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

A Systematic Review and Meta-analysis of Two Negative Pressure Wound Therapy Devices to Manage Cesarean Section Incisions

This paper aims to evaluate whether there is a device-dependent effect on the reduction of surgical site complications in obese patients (body mass index [BMI] ≥ 30 kg/m2) undergoing cesarean section (C-section). PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for the period, January 2011 to September 2021. English language articles describing a randomized controlled trial (RCT) that compared either a -80 or -125 mm Hg single-use negative pressure wound therapy (sNPWT) device to standard dressings in obese (BMI ≥ 30 kg/m2) patients undergoing C-section were included. Conference abstracts and "terminated" RCTs with published results were deemed eligible for inclusion. The primary outcome of interest was surgical site infection (SSI), classified as composite, superficial, or deep. Secondary outcomes assessed included seroma, dehiscence, hematoma, bleeding, reoperation, readmission, blistering, and (composite) wound complications. A total of 223 titles were identified, of which 129 were screened by full-text review. Eleven RCTs encompassing 5,847 patients met the inclusion criteria and were considered eligible for further analysis (-80 mm Hg: six studies; -125 mm Hg: five studies). A statistically significant improvement in the composite SSI (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.54-0.89) and superficial SSI (OR: 0.66; 95% CI: 0.50-0.86) outcomes was observed with the -80 mm Hg device, compared with standard dressings. The same effect on SSI outcomes was not observed with the -125 mm Hg device (composite SSI-OR: 0.91; 95% CI: 0.64-1.28; superficial SSI-OR: 1.12; 95% CI: 0.70-1.78). There were no statistically significant differences in any of the other assessed outcomes. sNPWT devices may differ in their ability to reduce composite or superficial SSI after C-section. KEY POINTS: · Negative pressure benefits obese patients undergoing C-section.. · Negative pressure devices may differ in performance.. · A head-to-head clinical trial is needed..

Updated Scenario on Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT) is a widely used and effective treatment for managing complex wounds. This document discusses how NPWT can be used in wound care in an updated way. The updated scenario on NPWT provides a concise overview of the current state of NPWT and its implications in clinical practice. It highlights recent developments in NPWT, as well as the advancements in this field. As part of NPWT, vacuum-assisted closure is used and negative pressure is applied to the wound bed. It discusses the key components and mechanisms. In addition to improving wound healing, NPWT also reduces infection rates and improves patient comfort, among other benefits. In addition, this document discusses the specific indications and contraindications of NPWT, as well as the types of wounds that can be treated with NPWT, including diabetic foot ulcers, pressure ulcers, and traumatic wounds. The document emphasizes the importance of choosing patients appropriately and assessing wounds to ensure optimal outcomes. In addition, it provides evidence-based guidelines and clinical recommendations on NPWT. In addition to reviewing the latest research findings supporting NPWT in a variety of clinical settings, it also discusses randomized controlled trials and systematic reviews. In addition, it discusses the potential complications and challenges associated with NPWT, including pain, bleeding, and device malfunction. The purpose of this document is to shed light on the role of NPWT in wound care management by providing an updated scenario. NPWT can be incorporated into clinical practice by healthcare professionals if they understand its principles, benefits, indications, and limitations. Healthcare providers can optimize patient outcomes and improve wound healing in diverse patient populations by staying abreast of the latest advancements in NPWT.

Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: Systematic literature review and meta-analysis

BACKGROUND

To evaluate whether a single-use negative pressure wound therapy (sNPWT) device can reduce the incidence of surgical site infection (SSI) in at-risk patients with closed surgical incisions across a range of surgical specialties, compared with standard care.

METHODS

PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched from the period January 2011 to April 2021.

RESULTS

Out of 15,283 articles identified, 19 were included. A statistically significant improvement (p ​< ​0.05) in the composite SSI (odds ratio [OR]: 0.36; 95 ​% confidence interval [CI]: 0.27-0.49), superficial SSI (OR: 0.30; 95 ​% CI: 0.17-0.53), and deep SSI (OR: 0.67; 95 ​% CI: 0.46-0.96) outcomes was observed with the sNPWT device compared with standard care in a pooled analysis of all surgical specialties.

CONCLUSION

A -80 ​mmHg sNPWT device reduces the incidence of composite, superficial, and deep SSIs when compared with standard care across a heterogenous at-risk surgical population containing a variety of surgical specialties.

Evaluation of a new low-cost negative pressure wound therapy in the treatment of diabetic foot ulcers

OBJECTIVE

To investigate the effectiveness of a new and low-cost negative pressure wound therapy (LC-NPWT) in the treatment of diabetic foot ulcers (DFUs).

METHOD

In this retrospective cohort study, patients from our inpatient clinic with Wagner grade 3 DFUs were given LC-NPWT or conventional wound dressings. The primary outcome was the wound healing rates. Complete wound healing, defined as complete re-epithelialisation of the wound, was recorded during the two months of follow-up. The definition of complete epidermis of the wound was that the skin was closed (100% re-epithelialisation), with no drainage or dressing. The secondary outcomes were the number of inpatient days and surgical procedures, and outcomes after hospital discharge. The wound score from the Bates-Jensen wound assessment tool and the levels of the inflammation factors procalcitonin (PCT), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were compared between the two groups. The Kaplan-Meier survival estimate was used to examine the cumulative wound healing rate.

RESULTS

The study cohort comprised 41 patients. The two-month wound healing rate was higher in patients in the LC-NPWT group than in the control group (15/21 (71.4%) versus 8/20 (40.0%), respectively; p=0.043). At the end of the two-month follow-up period, the cumulative wound healing rate was higher in the LC-NPWT group than in the control group (p=0.032). Patients in the LC-NPWT group had fewer inpatient days (19.3±3.84 versus 25.05±4.81; p<0.001) and shorter duration of antibiotic use (32.14±3.89 days versus 36.10±5.80 days; p=0.014) than those who received conventional wound dressings. There were significant improvements in mean wound score between the LC-NPWT group and the control group (p<0.001). After one week of treatment, the blood levels of PCT (0.03±0.30ng/ml versus 0.07±0.08ng/ml; p=0.039), CRP (14.55±13.40mg/l versus 24.71±18.10mg/l; p=0.047) and ESR (42.05±29.29mm/h versus 61.65±22.42mm/h; p=0.021) were lower in patients who received LC-NPWT than those who received conventional wound dressings.

