Incisional vacuum-assisted closure therapy

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Reducing Surgical Site Infection with Negative-Pressure Wound Therapy After Open Abdominal Surgery: A Prospective Randomized Controlled Study

BACKGROUND AND AIMS

Surgical site infection, in particular superficial incision infection, is a common type of complication following abdominal surgery. Negative-pressure wound therapy has been confirmed to reduce the incidence of surgical site infection in various surgeries, but there are few prospective randomized studies into its application to abdominal surgery.

MATERIAL AND METHODS

A prospective randomized controlled study was conducted in which patients with abdominal surgery and open surgery were randomly divided into a negative-pressure wound therapy experimental group and a gauze-covering control group. Information about demographic data, type of surgery, surgical sites, incision treatment outcomes, surgical site infection factors, and follow-up was recorded.

RESULTS

From May 2015 to December 2015, 71 patients were enrolled in this study, including 33 in the experimental group and 38 in the control group. There were 10 cases of incision complications, all superficial infections, with an incidence of 14.1%. The surgical site infection incidence was statistically different between the experimental and control groups (3.0% vs 23.7%, p = 0.031). Multivariate logistic regression analysis showed that incision length ⩾20 cm increased the surgical site infection incidence (odds ratio value of 15.576, p = 0.004) and that the application of negative-pressure wound therapy reduced the surgical site infection incidence (odds ratio value of 0.073, p = 0.029).

CONCLUSION

Negative-pressure wound therapy can reduce the incidence of surgical site infection in open abdominal surgery.

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Background

Postoperative wound complications are common following surgical procedures. Negative‐pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions.

Methods

This was a systematic review and meta‐analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions.

Results

Ten studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence.

Conclusion

Compared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.

Good for closed wounds too

Video Abstract

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words ‘prevention’, ‘negative pressure wound therapy (NPWT)’, ‘active incisional management’, ‘incisional vacuum therapy’, ‘incisional NPWT’, ‘incisional wound VAC’, ‘closed incisional NPWT’, ‘wound infection’, and ‘SSIs’ identified peer‐reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m²); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high‐risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

Closed-Incision Negative-Pressure Therapy Versus Antimicrobial Dressings After Revision Hip and Knee Surgery: A Comparative Study

BACKGROUND

This study evaluates the efficacy of closed-incision negative-pressure therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after revision hip and knee surgery.

METHODS

A retrospective quality improvement analysis of 138 consecutive revision hip and knee operations performed by a single surgeon over a 34-month period was performed. ciNPT was used selectively in higher-risk patients with multiple risk factors for SSIs over the last 15 months of the study period. Rates of wound complications, SSIs, and reoperation were compared with patients treated with a sterile antimicrobial dressing.

RESULTS

Antimicrobial dressings were used in 108 patients, whereas ciNPT was used in 30 patients. Patients treated with ciNPT developed fewer overall wound complications (6.7% vs 26.9%, P = .024) and fewer total SSIs (3.3% vs 18.5%, P = .045) than patients treated with antimicrobial dressings. In addition, there were trends toward a lower rate of superficial wound dehiscence (6.7% vs 19.4%, P = .163), fewer deep periprosthetic joint infections (0.0% vs 9.3%, P = .118), and fewer reoperations (3.3% vs 13.0%, P = .191) among patients treated with ciNPT.

CONCLUSION

Our findings suggest that ciNPT may decrease wound complications and SSIs in patients undergoing revision hip and knee surgery.

Our First Experience With Negative Pressure Incision Management System Implemented on the Clean Surgical Incision in the Renal Transplantation Recipient: A Case Report

Multiple comorbidities and environmental factors increase the complications of incisional wounds in patients. It was demonstrated in previous prospective and randomized studies that negative pressure wound therapy (NPWT) reduced wound infection and other complications in clean, closed surgical incisions. In this case report, the Prevena incision management system was implemented on the clean, closed surgical incision of a 52-year-old female patient, who was given a renal transplantation from cadaver postoperatively in the operating theater. It was removed from the patient on the fifth day after the operation. Following the removal of Prevena, the wound and surrounding skin of the patient were observed. Wound healing was complete, and no skin lesion or tool-related complication was found around the wound due to NPWT. The Prevena NPWT system can be conveniently and safely implemented on the operational incision in renal transplant recipients in order to prevent surgical wound complications.

Role of negative pressure wound therapy in total hip and knee arthroplasty

Negative-pressure wound therapy (NPWT) has been a successful modality of wound management which is in widespread use in several surgical fields. The main mechanisms of action thought to play a role in enhancing wound healing and preventing surgical site infection are macrodeformation and microdeformation of the wound bed, fluid removal, and stabilization of the wound environment. Due to the devastating consequences of infection in the setting of joint arthroplasty, there has been some interest in the use of NPWT following total hip arthroplasty and total knee arthroplasty. However, there is still a scarcity of data reporting on the use of NPWT within this field and most studies are limited by small sample sizes, high variability of clinical settings and end-points. There is little evidence to support the use of NPWT as an adjunctive treatment for surgical wound drainage, and for this reason surgical intervention should not be delayed when indicated. The prophylactic use of NPWT after arthroplasty in patients that are at high risk for postoperative wound drainage appears to have the strongest clinical evidence. Several clinical trials including single-use NPWT devices for this purpose are currently in progress and this may soon be incorporated in clinical guidelines as a mean to prevent periprosthetic joint infections.

