Early Intervention of Negative Pressure Wound Therapy Using Vacuum-Assisted Closure in Trauma Patients: Impact on Hospital Length of Stay and Cost

Treatment of Complex Thoracic and Abdominal Trauma Patients: A Review of Literature and Negative Pressure Wound Therapy Treatment Options

Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.

NPWT resource use compared with standard moist wound care in diabetic foot wounds: DiaFu randomized clinical trial results

Background

Diabetic foot ulcers not only have a negative impact on patient mortality, morbidity and quality of life, but also require high resource utilization to achieve complete wound healing. The aim of this evaluation was to compare resource utilization of negative pressure wound therapy (NPWT) and standard moist wound care (SMWC) for diabetic foot wounds after amputation, surgical debridement or wound cleansing.

Methods

The multicenter clinical DiaFu study enrolled 368 adults with diabetic foot ulcers between December 23, 2011 and October 21, 2014. Patients were randomly assigned to NPWT and SMWC. Evaluation of direct resource use comprised inpatient and outpatient treatment time, and personnel and material for wound treatment within 16 weeks. This resource use analysis was primarily based on the per protocol population (NPWT 44; SMWC 110).

Results

Treatment duration was 16 days shorter with NPWT (mean (SD) 82.8 (31.6), SMWC 98.8 (24.6); U test, p = 0.001) with 14.9 days shorter outpatient treatment (mean (SD) NPWT 68.3 (31.1), SMWC 83.2 (29.7)). The number of dressing changes per study participant was lower with NPWT (mean (SD) 35.1 (18.6), SMWC (42.9 (21.4); U test, p = 0.067). Time per dressing change was significantly lower with SMWC (mean (SD) 19.7 (12.8), NPWT (16.5 (8.2) minutes; U test, p < < 0.0001). Time for surgical debridements per study participant was 23.3 minutes shorter with NPWT (mean (SD) 20.5 (20.5), SMWC (43.8 (46.7); U test, p = 0.395).

Conclusions

Resource use was lower for NPWT, which may be an efficient treatment alternative to SMWC for diabetic foot wounds, to be demonstrated in subsequent cost analyses.

Trial registration

clinicaltrials.govNCT01480362 on November 28, 2011

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00569-w.

NPWT Resource Use Compared With Conventional Wound Treatment in Subcutaneous Abdominal Wounds With Healing Impairment After Surgery: SAWHI Randomized Clinical Trial Results

OBJECTIVE

To compare resource utilization of NPWT and CWT for SAWHI after surgery.

SUMMARY OF BACKGROUND DATA

NPWT is widely used in the management of complex wounds but high-level evidence of its resource use remains sparse.

METHODS

The multicenter, multinational, randomized clinical SAWHI study enrolled a total of 539 consecutive, compliant adult patients with SAWHI after surgery without fascial dehiscence between August 2, 2011, and January 31, 2018. Patients were randomly assigned to NPWT and CWT stratified by study site and wound size using a centralized web-based tool. Evaluation of direct resource use comprised inpatient and outpatient time, personnel and material for wound treatment, and associated wound-related procedures. The resource use analysis was primarily based on the per protocol population (NPWT 157; CWT 174).

RESULTS

Although treatment length within 42 days was significantly shorter in the NPWT arm {Mean [Standard deviation (SD)] NPWT 22.8 (13.4); CWT 30.6 (13.3); P < 0.001 U-test}, hospitalization time was shorter with CWT [Mean (SD) NPWT 13.9 (11.1); CWT 11.8 (10.8); P = 0.047 U-test]. Significantly more study participants were outpatient with CWT [N=167 (96.0%)] than with NPWT [N = 140 (89.2%) (P = 0.017)]. Time for dressing changes per study participant [Mean (SD) (min) NPWT N = 133, 196 (221.1); CWT N = 152, 278 (208.2); P < .001 U-test] and for wound-related procedures [Mean (SD) (min) NPWT 167 (195); CWT 266 (313); P < 0.001 U-test] was significantly lower with NPWT.

CONCLUSIONS

NPWT reduces resource use and maybe an efficient treatment alternative to CWT for SAWHI after surgery.

Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report

ABSTRACT

A 59-year-old man with recurrent rectal cancer and type 2 diabetes mellitus underwent palliative total pelvic exenteration and intraoperative radiotherapy. After surgery, he experienced a pelvic abscess and abdominal-perineal fistula. Profuse exudate contaminated the midline abdominal incision through the abdominal-perineal fistula and delayed healing. Because of a residual tumor and the high cost, negative-pressure wound therapy was not performed. After 76 days of local treatment that involved removing necrotic tissue, controlling inflammation with an antimicrobial silver dressing, absorbing and draining exudate with a hypertonic saline dressing, promoting granulation and preventing infection with a silver alginate dressing, and promoting re-epithelialization with recombinant human epidermal growth factor gel, the abdominal wound and abdominal-perineal fistula healed successfully.

Retrospective Clinical Evaluation of Negative-Pressure Wound Therapy for Infection Prevention Following Malignant Pelvic Bone Tumor Resection Reconstruction

OBJECTIVE

To evaluate the clinical outcomes of negative-pressure wound therapy (NPWT) for infection prevention following pelvic reconstruction after malignant bone tumor resection.