CONCLUSION

LC-NPWT is effective in the treatment of DFUs and provides a cheaper alternative for patients with DFUs that could potentially alleviate the economic distress these patients endure.

Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery

Background

Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery.

Methods

This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice.

Results

Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit.

Conclusions

Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

Effect of incisional negative pressure therapy and conventional treatment on wound complications after orthopaedic trauma surgery: A meta-analysis of randomized controlled studies

The results of this meta-analysis were applied to analyse the effects of Negative Pressure Wound Therapy (NPWT) and conventional dressings on post-surgical outcomes after trauma in orthopaedics. Through June 2023, a full review of the literature has been carried out with the help of 4 databases, PubMed, Embase, Cochrane Library, and the Web of Science. The quality of the literature was evaluated according to the classification and exclusion criteria established for this trial, which led to an analysis of 9 related trials. The results included the injury was deeply and superficially infected, and the wound was dehiscence. The 95% confidence interval (CI) and odds ratios (OR) were computed by means of a fixed-effect and a random-effect model. Meta-analyses were conducted with RevMan 5.3. There is no statistical significance between NPWT and routine therapy for deep wound infection (OR, 1.37; 95% CI, 0.82-2.27, p = 0.23); There was no difference in the incidence of inflammation in the wound than with conventional dressings (OR, 1.10; 95% CI, 0.84-1.45, p = 0.49); But NPWT was obviously superior to that of routine therapy in superficial wound infection (OR, 2.07; 95% CI, 1.32-3.25, p = 0.002) and wound dehiscence (OR, 2.44; 95% CI, 1.31-4.57, p = 0.005); But not with respect to wound exudate. therapy group, but no statistically significant difference was found with respect to wound exudation. (OR, 1.16; 95% CI, 0.86-1.57, p = 0.34). Given that some of the chosen trials are too small for this meta-analysis, caution should be exercised when treating their values. More high-quality research with a large sample is required in order to confirm the findings.

Impact of negative pressure wound treatment on incidence of surgical site infection in varied orthopedic surgeries: A systematic review and meta-analysis

Negative pressure wound therapy (NPWT) is a popular treatment to heal infected wounds. This meta-analysis aimed to determine if NPWT was more effective than conventional wound dressings for surgical site infections (SSI) in varied orthopaedic surgeries. Literature was retrieved from seven electronic databases (Medline, Web of Science, PubMed, Embase, Google Scholar, Cochrane Library, and CNKI). Randomised control trials (RCT) and retrospective cohort studies (RS) involving arthroplasty, fracture, and spinal surgery were extracted. SSI was our primary outcome, while total complications and length of hospital stay were secondary outcomes. We carried out the risk of bias assessment and meta-analysis using the Cochrane Risk of Bias 2.0 tool and Stata 17.0. Among the 798 studies retrieved, 18 of them met our inclusion criteria. We identified 13 RCTs and 5 RSs. The results of meta-analysis showed that the incidence of SSI in the NPWT group was significantly lower relative to the control group (OR = 0.60, 95% CI 0.47 to 0.77, P < 0.001). Subgroup analyses revealed that the incidences of SSI involving arthroplasty, fracture, and spinal surgery in the NPWT group accounted for 46%, 69%, and 37% relative to the control group, respectively. The incidence of SSI in RS (OR = 0.27, 95% CI 0.13 to 0.56) was significantly lower than that in RCT (OR = 0.69, 95% CI 0.54 to 0.90) (P = 0.02). Moreover, patients in the NPWT group had a lower total complication rate (OR = 0.51, 95% CI 0.34 to 0.76) and shorter hospital stays (SMD = -0.42, 95% CI -0.83 to -0.02), although high heterogeneity existed. NPWT may be an efficient alternative to help prevent the incidence of SSI and total complications as well as achieved shorten hospital stay in varied orthopaedic surgeries. The rational use of NPWT should be based on the presence of patients' clinical conditions and relevant risk factors.

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery: A case report

BACKGROUND

Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence. They require immediate and appropriate management before they progress to an irreversible condition. Although negative pressure wound therapy (NPWT) can prevent wound progression by increasing microcirculation, the inappropriate application of NPWT on complication-threatened transferred and replanted tissues can induce an adverse effect.

CASE SUMMARY

A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap. While applying a heating pad directly to the flap site, she sustained a deep second to third-degree contact burn over 30% of the transferred flap on postoperative 7 d. As the necrotic changes had progressed, we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d. After 4 d of NPWT application, the exposed fatty tissues of the flap changed to dry and brown-colored necrotic tissues. Upon further debridement, we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.

CONCLUSION

Although NPWT has been shown to be successful for treating various wound types, the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Simplified vacuum dressing system: effectiveness and safety in wounds management

PURPOSE

Negative pressure wound therapy (NPWT) has revolutionized wound care, but its high cost reduces the procedure's availability. To solve the problem, streamlined vacuum dressings systems have been proposed, but the utility of these devices has been poorly studied. The objective of this study was to evaluate a simplified vacuum dressing system model (SVDM).

METHODS

Randomized clinical trial in which wounds were treated with SVDM compared to a complex occlusive dressing (silver hydrofiber, SHF). The analyzed outcomes were cleaning, presence of granulation tissue, clinical appearance, and indication for surgical closure of wounds.