PICO™ incision closure in oncoplastic breast surgery: a case series

Single-use negative pressure wound therapy (PICO™) has been used on high-risk surgically incised wounds with encouraging results, but there is no evidence for its use in oncoplastic breast surgery. This article reports a case series with closed incisions in oncoplastic breast procedures following the introduction of PICO™.

Postoperative negative-pressure incision therapy following open colorectal surgery (Poniy): study protocol for a randomized controlled trial

BACKGROUND

Postoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality, and remain one of the most frequent surgical complications. In prospective trials with adequate follow-up, more than 20 % of patients undergoing elective colorectal surgery are affected and methods to reduce surgical site infections are urgently needed. Negative-pressure incision therapy is a novel intervention that holds promise to reduce postoperative wound infection rates, but has not yet been rigorously tested in a randomized controlled trial.

METHODS/DESIGN

The aim is to investigate whether the postoperative application of a negative-pressure incision therapy device for 5-7 days reduces the rate of surgical site infections following open elective colorectal surgery by 50 %. This is a randomized, controlled, observer-blinded multicentre clinical trial with two parallel study groups. The primary outcome measure will be the rate of surgical site infections within 30 days postoperatively. Surgical site infections are defined according to criteria of the US Centers for Disease Control and Prevention. Statistical analysis of the primary endpoint measure will be based on the intention-to-treat population. The global level of significance is set at 5 % (two-sided) and the sample size (n = 170 per group) is determined to assure a power of 80 %.

DISCUSSION

The Poniy trial will explore whether the rate of surgical site infections can be reduced by the application of a negative-pressure incision therapy device in patients undergoing open elective colorectal surgery. Its pragmatic design guarantees high external validity and clinical relevance.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien DRKS00006199 .

Negative pressure wound therapy use to decrease surgical nosocomial events in colorectal resections (NEPTUNE): study protocol for a randomized controlled trial

Background

Surgical site infections (SSIs) are the second most common form of nosocomial infection. Colorectal resections have high rates of SSIs secondary to the inherently contaminated intraluminal environment. Negative pressure wound therapy dressings have been used on primarily closed incisions to reduce surgical site infections in other surgical disciplines. No randomized control trials exist to support the use of negative pressure wound therapy following elective open colorectal resection to reduce surgical site infection.

Methods/Design

In this single-center, superiority designed prospective randomized open blinded endpoint controlled trial, patients scheduled for a colorectal resection via a laparotomy will be considered eligible. Patients undergoing laparoscopic resection will be enrolled but only randomized and included if the operation is converted to an open procedure. Exclusion criteria are patients receiving an abdominoperineal resection or a palliative procedure, as well as pregnant patients and those with an adhesive allergy. After informed consent, 300 patients will be randomized to the use of a standard adhesive gauze dressing or to a negative pressure wound device. Patients will be followed in hospital and reassessed on post-operative day 30. The primary outcome measure is SSI within the first 30 post-operative days. Secondary outcomes include the length of hospital stay, the number of return visits related to a potential or actual SSI, cost, and the need for homecare. The primary endpoint analysis follows the intention-to-treat principle.

Discussion

NEPTUNE is the first randomized controlled trial to investigate the role of incisional negative pressure wound therapy in decreasing the rates of surgical site infections in the abdominal incisions of patients following an elective, open colorectal resection. This low-risk intervention may help decrease the morbidity and costs associated with the development of an SSI in our patients.

Trial registration

NCT02007018 – clinicaltrials.gov; 5 December 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0817-8) contains supplementary material, which is available to authorized users.

Use of Negative Pressure Wound Therapy on Closed Surgical Incision After Total Ankle Arthroplasty

BACKGROUND

Wound healing problems of the anterior ankle incision are among the most common complications after total ankle arthroplasty, possibly resulting in exposure of the prostheses and infection. The aim of this study was to investigate the role of negative pressure wound therapy (NPWT) in decreasing the rate of wound healing problems after total ankle arthroplasty.

METHODS

This is a retrospective cohort study including consecutive patients who underwent total ankle arthroplasty by a single surgeon at a single institution between 2009 and 2013. The incisional negative pressure dressing was applied to all patients who underwent total ankle arthroplasty between 2012 and 2013 with a continuous application of -80 mm Hg negative pressure for 6 days postoperatively. The control group consisted of patients who underwent total ankle arthroplasty between 2009 and 2012 with a conventional nonadherent gauze dressing. Seventy-four patients were involved in this study: 37 in the control group and 37 in the incisional NPWT group.

RESULTS

All patients tolerated the incisional NPWT to completion without any dressing failures or skin problems. Both groups showed similar distributions in demographics and perioperative risk factors for wound healing. There were 9 (24%) wound healing problems in the control group and 1 (3%) in the incisional NPWT group. Incisional NPWT was found to reduce wound healing problems with an odds ratio of 0.10 (95% CI, 0.01-0.50; P = .004).

CONCLUSIONS

Our study demonstrated that there was a decreased incidence of wound healing problems following total ankle arthroplasty with incisional NPWT dressings. This is the first study evaluating the efficacy of incisional NPWT as an adjunct treatment for wound healing after total ankle arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A journey to zero: reduction of post-operative cesarean surgical site infections over a five-year period

BACKGROUND

Surgical site infections (SSI) are a substantial concern for cesarean deliveries in which a surgical site complication is most unwelcome for a mother with a new infant. Steps taken pre- and post-operatively to reduce the number of complications may be of substantial benefit clinically, economically, and psychologically.