METHODS

The study involved 82 patients who underwent pelvic reconstruction following en-bloc resection of malignant bone tumors between January 2003 and January 2016. Forty patients were treated with NPWT via implantation of vacuum-sealing drainage (VSD) materials into the pelvic cavity to prevent infection and wound problems (VSD group), and the remaining 42 patients underwent conventional treatment (control group). Study authors compared the inpatient length of stay, antibiotic use, drainage volume, time to wound closure, and infection rates between groups. Investigators also conducted cell cultures of the wound cavity washing fluid and hematoxylin-eosin staining for VSD materials to find recurrent tumor cells.

RESULTS

In the VSD group, one patient (2.5%) had a superficial wound problem. In the control group, 18 patients (42.9%) had deep infection or wound problems. The VSD group had a significantly decreased infection rate, duration of antibiotic administration and inpatient stay, as well as increased wound healing compared with the control group (P < .05). Further, no tumor cells were observed in the VSD material or the wound cavity washing fluid.

CONCLUSIONS

The application of NPWT with VSD material may be an effective and reliable method for preventing infection in patients who undergo pelvic reconstruction following malignant tumor resection.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Vacuum sealing drainage as a pre-surgical adjunct in the treatment of complex (open) hand injuries: Report of 17 cases

BACKGROUND

Few studies have been conducted to explore the use of the vacuum sealing drainage (VSD) technique in complex hand injuries. The aim of this study was to report outcomes in patients with complex hand injuries receiving VSD as a coadjuvant treatment prior to second-stage surgery.

METHODS

This case series study retrospectively reviewed the patients who underwent VSD for treatment of hand injuries. Inclusion criteria for the study were: (1) traumatic soft tissue defects of the hand and wrist, accompanied by different degrees of injury and exposure of bone, tendon, or blood vessel; (2) the wound surface of hand and wrist was seriously contaminated and direct wound closure was not possible; and (3) the soft tissues of hand and wrist were seriously lacerated or avulsed, and showed necrosis or acute infection. After debridement, one-stage and/or two-stage repairs using healthy adjacent tissues were performed and the wound was covered by the VSD materials. The non-cytotoxic polyethylene alcohol hydration seaweed salt foam was applied during the VSD treatment for its good biocompatibility. The drainage tube was connected to the vacuum equipment and the negative pressures were set at -60kPa to -40kPa. The VSD device was left in place for 5 to 7 days before removal. Either free skin grafting or skin flap transplantation was used for wound closure and/or reconstructive surgery. The hand injury severity score was used to assess wound severity. The surgical results were scored using the total active motion classification.

RESULTS

A total of 17 patients (13 and 4 patients had major and severe hand injuries), averaging 33.8 years were included. During the study period, 6 patients with severe hand injuries were not treated with VSD for the following reasons: (1) hemodynamic instability (n=1); (2) impaired coagulation function (n=1); (3) uncontrollable hemorrhage on the wound surface (n=2); and (4) exposure of the main blood vessels after surgical repair (n=2). VSD treatment was performed for an average of 7.4 days (range, 6-14 days) and the duration of wound healing averaged 23 days (range, 20-43 days). Wound infection was not reported prior to second-stage surgery. Only one of 17 patients had superficial necrosis at the flap edge, for a success rate of 94%. Average follow-up was 8.7 months (range, 4-13 months). Twelve (71%) patients reported excellent or good, four (23%) reported fair, and one (6%) reported poor results.

CONCLUSION

The VSD can effectively promote safe and rapid repair of local soft tissues with good prognosis.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

An Alternative Treatment Strategy for Complicated Chronic Wounds: Negative Pressure Therapy over Mesh Skin Graft

Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p < 0.0009, p < 0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take.

Closed Incision Negative Pressure Wound Therapy vs Conventional Dry Dressings After Primary Knee Arthroplasty: A Randomized Controlled Study

BACKGROUND

The purpose of this study was to assess the effect of negative pressure wound therapy (NPWT) on quality of life (QoL), wound complications, and cost after primary knee arthroplasty.

METHODS

A prospective analysis of 33 patients undergoing primary knee arthroplasty performed by 3 surgeons in one institution. The first 12 patients (3 bilateral and 9 unilateral) had conventional dry dressings (CDD) applied and cost of dressings was assessed. The other 21 patients all underwent bilateral knee arthroplasty and had either side randomized to receiving NPWT or CDD. Cost of dressings, wound complications, and QoL were compared.

RESULTS

One patient had a reaction to the NPWT requiring readmission. Another had persistent wound drainage that required NPWT application. There were no wound issues in the remaining 31 patients. The average cost in the first 12 patients was Australian dollar $48.70 with an average of 1.5 changes on ward. In the 21 patients receiving both dressings, the average cost for CDD was less (Australian dollar $43.51 vs $396.02, P ≤ .011, effect size [ES] = 1.06). When comparing QoL factors, wound leakage (0.14 vs 0.39 P = .019, ES = 1.02), and wound protection (0.16 vs 0.33, P = .001, ES = 0.021) were better in the NPWT group. There was no other significant difference in QoL factors. The average number of changes on the ward was less for the NPWT group (1.19 vs 1.38, P = .317, ES = 1.02).

