Complications of negative pressure wound therapy: a mini review

Negative Pressure Wound Therapy for Chronic Wounds

ABSTRACT

Chronic wounds, including those caused by venous and arterial insufficiency, diabetic complications, and pressure-induced ulcers, pose significant treatment challenges. Negative pressure wound therapy has been increasingly used for managing these wounds. This treatment aims to promote wound healing, prepare the wound bed for further surgical intervention, minimize the risk of infection, and potentially shorten the time to wound healing. Considering variances in techniques applied in different regions globally, there is an emerging need to comprehensively evaluate the effectiveness of negative pressure wound therapy on chronic wounds. Unfortunately, detailed descriptions of the techniques applied to achieve negative pressure are often lacking in existing literature abstracts, posing challenges for direct comparisons. This review aims to analyze the application of negative pressure wound therapy in the treatment of chronic wounds, summarize its advantages and disadvantages, and further explore the potential value and future research direction of negative pressure wound therapy in the repair of chronic wounds.

A critical overview of challenging roles of medicinal plants in improvement of wound healing technology

PURPOSE

Chronic diseases often hinder the natural healing process, making wound infections a prevalent clinical concern. In severe cases, complications can arise, potentially leading to fatal outcomes. While allopathic treatments offer numerous options for wound repair and management, the enduring popularity of herbal medications may be attributed to their perceived minimal side effects. Hence, this review aims to investigate the potential of herbal remedies in efficiently treating wounds, presenting a promising alternative for consideration.

METHODS

A literature search was done including research, reviews, systematic literature review, meta-analysis, and clinical trials considered. Search engines such as Pubmed, Google Scholar, and Scopus were used while retrieving data. Keywords like Wound healing 'Wound healing and herbal combinations', 'Herbal wound dressing', Nanotechnology and Wound dressing were used.

RESULT

This review provides valuable insights into the role of natural products and technology-based formulations in the treatment of wound infections. It evaluates the use of herbal remedies as an effective approach. Various active principles from herbs, categorized as flavonoids, glycosides, saponins, and phenolic compounds, have shown effectiveness in promoting wound closure. A multitude of herbal remedies have demonstrated significant efficacy in wound management, offering an additional avenue for care. The review encompasses a total of 72 studies, involving 127 distinct herbs (excluding any common herbs shared between studies), primarily belonging to the families Asteraceae, Fabaceae, and Apiaceae. In research, rat models were predominantly utilized to assess wound healing activities. Furthermore, advancements in herbal-based formulations using nanotechnology-based wound dressing materials, such as nanofibers, nanoemulsions, nanofiber mats, polymeric fibers, and hydrogel-based microneedles, are underway. These innovations aim to enhance targeted drug delivery and expedite recovery. Several clinical-based experimental studies have already been documented, evaluating the efficacy of various natural products for wound care and management. This signifies a promising direction in the field of wound treatment.

CONCLUSION

In recent years, scientists have increasingly utilized evidence-based medicine and advanced scientific techniques to validate the efficacy of herbal medicines and delve into the underlying mechanisms of their actions. However, there remains a critical need for further research to thoroughly understand how isolated chemicals extracted from herbs contribute to the healing process of intricate wounds, which may have life-threatening consequences. This ongoing research endeavor holds great promise in not only advancing our understanding but also in the development of innovative formulations that expedite the recovery process.

Phosphoenolpyruvate carboxykinase-1 targeted siRNA promotes wound healing in type 2 diabetic mice by restoring glucose homeostasis

It is well-accepted that the liver plays a vital role in the metabolism of glucose and its homeostasis. Dysregulated hepatic glucose production and utilization, leads to type 2 diabetes (T2DM). In the current study, RNA sequencing and qRT-PCR analysis of nanoformulation-treated T2DM mice (TGthr group) revealed beneficial crosstalk of PCK-1 silencing with other pathways involved in T2DM. The comparison of precise genetic expression profiles of the different experimental groups showed significantly improved hepatic glucose, fatty acid metabolism and several other T2DM-associated crucial markers after the nanoformulation treatment. As a result of these improvements, we observed a significant acceleration in wound healing and improved insulin signaling in vascular endothelial cells in the TGthr group as compared to the T2DM group. Enhanced phosphorylation of PI3K/Akt pathway proteins in the TGthr group resulted in increased angiogenesis as observed by the increased expression of endothelial cell markers (CD31, CD34) thereby improving endothelial dysfunctions in the TGthr group. Additionally, therapeutic nanoformulation has been observed to improve the inflammatory cytokine profile in the TGthr group. Overall, our results demonstrated that the synthesized therapeutic nanoformulation referred to as GPR8:PCK-1siRNA holds the potential in ameliorating hyperglycemia-associated complications such as delayed wound healing in diabetes.