RESULTS

Fifty injuries were treated (25 in each group), most located on lower limbs. SVDM proved to be more effective than SHF in the evaluated outcomes. Wound recalcitrance reduced the effectiveness of the equipment used. Despite its efficacy, complications occurred, the most frequent related to dressing changes: minor bleeding, foam adherence to a wound bed, and pain. Only for bleeding no favorable risk-benefit ratio was found. There were no severe complications, worsening conditions of injuries, or deaths.

CONCLUSIONS

SVDM proved to be an effective and acceptably safe device for managing studied wounds.

Skin grafting treatment of adolescent lower limb avulsion injury

Background

Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries.

Main body

Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity.

Conclusion

This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.

Single use negative-pressure wound therapy compared to standard care in patients after carbon dioxide laser surgery for hidradenitis suppurativa

Negative pressure wound therapy is a commonly used treatment modality for surgical wounds healing by secondary intention. In an open, split side study with 12 patients, we compared low negative pressure wound therapy to conventional foam dressing the first postoperative week after carbon dioxide laser vaporization of hidradenitis suppurativa lesions. The primary outcome was time to complete wound healing, comparing the two intervention sites. Secondary endpoints included perception of pain during intervention period and patient registered impact of the regimes on daily life activities. Low negative pressure wound therapy the first postoperative week tended to reduce the time to complete wound healing. Patients reported significant lower pain levels from wounds treated with a negative pressure wound device the first postoperative week. Eleven out of 12 study participants had a preference to the negative pressure wound therapy regime to a conventional regime with foam dressings.

Negative Pressure Wound Therapy for Improved Nipple Survival in Large Volume Reduction Mammaplasty

BACKGROUND

Large volume breast reductions are at increased risk of nipple ischemia and necrosis due to tenuous blood supply of long pedicles. We adapted incisional negative pressure wound therapy to augment nipple survival in such patients undergoing mammaplasty by inferior pedicle technique.

METHODS

Patients with nipple-to-inframammary fold distance >14 cm were informed of increased risk of requiring free nipple graft. All patients underwent inferior pedicle technique with Wise pattern skin incision. Once incisions were closed and the nipple-areolar complex was inset, the complex was assessed for vascularity. In 12 cases there was evidence of compromised arterial inflow or venous outflow. For these patients, incisional negative pressure wound therapy was applied to the bilateral nipple-areolar complexes for 5-7 days.

RESULTS

None of the 12 patients (24 breasts) in this series experienced nipple-areolar complex ischemia or necrosis. Only 2 patients experienced delayed wound healing which was successfully managed by local wound care.

CONCLUSIONS

This study demonstrates the utility of negative pressure wound therapy in nipple survival for at-risk patients. We believe it augments healing by allowing improved micro-circulation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparing Traditional and Disposable Negative-Pressure Wound Therapy Use by Medicare Home Health Patients

OBJECTIVE

Since 2017, home health agencies (HHAs) have received reimbursement for the provision of negative-pressure wound therapy (NPWT) using disposable, portable devices to eligible Medicare fee-for-service beneficiaries. This study aimed to describe the use of disposable NPWT (dNPWT) versus traditional, durable medical equipment-based NPWT (tNPWT) in the home health setting over time and compare the types of beneficiaries using and associated Medicare payments for NPWT separate from the home health payment bundle.

METHODS

Medicare fee-for-service claims were used to identify beneficiaries receiving NPWT from HHAs during home health stays. Assessment and Medicare administrative data were linked to compare characteristics between those receiving tNPWT or dNPWT and to calculate and contrast average Medicare payments for NPWT provided during the home health episode.

RESULTS

In 2019, the vast majority of NPWT used was tNPWT (>99%). Beneficiaries using dNPWT had fewer health risk factors and used substantially less medical care than beneficiaries using tNPWT ($47,187 vs $60,440 in annual total Medicare payments per beneficiary). However, the average Medicare payments for dNPWT exceeded that of tNPWT ($1,624 vs $899) during a home health episode.

CONCLUSIONS

Although dNPWT is well-suited for the home, its uptake has been slow. This may be attributable to HHAs' confusion in billing for dNPWT or differences in the wound types appropriate for dNPWT versus tNPWT. Policymakers should continue to monitor the use of dNPWT in the home health setting, especially given the greater average Medicare payment of dNPWT per episode.

Novel home use of mechanical negative pressure wound therapy in diabetic foot ulcers

OBJECTIVE

Mechanical negative pressure wound therapy is an ultraportable, light weight and disposable single-use device that has been shown to promote wound healing. This study evaluated home use of a mechanically powered negative pressure wound therapy (NPWT) in diabetic foot wounds.

METHODS

Patients underwent revascularisation and/or debridement or amputation before starting mechanical NPWT. Wound outcomes and images of the wounds were recorded at each follow-up visit by the wound nurse. Patients were followed up until wound closure or end of therapy.

RESULTS

A total of 12 patients (each with one wound) were included in the study. Of the 12 wounds, 33.3% (n=4) of wounds achieved primary wound closure while the remaining 66.6% (n=8) of wounds demonstrated a mean wound size reduction of 37.5±0.13%. Of the closed wounds, mean time to healing was 4.75±2.50 weeks. There was 100% limb salvage with no further debridement or amputations, and no 30-day unplanned readmissions. Mean length of hospital stay before starting home NPWT was 9.75±6.31 days. Mean number of NPWT changes was 8.33±2.67 sessions, while mean duration of therapy was 4.0±1.54 weeks. Mean cost of home NWPT therapy was US$1904±731 per patient.

CONCLUSION

The home use of mechanically powered NPWT in diabetic foot wounds demonstrated excellent wound healing rates and 100% limb salvage, with no complications.