CONCLUSION

We found no benefit in wound healing or cost with NPWT post knee arthroplasty. There was some benefit in NPWT QoL factors less wound leakage and better protection.

Neo-digit functional reconstruction of mutilating hand injury using transplantation of multiple composite tissue flaps

PURPOSE

Functional reconstruction of mutilating hand injuries poses a challenge to the surgeon. We present our experience with use of multiple composite tissue flaps transplant for functional reconstruction of hand in patients with mutilating hand injuries. The associated merits and demerits of these surgical approaches are briefly discussed.

METHODS

From August 2004 to October 2014, functional reconstruction of hand with transplantation of multiple composite tissue flaps was performed in 8 patients. These included the toe with dorsal pedis artery flap, the reverse posterior interosseous artery flap, and the anterolateral thigh flap. Mean interval from injury to functional reconstruction was 10.6 days.

RESULTS

All transplanted skin flaps and reconstructed neofingers survived completely. Only 1 patient developed wound infection at the recipient site (hand), which resolved without any debridement or revision surgery. At the donor site (foot), partial skin necrosis was observed in 1 patient, which healed with local wound care. In other patients, all wounds healed without any complications. The average range of movement at the neofinger metacarpophalangeal and interphalangeal joints was 38° and 73°, respectively. None of the patients required revision surgery.

CONCLUSION

Use of negative pressure wound therapy and multiple composite tissue flap transplantation appears to be an effective strategy for hand functional reconstruction in patients with mutilating hand injuries. Among the multiple composite tissue flaps, use of toe transplantation combined with reverse posterior interosseous artery flap appears to be the best option.

What's new in wound treatment: a critical appraisal

With the growing demand for the specialized care of wounds, there is an ever expanding abundance of wound care modalities available. It is difficult to identify which products or devices enhance wound healing, and thus, a critical and continual look at new advances is necessary. The goal of any wound regimen should be to optimize wound healing by combining basic wound care modalities including debridement, off-loading, and infection control with the addition of advanced therapies when necessary. This review takes a closer look at current uses of negative pressure wound therapy, bioengineered alternative tissues, and amniotic membrane products. While robust literature may be lacking, current wound care advances are showing great promise in wound healing.

Reduction of diabetic foot ulcer healing times through use of advanced treatment modalities

Diabetic wounds are a major health care problem associated with delayed healing and high amputation rates. This review systematically evaluated newer wound care therapies for the treatment of diabetic wounds. More recent means of approaching diabetic foot ulcers include various dressings, off-loading shoes, and bioengineered skin constructs and growth factors. Electrical stimulation, phototherapy, electromagnetic fields, and shockwave therapy have been further proposed as potential treatments. A brief overview of these treatments is presented using peer-reviewed evidenced-based literature. A review of the literature demonstrated that treatment of diabetic wounds has focused on either prevention of the wounds in the form of off-loading shoes or adequate protective dressings or on direct treatment of wounds with bioengineered skin constructs, growth factors, or medical devices that accelerate wound healing. The authors' conclusion, following extensive literature review, is that although excellent national and international guidelines exist regarding suggested approaches to the treatment of the diabetic foot ulcer, there is no definitive or universal consensus on the choice of specific treatment modalities. The importance of optimizing comorbidities and the disease state, hemodynamics, local and peripheral skin and wound care, and metabolic challenges while reducing biological and bacterial burden and minimizing trauma remain the primary approach, followed by choice of the most appropriate treatment material or product.

Clinical recommendations and practical guide for negative pressure wound therapy with instillation

Effective wound management involves a comprehensive assessment of the patient and the wound to determine an optimal wound treatment plan. It is critical to identify and address factors that may impair wound healing, prior to selecting the most appropriate therapy for each patient. Negative pressure wound therapy (NPWT) is a well-established advanced therapy that has been successful in adjunctive management of acute and chronic wounds. In recent years, the introduction of topical wound solution delivery in combination with NPWT has provided further benefits to wound healing. A commercially available system now offers automated, volumetric control of instilled topical wound solutions with a dwell time in combination with NPWT (NPWTi-d; V.A.C. VeraFlo Therapy, KCI, an Acelity company, San Antonio, TX). This NPWTi-d system differs from other instillation systems in that a timed, predetermined volume of topical wound solution is intermittently delivered (versus continuously fed) and allowed to dwell in the wound bed (without NPWT), for a user-selected period of time before NPWT is resumed. This added accuracy and process simplification of solution delivery in tandem with NPWT have prompted use of NPWTi-d as first-line therapy in a wider subset of complex wounds. However, considerably more research is required to validate efficacy of NPWTi-d in various wound types. The purpose of this review is to provide a relevant overview of wound healing, describe current literature supporting the adjunctive use of NPWTi-d, propose a clinical approach for appropriate application of NPWTi-d and conclude with case studies demonstrating successful use of NPWTi-d. Based on this review, we conclude that either a large case series examining effects of NPWTi-d on different wound types or possibly a large prospective registry evaluating NPWTi-d with real-world topical wound solutions versus immediate debridement and closure would be valuable to the medical community in evaluating the efficacy of this promising therapy.