Closed-incision negative pressure therapy as a strategy to reduce sternal wound infection in identified high-risk patients: a multicentre propensity matched study

OBJECTIVES

The premise of this retrospective study was to evaluate the intraoperative use of closed-incision negative pressure therapy (ciNPT) to help reduce the incidence of postoperative sternal wound infections in multimorbid patients with an elevated risk of developing a sternal wound infection post cardiac surgery versus a cohort that received standard-of-care dressings.

METHODS

Data for all adult patients were collected from each cardiothoracic surgery unit across 3 hospitals in the United Kingdom. High-risk patients had 2 or more recognized risk factors. Fisher's exact test (two-tailed) and unpaired t-test were used to help analyse categorical and continuous data. Propensity matching was performed to compare the 2 groups.

RESULTS

A total of 5,288 patients who had cardiac surgery were included. Propensity matching led to 766 matched cases. There were significantly fewer sternal wound infections in the ciNPT group [43 (5.6%) vs 119 (15.5%) cases; P = 0.0001], as well as fewer deep sternal wound infections [14 (1.8%) vs 31 (4.0%) cases; P = 0.0149] and superficial sternal wound infections [29 (3.8%) vs 88 (11.4%) cases; P = 0.0001]. A higher mean length of stay in the ciNPT group was statistically significant (11.23 ± 13 vs 9.66 ± 10 days; P = 0.0083) as was a significantly higher mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (11.143 ± 13 vs 8.094 ± 11; P = 0.0001). A statistically significant higher readmission to the intensive care unit due to sternal wound infection was noted for the controls [16 (2.08%) vs 3 (0.39%) readmissions; P = 0.0042].

CONCLUSIONS

The ciNPT appears to be an effective intervention to help reduce the incidence of sternal wound infection in high-risk individuals undergoing cardiac surgery.

Negative pressure wound therapy: Where are we in 2022?

The use of negative pressure wound therapy (NPWT) continues to be an important tool for surgeons. As the use and general acceptance of NPWT have grown, so have the indications for its use. These indications have expanded to include soft tissue defects in trauma, infection, surgical wound management, and soft tissue grafting procedures. Many adjuvants have been engineered into newer generations of NPWT devices such as wound instillation of fluid or antibiotics allowing surgeons to further optimize the wound healing environment or aid in the eradication of infection. This review discusses the recent relevant literature on the proposed mechanisms of action, available adjuvants, and the required components needed to safely apply NPWT. The supporting evidence for the use of NPWT in traumatic extremity injuries, infection control, and wound care is also reviewed. Although NPWT has a low rate of complication, the surgeon should be aware of the potential risks associated with its use. Furthermore, the expanding indications for the use of NPWT are explored, and areas for future innovation and research are discussed.

Prophylactic negative pressure wound therapy is not effective for preventing driveline infection following left ventricular assist device implantation

BACKGROUND

Driveline infection (DLI) following left ventricular assist device (LVAD) implantation remains an unresolved problem. Negative pressure wound therapy (NPWT) promotes wound healing by applying negative pressure on the surface of the wound. Recently, the prophylactic application of NPWT to closed surgical incisions has decreased surgical site infections in various postsurgical settings. Therefore, we evaluated the efficacy and safety of prophylactic NPWT for preventing DLI in patients with LVAD implantation.

METHODS

Prophylactic NPWT was provided to 50 patients who received continuous-flow LVADs as bridge-to-transplant therapy at our institution between May 2018 and October 2020 (NPWT group). The negative pressure dressing was applied immediately after surgery and retained on the driveline exit site for 7 days with a continuous application of -125 mm Hg negative pressure. The primary outcome was DLI within 1 year of LVAD implantation. We compared the rate of DLI incidence in the NPWT group with that in the historical control cohort (50 patients) treated with the standard dressing (SD) who received LVAD implantation between July 2015 and April 2018 (SD group).

RESULTS

No severe complications were associated with the NPWT. During the follow-up period, DLI was diagnosed in 16 participants (32%) in the NPWT group and 21 participants (42%) in the SD group. The rates of DLI incidence and freedom from DLI did not differ between groups (p = 0.30 and p = 0.63).

CONCLUSIONS

Prophylactic NPWT at the driveline exit site was safe following LVAD implantation. However, it did not significantly reduce the risk of DLI.