Moist Wound Healing with Commonly Available Dressings

Significance: A moist wound environment has several benefits that result in faster and better quality of healing. It facilitates autolytic debridement, reduces pain, reduces scarring, activates collagen synthesis, facilitates and promotes keratinocyte migration over the wound surface, and supports the presence and function of nutrients, growth factors, and other soluble mediators in the wound microenvironment. Recent Advances: Wound dressings can be utilized to create, maintain, and control a moist environment for healing. Moist wound dressings can be divided into films, foams, hydrocolloids, hydrogels, and alginates. We are also including negative pressure wound therapy systems in the moist dressings. Critical Issues: An optimal wound dressing should provide a moist environment and have an optimal water vapor transmission rate (WVTR) and absorptive capacity. It should also protect the wound against trauma and contamination and be easy to apply, painless to remove, and esthetically acceptable or even pleasing. Future Directions: Interventions, particularly dressing changes, by medical caregivers are labor intensive and expensive and there should be a continuous effort to reduce their number per week. Smart dressings with integrated microsensors and delivery capabilities that would allow wireless real-time monitoring and treatment of the wound would be very advantageous. This way the state of the wound as well as the wear time of the dressing could be assessed without dressing removal or visit to the wound care center. In addition, an ability to adjust the WVTRs to the exudate level of the wound (or having a large absorptive capacity without changing the WVTR) would be useful. This feature would guarantee an optimal level of hydration of the wound surface throughout the treatment.

Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial

Negative pressure wound therapy (NPWT) has been shown to improve clinical outcomes for children with burns by accelerating wound re-epithelialisation. Its effects on healthcare costs, however, remain poorly understood. The aim of this study was to evaluate the cost-effectiveness of NPWT from a healthcare provider perspective using evidence from the SONATA in C randomised controlled trial, in which 101 children with small-area burns were allocated to either standard care (silver-impregnated dressings) or standard care in combination with adjunctive NPWT. The primary outcome, time to re-epithelialisation, was assessed through a blinded photographic review. Resource usage and costs were prospectively recorded for each participant for up to 6 months. Incremental cost-effectiveness ratios and dominance probabilities were estimated and uncertainty quantified using bootstrap resampling. Mean costs per participant—including dressings, labour, medication, scar management, and theatre operations—were lower in the NPWT group (AUD $903.69) relative to the control group (AUD $1669.01). There was an 89% probability that NPWT was dominant, yielding both faster re-epithelialisation and lower overall costs. Findings remained robust to sensitivity analyses employing alternative theatre costs and time-to-re-epithelialisation estimates for grafted patients. In conclusion, adjunctive NPWT is likely to be a cost-effective and dominant treatment for small-area paediatric burns (ANZCTR.org.au:ACTRN12618000256279).

Treatment of Pediatric Sternotomy Wound Complications: A Minimally Invasive Approach

BACKGROUND

 Pediatric sternal wound complications (SWCs) include sterile wound dehiscence (SWD) and superficial/deep sternal wound infections (SSWI/DSWI), and are generally managed by repetitive debridement and surgical wound approximation. Here, we report a novel nonsurgical management strategy of pediatric sternotomy wound complications, using serial noninvasive wound approximation technique combined with single-use negative pressure wound therapy (PICO) device.

METHODS

 Nine children with SWCs were managed by serial approximation with adhesive skin tapes and serial PICO device application. Thorough surgical debridement or surgical approximations were not performed.

RESULTS

 Three patients were clinically diagnosed as SWD, two patients as SSWI, and four patients as DSWI. None of the wounds demonstrated apparent mediastinitis or bone destructions. PICO device was applied at 16.1 days (range: 6-26 days) postoperatively, together with serial wound approximation by skin tapes. The average duration of PICO use was 16.9 days (range: 11-29 days) and the wound approximation was achieved in all patients. None of the patients underwent aggressive surgical debridement or invasive surgical approximation by sutures.

CONCLUSION

 We report our successful management of selected pediatric SWCs, using serial noninvasive wound approximation technique combined with PICO device.

Randomized clinical trial of negative pressure wound therapy as an adjunctive treatment for small-area thermal burns in children

Background

The efficacy of negative pressure wound therapy (NPWT) in the acute management of burns remains unclear. The purpose of this trial was to compare standard Acticoat™ and Mepitel™ dressings with combined Acticoat™, Mepitel™ and continuous NPWT to determine the effect of adjunctive NPWT on re‐epithelialization in paediatric burns.

Methods

This two‐arm, single‐centre RCT recruited children with acute thermal burns covering less than 5 per cent of their total body surface area. The primary outcome was time to re‐epithelialization. Blinded assessments were performed using photographs captured every 3–5 days until discharge. Secondary measures included pain, itch, grafting, perfusion and scar management referrals.

Results

Some 114 patients were randomized. Median time to re‐epithelialization was 8 (i.q.r. 7–11) days in the NPWT group and 10 (8–14) days in the control group. In a multivariable model, NPWT decreased the expected time to wound closure by 22 (95 per cent c.i. 7 to 34) per cent (P = 0·005). The risk of referral to scar management was reduced by 60 (18 to 81) per cent (P = 0·013). Four participants in the control group and one in the NPWT group underwent grafting. There were no statistically significant differences between groups in pain, itch or laser Doppler measures of perfusion. Adverse events were rare and minor, although NPWT carried a moderate treatment burden, with ten patients discontinuing early.

Conclusion

Adjunctive NPWT hastened re‐epithelialization in small‐area burn injuries in children, but had a greater treatment burden than standard dressings alone. Registration number: ACTRN12618000256279 ( http://ANZCTR.org.au).

Securing split-thickness skin grafts using negative-pressure wound therapy without suture fixation

OBJECTIVE

Negative-pressure wound therapy (NPWT) is generally applied as a bolster for split-thickness skin grafts (STSG) after the graft has been secured with sutures or skin staples. In this study, NPWT was applied to secure STSGs without any sutures or staples. Surgical outcomes of using NPWT without sutures was compared with a control group.