A Wireless Electroceutical Dressing Lowers Cost of Negative Pressure Wound Therapy

Objective: To test whether the use of a wireless electroceutical dressing (WED) (Procellera^®) in conjunction with a 5-day negative pressure wound therapy (NPWT) may reduce the number of dressing changes required per week with this therapy. Approach: At the Ohio State University Comprehensive Wound Center, chronic wound patients (n=30) undergoing NPWT were randomized into two arms following consent as approved by the institutional review board. The control arm received standard of care NPWT, where the dressing change was performed thrice a week. The test arm received the same care except that the WED was added as an interface layer and dressing change was limited to twice a week. Results: A reduced cost of care was achieved using the WED in conjunction with NPWT. Despite fewer dressing changes in wounds dressed with the WED, closure outcomes were comparable with no overt signs of any wound complication, including infection. The cost of NPWT care during the week was significantly lower (from $2918 to $2346) in the WED-treated group compared with patients in the control arm. Innovation: This work introduces a novel technology platform involving a WED, which may be used in conjunction with NPWT. If used as such, NPWT is effective in decreasing the frequency of dressing change and lowering the cost of care. Conclusion: This work points toward the benefit of using the WED combined with NPWT. A larger clinical trial investigating the cost-effectiveness of WED in wound care is warranted.

Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care

To evaluate the clinical use and economic aspects of negative pressure wound therapy (NPWT) after dorsal stabilisation of spinal fractures. This study is a prospective randomised evaluation of NPWT in patients with large surgical wounds after surgical stabilisation of spinal fractures by internal fixation. Patients were randomised to either standard wound dressing treatment (group A) or NPWT (group B). The wound area was examined by ultrasound to measure seroma volumes in both groups on the 5th and 10th day after surgery. Furthermore, data on economic aspects such as nursing time for wound care and material used for wound dressing were evaluated. A total of 20 patients (10 in each group) were enrolled. Throughout the whole study, mean seroma volume was significantly higher in group A than that in group B (day 5: 1·9 ml versus 0 ml; P = 0·0007; day 10: 1·6 ml versus 0·5 ml; P <0·024). Furthermore, patients of group A required more wound care time (group A: 31 ± 10 minutes; group B 13·8 ± 6 minutes; P = 0·0005) and more number of compresses (total number; group A 35 ± 15; group B 11 ± 3; P = 0·0376). NPWT reduced the development of postoperative seroma, reduced nursing time and reduced material required for wound care.

Subatmospheric pressure therapy in the treatment of traumatic soft tissue injuries

OBJECTIVE

To evaluate the use of subatmospheric pressure therapy in the treatment of acute traumatic injuries of the soft tissues, especially in the limbs.

METHODS

One hundred and seventy-eight patients with traumatic wounds were treated by the Center for Complex Wounds in the period from January 2010 to December 2011, and submitted to subatmospheric pressure therapy (SPT).

RESULTS

Of the 178 patients who underwent SPT, 129 (72.5%) were male and 49 (27.5%) were aged between 18 and 40 years. Degloving injuries to the limbs were the most common type of traumatic wounds, being responsible for the hospitalization of 83 (46.6%) patients. Mean hospital stay was 17.5 days. A total of 509 procedures were performed (average 2.9 per patient). SPT was used in 287 procedures, 209 (72.8%) on traumatic wounds and 78 (27.2%) of skin grafts. The number of exchanges of the SPT apparel per patient was 1.6 and the mean time of use, 8.5 days.

CONCLUSION

SPT significantly reduced morbidity and healing time of injuries when compared with previously performed dressing treatments. The subatmospheric pressure therapy is a useful method in treating acute traumatic wounds, acting as a bridge between the emergency treatment and the final coverage of the skin lesions, being better when compared with more traditional methods of plastic surgery.

Recent accomplishments in wound healing

The challenge to balance limited resources with infinite demand has encouraged an evolution in the way health care services are managed and operated. Chronic wound management is complex and prolonged, and places a considerable financial burden on health services. A typical driver of cost includes the necessity to change dressings on a regular basis. Over the last few decades, several scientific and biological advances have furthered the development of wound care products and facilitated wound management. This article investigates some of the major advancements that have occurred within the wound-care arena during the last 5 years and how these advancements are being translated to provide better delivery of clinical care to patients.

Incisional negative pressure wound therapy after hemiarthroplasty for femoral neck fractures - reduction of wound complications

The aim of the study was to evaluate the use of incisional negative pressure wound therapy (iNPWT) in wound healing after femoral neck fracture (FNF) treated with hip hemiarthroplasty (HA) and its influence on postoperative seromas, wound secretion, as well as time and material consumption for dressing changes. The study is a prospective randomised evaluation of iNPWT in patients with large surgical wounds after FNF. Patients were randomised either to be treated by iNPWT (group A) or a standard wound dressing (group B). Follow-up included ultrasound measurements of seroma volumes on postoperative days 5 and 10, duration of wound secretion, and time and material spent for wound dressing changes. For comparison of the means, we used the t-test for independent samples, P > 0·05 was considered significant. There were 21 patients randomised in this study. Group A (11 patients, 81·6 ± 5·2 years of age) developed a seroma of 0·257 ± 0·75 cm(3) after 5 days and had a secretion of 0·9 ± 1·0 days, and the total time for dressing changes was 14·8 ± 3·9 minutes, whereas group B (ten patients, 82·6 ± 8·6 years of age) developed a seroma of 3·995 ± 5·01 cm(3) after 5 days and had a secretion of 4·3 ± 2·45 days, and the total time for dressing changes was 42·9 ± 11·0 minutes. All mentioned differences were significant. iNPWT has been used on many different types of traumatic and non-traumatic wounds. This prospective, randomised study has demonstrated decreased development of postoperative seromas, reduction of total wound secretion days and reduction of needed time for dressing changes.