METHODS

A risk-based approach to incision management was developed and implemented for all cesarean deliveries at our institution. A number of incremental interventions for low-risk and high-risk patients including pre-operative skin preparations, standardized pre- and post-operative protocols, post-operative nanocrystalline silver anti-microbial barrier dressings, and incisional negative pressure wound therapy (NPWT) were implemented sequentially over a 5-y period. A systematic clinical chart review of 4,942 patients spanning all cesarean deliveries between 2007-2012 was performed to determine what effects the interventions had on the rate of SSI for cesarean deliveries.

RESULTS

The percentage of SSI was reduced from 2.13% (2007) to 0.10% (2012) (p<0.0001). There were no substantial changes in the patient population risk factors over this time. As a result of the changes in incision management practice, a total of 92 cesarean post-operative SSIs were avoided: A total cost saving of nearly $5,000,000.

CONCLUSION

Applying a clinical algorithm for assessing the risk of surgical site complication and making recommendations on pre-operative and post-operative incision management can result in a substantial and sustainable reduction in cesarean SSI.

Vertically drained closed incision NPWT. A novel method for managing surgical incisions: a case series

Topical negative pressure wound therapy (NPWT) is being used with increasing frequency to treat closed surgical incisions that are at high risk for wound complications. Known benefits of topical NPWT include improved perfusion, physical wound support and isolation. This case series report of four colon operations introduces a method to manage closed surgical incisions that is designed to potentiate the effects of topical NPWT. Channel drains are placed vertically through a closed incision and in contact with the foam sponge of a NPWT dressing. The drains transmit negative pressure into the wound in order to enhance fluid removal, reduce dead space and improve tissue apposition for primary healing.

DECLARATION OF INTEREST

Dr Leiboff received no funding for this study. Dr Leiboff is President of Tools for Surgery, L.L.C.

Use of incisional negative pressure wound therapy on closed median sternal incisions after cardiothoracic surgery: clinical evidence and consensus recommendations

Negative pressure wound therapy is a concept introduced initially to assist in the treatment of chronic open wounds. Recently, there has been growing interest in using the technique on closed incisions after surgery to prevent potentially severe surgical site infections and other wound complications in high-risk patients. Negative pressure wound therapy uses a negative pressure unit and specific dressings that help to hold the incision edges together, redistribute lateral tension, reduce edema, stimulate perfusion, and protect the surgical site from external infectious sources. Randomized, controlled studies of negative pressure wound therapy for closed incisions in orthopedic settings (which also is a clean surgical procedure in absence of an open fracture) have shown the technology can reduce the risk of wound infection, wound dehiscence, and seroma, and there is accumulating evidence that it also improves wound outcomes after cardiothoracic surgery. Identifying at-risk individuals for whom prophylactic use of negative pressure wound therapy would be most cost-effective remains a challenge; however, several risk-stratification systems have been proposed and should be evaluated more fully. The recent availability of a single-use, closed incision management system offers surgeons a convenient and practical means of delivering negative pressure wound therapy to their high-risk patients, with excellent wound outcomes reported to date. Although larger, randomized, controlled studies will help to clarify the precise role and benefits of such a system in cardiothoracic surgery, limited initial evidence from clinical studies and from the authors' own experiences appears promising. In light of the growing interest in this technology among cardiothoracic surgeons, a consensus meeting, which was attended by a group of international experts, was held to review existing evidence for negative pressure wound therapy in the prevention of wound complications after surgery and to provide recommendations on the optimal use of negative pressure wound therapy on closed median sternal incisions after cardiothoracic surgery.

Management in high-risk patients

Injuries to the foot and ankle are often missed or underestimated in patients with polytrauma and are a source of long-term limitations. Injures below the knee are among the highest causes for unemployment, longer sick leave, more pain, more follow-up appointments, and decreased overall outcome. As mortalities decrease for patients with polytrauma a greater emphasis on timely diagnosis and treatment of foot and ankle injuries is indicated. Geriatric patients represent nearly one-quarter of trauma admissions in the United States. This article discusses perioperative management and complications associated with foot and ankle injuries in polytrauma, and in diabetic and geriatric patients.

The enhanced healing of a high-risk, clean, sutured surgical incision by prophylactic negative pressure wound therapy as delivered by Prevena™ Customizable™: cosmetic and therapeutic results

According to the literature, incisional closure complications may range from postoperative surgical site infections, representing 17-22% of health care-associated infections, surgical wound dehiscence and formation of haematomas or seromas, and can lead to delayed or impaired incision healing. These kinds of situations are more common when wounds are closed under tension or in specific patient morbidities. Obesity, in particular, is associated with an impaired blood flow to tissues, predisposing the patient to increased risk of wound complications by various mechanisms. Incisional complications can become relevant economic burdens for health care systems because of an increase in the average length of hospital stay and readmissions, and additional medical and surgical procedures. Thus, a preventive therapy may have a critical role in the management of healing. Negative pressure wound therapy (NPWT) technology as delivered by Prevena™ Customizable™ (Kinetic Concepts Inc., San Antonio, TX) has recently been the focus of a new investigation, as a prophylactic measure to prevent complications via immediate postoperative application in high-risk, clean, closed surgical incisions. The authors present a 62-year-old class II obese female, who underwent bilateral inguinal dermolipectomy. Prophylactic NPWT as delivered by Prevena™ was performed successfully over surgical incisions. Cosmetic and therapeutic results are shown.