Modulation of Lymphangiogenesis in Incisional Murine Diabetic Wound Healing Using Negative Pressure Wound Therapy

Objective: Despite the significant function of lymphatics in wound healing, and frequent clinical use of Negative Pressure Wound Therapy (NPWT), the effect of mechanical force application on lymphangiogenesis remains to be elucidated. We utilize a murine incisional wound healing model to assess the mechanisms of lymphangiogenesis following NPWT. Approach: Dorsal incisional skin wounds were created on diabetic mice (genetically obese leptin receptor-deficient mice [db/db]; n = 30) and covered with an occlusive dressing (Control, n = 15) or NPWT (-125 mmHg, continuous, 24 h for 7 days; NPWT, n = 15). The wounds were macroscopically assessed for 28 days. Tissue was harvested on day 10 for analysis. Qualitative functional analysis of lymphatic drainage was performed on day 28 using Evans Blue staining (n = 2). Results: NPWT increased lymphatic vessel density (40 ± 20 vs. 12 ± 6 podoplanin [PDPN]⁺ and 25 ± 9 vs. 14 ± 8 lymphatic vessel endothelial receptor 1 [LYVE-1]⁺) and vessel diameter (28 ± 9 vs. 12 ± 2 μm). Western blotting verified the upregulation of LYVE-1 with NPWT. Leukocyte presence was higher with NPWT (22% ± 3.7% vs. 9.1% ± 4.1% lymphocyte common antigen [CD45]⁺) and the leukocytes were predominately B cells clustered within vessels (8.8% ± 2.5% vs. 18% ± 3.6% B-lymphocyte antigen CD20 [CD20]⁺). Macrophage presence was lower in the NPWT group. Lymphatic drainage was increased in the NPWT group, which exhibited greater Evans Blue positivity. Innovation: The lymphangiogenic effects take place independent of macrophage infiltration, appearing to correlate with B cell presence. Conclusion: NPWT promotes lymphangiogenesis in incisional wounds, significantly increasing the lymph vessel density and diameter. This study highlights the potential of NPWT to stimulate lymphatic drainage and wound healing of surgical incisions.

Negative-Pressure Wound Therapy: What We Know and What We Need to Know

Negative-pressure wound therapy (NPWT) promotes wound healing by applying negative pressure to the wound surface. A quarter of a century after its introduction, NPWT has been used in various clinical conditions, although molecular biological evidence is insufficient due to delay in basic research. Here, we have summarized the history of NPWT, its mechanism of action, what is currently known about it, and what is expected to be known in the future. Particularly, attention has shifted from the four main mechanisms of NPWT to the accompanying secondary effects, such as effects on various cells, bacteria, and surgical wounds. This chapter will help the reader to understand the current status and shortcomings of NPWT-related research, which could aid in the development of basic research and, eventually, clinical use with stronger scientific evidence.

Negative Pressure Wound Therapy in the Head and Neck: A Summary of Uses and Application Techniques

Negative pressure wound therapy (NPWT) has had an expanded role in the management of complex wounds including its increasing use for complex wounds in the head and neck region. Challenges for use in the head and neck region include variations in surface topography and the proximity of sensitive mouth, nose, ear, eye, and tracheal openings. Despite these challenges, NPWT has been used in the head and neck immediately following free flap surgery, to prepare wounds for skin grafting or local flaps, to treat orocutaneous and pharyngocutaneous fistulas, to treat necrotizing and deep neck space infections, to temporize and palliate, and to treat chronic wounds with exposed bone and hardware among others. This review demonstrates the proven track record of successful uses of NPWT in the aforementioned scenarios, provides suggestions to improve efficacy, as well as an algorithm for use in certain clinical situations.

Early Reconstruction Delivered Better Outcomes for Severe Open Fracture of Lower Extremities: A 15-Year Retrospective Study

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.

Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence

PURPOSE

Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients.

PATIENTS AND METHODS

This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model.

RESULTS

A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]).

CONCLUSION

Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.

Outcome of Prophylactic Postoperative Negative Pressure Wound Treatment in Colorectal Cancer Patients

BACKGROUND

Wound infection is a common cause of morbidity in colorectal surgery. We speculated that a prophylactic Negative Pressure Wound Treatment (NPWT) is associated with less postoperative wound complications for colorectal cancer patients who undergo a colectomy.

METHODS

Multivariate analysis was used to investigate the association between NPWT and wound complications for patients with colorectal cancer who underwent a colectomy using data from the National Surgical Quality Improvement Program (NSQIP) database during the 2013 - 2019 period.

RESULTS

We investigated 96 105 patients who underwent colectomy for colorectal cancer during 2013-2019 within the database. Negative Pressure Wound Treatment was utilized for 270 patients following the principal procedure (.3%). Patients who had NPWT had dirtier wounds, less bowel preparation, more extensive surgery (total colectomy vs partial colectomy), higher stoma creation, and more non-elective operations. Multiple factors were associated with postoperative wound complications such as smoking Adjusted Odd Ratio (AOR:1.27, P < .01), chronic steroid use (AOR: 1.30, P < .01), obesity (AOR: 1.54, P < .01), and serum albumin level less than 3.5 g/dL (AOR: 1.29, P < .01). Overall, there was no significant decrease in wound complications using NPWT (AOR: .66, P = .14). However, a sub-group of patients who underwent emergent/urgent operation had a significant lower risk of wound complications using NPWT (AOR: .3, CI: .09-.99, P = .04).