Wound Dressings and Comparative Effectiveness Data

Significance: Injury to the skin provides a unique challenge, as wound healing is a complex and intricate process. Acute wounds have the potential to move from the acute wound to chronic wounds, requiring the physician to have a thorough understanding of outside interventions to bring these wounds back into the healing cascade. Recent Advances: The development of new and effective interventions in wound care remains an area of intense research. Negative pressure wound therapy has undoubtedly changed wound care from this point forward and has proven beneficial for a variety of wounds. Hydroconductive dressings are another category that is emerging with studies underway. Other modalities such as hyperbaric oxygen, growth factors, biologic dressings, skin substitutes, and regenerative materials have also proven efficacious in advancing the wound-healing process through a variety of mechanisms. Critical Issues: There is an overwhelming amount of wound dressings available in the market. This implies the lack of full understanding of wound care and management. The point of using advanced dressings is to improve upon specific wound characteristics to bring it as close to "ideal" as possible. It is only after properly assessing the wound characteristics and obtaining knowledge about available products that the "ideal" dressing may be chosen. Future Directions: The future of wound healing at this point remains unknown. Few high-quality, randomized controlled trials evaluating wound dressings exist and do not clearly demonstrate superiority of many materials or categories. Comparative effectiveness research can be used as a tool to evaluate topical therapy for wound care moving into the future. Until further data emerge, education on the available products and logical clinical thought must prevail.

Negative pressure wound therapy with Bio-Dome dressing technology in the treatment of complex wounds: a case series

The treatment of complex wounds is difficult and not always effective. Various treatment options are used with varying degrees of success. Negative pressure wound therapy (NPWT) is a cost-efficient and effective way to help treat these wounds. The use of a vacuum device applies the negative pressure to the site of the wound and promotes waste removal and increases circulation and tissue formation. While various NPWT systems are currently on the market, we utilised the ConvaTec Engenex® system with Bio-DomeTM technology; however, our case study is not intended to advocate the specific use of this system, but instead focuses on the use of NPWT as a viable option for wound healing. Each of the following case study patients presented with difficult-to-heal wounds that failed traditional therapeutic approaches. Through the use of NPWT, our patients saw major wound size reductions. Each patient exhibited at least a 94% reduction in wound area, wound volume or both.

Evaluation of wound care and health-care use costs in patients with diabetic foot ulcers treated with negative pressure wound therapy versus advanced moist wound therapy

BACKGROUND

We conducted a post-hoc retrospective analysis of patients enrolled in a randomized controlled trial to evaluate overall costs of negative pressure wound therapy (NPWT; V.A.C. Therapy; KCI USA, Inc, San Antonio, Texas) versus advanced moist wound therapy (AMWT) in treating grade 2 and 3 diabetic foot wounds during a 12-week therapy course.

METHODS

Data from two study arms (NPWT [n = 169] or AMWT [n = 166]) originating from Protocol VAC2001-08 were collected from patient records and used as the basis of the calculations performed in our cost analysis.

RESULTS

A total of 324 patient records (NPWT = 162; AMWT = 162) were analyzed. There was a median wound area reduction of 85.0% from baseline in patients treated with NPWT compared to a 61.8% reduction in those treated with AMWT. The total cost for all patients, regardless of closure, was $1,941,472.07 in the NPWT group compared to $2,196,315.86 in the AMWT group. In patients who achieved complete wound closure, the mean cost per patient in the NPWT group was $10,172 compared to $9,505 in the AMWT group; the median cost per 1 cm(2) of closure was $1,227 with NPWT and $1,695 with AMWT. In patients who did not achieve complete wound closure, the mean total wound care cost per patient in the NPWT group was $13,262, compared to $15,069 in the AMWT group. The median cost to close 1 cm(2) in wounds that didn't heal using NPWT was $1,633, compared to $2,927 with AMWT.

CONCLUSIONS

Our results show greater cost effectiveness with NPWT versus AMWT in recalcitrant wounds that didn't close during a 12-week period, due to lower expenditures on procedures and use of health-care resources.

Exploring portable negative pressure wound therapy devices in the community

Case studies and clinical reviews support the use of negative pressure wound therapy (NPWT) for managing a range of wound types, yet very few scientific studies fully support its effectiveness. However, it has been argued that NPWT can provide excellent symptom management, reduce the frequency of dressing changes and provide a cost-effective alternative to traditional wound therapies due to faster healing times, leading to a reduction in overall treatment costs. Use of NPWT within community environments is increasing as length of hospital in-patient stay decreases, and many patients who would have traditionally been admitted to an acute setting with a complex or highly exuding wound are now managed by community nurses. This article presents a narrative review of NPWT, identifies safety precautions that require consideration and explores the application of smaller/disposable NPWT systems that are now available.