Incisional negative pressure wound therapy decreases the frequency of postoperative perineal surgical site infections: a cohort study

BACKGROUND

Abdominoperineal resection is a procedure associated with high rates of perineal surgical site infections, causing distress to the patient, costs to the hospital system, and delays in further treatment.

OBJECTIVE

The aim of this study was to investigate the role of incisional negative pressure wound therapy in decreasing the rates of perineal surgical site infection.

DESIGN

This retrospective cohort study had a historical, consecutively sampled control group.

SETTINGS

This study was conducted at a single-institution tertiary care academic institution.

PATIENTS

All patients undergoing an abdominoperineal resection between 2008 and 2012 were assessed.

INTERVENTIONS

Perineal incisional negative pressure wound therapy was applied to all patients following an abdominoperineal resection between 2010 and 2012 at 125 mmHg continuous suction for 5 days postoperatively.

MAIN OUTCOME MEASURES

The development of a perineal surgical site infection within the first 30 days postoperatively was the primary outcome measured.

RESULTS

Fifty-nine patients were included: 27 in the incisional negative pressure wound therapy group and 32 in the control group. A statistically lower proportion of perineal surgical site infections were detected in the incisional negative pressure wound therapy group than in the standard dressing group (15% vs 41%; p = 0.02). Both populations were similar in perioperative risk factors, with the exception of increased levels of blood urea nitrogen, a higher proportion of hypertensive patients, and a longer mean operative time in the incisional negative pressure wound therapy group. Additionally, an increased length of stay was observed in the incisional negative pressure wound therapy group (11 vs 8 days; p = 0.03). After adjusting for confounders, including the type of perineal dissection, incisional negative pressure wound therapy was found to be an independent predictor of not developing an surgical site infection (adjusted OR, 0.11; 95% CI, 0.04-0.66; p = 0.01).

LIMITATIONS

The study's retrospective nature limits the results because of the risk of interpreter bias, although this was addressed in part by reviewing data in duplicate. We controlled for the potential for selection bias with our consecutive sampling model.

CONCLUSIONS

Our study demonstrates a role for incisional negative pressure wound therapy in decreasing rates of perineal surgical site infection following abdominoperineal resection. Prospective randomized trials will be required to further investigate this intervention.

The evidence-based principles of negative pressure wound therapy in trauma & orthopedics

Negative pressure wound therapy is a popular treatment for the management of both acute and chronic wounds. Its use in trauma and orthopedics is diverse and includes the acute traumatic setting as well as chronic troublesome wounds associated with pressure sores and diabetic foot surgery. Efforts have been made to provide an evidence base to guide its use however this has been limited by a lack of good quality evidence. The following review article explores the available evidence and describes future developments for its use in trauma and orthopaedic practice.

Negative-pressure wound therapy over surgically closed wounds in open fractures

PURPOSE

To evaluate the outcome of open fracture surgery with negative-pressure wound therapy (NPWT) applied directly over surgical wounds.

METHODS

Medical records of 10 men and 4 women aged 6 to 70 (mean, 43.7) years who underwent internal fixation, external fixation, or splint application for open fractures of the lower leg (n=7), foot and ankle (n=5), or knee (n=2), and NPWT were reviewed. The NPWT was applied directly over the surgical wound without a non-adherent contact layer. The foam was changed every 3 days. The standard negative pressure was 125 mm Hg. The NPWT was stopped when the wound discharge became <50 ml per day. The duration of NPWT and the level of negative pressure were recorded, as were wound condition, reasons for NPWT, and outcome.

RESULTS

The mean duration of NPWT was 9.1 (range, 3-24) days. Four patients developed maceration of the skin under the foam, whereas 2 patients developed skin blisters under the drape. No necrosis of flap skin or infection occurred, and all the fractures eventually united.

CONCLUSIONS

Maceration of the skin was seen in some cases but did not affect the overall outcome. NPWT directly over the skin surface had no deleterious effect on wound and fracture healing.

Negative pressure wound therapy for managementof the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication

Objectives

The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT).

Methods

We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail.

Results

A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action.

Conclusions

There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement.

Cite this article: Bone Joint Res 2013;2:276–84.

Incisional negative pressure wound therapy significantly reduces surgical site infection in open colorectal surgery

BACKGROUND

Surgical site infections in colorectal surgery remain a common problem, and are associated with an increase in cost of care and length of stay.

OBJECTIVE

This study aims to evaluate the effect of known risk factors and the use of incisional negative pressure wound therapy on surgical site infection rates.

DESIGN

This is a single-center retrospective study with the use of chart review.

SETTINGS

The study took place at a tertiary academic medical center.

PATIENTS

All patients undergoing open colectomy at a single institution from 2009 through 2011 were studied.

MAIN OUTCOME MEASURES

The primary outcome measured was the presence or absence of surgical site infection.

RESULTS

Overall, 69 of the 254 patients (27.2%) experienced surgical site infection; 4 (12.5%) surgical site infections were seen in patients undergoing incisional negative pressure wound therapy and 65 (29.3%) were seen in patients undergoing standard closure. Multiple logistic regression revealed 2 significant factors: diabetes mellitus increased the chance of surgical site infection (OR, 1.98; p < 0.05), and the use of incisional negative pressure wound therapy decreased the chance of surgical site infection (OR, 0.32; p < 0.05). Obesity was associated with a trend toward increasing surgical site infection (OR, 1.64; p = 0.10).