CONCLUSION

Prophylactic NPWT is associated with a decrease in wound complications of patients who underwent an emergent/urgent colectomy for colorectal cancer. However, we could not find any significant decrease in wound complications for elective colorectal procedures for colorectal cancer. Further clinical trials are needed to confirm these study results.

Roles of Oxidative Stress and Raftlin in Wound Healing Under Negative-Pressure Wound Therapy

Background

Negative-pressure wound therapy (NPWT) is an effective way to promote wound healing. However, its mechanisms have not been investigated thoroughly. Growing evidence suggests that oxidative stress and Raftlin levels play important roles in wound healing. However, whether NPWT promotes wound healing through this mechanism remains unclear.

Purpose

Our study focuses on the different levels of oxidative stress and antioxidant response between wounds treated by NPWT and routine dressing change. The objective of this study was to measure the differences in Raftlin levels between the two groups, which is a new biomarker related to wound healing.

Methods

We divided 48 male Sprague-Dawley rats with identical full-thickness skin defects into two groups. At specific times (0, 3, 5, 7, 9, 11, and 13 days after surgery), wound tissue samples were obtained for immunohistochemistry and biochemical analysis. The expression of Raftlin and levels of oxidative stress, including malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) levels were measured by biochemical analysis. Wound-healing times were also compared.

Results

In the NPWT group, MDA levels were significantly decreased on days 3, 5, and 7. Furthermore, the expressions of SOD and CAT were significantly reduced on days 3 and 5. Our data also revealed that Raftlin was significantly upregulated across the whole period of wound healing. Moreover, wound healing in the NPWT group was significantly more rapid (16 days on average) than in the control group (24 days on average). On day 13 post surgery, the wound-healing percentage in the NPWT group was 91%, while that in the control group was 48%.

Conclusion

NPWT may promote wound healing by upregulating Raftlin and inhibiting oxidative stress levels.

Biomechanical Motion-Activated Endogenous Wound Healing through LBL Self-Powered Nanocomposite Repairer with pH-Responsive Anti-Inflammatory Effect

Wound care is still worthy of concern, and effective measures such as electrical stimulating therapy (EST) have sparked compellingly for wound repair. Especially, portable and point-of-care EST devices get extremely desired but these are often limited by inevitable external power sources, lack of biological functions, and mechanical properties conforming to skin tissue. Herein, a dress-on-person self-powered nanocomposite bioactive repairer of wound is designed. As such, the cooperation of the film prepared by layer-by-layer self-assembling 2-hydroxypropyltrimethyl ammonium chloride chitosan (HTCC), alginate (ALG), and poly-dopamine/Fe³⁺ nanoparticles (PFNs), with a self-powered nanogenerator (SN) driven by motion into a nanocomposite repairer (HAP/SN-NR) is conducted. The HAP/SN-NR not only guides cell behavior (proliferation and migration rate ≈61.7%, ≈52.3%), but also facilitates neovascularization (enhanced CD31 expression >4-fold) through its self-powered EST, and the endogenous wound closure with no inflammatory in rats owing to reactive oxygen species (ROS)-clearance of HAP/SN-NR in vitro/vivo through responsively releasing poly-dopamine nanoparticles at wound pH. Enormous efforts illustrate that the repairer is endowed with high self-adhesion to tissue, self-healing, and biodegradation, accelerating wound healing (50% closure ≈5 days). This strategy sheds light on novel multifunctional portable sensor-type dressings and propels the development of intelligent medical devices.

Wound Healing Activities and Potential of Selected African Medicinal Plants and Their Synthesized Biogenic Nanoparticles

In Africa, medicinal plants have been traditionally used as a source of medicine for centuries. To date, African medicinal plants continue to play a significant role in the treatment of wounds. Chronic wounds are associated with severe healthcare and socio-economic burdens despite the use of conventional therapies. Emergence of novel wound healing strategies using medicinal plants in conjunction with nanotechnology has the potential to develop efficacious wound healing therapeutics with enhanced wound repair mechanisms. This review identified African medicinal plants and biogenic nanoparticles used to promote wound healing through various mechanisms including improved wound contraction and epithelialization as well as antibacterial, antioxidant and anti-inflammatory activities. To achieve this, electronic databases such as PubMed, Scifinder^® and Google Scholar were used to search for medicinal plants used by the African populace that were scientifically evaluated for their wound healing activities in both in vitro and in vivo models from 2004 to 2021. Additionally, data on the wound healing mechanisms of biogenic nanoparticles synthesized using African medicinal plants is included herein. The continued scientific evaluation of wound healing African medicinal plants and the development of novel nanomaterials using these plants is imperative in a bid to alleviate the detrimental effects of chronic wounds.

Treatment of a Rare Case of Orbital Necrotizing Fasciitis Utilizing Negative Pressure Wound Therapy

We present a severe case of orbital necrotizing fasciitis that was treated utilizing negative pressure wound therapy (NPWT). 