Free flap transplantation combined with skin grafting and vacuum sealing drainage for repair of circumferential or sub-circumferential soft-tissue wounds of the lower leg

Background

This study is aimed at evaluating the operation techniques and clinical significance of free flap transplantation combined with skin grafting and vacuum sealing drainage (VSD) in repairing severe traumatic extensive circumferential or semi-circumferential soft-tissue defects of the lower leg.

Material/Methods

Thirty patients with severe lower leg injuries were treated by free flap transplantation combined with skin grafting and VSD from January 2008 to June 2011. The size of the wounds ranged from 23×8 cm to 44×28 cm and all affected more 70% of the low leg circumferential area. Wounds were complicated by exposure, necrosis, or infection of deep tissues. The wounds were first debrided and covered by VSD. When the condition of the wound had improved (5 to 7 days later), free flaps were harvested to reconstruct damaged tissue and skin grafts and VSD was used to cover granulation tissues around the transplanted flap.

Results

Granulation tissues developed and the area requiring flap cover decreased in all 30 patients after debridement and VSD. In 28 of 30 cases, the transplanted flaps grew well without complication. Peripheral necrosis was observed in only 2 cases, which required a second debridement and skin graft. Ten wound areas covered by grafts were left with scattered peripheral wounds, which healed with the help of 1 more skin graft or dressing change. Morphological appearance and functional recovery were satisfactory in all 30 cases.

Conclusions

Initial debridement and the temporary VSD cover followed after several days by free flap transplantation combined with skin grafting and VSD protection is a reliable treatment regimen for traumatic large circumferential or sub-circumferential soft tissue wounds of the lower leg with deep tissue exposure.

A retrospective cohort study evaluating efficacy in high-risk patients with chronic lower extremity ulcers treated with negative pressure wound therapy

The purpose of this study was to evaluate the efficacy of negative pressure wound therapy (NPWT) compared with standard of care on wound healing in high-risk patients with multiple significant comorbidities and chronic lower extremity ulcers (LEUs) across the continuum of care settings. A retrospective cohort study of 'real-world' high-risk patients was conducted using Boston University Medical Center electronic medical records, along with chart abstraction to capture detailed medical history, comorbidities, healing outcomes and ulcer characteristics. A total of 342 patients, 171 NPWT patients with LEUs were matched with 171 non-NPWT patients with respect to age and gender, were included in this cohort from 2002 to 2010. The hazard ratios (HRs) were estimated by COX proportional hazard models after adjusting for potential confounders. The NPWT patients were 2·63 times (95% CI = 1·87-3·70) more likely to achieve wound closure compared with non-NPWT patients. Moreover, incidence of wound closure in NPWT patients were increased in diabetic ulcers (HR = 3·26, 95% CI = 2·21-4·83), arterial ulcers (HR = 2·27, CI = 1·56-3·78) and venous ulcers (HR = 6·31, 95% CI = 1·49-26·6) compared with non-NPWT patients. In addition, wound healing appeared to be positively affected by the timing of NPWT application. Compared with later NPWT users (1 year or later after ulcer onset), early NPWT users (within 3 months after ulcer onset) and intermediate NPWT users (4-12 months after ulcer onset) were 3·38 and 2·18 times more likely to achieve wound healing, respectively. This study showed that despite the greater significant comorbidities, patients receiving NPWT healed faster. Early use of NPWT demonstrated better healing. The longer the interval before intervention is with NPWT, the higher the correlation is with poor outcome.

Use of negative pressure wound therapy to help facilitate limb preservation

Because of changes in demography, non-communicable diseases cause more deaths worldwide than infectious disease for the first time in history. One of the most prevalent of these maladies is diabetes mellitus, which resulted in 4.6 million deaths in 2011. There will be approximately 552 million people with diabetes worldwide by 2030. For these patients, one of the most common severe complications will be a foot wound. Patients with diabetes have at least a 25% lifetime risk of developing a foot ulcer. Many of these infections go on to amputation. Those patients have a 50% mortality rate in the 5 years following the initial amputation. Indeed, these problems are costly as well. In 2010, spending on diabetes was estimated to account for 11.6% of the total health care expenditure in the world. This review merges scientific evidence with expert experience to show the role of negative pressure wound therapy using reticulated open cell foam (V.A.C.® Therapy, KCI USA, Inc., San Antonio, TX) in limb preservation.

Sequential therapy of vacuum sealing drainage and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities

PURPOSE

The aim of the study is to evaluate the surgical technique and clinical significance of the sequential therapy of vacuum sealing drainage (VSD) and free-flap transplantation for children with extensive soft-tissue defects below the knee in the extremities.