LIMITATIONS

This study is limited by its retrospective nature and the high baseline prevalence of surgical site infection.

CONCLUSIONS

Incisional negative pressure wound therapy appears to reduce surgical site infection in open colorectal surgery. Further study may be helpful to identify patient populations who would have the greatest benefit from this technique(see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A115).

Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients

STUDY DESIGN

A prospective randomized controlled trial.

OBJECTIVE

To assess the ability of local vancomycin powder in controlling postoperative infection in spine surgery.

SUMMARY OF BACKGROUND DATA

Despite improvements through the use of prophylactic systemic antibiotics, surgical site infections remain a significant problem in spine surgical procedures. Various retrospective and prospective studies have reported the efficacy of local application of vancomycin powder in reducing the infection in animal and human studies. However, there were no randomized control trials that reported on its efficacy.

METHODS

Prospective randomized controls of 907 patients with various spinal pathologies were treated surgically during a period of 18 months. The control group received standard systemic prophylaxis only, whereas the treatment group received vancomycin powder in the surgical wound in addition to systemic prophylaxis. Patient demographics, comorbidities, level of spinal pathology, estimated blood loss, nutritional status, and hemoglobin were recorded. Incidence of infection was the primary outcome evaluated.

RESULTS

There were 8 infections (1.68%) in the control group (6 instrumented and 2 noninstrumented, 6 deep and 2 superficial) with bacteria cultured in 3 (1 Escherichia coli and 2 Staphylococcus aureus). In the treatment group, 7 infections (1.61%) were observed (6 instrumented and 1 noninstrumented surgical procedures, 6 deep and 1 superficial) with bacteria cultured in 3 (1 Staphylococcus aureus and 2 Klebsiella). No adverse effects were observed from the use of vancomycin powder. Statistically no significant difference was seen in infection rate between the treatment group and control group.

CONCLUSION

The local application of vancomycin powder in surgical wounds did not significantly reduce the incidence of infection in patients with surgically treated spinal pathologies. The use of vancomycin powder may not be effective when incidence of infection is low.

Incisional Negative Pressure Therapy to Prevent Wound Complications Following Cesarean Section in Morbidly Obese Women

Objective. We sought to evaluate the efficacy of incisional negative pressure therapy in decreasing postoperative wound complications when placed prophylactically over clean, closed incisions following cesarean section in obese patients. Study design. This was a retrospective cohort study comparing rates of wound complications following cesarean sections in morbidly obese women prior to and following the institution of standard use of prophylactic incisional negative pressure therapy. All women with a body mass index greater than 45 kg/m2 undergoing cesarean section in a 2-year period in a single institution were included. The exposure was incisional negative pressure therapy, which began in September 2009, versus standard wound dressing used in the previous year. The main outcome was wound complication identified by ICD-9 codes. Demographic and wound outcomes were compared with χ2 and t tests. Stata version 11.0 was used for all analysis. Results. A total of 63 women met the inclusion criteria, 21 of whom received negative pressure wound therapy. The historical comparison and exposure groups were similar in all characteristics studied with the exceptions of length of surgery (64 vs 76 minutes, P = .03), length of labor (78 vs 261 minutes, P = .02), scheduled versus nonscheduled (77% vs 52%, P = .04), and mean age (29.5 vs 26.1 years, P = .04), respectively. There were 5 wound complications in the control group (10.4%) and none (0%) in the study group ( P = .15). Conclusions. This pilot study suggests a decrease in wound complications in morbidly obese women receiving incisional negative pressure therapy following cesarean section.

Negative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play

As of 2012, the number of people with diabetes is increasing in every country, and half of the people with diabetes do not know they are afflicted with the malady.1 Furthermore, it is believed that every 20 seconds a lower limb is lost around the world because of complications related to diabetes.6 In a short period, NPWT has transformed wound care across the globe, and other technologies are beginning to emerge that may provide clinicians with the tools necessary for identifying wounds at risk for delayed healing and recurrence. The future of diabetic limb salvage will rely heavily on these and other advances.

A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia

BACKGROUND

Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure.

METHODS

This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences.

RESULTS

There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation.

CONCLUSIONS

This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion

STUDY DESIGN

Retrospective comparative study using prospectively collected data.

OBJECTIVE

To compare the rate of infection with and without the use of vancomycin powder application during posterior cervical instrumentation.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSI) are a significant source of morbidity in multilevel posterior-instrumented fusions for cervical spondylotic myelopathy (CSM). Local delivery of antibiotics has been associated with decreased rates of SSI in posterior-instrumented fusions, but no study has addressed the effects of these measures on a population composed of exclusively multilevel posterior cervical instrumentation performed with decompression for CSM.

METHODS

All patients undergoing multilevel posterior decompression and instrumentation for CSM by a single surgeon from 2003-2011 were included. Post hoc analysis of prospectively collected data was analyzed comparing consecutive patients treated without the use of vancomycin powder with those treated after the initiation of vancomycin powder prophylaxis. Intervention cohort and controls were examined for differences in SSI rate, body mass index, neurological status, comorbidities, and complications.

RESULTS

A total of 112 patients were included in the study. Intervention (n = 40) and control (n = 72) groups were statistically similar with regard to age, body mass index, comorbidities, estimated blood loss, and operative time. Univariate analysis showed a significant decrease in infection rate in the intervention group (0%) compared with the control group (15%) in this high-risk population (P = 0.007; power = 81%). No adverse events were noted in the intervention group associated with the use of vancomycin powder.