METHODS

Patients with STSGs were divided into two groups: a 'no suture' group using only NPWT, and a control group using conventional fixings. In the no suture group, the grafts were covered with meshed wound dressing and ointment. The NPWT foam was placed over the STSG and negative pressure applied. In the control group, grafts were fixed in place using tie-over bolster, securing with fibrin glue, or NPWT after sutures.

RESULTS

A total of 30 patients with 35 graft sites participated in the study. The mean rate of graft take in the no suture group was 95.1%, compared with 93.3% in the control group, with no significant difference between them. No graft shearing occurred in the no suture group. Although the difference did not reach statistical significance, mean surgical time in the no suture group (31.5 minutes) tended to be shorter than that in the control group (55.7 minutes).

CONCLUSION

By eliminating sutures, the operation time tended to be shorter, suturing was avoided and suture removal was not required meaning that patients could avoid the pain associated with this procedure. Furthermore, the potential for staple retention and its associated complications was avoided, making this method potentially beneficial for both medical staff and patients.

Use of disposable negative pressure wound therapy on split-thickness skin graft recipient sites for peripheral arterial disease foot wounds: A case report

Split-thickness skin graft (STSG) helps to promote healing of wounds by providing a viable soft tissue cover. However, the success of which is influenced by how well it takes to the recipient site. Studies have demonstrated that negative pressure wound therapy (NPWT) is an excellent modality to promote graft survival. Technological advancements have made possible the invention of disposable, ultraportable, and mechanically operated versions for improved user experience. Alas, little has been discussed about their benefits on STSG. Therefore, the purpose of this case report is to highlight the effective use of disposable NPWT on freshly applied STSG. We report here a novel use of the disposable NPWT (SNAP therapy system) for STSG recipient sites in two patients with peripheral arterial disease (PAD) foot wounds. In both patients, there was 100% STSG uptake, and the lightweight disposable NPWT system makes for a more cost-effective and comfortable experience for patients. Disposable NPWT may be a feasible alternative to conventional NPWT to aid with STSG uptake for PAD foot wound recipient sites.

Wound-Healing Following Negative-Pressure Wound Therapy with Use of a Locally Developed AquaVac System as Compared with the Vacuum-Assisted Closure (VAC) System

BACKGROUND

Negative-pressure wound therapy (NPWT) gained widespread clinical use after its introduction in the 1990s because of its many beneficial effects on the wound environment. However, high treatment costs have limited its use in third-world countries. The present study compares a low-cost, locally developed NPWT system with a commercially available system in terms of efficacy, reliability, ease of application, and safety.

METHODS

This prospective, randomized controlled trial involved 36 patients who were managed with NPWT with either a low-cost, locally developed system (AquaVac) or a commercially available Vacuum-Assisted Closure Advanced Therapy System (VAC ATS; KCI). The low-cost NPWT system described consists of a converted aquarium pump as a reusable vacuum source and a dressing system that can be found in the hospital supply room: food plastic wrap as an occlusive drape, surgical gauze as wound filler, nasogastric tubes as tubing, and used intravenous (IV) bottles as effluent canisters. The purpose of the study was to compare the 2 systems in terms of (1) time to apply the dressing, (2) exudate levels, (3) amount of granulation tissue, (4) wound size reduction, (5) average cost of treatment, (6) visual analog scale (VAS) pain scores, and (7) complications.

RESULTS

The experimental low-cost system had a small but statistically insignificant advantage over the commercially available system in terms of application time, pain during dressing changes, and wound contraction percentage. The 2 systems were comparable in terms of the amount of exudate, granulation tissue coverage, and VAS scores during the course of treatment. No wound or periwound complications were observed. The systems were significantly different in terms of cost, with the AquaVac system being 7 times less expensive than the VAC ATS system ($63.75 compared with $491.38 USD).

CONCLUSIONS

The low-cost AquaVac system was shown to be comparable with the commercial VAC ATS system, suggesting that it is an effective and safe alternative method for NPWT in resource-challenged settings.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

A prospective, randomized, controlled clinical trial on the efficacy of a single-use negative pressure wound therapy system, compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities

Multicenter, phase‐4, randomized, comparative‐efficacy study in patients with VLUs or DFUs comparing for noninferiority the percentage change in target ulcer dimensions (area, depth, and volume) a single‐use negative pressure wound therapy (s‐NPWT) system versus traditional NPWT (t‐NPWT) over a 12‐week treatment period or up to confirmed healing. Baseline values were taken at the randomization visit. Randomized by wound type and size, 164 patients with non‐infected DFUs and VLUs were included. The ITT population was composed of 161 patients (101 with VLUs, 60 with DFUs) and 115 patients completed follow‐up (64 in the s‐NPWT group and 51 in the t‐NPWT group) (PP population). The average age for all patients was 61.5 years, 36.6% were women, and treatment groups were statistically similar at baseline. Primary endpoint analyses on wound area reduction demonstrated statistically significant reduction in favor of s‐NPWT (p = 0.003) for the PP population and for the ITT population (p < 0.001). Changes in wound depth (p = 0.018) and volume (p = 0.013) were also better with s‐NPWT. Faster wound closure was observed with s‐NPWT (Cox Proportional Hazards ratio (0.493 (0.273, 0.891); p = 0.019) in the ITT population. Wound closure occurred in 45% of patients in the s‐NPWT group vs. 22.2% of patients in the t‐NPWT group (p = 0.002). Median estimate of the time to wound closure was 77 days for s‐NPWT. No estimate could be provided for t‐NPWT due to the low number of patients achieving wound closure. Device‐related AEs were more frequent in the t‐NPWT group (41 AEs from 29 patients) than in the s‐NPWT group (16 AEs from 12 patients). The s‐NPWT system met noninferiority and achieved statistical superiority vs. t‐NPWT in terms of wound progression toward healing over the treatment period. When NPWT is being considered for the management of challenging VLUs and DFUs, s‐NPWT should be considered a first choice over other types of NPWT.

