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Matiasek et al. Plast Aesthet Res 2018;5:36 I http://dx.doi.org/10.20517/2347-9264.2018.50 Page 3 of 11
[7]
treatment of complex wounds using this technique . When select a flap for the reconstruction of a pressure
wound, several factors must be considered including the site of the pressure sore, the flap design and the
[7]
location of the flap relative to the site of coverage .

Before undertaking any wound closure surgical procedure, the wound bed must be clean and clear of
infection. Risk factors such as malnutrition, shear force, missing sensibility, moist wound situation and
incontinence need to be managed prior to surgery. Any source of infection must be cleared and if the patient
requires it, a nutritional support programme should be undertaken.

Negative pressure wound therapy (NPWT) has played an increasingly significant role in wound management
and a number of uses for this method have been reported, ranging from acute and chronic wounds, to closure
of open sternal and abdominal wounds, and assistance with skin grafts. In terms of wound bed preparation
[1]
the efficacy of NPWT has been well documented . NPWT is a physically acting treatment which is designed
to create a moist, sterile wound environment under sub-atmospheric pressure. This helps promote wound
[1,8]
granulation, epithelisation and contraction of the wound .

Due to a number of factors, including less frequent dressing changes, reduced nursing time, improved healing
rates, and decreased lengths of hospital stay, cost savings have been reported when using NPWT [1,9,10] . In terms
[11]
of serious adverse events during NPWT, these have been rarely reported . In comparison to traditional wet-
[12]
to-moist dressings, NPWT has shown benefits in the reduction of wound volume .
To summarise, NPWT helps increase wound blood flow, increases granulation tissue formation and stimulates
wound healing pathways through shear stress mechanisms.

A modification of NPWT added instillation of topical wound irrigation solutions to traditional NPWT. This
combined therapy, termed NPWT with instillation (NPWTi), has been shown to be effective in the treatment
of a variety of complex wounds and reduces bioburden and biofilms present in wounds, which helps the
[13]
healing process .
Multiple microorganisms, in particular Staphylococcus aureus and Streptococcus spp. are frequently found
[14]
to colonise PUs . Morbidity and mortality are significantly increased if an infection is caused by antibiotic
resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum
β-lactamase (ESBL) [15-19] .

Octenidine is a broad spectrum antiseptic agent which has been demonstrated to be effective in eradicating
many microbes, typically found in wounds [20,21] . Octenidine has the ability to reduce or prevent the
microorganism-induced formation of biofilms in chronic wounds, which is of particular importance as these
[22]
microorganisms can promote the incidence and the persistence of infections . An additional benefit is that
[23]
octenidine based rinsing solutions have a rapid onset of action and have good tissue tolerability .

When NPWT is combined with instillation, the negative pressure is not maintained during the instillation of
the rinsing solution and at this time, the system is prone to leakage. Therefore the instillation needs to be kept
to a minimum, using a fast acting wound rinsing solution.

The aim of this study was firstly to assess octenidine based wound irrigation solution in ex vivo exudate
samples and to compare octenidine with other rinsing solutions. Furthermore, we examined the impact of
using NPWTi together with octenilin® wound irrigation solution on 13 patients with category 4 PUs (sacral,