CONCLUSION

The local application of vancomycin was associated with a significant reduction in the risk of SSI in multilevel posterior cervical-instrumented fusions for CSM. This study supports the growing body of evidence that vancomycin powder placed in the wound can reduce the incidence of postoperative wound infections, and is the first that addresses this specific population.

LEVEL OF EVIDENCE

2.

Simplified negative pressure wound therapy: clinical evaluation of an ultraportable, no-canister system

The aim of this study was to evaluate a prototype negative pressure wound therapy (NPWT) system that has been developed to simplify NPWT for wounds at the lower end of the acuity scale. The new device has a single preset pressure of −80 mmHg, is single use and operates without an exudate canister. The disposable NPWT system (PICO™) was tested in a prospective, non‐comparative, multicentre clinical trial to assess device functionality and clinical acceptance. Twenty patients were recruited for a maximum treatment period of 14 days. The NPWT devices were fitted with data log chips to enable longitudinal assessment of negative pressure and leak rates during therapy. Sixteen (80%) patients had closed surgical wounds, two (10%) patients had traumatic wounds and two (10%) patients received meshed split thickness skin grafts. The mean study duration was 10·7 days (range: 5–14 days) and the mean dressing wear time per individual patient was 4·6 days (range: 2–11). Fifty‐five percent of wounds had closed by the end of the 14‐day study or earlier, with a further 40% of wounds progressing to closure. Real‐time pressure monitoring showed continuous delivery of NPWT. Three cases are discussed representing different wound locations and different patient factors that can increase the risk of post‐surgical complications. Clinical studies of the disposable NPWT system confirmed the ability of the simplified single‐use device to function consistently over the expected wear time. The anticipated reduced costs, ease of use and increased mobility of patients using this system may enable NPWT benefits to be available to a greater proportion of patients.

Management of high-energy foot and ankle injuries in the geriatric population

By the year 2035 almost 20% of the US population of 389 million people will be 65 years and older. What this group has, compared with aged populations in the past, is better health, more mobility, and more active lifestyles. From January 1989 through December 2010, a total of 494 elderly patients with 536 foot and ankle injuries were identified. Within this group, 237 (48%) patients with 294 injuries were sustained as a result of a high-energy mechanism. These mechanisms consisted of 170 motor vehicle accidents, 30 as a result of high (not ground level) energy falls, 2 from industrial accidents, and 35 classified as other, which included sports, blunt trauma, bicycle, airplane or boating accidents, crush injuries, and injuries resulting from a lawn mower. The injuries produced were 17 metatarsal fractures, 9 Lisfranc injuries, 10 midfoot (navicular, cuneiform, or cuboid) fractures, 23 talus fractures, 63 calcaneal fractures, 73 unimalleolar, bimalleolar, or trimalleolar ankle fractures, 45 pilon fractures, and 3 pure dislocations of the foot or ankle. Overall, 243 (83%) of these injuries underwent surgical fixation and data have shown that when surgery is used to manage high-energy injuries of the foot and ankle in the elderly individuals, the complications and outcomes are similar to those seen in younger patients. Therefore, the decision for surgical intervention for high-energy injuries of the foot and ankle should be based primarily on the injury pattern and not solely on the age of the patient.

Negative pressure surgical management after pathological scar surgical excision: a first report

Wound dehiscence is a surgical complication caused by the application of opposing and distracting forces tending to pull apart the suture line. In recent years, a novel negative pressure surgical management system has been developed to prevent surgical wound complications. This system creates a closed environment that removes exudates and other potentially infectious material, protects the surgical site from external contamination, provides support in holding the edges of the incision together and promotes wound healing. In this study, we describe our first experience with Prevena™, a closed incision negative pressure management system used on suture line following wide pathological scars excision for the prevention of postoperative wound dehiscence. Eight patients with wide and mature pathological skin scars were treated with Prevena™. The device was positioned directly after surgical correction for 8 days with a continuous application of -125 mmHg negative pressure. All treated patients had no postoperative surgical wound dehiscence. In one case, a limit of the device was represented by its poor adherence on hairy surface, hampering the maintenance of an appropriate local negative pressure. In another case, suture line was longer than Prevena™ foam and it was covered partially. Prevena™ system appears to be safe, easy to use and may represent a support technique to wide pathological skin scars surgical correction.

Use of negative pressure wound therapy over clean, closed surgical incisions

The literature has reported that surgical site infections account for 17-22% of health care-associated infections, while surgical wound dehiscence rates range from 0.25% to 3.0% (post laparatomies), 1.6% to 42.3% (post-caesarean incisions) and 0.5% to 2.5% (sternal incisions). These types of incisional complications can become a significant cost burden to the health care system because of lengthy hospital stays and readmissions, additional nursing care and added surgical procedures. Therefore, the type of therapy used for surgical incisions plays a critical role in the healing process. The success of negative pressure wound therapy (NPWT; V.A.C.® Therapy; KCI USA, Inc., San Antonio, TX) for open wounds has been well documented and has led to its use over clean, closed surgical incisions. This review will focus on clinician experience and literature review of incisional NPWT and will include clinical cases describing NPWT's successful use over surgical incisions.