Feasibility of a disposable canister-free negative-pressure wound therapy (NPWT) device for treating open wounds in horses

BACKGROUND

Wounds are among the most common medical conditions affecting horses and have a major economic impact on the horse industry. Wound healing in horses is distinct to that documented in other species, and often results in delayed healing and extensive scarring, with compromised functional and aesthetic outcomes. To date, there is no conventional method objectively proven to accelerate healing or to successfully prevent complications associated with second intention healing. Several effects of Negative Pressure Wound Therapy (NPWT) may be particularly useful to the management of wounds in horses. However, cumbersome designs of classic NPWT devices render them unsuitable for equine practice. A new lightweight, portable and disposable unit of NPWT (PICO®), should facilitate the use of this modality by equine practitioners. The aim of this study was to evaluate the feasibility of using this canister-free system to treat experimental open wounds in horses.

RESULTS

No difficulties were encountered with the application or maintenance of the PICO® system during the ex vivo experiment or during the preliminary in vivo experiment conducted on intact skin. All horses readily tolerated the PICO® but difficulties with adhesion and seal prevented the completion of the experimental wound study despite the use of many adjunctive adhesives.

CONCLUSION

The current PICO® dressing design is not suitable to be used as a dressing for open wounds in horses though the device is well tolerated by equine patients. A dressing with a wider adhesive edge, a superior adhesive and a more flexible pad would likely be better adapted to enable its future use in equine practice.

INCISIONAL NEGATIVE-PRESSURE WOUND THERAPY IN REVISION TOTAL HIP ARTHROPLASTY DUE TO INFECTION

OBJECTIVE

To present our institution's experience with negative-pressure wound therapy (NPWT) as an adjuvant in wound healing of patients who have undergone revision total hip arthroplasty (THA) due to septic loosening in the presence of active fistula.

METHODS

We prospectively assessed patients presenting with THA infection, associated with the presence of fistula, treated with a PICO^® device for NPWT, in combination with the standard treatment for prosthesis infection in our institution. Resolution of the infectious process and healing of the surgical wound without complications were considered an initial favorable outcome.

RESULTS

We assessed 10 patients who used PICO^® in our department. No complications were identified in association with the use of the NPWT device. The mean follow-up of the patients after use of the device was 12.7 months. Only one patient progressed with fistula reactivation and recurrence of infection.

CONCLUSION

NPWT can be used in wound complications and infection following THA procedures safely and with promising results. Randomized prospective studies should be conducted to confirm its effectiveness. Level of Evidence IV, Case Series.

Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality

BACKGROUND

Negative pressure wound therapy (NPWT) for postsurgical incision treatment has demonstrated benefits. A prospective randomized study was developed including 32 patients who underwent bilateral breast reduction mammoplasty. Patients served as their own control and received NPWT to one breast and fixation strips to the other breast.

METHODS

The primary outcome was the number of wound healing complications within 21 days when comparing NPWT treatment with fixation strips. The secondary outcome was aesthetic appearance and quality of scarring using questionnaires [visual analogue scale (VAS) and Patient and Observer Scar Assessment Scale (POSAS)] scored at day 42-, 90-, 180- and 365-day follow-up using additional scar measurement modalities, such as viscoelasticity.

RESULTS

For the 32 included patients, the number of wound complications was significantly lower (p < 0.004) for the NPWT treated sites compared to fixation strips. POSAS and VAS scores at 42 and 90 days revealed a significantly better quality of scarring in the NPWT treatment breasts than in fixation strips. At 180-day follow-up, there was a significant improvement in total VAS scores, as well as a comparable improvement in POSAS scores. No consistent significant improvement in scar quality was demonstrated with the assays that were used.

CONCLUSIONS

Our study showed less complications and a significant improvement in quality of scarring in favor of the NPWT-treated sites. The results indicate NPWT to be an attractive option for these patients.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty

BACKGROUND

It has been proposed that negative pressure wound therapy (NPWT) applied prophylactically to a closed incision may decrease the incidence of wound complications. Patients undergoing reduction mammaplasty are at risk of wound complications such as delayed healing, infection, and dehiscence, and the bilateral nature of the surgery allows for a within-patient randomized study to evaluate incisional NPWT's effect in reducing healing complications.

METHODS

In this multicenter trial, 200 patients undergoing bilateral reduction mammaplasty were treated with PICO Single-Use NPWT System or standard wound-care dressings randomized to right or left breast for up to 14 days to enable within-patient comparison. Follow-up assessments were conducted to evaluate the difference in incision healing complications up to 21 days postsurgery. Healing complications (for the primary endpoint) were defined as delayed healing (incision not 100% closed by 7 days) and occurrence of dehiscence or infection within 21 days. Individual healing complications were assessed separately as secondary endpoints.

RESULTS

Significantly fewer healing complications (primary endpoint) were noted in NPWT-treated breasts [113 (56.8%)] versus standard care [123 (61.8%)]. The difference of 10 (5.0%) patients with fewer healing complications using NPWT was statistically significant (P = 0.004). NPWT also resulted in a significantly lower incidence of dehiscence (secondary endpoint) compared with standard care [32 patients (16.2%) versus 52 patients (26.4%)] by day 21, a relative reduction of 38% (P < 0.001).

CONCLUSIONS

This is the first major prospective, within-patient, randomized, controlled, multicenter study to provide evidence for an incisional NPWT strategy to reduce healing complications.