The conditions caused by the disease and the utility of the treatment were discussed. Additionally, the functionality and the process of the treatment were thoroughly analyzed. Potential complications from utilizing NPWT were also identified. When the patient was tested, it was found that he had intra op cultures with group B Streptococcus pyogenes (Strep pyogenes). CT scans were also conducted to analyze his right lateral periorbital tissue. Subsequently, the patient was admitted to the ICU, where a wound vacuum-assisted closure (VAC) was placed on his right eye. Once the NPWT was complete, the patient was prescribed antibiotics and was able to improve the health within his right eye.

[ALGINATE versus negative-pressure therapy: Comparison of the clinical effectiveness, tolerance and costs in management of patients after surgical excision. Multicenter, randomized non-inferiority clinical trial on 113 patients]

INTRODUCTION

Pure calcium alginate dressing (ALGINATE) and Negative Pressure Wound Therapy (NPWT) are frequently used for the preparation of skin excisions for a split thickness skin graft take. The trial compared the healing efficacy, safety and cost of patient care for these two treatments.

PATIENTS AND METHODS

This randomized, non-inferiority trial enrolled 113 patients who underwent skin excision (>30 cm²) and received ALGINATE or NPWT. The primary outcome was the time to obtain optimal granulation tissue for a split thickness skin graft take. Secondary outcomes were the occurrence of adverse events (AEs) and the impact of the patient care cost on the Social Security budget.

RESULTS

The mean time to optimal granulation was similar between ALGINATE and NPWT: approximately 20 days. No AE was reported with ALGINATE while 24 % of patients treated with NPWT presented an AE. Following hospitalization, 94 % of ALGINATE patients were cared for at home by a private nurse, while 90 % of NPWT patients were followed up in aftercare and rehabilitation facilities or home hospitalization. Therefore, the cost of treatment per patient for the French Social Security was 498 € with ALGINATE and 2104 € with NPWT.

CONCLUSION

This trial has demonstrated that ALGINATE has a similar healing efficacy to that of NPWT, and that it is markedly better with regard to patient safety and cost savings. ALGINATE should therefore be preferred to NPWT in this indication.

Perspectives on the Process of Negative Pressure Wound Therapy at Home in Patients With Chronic Wound: A Qualitative Descriptive Study

The purpose of this study was to explore the experience of negative pressure wound therapy (NPWT) at home among Chinese chronic wound patients. Qualitative descriptive study design was adopted, and qualitative data were collected through semistructured in-depth interviews. A purposive, sampling method was used. Informants were recruited from one single wound healing center of a teaching hospital and were interviewed following one course of NPWT at home. A thematic content analysis was undertaken in the framework of input-process-output theory to guide analysis. Of the 13 participants interviewed, 9 were female and 4 were male with an age ranging from 20 to 69 years. Two major categories with their corresponding codes were identified. The first, positive experience, had 6 codes: high-degree identity and feeling hope (input); easy operation and convenience (process); improvement of symptoms and effective treatment (output). The second category, negative experience, had 11 codes: high expenditure, defects of the NPWT device, health education deficiency, and lack of independence and rationales in making decision of NPWT (input); poor communication with wound professionals, unexpected circumstances, therapeutic side effects, and a change of self-image (process); impact on physical symptoms and daily life, impact on social activities, and impact on psychological well-being (output). Patients considered the NPWT at home as a promising regimen, but they also had a feeling of not being prepared and lack of health education to make medical decision independently. The participants' perceptions and experiences would provide valuable information to promote the intervention program of health education and advance service process optimization.

Early wound complications after orthopaedic surgery for haemophilia: What can we do more

BACKGROUND

The characteristics of the haemophilia may endanger the patient with haemophilia (PWH) to higher ratio of wound complication, even lead to the refractory wound problem. The early wound complication in PWH has not been well studied in literature.

METHODS

Between the period from 2002 to 2018, 250 patients underwent 323 elective orthopaedic surgical procedures for the treatment of haemophilic musculoskeletal disorders. The medical records were retrospectively reviewed. The patients were evaluated for postoperative wound complications within 30 days. Risk factors related to wound complications were further analysed. The patients underwent vacuum sealing drainage (VSD) for refractory wound healing problem were further analysed.

RESULTS

Twenty-four patients of 250 patients experienced early wound complication within postoperative 30 days. The incidence of wound complication in the patients without preoperative infection was 6.5%. Positive inhibitor and surgery for pseudotumour were associated with higher rate of wound complication after logistic regression, with the odds ratios (OR) of 5.7 (95% CI, 1.08 to 30.3) and 4.9 (95% CI, 1.3 to 18.5), respectively. Eight patients underwent VSD treatment for refractory wound healing problem and recovered uneventfully. The total VSD treatment cycle was 2.25 (from 2 to 4). The average factor consumption was 26.1 IU kg^-1  d^-1 . The patients complicated with infection had higher, but not statistically significantly, treatment duration, factor consumption and peri-VSD total blood loss than the patients without infection.