METHODS

Twenty-two children (aged from 3 to 10 years) received sequential therapy of VSD and free-flap transplantation. All cases suffered from extensive area soft-tissue defects and exposure or partial defects of bones, tendons and other deep tissues. The wound sizes varied from 10 cm × 6 cm to 30 cm × 22 cm. Amongst 22 cases, 12 cases had fresh wounds and the remaining 10 children had necrotising infection. After complete debridement, the wounds were covered by VSD. External fixation or Kirschner-wire fixation should be performed for the cases complicated by unsteady fractures. After the removal of negative pressure VSD devices, free-flap transplantations were performed in 8 cases after debridement, and 14 cases received combined therapy of free-flap transplantation and skin grafting depending upon the severity of soft-tissue and deep-tissue defects. The flap survival and wound healing were followed up postoperatively.

RESULTS

After VSD treatment, the infection of deep-tissue exposure was effectively prevented, and granulation tissues surrounding the exposed areas of tendons and bones grew well. All patients who received free-flap transplantation at the second stage survived without the occurrence of vascular crisis, infection or sinus formation. During follow-up ranging from 6 to 24 months, all the patients were satisfied with the morphological appearance and functional recovery of the affected limbs.

CONCLUSION

Sequential therapy of VSD and free-flap transplantation can serve as a reliable option for children with extensive soft-tissue defects below the knee in the extremities and exposed deep tissues, after complete debridement, which significantly shortens remedy period, enhances success rate for surgery and achieves maximal restoration of limb function.

Negative pressure wound therapy in acute, contaminated wounds: documenting its safety and efficacy to support current global practice

Negative pressure wound therapy (NPWT) is in widespread use and its role in wound care is expanding worldwide. It is estimated that 300 million acute wounds are treated globally each year. Currently, sporadic data exist to support NPWT in acutely contaminated wounds. Despite lack of data, use of negative pressure wound therapy in such cases is increasing across the globe. We retrospectively reviewed 86 consecutive patients, totalling 97 contaminated wounds. All wounds were Class IV based on US Center for Disease Control criteria. Sepsis criteria were present in 78/86 (91%) of patients. All patients were managed with NPWT. Wound type, degree of tissue destruction, presence of infection, wound dimension, timing of initial NPWT, type and timing of wound closure and patient comorbidities were recorded. Outcome endpoints included durability of wound closure and death. Wound location was 41/97 (42%) in the torso; 56/97 (58%) at the extremities. Tissue necrosis was present in 84/97 (87%) of wounds. Infection was present in 86/97 (89%) of wounds. Average wound size was 619 cm(2) when square surface area measured; 786 cm(3) when volume measurements taken. Mean time to wound closure was 17 days, median 10 days and mode 6 days. Durability of wound closure 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT. Contemporary NPWT related acute wound care is expanding empirically, in quantity and scope across the globe. However, several areas of concern are known regarding this contemporary use of NPWT in acute wounds. Thus, it is important to assess the safety and efficacy of such expanded empiric NPWT practice. Based on our findings with NPWT in the largest known patient cohort of this type, NPWT appears safe and effective in managing acute, contaminated wounds including patients meeting sepsis criteria. These findings provide evidence-based support for current worldwide empiric NPWT-related acute wound care.

A novel option in negative pressure wound therapy (NPWT) for chronic and acute wound care

INTRODUCTION

Negative pressure wound therapy (NPWT) has become a widely accepted technique in treatment of all kinds of wounds. After a long period of clinical application of the V.A.C.™ system (KCI Inc., San Antonio, Texas, USA) a number of options for delivery of NPWT are now commercially available. An urgent need exists for evidence demonstrating clinical efficacy of these new devices to support clinicians regarding their choice of NPWT.

METHODS

42 patients with an acute or chronic wound were randomly assigned to either treatment by V.A.C.™ (group A) or therapy with an alternative newly available polyurethane foam-based NPWT system (RENASYS GO™ - F/P, Smith & Nephew GmbH) (group B). In both groups NPWT was applied after surgical debridement to prepare the wound bed for skin grafting. After skin grafting NPWT was applied additionally to secure skin grafts and improve grafts survival. Primary outcome measures were the time to complete healing (days) and duration of the NPWT application (days). Secondary outcome measures were the number of dressing changes and reported complications. In addition, we evaluated the cost-benefit in the clinical implementation.

RESULTS

There were no significant differences comparing the investigated parameters between both groups. Especially average time to complete healing and average time NPWT was applied did not differ (p>0.05). No complications occurred in either group. By an almost identical supply agreement of both providers for our hospital RENASYS™ system appeared to be more cost-effective.

CONCLUSION

After a long period of preserving a monopoly market position of the V.A.C.™ system, a new comparable option was successfully tested in this preliminary study. The polyurethane foam-based NPWT system (RENASYS GO™ - F/P, Smith & Nephew GmbH) is an efficient and cost-effective alternative NPWT system, which we effectively implemented in therapeutic management of different kinds of wounds.

Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty

PURPOSE

The purpose of this study was to evaluate the use of negative pressure wound therapy (NPWT) to improve wound healing after total hip arthroplasty (THA) and its influence on the development of postoperative seromas in the wound area.

MATERIALS

The study is a prospective randomised evaluation of NPWT in patients with large surgical wounds after THA, randomising patients to either a standard dressing (group A) or a NPWT (group B) over the wound area. The wound area was examined with ultrasound to measure the postoperative seromas in both groups on the fifth and tenth postoperative days.