Clinical evidences, personal experiences, recent applications

Management of difficult wounds can be a complex, challenging and expensive task, especially for wounds showing a slow healing process. Topical negative pressure (TNP) therapy has greatly improved difficult wounds treatment. It allows to treat patient on an outpatient management, to reduce the complication rate with shorter hospital stay, to avoid frequent dressings with expensive advanced materials and allow a lower commitment of health professionals. Vacuum Assisted Closure^® (VAC^®) system is a therapeutic device based on the administration of a controlled TNP introduced by Morykwas and Argenta in 1997. It is indicated in different kinds of wound, but clinical evidences are present only for few of them. In this work we summarize indications and recommendations for VAC^® therapy and we analyze the actual better choice of treatment based on evidences and personal experience in order to stimulate further studies. Finally we introduce recent applications of VAC^® system such as Prevena^®, VAC Instill^® and VAC Via^®. Prevena^® is a system based on TNP indicated in the management of closed wounds that present risk factors for dehiscence. VAC Instill^® is a system that allows to associate TNP and topical administration of solutions, such as antibiotics or disinfectants, to treat specific type of wounds. VAC Via^® is a device based on TNP, characterized by little dimension and a preset system that allow the treatment of little wounds for 7 d, with no impairment for the patient. The aim of our paper is to describe a report of VAC^® therapy use in order to stimulate further studies and to define the level of evidence of VAC^® therapy.

Negative pressure wound therapy for at-risk surgical closures in patients with multiple comorbidities: a prospective randomized controlled study

PURPOSE

The purpose of this study is to evaluate the effect of Negative Pressure Wound Therapy (NPWT) on closed surgical incisions. We performed a prospective randomized controlled clinical trial comparing NPWT to standard dry dressings on surgical incisions.

METHODS

Patients presenting to a high-volume wound center were randomized to receive either a V.A.C. (KCI, San Antonio, TX) or a standard dry dressing over their incision at the conclusion of surgery. These were primarily high-risk patients with multiple comorbidities. The 2 groups were compared, and all incisions were evaluated for infection and dehiscence postoperatively.

RESULTS

Eighty-one patients were included for analysis. Thirty-seven received dry dressings, and 44 received NPWT. Seventy-four of these underwent lower extremity wound closure. Average follow-up was 113 days. There were no differences in demographic, preoperative, and operative variables between groups; 6.8% of the NPWT group and 13.5% of the dry dressing group developed wound infection, but this was not statistically significant (P = 0.46). There was no difference in time to develop infection between the groups. There was no statistical difference in dehiscence between NPWT and dry dressing group (36.4% vs 29.7%; P = 0.54) or mean time to dehiscence between the 2 groups (P = 0.45). Overall, 35% of the dry dressing group and 40% of the NPWT group had a wound infection, dehiscence, or both. Of these, 9 in the NPWT group (21%) and 8 in the dry dressing group (22%) required reoperation.

CONCLUSIONS

There is a significant rate of postoperative infection and dehiscence in patients with multiple comorbidities. There was no difference in the incidence of infection or dehiscence between the NPWT and dry dressing group. This study is registered with ClinicalTrials.gov. The unique registration number is NCT01366105.

Evaluation of closed incision management with negative pressure wound therapy (CIM): hematoma/seroma and involvement of the lymphatic system

The objective of this porcine study was to evaluate the effect of closed incision management with negative pressure wound therapy (CIM) on hematoma/seroma formation, fluid removal into the CIM canister, and involvement of the lymphatic system. In each swine (n = 8), two sets of ventral contralateral subcutaneous dead spaces with overlying sutured incisions were created. Stable isotope-labeled nanospheres were introduced into each subcutaneous dead space. Each contralateral incision was assigned to CIM (continuous -125 mmHg negative pressure) and control (semipermeable film dressing), respectively. Following 4 days of therapy, hematoma/seroma was weighed, total fluid volume in canisters was measured, five pre-identified lymph nodes were harvested, and five key organs were biopsied. There was 25 ± 8 g (standard error [SE]) (63%) less hematoma/seroma in CIM sites compared to control sites (p = 0.002), without any fluid collection in the CIM canister. In lymph nodes, there were ∼60 μg (∼50%) more 30- and 50-nm nanospheres from CIM sites than from control sites (p = 0.04 and 0.05, respectively). There was significantly greater nanosphere incidence from CIM sites than from control sites in lungs, liver, and spleen (p < 0.05); no nanospheres were detected in kidney biopsies. Thus, in this porcine model, application of CIM significantly decreased hematoma/seroma levels without fluid collection in the canister, which may be explained by increased lymph clearance.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

First experience with a new negative pressure incision management system on surgical incisions after cardiac surgery in high risk patients

BACKGROUND

Sternal wound infection remains a serious potential complication after cardiac surgery. A recent development for preventing wound complications after surgery is the adjunctive treatment of closed incisions with negative pressure wound therapy. Suggested mechanisms of preventive action are improving the local blood flow, removing fluids and components in these fluids, helping keep the incision edges together, protecting the wound from external contamination and promoting incision healing. This work reports on our initial evaluation and clinical experience with the Prevena™Incision Management System, a recently introduced new negative pressure wound therapy system specifically developed for treating closed surgical incisions and helping prevent potential complications. We evaluated the new treatment on sternal surgical incisions in patients with multiple co-morbidities and consequently a high risk for wound complications.

METHODS

The Prevena™incision management system was used in 10 patients with a mean Fowler risk score of 15.1 [Range 8-30]. The negative pressure dressing was applied immediately after surgery and left in place for 5 days with a continuous application of -125 mmHg negative pressure. Wounds and surrounding skin were inspected immediately after removal of the Prevena™ incision management system and at day 30 after surgery.