CONCLUSIONS

PWH had an incidence of 6.5% of early wound healing problem after elective orthopaedic surgery for musculoskeletal disorder in the present study. The presence of positive inhibitor and surgical procedure for haemophiliac pseudotumour are associated with higher incidence of wound healing problem. The VSD is an effective alternative for the treatment of refractory wound healing problem for PWH, especially for the patients complicated with infection.

Negative pressure wound therapy in the treatment of surgical site infection in cardiac surgery

OBJECTIVES

to describe the relationship between epidemiological and clinical characteristics of postoperative cardiac surgery patients undergoing negative pressure wound therapy for the treatment of surgical site infection.

METHODS

an observational, cross-sectional analytical study including a convenience sample consisting of medical records of patients undergoing sternal cardiac surgery with surgical site infection diagnosed in medical records treated by negative pressure wound therapy.

RESULTS

medical records of 117 patients, mainly submitted to myocardial revascularization surgery and with deep incisional surgical site infection (88; 75.2%). Negative pressure wound therapy was used on mean for 16 (±9.5) days/patient; 1.7% had complications associated with therapy and 53.8% had discomfort, especially pain (93.6%). The duration of therapy was related to the severity of SSI (p=0.010) and the number of exchanges performed (p=0.045).

CONCLUSIONS

negative pressure wound therapy has few complications, but with discomfort to patients.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial

Supplemental Digital Content is available in the text.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments.

Inpatient Versus Outpatient Management of Negative Pressure Wound Therapy in Pediatric Patients

BACKGROUND

Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients.

MATERIALS AND METHODS

We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with ≤50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with >50% of NPWT.

RESULTS

We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy.

CONCLUSIONS

Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall cost-effective treatment setting for NPWT in the pediatric population.

Modified Usage of Negative Pressure Wound Therapy for the Management of Severe Deep Fascial Space Infections in the Head and Neck

Purpose

Although negative pressure wound therapy (NPWT) has been widely used in complicated wound care, there are still some obstacles regarding its use in the treatment of severe deep fascial space infections in the head and neck. The purpose of this study is to describe a new modified usage of NPWT and investigate the clinical efficacy of this system in a consecutive case series of severe deep fascial space infections.

Methods

The investigators implemented a new modification of NPWT for the management of severe deep fascial space infections. In this new system, the half-plugged bar-shaped foam material was arranged along with the through-and-through side-holed latex drainage tube, which could maintain negative pressure in the distal part of the spaces, and the tube was easy to remove 5–7 days after surgery. Twelve patients had severe deep fascial space infections in the head and neck with a direct threat to the airway. The median time of removal of the NPWT device, the median amount of drainage fluid and the median healing time were investigated.

Results

A total of 7 male and 5 female patients with an average age of 63.2 years old were included in this study. The median time of removal of the NPWT device was 6 days (ranging from 4 to 7 days). The median amount of drainage fluid within 3 days after surgery was 420 mL (ranging from 280–760 mL), and the median time for complete wound healing was 12 days (ranging from 10 to 21 days).

Conclusion

The results of this study suggest that the modification of NPWT provides various advantages and leads to excellent clinical outcomes in the treatment of severe deep fascial space infections. Future studies will focus on the safety verification of portable usage and the cost effectiveness analysis of NPWT.

Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In conjunction with advice from internal and external reviewers and expert consultants in the field, this update is based on a systematic review of the literature centred on the following: the Population (P), Intervention (I), Comparator (C) and Outcomes (O) framework; the use of the SIGN guideline/Cochrane review system; and the 21 point scoring system advocated by IWGDF/EWMA. This has resulted in 13 recommendations. The recommendation on sharp debridement and the selection of dressings remain unchanged from the last recommendations published in 2016. The recommendation to consider negative pressure wound therapy in post-surgical wounds and the judicious use of hyperbaric oxygen therapy in certain non-healing ischaemic ulcers also remains unchanged. Recommendations against the use of growth factors, autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide or interventions reporting improvement of ulcer healing through an alteration of the physical environment or through other systemic medical or nutritional means also remain. New recommendations include consideration of the use of sucrose-octasulfate impregnated dressings in difficult to heal neuro-ischaemic ulcers and consideration of the use of autologous combined leucocyte, platelet and fibrin patch in ulcers that are difficult to heal, in both cases when used in addition to best standard of care. A further new recommendation is the consideration of topical placental derived products when used in addition to best standard of care.