Incisional Negative-Pressure Wound Therapy for Perineal Wounds After Abdominoperineal Resection for Rectal Cancer, a Pilot Study

Objective: Abdominoperineal resection (APR) is associated with high incidence of surgical wound infections. The use of incisional negative-pressure wound therapy (iNPWT) is known to reduce wound infections for several surgical indications. The aim of this pilot study was to investigate the potential of a new portable negative-pressure therapy device on perineal wound healing in patients undergoing APR. Approach: A new single-use incisional negative-pressure therapy device was applied in 10 patients. A negative pressure of -80 mmHg was continued for 7 days postsurgery. Incidence of wound complications and time to wound healing were compared with a historical control group of 10 patients undergoing APR in 2014, treated with conventional wound care. Results: Patient characteristics were comparable in both groups. Mean 1.6 dressings were used per patient. A wound complication was diagnosed in seven patients versus six in the control group. Wound infections were diagnosed median 11.5 days after surgery, compared with 10.5 days in the control group. Duration of wound healing was shorter in the study group (median 8.5 weeks vs. 13 weeks). Innovation: This is the first study to report on the use of this iNPWT device for patients who underwent APR for rectal cancer. Conclusion: In this study, iNPWT did not reduce wound complications. Wound infections occurred slightly later and seemed to have a less severe clinical course. After treatment with iNPWT, the duration of wound healing was shorter.

Use of ultraportable vacuum therapy systems in the treatment of venous leg ulcer

BACKGROUND

The high incidence of venous leg ulcers and the difficult to give a complete healing involves in an increase of costs for National Health System. Main therapies to obtain a fast healing are compressive bandages, treatment of abnormal venous flow and in-situ-strategies of wound care. Negative pressure therapy does not conventionally used, because these systems not allow the use of compression bandages. Recently the development of ultraportable devices has improved the compliance and the results.

METHODS

Ten patients with venous chronic ulcer on the lower extremities were recruited for this study: all patients had venous leg ulcers from at least one year. We treated the patients with autologous partial thickness skin graft and subsequently we applied NANOVA device included in compressive bandage. We used NANOVA for fourteen days and after we made traditional medications. We submitted a questionnaire to evaluate the impact of dressing and NANOVA device in the quality of life of patients.

RESULTS

The device contributed to the formation of granulation tissue and increased the success rate of autologous skin graft without limiting mobility of patient. In addition to this, we have been able to perform compression bandages thanks to small size of this device. Eight ulcers healed within 90 days of medication.

CONCLUSIONS

We believe that ultraportable negative pressure systems are useful devices for treatment of venous leg ulcers because them allows to realize a compressive bandage without mobility limitations.

Meta-Analysis of Comparative Trials Evaluating a Prophylactic Single-Use Negative Pressure Wound Therapy System for the Prevention of Surgical Site Complications

Background: We report the first meta-analysis on the impact of prophylactic use of a specific design of negative pressure wound therapy (NPWT) device on surgical site complications.

Methods: Articles were identified in which the specific single-use NPWT device (PICO^⋄, Smith & Nephew) was compared with standard care for surgical site infection (SSI), dehiscence, or length of stay (LOS). Risk ratio (RR) ±95% confidence interval (CI) (SSI; dehiscence) or mean difference in LOS ±95% CI was calculated using RevMan v5.3.

Results: There were 1863 patients (2202 incisions) represented by 16 articles. Among 10 randomized studies, there was a significant reduction in SSI rate of 51% from 9.7% to 4.8% with NPWT intervention (RR 0.49 [95% CI 0.34–0.69] p < 0.0001). There were six observational studies assessing reduction in SSI rate of 67% from 22.5% to 7.4% with NPWT (RR 0. 32 [95% CI 0.18–0.55] p < 0.0001). Combining all 16 studies, there was a significant reduction in SSI of 58% from 12.5% to 5.2% with NPWT (RR 0.43 [95% CI 0.32–0.57] p < 0.0001). Similar effects were seen irrespective of the kind of surgery (orthopedic, abdominal, colorectal, or cesarean section), although the numbers needed to treat (NNT) were lower in operations with higher frequencies of complications. There was a significant reduction in dehiscence from 17.4% to 12.8% with NPWT (RR 0.71 [95% CI 0.54–0.92] p < 0.01). The mean reduction in hospital LOS by NPWT was also significant (−0.47 days [95% CI −0.71 to −0.23] p < 0.0001).

Conclusions: The significant reduction in SSI, wound dehiscence, and LOS on the basis of pooled data from 16 studies shows a benefit of the PICO single-use NPWT system compared with standard care in closed surgical incisions.

Prevention of Periprosthetic Joint Infection: Examining the Recent Guidelines

BACKGROUND

The global rise in infectious disease has led the Center for Disease Control and Prevention and the World Health Organization to release new guidelines for the prevention of surgical site infection.

METHODS

In this article, we summarize current recommendations based on level of evidence, review unresolved and unaddressed issues, and supplement them with new literature.

RESULTS

Although the guidelines discuss major issues in reducing surgical site infection, many questions remain unanswered.

CONCLUSION

These guidelines will hopefully help in setting a standard of care based on best evidence available and focus investigators on areas where evidence is lacking.

Accelerated wound healing with combined NPWT and IPC: a case series

Negative pressure wound therapy (NPWT) and intermittent pneumatic compression (IPC) have traditionally been used in patients with chronic complicated non-healing wounds. The aim of this study (retrospective case series) was to describe the use of NPWT in combination with IPC in patients with a relatively short history (2-6 months) of ulcers. All wounds showed improved healing during the treatment period with marked or moderate reduction in ulcer size, and granulation tissue formation was markedly stimulated. Oedema was markedly reduced due to IPC. Treatment was generally well tolerated. The results of this study indicate that combined NPWT and IPC can accelerate wound healing and reduce oedema, thus shortening the treatment period. Therefore, patients may have a shorter healing period and may avoid entering a chronic wound phase. However, controlled studies of longer duration are needed in order to show the long-term effect of a more accelerated treatment course.

Alternatives to antibiotics for prevention of surgical infection

BACKGROUND

Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI.

METHODS

A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade.

RESULTS

Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care.

CONCLUSION

There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.

A novel facilitated negative-pressure wound therapy for thoracic incision infection after esophagectomy

BACKGROUND

Negative-pressure wound therapy (NPWT) is the therapeutic management of traumatic soft-tissue wounds and infections. The efficacy of NPWT in the treatment of thoracic incision infection is unclear. We assess the effectiveness and safety of a novel facilitated NPWT for thoracic incision infection after esophagectomy.