RESULTS

Wounds and surrounding skin showed complete wound healing with the absence of skin lesions due to the negative pressure after removal of the Prevena™ dressing. No device-related complications were observed. No wound complications occurred in this high risk group of patients until at least 30 days after surgery.

CONCLUSIONS

The Prevena™system appears to be safe, easy to use and may help achieve uncomplicated wound healing in patients at risk of developing wound complications after cardiothoracic surgery.

Negative pressure therapy on primarily closed wounds improves wound healing parameters at 3 days in a porcine model

OBJECTIVES

We investigated the role of negative pressure therapy (NPT) in postoperative primary wound treatment and closure. To date, extensive evidence exists demonstrating the benefit of negative pressure dressings in the treatment of open wounds; our experiment tested the hypothesis that negative pressure dressings improve healing of closed (sutured) wounds.

METHODS

A porcine model was used to collect data on the characteristics of closed wounds after 3 days of treatment with NPTs as compared with control dressings.

RESULTS

In six pigs with a total of 56 wounds, load to failure (N/mm) in controls was 0.348 (standard deviation [SD] 0.109) versus NPT at 0.470 (SD, 0.194) with a P value of 0.001; energy to failure (mJ/mm) in controls was 0.85 (SD, 0.378) versus NPT at 1.128 (SD, 0.638) with a P value of 0.035. Blinded grading of clinical wound appearance and cross-sectional hematoma size were also improved at 72 hours.

CONCLUSIONS

NPT dressings applied to surgically closed wounds enhance the healing characteristics of porcine wounds at 3 days.

CLINICAL RELEVANCE

We have observed that primarily closed surgical wounds may benefit from treatment with NPT. The benefit of using NPTs may be most pronounced in situations in which wounds are closed under tension, involve considerable soft tissue trauma, or may be at risk of subdermal hematoma formation.

Closed incision management with negative pressure wound therapy (CIM): biomechanics

A novel closed incision management with negative pressure wound therapy (CIM) has been developed for convenient use with closed incisions that has the potential to be beneficial for patients at risk for postoperative complications. Incisions are typically under lateral tension. This study explored the biomechanical mechanisms by which integrity of the incisional closure is enhanced by CIM. CIM was hypothesized to affect local stresses around closed incisions in a beneficial manner. Finite element analyses (FEA) indicated that application of CIM decreased the lateral stresses ~50% around the incision and changed the direction of the stresses to a distribution that is typical of intact tissue. Bench evaluations corroborated findings that CIM significantly increased the force required to disrupt the closed incision by ~50% as compared with closure alone. In conclusion, using 2 FEAs and bench modeling, CIM was shown to reduce and normalize tissue stresses and bolster appositional forces at the incision.

Navigating new technologies in negative pressure wound therapy

Plastic surgeons and their support staff are tasked with proficient management of a wide variety of complex wounds. Since its introduction, negative pressure wound therapy (NPWT) has increasingly been used within the plastic surgery specialty to improve and simplify wound management. Increased usage of the therapy has prompted the development of a myriad of new NPWT systems. While an expanded product selection allows greater choice to maximize patient outcomes, sound decision-making also requires a clear understanding of the characteristics of various NPWT systems and applications. Wound-specific NPWT systems of varying size are available for low- to moderate-severity wounds, clean closed incisions, and acute abdominal wounds. Wound size and severity, amount of exudate, and patient mobility issues have become important considerations when choosing an NPWT device. The purpose of this article is to familiarize the reader with the latest sophistications in NPWT systems to guide decision making and usage.

A new negative pressure dressing (PrevenaTM) to prevent wound complications following lower limb distal arterial bypass

Wound complications in patients undergoing distal arterial bypass grafting are common and can lead to loss of limb and life. Vacuum-assisted closure (VAC) has been in use for some time and has proven to expedite the process of wound healing when used in those with open sterile or infected wounds. Recent modifications to the VAC system to make it a topical closed incision dressing have been successful and led to the development of the new PrevenaTM dressing. We present the first application of this purpose-built closed incision site vacuum dressing in a patient with multiple potential risk factors undergoing popliteal-tibial bypass grafting.

Description of a technique for vacuum-assisted deep drains in the management of cavitary defects and deep infections in devastating military and civilian trauma

BACKGROUND

Deep soft-tissue defects often present in high-energy trauma and during the surgical treatment of infection. Injuries caused by high-velocity projectiles can create deep soft-tissue defects that are challenging to manage. Persistent, deep wound cavities have been associated with infection and prolonged wound healing. This article presents a technique that marries vacuum-assisted wound closure technology with traditional drains to allow for management of deep soft-tissue cavities.

METHODS

A deep drain was placed in the cavitary lesion with application of a negative-pressure wound therapy sponge in the standard fashion. The deep drain was brought into the sponge and fenestrated as to allow the sponge to evacuate the deep drain. Several illustrative cases are presented.

RESULTS

Conversion of deep cavitary defects to superficial defects allowed for delayed primary or secondary closure of the wound defects without the need for increasing the size of the superficial wound to facilitate drainage. Deep infection was also successfully controlled without incurring the additional surgical soft-tissue trauma typical of standard technique.

CONCLUSIONS

The use of the active deep suction decreases edema and dead space, theoretically reducing the chance of infection. It also prevents premature walling off of deeper cavities, which can occur with the use of vacuum-assisted closure therapy on superficial defects. Our method of wound management allows for the reduction of the deep cavitary defects without delaying wound closure or creating more tissue damage.