RESULTS

There were 19 patients randomised in this study. Ten days after surgery, group A (ten patients, 70.5 ± 11.01 years of age) developed seromas with an average size of 5.08 ml and group B (nine patients, 66.22 ± 17.83 years of age) 1.97 ml. The difference was significant (p = 0.021).

CONCLUSION

NPWT has been used on many different types of traumatic and non traumatic wounds. This prospective, randomised study has demonstrated decreased development of postoperative seromas in the wound and improved wound healing.

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.

Costs of hospitalized ventilator-dependent children: differences between a ventilator ward and intensive care unit

Hospitalizing clinically stable patients in critical care settings results in unnecessary healthcare costs and thwarts timely patient throughput. Some pediatric hospitals care for their stable ventilator-dependent children outside of pediatric intensive care units (PICUs). To date, no analysis of the costs of these pediatric ventilator units compared to PICUs has been performed. We conducted a retrospective comparison of PICU and ventilator ward costs of hospitalizations for 103 admissions in which ventilator-dependent children served as their own matched controls between 2004 and 2007. For included admissions, patients were hospitalized in both units during the same admission and spent more than 1 day in their initial unit. Comparisons of costs were made using the last full PICU day and first full ward day. For the study period, the mean PICU cost of hospitalization per day was $3,565 (standard deviation [SD] ± 716.50). The mean ward cost was $2,052 (SD ± 617). The mean PICU cost was significantly larger than the mean ward cost (paired t-test, P < 0.0001). Ventilator ward total and variable costs were significantly less than those in the PICU, and such units represent a potential cost saving measure for hospitals that care for ventilator-dependent children.

The new reconstructive ladder: modifications to the traditional model

The traditional reconstructive ladder has withstood the test of time, serving as a thought paradigm to guide surgeons in choosing their method of wound closure for an assortment of defects. Advances in anatomical understanding and technological innovations have improved our ability to achieve definitive closure in a wide variety of patients. In this article, the older construct is updated to reflect the use of negative-pressure wound therapy and dermal matrices. Perforator flap concepts are also discussed in terms of their inclusion as a rung on the ladder.

Economic evaluation of Vacuum Assisted Closure® Therapy for the treatment of diabetic foot ulcers in France

The objective of the study was to assess the cost-effectiveness of Vacuum Assisted Closure® (V.A.C.®) Therapy compared with advanced wound care (AWC) for the treatment of diabetic foot ulcers (DFUs) in France. A cost-effectiveness model intended to reflect the management of DFUs was updated for the French setting. The Markov model follows the progression of 1000 hypothetical patients over a 1-year period. The model was populated with French-specific data, obtained from published sources and clinical experts. The analysis evaluated costs and health outcomes, in terms of quality-adjusted life-years (QALYs), wounds healed and amputations, from the perspective of the payer. The patients treated with V.A.C.® Therapy experienced more QALYs (0.787 versus 0.784) and improved healing rates (50.2% versus 48.5%) at a lower total cost of care (€24,881 versus €28,855 per patient per year) when compared with AWC. Sensitivity analyses conducted around key model parameters indicated that the results were affected by hospital resource use and costs. DFU treatment using V.A.C.® Therapy in France was associated with lower costs, additional QALYs, more healed ulcers and fewer amputations than treatment with AWC. V.A.C.® Therapy was therefore found to be the dominant treatment option.

Can the costs of critical care be controlled?

PURPOSE OF REVIEW

Critical care medicine (CCM) is expensive. CCM costs have continued to rise since they were first calculated in the 1970s. By 2005, CCM costs in the US were estimated to be $81.7 billion accounting for 13.4% of hospital costs, 4.1% of the national health expenditures and 0.66% of the gross domestic product.

RECENT FINDINGS

This review first addresses the methodology and inherent limitations of calculating global CCM costs using the Russell equation and the challenges of defining critical care in the US when universal definitions of intensive care unit (ICU) bed types do not exist. Studies and concepts recently put forth to control CCM costs are then discussed. These include rationing ICU care, caring for patients in non-ICU locations, regionalizing care, changing the ICU workforce, imposing care protocols and bundles, and adjusting long-term ICU traditions. Many of these programs have benefits but may also have unintended expenses. Even documenting ICU costs themselves may be quite challenging as costs are frequently shifted between the ICU and its supporting clinical and hospital services.

SUMMARY

Cost containment is difficult to attain in critical care as the programs proposed to achieve cost control may be so pricey, that potential cost savings are offset. Some CCM cost saving methodologies may benefit patient care, whereas others may be detrimental to society. CCM cost containment may prove as illusory in the future as it has been in the past.

An overview of negative pressure wound therapy for the lower extremity

Since its introduction into the market, negative pressure wound therapy (NPWT), also known as topical negative pressure, has become an important adjuvant therapy for the treatment of many types of wounds. Surgeons and physicians of all subspecialties have adopted NPWT into their practices. NPWT has become a mainstay in the management of lower extremity soft tissue pathology, especially in patients with traumatic, diabetic, postsurgical, and peripheral vascular disease-associated wounds. This article reviews the background, currently understood mechanisms of action, applications, contraindications, reported complications, advantages, criticisms, and techniques in the lower extremity.