METHODS

Between Jan. 2013 and Mar. 2016, 380 patients underwent open esophagectomy in our department. Forty-five patients with thoracic incision infection were retrospectively reviewed. Of these patients, 25 were treated with NPWT and 20 patients were treated with open wound dressing. The patients' clinical demographic data, postoperative outcomes and wound treatment cost are reviewed.

RESULTS

The thoracic incision infection rate was 11.8%. All of the incision infections were cured in the hospital or on an outpatient basis. No allergic reactions or other side effects occurred with NPWT. Although the patients who were treated with NPWT did not have a significantly shorter postoperative hospital stay than those treated with open wound dressing (P=0.092), the use of NPWT therapy for thoracic incision infection led to a shorter wound healing times (13 vs. 20 days; P=0.004) and a lower wound treatment cost (P=0.020).

CONCLUSIONS

Thoracic incision infection is a common complication of esophagectomy. NPWT is a safe and effective therapeutic management for thoracic incision infection that is associated with shortened wound healing times and reduced wound treatment costs than traditional open wound treatment.

NEGATIVE-PRESSURE WOUND THERAPY IN THE TREATMENT OF COMPLEX INJURIES AFTER TOTAL KNEE ARTHROPLASTY

OBJECTIVE

To present an experience with negative-pressure wound therapy (NPWT) in the treatment of surgical wounds in patients treated for infections after total knee arthroplasty (TKA) with or without dehiscence and prophylaxis in wounds considered at risk of healing problems.

METHODS

We prospectively evaluated patients with TKA infection with or without surgical wound dehiscence and patients with risk factors for infection or surgical wound complications treated with Pico^(r) device for NPWT in addition to standard treatment of infection or dehiscence in our institution. We considered as an initial favorable outcome the resolution of the infectious process and the closure of the surgical wound dehiscences in the treated cases and the good progression of the wound without complicating events in the prophylactic cases.

RESULTS

We evaluated 10 patients who used Pico^(r) in our service. All patients had a favorable outcome according to established criteria. No complications were identified regarding the use of the NPWT device. The mean follow-up of the patients after the use of the device was 10.5 months.

CONCLUSION

The NPWT can be safely used in wound infections and complications following TKA with promising results. Long-term randomized prospective studies should be conducted to prove its effectiveness. Level of Evidence IV, Case Series.

Use of ultraportable vacuum therapy systems in the treatment of venous leg ulcer

BACKGROUND

The high incidence of venous leg ulcers and the difficult to give a complete healing involves in an increase of costs for National Health System. Main therapies to obtain a fast healing are compressive bandages, treatment of abnormal venous flow and in-situ-strategies of wound care. Negative pressure therapy does not conventionally used, because these systems not allow the use of compression bandages. Recently the development of ultraportable devices has improved the compliance and the results.

METHODS

Ten patients with venous chronic ulcer on the lower extremities were recruited for this study: all patients had venous leg ulcers from at least one year. We treated the patients with autologous partial thickness skin graft and subsequently we applied NANOVA device included in compressive bandage. We used NANOVA for fourteen days and after we made traditional medications. We submitted a questionnaire to evaluate the impact of dressing and NANOVA device in the quality of life of patients.

RESULTS

The device contributed to the formation of granulation tissue and increased the success rate of autologous skin graft without limiting mobility of patient. In addition to this, we have been able to perform compression bandages thanks to small size of this device. Eight ulcers healed within 90 days of medication.

CONCLUSIONS

We believe that ultraportable negative pressure systems are useful devices for treatment of venous leg ulcers because them allows to realize a compressive bandage without mobility limitations.

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.

Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial

Objectives

Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties.

Methods

A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group.

Results

An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06).

Conclusions

Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications.

Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

Biomechanical Modeling of the Forces Applied to Closed Incisions During Single-Use Negative Pressure Wound Therapy

OBJECTIVES

The use of negative pressure wound therapy (NPWT) on closed surgical incisions is an emerging technology that may reduce the incidence of complications such as surgical site infections. One of the mechanisms through which incisional NPWT is thought to operate is the reduction of lateral tension across the wound.

METHODS

Finite element analysis computer modeling and biomechanical testing with Syndaver SynTissue™ synthetic skin were used to explore the biomechanical forces in the presence of the PICO(⋄) (Smith & Nephew Ltd, Hull, United Kingdom) negative pressure wound therapy system on a sutured incision.

RESULTS

Finite element analysis modeling showed that the force on an individual suture reduced to 43% of the force without negative pressure (from 1.31 to 0.56 N) at -40 mm Hg and to 31% (from 1.31 to 0.40 N) at -80 mm Hg. Biomechanical testing showed that at a pressure of -80 mm Hg, 55% more force is required for deformations in the tissue compared with the situation where no negative pressure wound therapy dressing is active. The force required for the same deformation at -120 mm Hg is only 10% greater than at -80 mm Hg, suggesting that most of the effect is achieved at -80 mm Hg.

CONCLUSIONS

The results show that a canister-less single-use NPWT device is able to reduce the lateral tension across a closed incision, which may explain observed clinical reductions in surgical site complications with incisional NPWT.

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.

Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments

Negative-pressure wound therapy (NPWT) plays an important role in the treatment of complex wounds. Its effect on limb salvage in the management of the diabetic foot is well described in the literature. However, a successful outcome in this subgroup of diabetic patients requires a multidisciplinary approach with careful patient selection, appropriate surgical debridement, targeted antibiotic therapy, and optimization of healing markers. Evolving NPWT technology including instillation therapy, nanocrystalline adjuncts, and portable systems can further improve results if used with correct indications. This review article summarizes current knowledge about the role of NPWT in the management of the diabetic foot and its mode of action, clinical applications, and recent developments.

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.