MicroRNA-126: a promising biomarker for angiogenesis of diabetic wounds treated with negative pressure wound therapy

BACKGROUND

Negative pressure wound therapy represents an effective therapy to treat nonhealing diabetic wounds by promoting angiogenesis, of which the mechanism hasn't been investigated thoroughly. Growing evidence suggests that miRNAs hold great potential to be clinical biomarkers, and miR-126 is an essential angiogenesis regulator in diabetic wound repair.

PURPOSE

Our study aims to explore the effect of NPWT on the expression of miR-126 in the wound tissue and plasma of diabetic rat models and the association between circulating miR-126 and two quantitative indexes of angiogenesis.

METHODS

Full-thickness excisional wounds were created on the back of diabetic rats. Measure the wound closure and collect the wound tissue and blood for H&E, immunohistochemistry, Western blot and RT-PCR. Here we demonstrated that significantly increased capillary density and arteriolar density in the NPWT group at each specified time-point.

RESULTS

In the NPWT group, miR-126 expression was significantly increased on days 3, 5, 7, and 9 (P<0.05). Furthermore, statistically significant increases in VEGF mRNA and protein expression and p-ERK expression, as well as decreased SPRED1 expression, were noted upon treatment with NPWT on day 9. Our data revealed that miR-126 expression in the wound and plasma was significantly associated (P<0.05). Moreover, a positive correlation was also detected between increased levels of circulating miR-126 and arteriolar density, as well as capillary density (P<0.05).

CONCLUSION

The study suggested that miR-126 was upregulated by NPWT and could represent a promising monitoring tool for angiogenesis in diabetic wounds treated with NPWT.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

Vacuum-Assisted Closure (VAC) Using Multiple Foam Pieces for Hidden Space Drainage through Less Exposure in Musculoskeletal Infections

Background: Purulent musculoskeletal infections often require surgical debridement and drainage. However, when the infection is extensive or involving multiple layers of tissues, maintaining drainage of the involved spaces can be difficult, even with the application of vacuum-assisted closure (VAC) therapy. Wide exposure and aggressive debridement is often required for such cases, which in turn may complicate wound coverage.

Methods: A retrospective review was performed for 16 patients with musculoskeletal infections treated surgically. The diagnosis for the patients consisted of necrotizing fasciitis, large soft tissue abscess, peri-hardware abscess, infected compartment syndrome, emphysematous osteomyelitis, and gas gangrene of diabetic foot. We minimized the incision and resection for debridement and drainage, and instead we placed multiple foam pieces between the tissues involved with VAC, to maintain drainage of the hidden spaces with negative pressure.

Results: Infection was successfully controlled in all cases. The mean duration of VAC treatment was 16.1 days (range, 5–36) and the mean number of VAC changes was 5.1 (range, 1–13). Primary wound closure was achieved in 11 cases, while skin grafts were used to cover the remaining five cases, which consisted of necrotizing fasciitis, infected compartment syndrome, and diabetic foot gas gangrene. No complications specifically associated with VAC therapy were observed.

Conclusions: VAC using multiple foam pieces for hidden space drainage appears to be effective for infection control. It is helpful for minimizing exposure and resection for drainage and debridement, although subsequent reduction of the necessity or the level of wound coverage should further be investigated.

Management of the Open Abdomen after Liver Transplantation

INTRODUCTION

The optimal management of the open abdomen (OA) after liver transplantation (LT) is unclear. The negative pressure wound therapy (NPWT) has been shown to be safe and can increase the chance for early fascial closure in trauma or septic patients. However, little data are available on the specific setting of LT. We aimed to report our experience of OA after LT, marked by the recent use of NPWT.

METHODS

All patients with postponed wall closure after LT, from 2002 to 2014, in a single institution were included and retrospectively analyzed. Our management of OA after LT has shifted from skin-only closure (SOC) followed by abdominal wall reconstruction at a distance to the use of NPWT with early fascial closure.

RESULTS

Of the 1559 LTs performed during the study period, immediate abdominal wall closure at the end of transplantation could not be achieved in 46 (2.9%) patients. Of them, SOC was performed in 22 (47.8%) patients, whereas vacuum-assisted closure (VAC) therapy was used in 24 (52.1%) patients. The comprehensive complication indexes (CCI) were similar [CCI: 66 (0-100) in the SOC group vs. 56 (0-100) in the VAC group; p = 0.55]. No evisceration or fistula occurred in both groups. One (4.2%) postoperative bleeding case was reported in the VAC group. Early fascial closure was achieved within a median of 5.5 days (1-12) for the 24 patients (100%) of the VAC group. In four of them, a biological mesh was necessary. Only nine patients (52.9%) of the survivors in the SOC group underwent abdominal reconstruction.

CONCLUSION

The NPWT in patients with OA after LT enables early fascial closure with limited morbidity provided a specific attention is given to the risk of bleeding. These results support the use of NPWT as the first option in OA patients after LT.

