Saba, Israel
7. Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Israel

Abstract:
Deep tissue pressure injury (DTPI) is a localized injury to the deep tissues with or without skin damage, with higher prevalence observed in the elderly and paraplegic population. Primary closure of large, stage 4 DTPIs is rarely feasible and flap closure is customarily considered. We describe a novel reconstructive approach for primary closure of stage 4 DTPIs in 7 patients with 8 wounds: 4 paraplegics, two following surgery and one following an acute deterioration of his general condition. Wounds were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of the TopClosure® tension relief system (TRS) and regulated oxygen-enriched and irrigation negative pressure-assisted wound therapy (ROI-NPT). Primary closure of DTPIs was achieved in all wounds. Four were closed over 6-45 days [average of 18.5 days] (in one, applying a previously failed double V-Y advancement flaps) and four by immediate primary closure. Surgery time ranged between 1-3 hours [average of 2.1 hours]  and hospitalization 9-38 days . All wounds healed with no recurrence, with a follow-up of 1-33 months (average of 13.8 months) return to partial loading of operated area ranged from immediately after surgery to 4 weeks and full weight-bearing was achieved within 4-6 weeks.
This unique, novel treatment method extends skin stretching capacities and secure wound closure by the TRS with an upgraded local cleansing and decontamination of infected wounds through ROI-NPT, allowing for early and immediate primary closure of DTPI by a simplified surgical procedure. These results call for the reassessment of the traditional dogma of the reconstructive ladder techniques for DTPI, and its replacement by this straightforward, fast and safe management by TRS-ROI-NPT as a first line technique. In addition, initial application of TRS-ROI-NPT for primary wound closure and for securing wound edges, offers the flexibility of applying any suitable flap in the event of DTPI closure failure and recurrence, thus serving as an ideal method for patients in whom the risk of pressure injury recurrence is high.