Intraoral Vacuum-Assisted Closure Therapy-A Pilot Study in Medication-Related Osteonecrosis of the Jaw

PURPOSE

For approximately 2 decades, vacuum-assisted closure (VAC) therapy has been widely used for the management of complex wounds and soft tissue defects on the external surface of the body. As yet, this technique has not been studied for intraoral wound management. Therefore, this study evaluated the feasibility, safety, and effectiveness of intraoral VAC therapy in patients with medication-related osteonecrosis of the jaw (MRONJ).

PATIENTS AND METHODS

After successful construction of an intraoral device providing sufficient airtight sealing, individually manufactured appliances were used in a prospective clinical trial of 3 patients using the VAC therapy system.

RESULTS

Intraoral VAC therapy showed some success and did not produce serious side effects. Different positive effects, such as formation of new granulation tissue, cessation of pain, and pus suppuration, were found.

CONCLUSION

This prospective proof-of-principle study showed that intraoral VAC therapy is feasible and safe. It could play a role in the management of MRONJ and other types of intraoral wounds (eg, osteoradionecrosis, postoperative wound dehiscence, etc).

Uso de curativo a vácuo como terapia adjuvante na cicatrização de sítio cirúrgico infectado

Resumo Infecções de sítios cirúrgicos com envolvimento de próteses sintéticas constituem grande desafio para tratamento. Apresentamos o caso de uma paciente com múltiplas comorbidades, histórico de enxerto aortobifemoral há 6 anos e reabordagem das anastomoses femorais por reestenoses há 5 anos. Apresentou dor inguinal esquerda e abaulamento súbitos com diagnóstico de pseudoaneurisma femoral roto e instabilidade hemodinâmica. Foi submetida a correção emergencial com interposição de prótese de dácron recoberta por prata e correção de grande hérnia incisional abdominal com tela sintética ao mesmo tempo. No pós-operatório, manteve-se por longo período sob terapia intensiva com dificuldade de extubação. Nesse ínterim, apresentou deiscência das suturas e fístula purulenta inguinal esquerda em contato com a prótese vascular. Optou-se pelo tratamento conservador, com desbridamento das feridas e aplicação de curativo a vácuo. A paciente evoluiu com melhora e cicatrização das feridas. Essa pode se constituir em ferramenta importante em casos similares.

Reviewing the benefits and harm of NPWT in the management of closed surgical incisions

The use of negative pressure wound therapy (NPWT) for the treatment of open traumatic, non-traumatic, chronic wounds and coverage over skin grafts has increased in popularity over the past decade. Although the exact mechanism of the action of NPWT on wound healing is still an active area of research, evidence propose it is achieved by removing oedema, increasing blood circulation, reducing bacterial bio-burden, providing a moist wound-healing environment, and increasing granulation tissue formation. In recent years, there has been an emerging body of literature describing a novel application of NPWT on closed surgical wounds, especially on closed orthopaedic incisional (COI) wounds. It has been suggested that applying NPWT to a COI may decrease the incidence of surgical wound-healing complications, such as hematoma, seroma, infection, or dehiscence, and hasten the healing of the incision. This review will evaluate the potential effect on the reduction of postoperative closed wound complications and examine the benefits and harm of NPWT in the management of COI.

Role of Negative-Pressure Wound Therapy in the Management of Submandibular Fistula After Reconstruction for Osteoradionecrosis

PURPOSE

Although negative-pressure wound therapy (NPWT) for complicated wounds has been extensively studied, it is rarely used in cases involving a submandibular fistula due to radiation-induced osteoradionecrosis of the mandible. This study aimed to investigate the efficacy of NPWT for submandibular fistulas after reconstruction for osteoradionecrosis.

PATIENTS AND METHODS

Nine patients with submandibular fistulas after reconstruction for osteoradionecrosis treated with NPWT between 2011 and 2014 were included in the study. The wound healing was documented.

RESULTS

The NPWT device was removed postoperatively between days 7 and 12 (mean duration, 9.6 days). The wound bed was filled with healthy granulation tissue, and successful healing by second intention was observed in all patients within 2 weeks. No complications were observed. The follow-up ranged from 4 to 27 months (mean, 18 months); the fistulas exhibited excellent healing, and no recurrence or infection was observed.

CONCLUSIONS

NPWT is a safe, effective technique for managing submandibular fistulas after reconstruction for osteoradionecrosis.

Uses of negative pressure wound therapy in orthopedic trauma

Negative pressure wound therapy (NPWT) is a useful management tool in the treatment of traumatic wounds and high-risk incisions after surgery. Since its development nearly 2 decades ago, uses and indications of NPWT have expanded, allowing its use in a variety of clinical scenarios. In addition to providing a brief summary on its mechanism of action, this article provides a focused, algorithmic approach on the use of NPWT by reviewing the available data, the appropriate clinical scenarios and indications, and the specific strategies that can be used to maximize outcomes.