Closed-incision negative-pressure wound therapy reduces superficial surgical site infections after open colon surgery: an NSQIP Colectomy Study

BACKGROUND

The use of closed-incision negative-pressure wound therapy (iNPWT) has increased in the last decade across surgical fields, including colectomy.

AIM

To compare postoperative outcomes associated with use of iNPWT following open colectomy from a large national database.

METHODS

A retrospective review of patients who underwent operations from 2015 to 2020 was performed using the National Surgical Quality Improvement Program (NSQIP) Targeted Colectomy Database. Intraoperative placement of iNPWT was identified in patients undergoing open abdominal operations with closure of all wound layers including skin. Propensity score matching was performed to define a control group who underwent closure of all wound layers without iNPWT. Patients were matched in a 1:4 (iNPWT vs control) ratio and postoperative rates of superficial, deep and organ-space surgical site infection (SSI), wound disruption, and readmission.

FINDINGS

A matched cohort of 1884 was selected. Patients with iNPWT had longer median operative time (170 (interquartile range: 129-232) vs 161 (114-226) min; P<0.05). Compared to patients without iNPWT, patients with iNPWT experienced a lower rate of 30-day superficial incisional SSI (3% vs 7%; P<0.05) and readmissions (10% vs 14%; P<0.05). iNPWT did not decrease risk of deep SSI, organ-space SSI, or wound disruption.

CONCLUSION

Although there is a slightly increased operative time, utilization of iNPWT in open colectomy is associated with lower odds of superficial SSI and 30-day readmission. This suggests that iNPWT should be routinely utilized in open colon surgery to improve patient outcomes.

Influence of Closed-incision Negative Pressure Wound Therapy on Abdominal Site Complications in Autologous Breast Reconstruction

Background

Closed-incision negative pressure wound therapy (ciNPWT) has shown promise in reducing surgical wound complications. Among its numerous benefits, it allows for exudate management and tension offloading from wound edges. The purpose of this systematic review and meta-analysis was to assess the efficacy of prophylactic ciNPWT versus conventional dressings on abdominal donor site complications in microsurgical breast reconstruction (MR).

Methods

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in January 2023. PubMed and Embase were searched to identify all relevant studies. Data collected included rates of total wound complications, wound dehiscence, infection, seroma, and length of hospital stay.

Results

A total of 202 articles were screened, and eight studies (1009 patients) met the inclusion criteria. Use of ciNPWT was associated with a significantly lower rate of wound dehiscence (OR, 0.53; 95% confidence interval, 0.33-0.85; P = 0.0085, I2 = 0%). There was no significant difference in the rate of total wound complications [odds ratio (OR), 0.63; 95% CI, 0.35-1.14; P = 0.12, I2 = 69%], donor site infection (OR, 0.91; 95% CI, 0.42-1.50; P = 0.47, I2 = 13%), seroma (OR, 0.74; 95% CI, 0.22-2.49; P = 0.63, I2 = 57%), or length of hospital stay (SMD, 0.089; 95% CI, -0.13-0.35; P = 0.37, I2 = 29%).

Conclusions

Although exudate management by ciNPWT fails to reduce surgical site infection, seroma formation, and overall length of stay, ciNPWT tension offloading properties seem to be associated with lower rates of wound dehiscence when compared with conventional dressings in abdominal-based autologous breast reconstruction.

ROLE OF INCISIONAL VACUUM THERAPY IN ENDOPROSTHETIC BONE RECONSTRUCTION SURGERY

Reconstructive surgery with endoprostheses is the chosen method for treating bone malignancies. Postoperative infections are frequent complications, and their treatment involves prolonged hospital stays and antibiotic therapy. Among the advancements aimed at reducing the rate of postoperative infection, the use of incisional negative pressure therapy (iNPT) has shown promising results, with no reports in the literature regarding its use in patients with such conditions.

Objective

To evaluate the effectiveness of iNPT in reducing postoperative complications in surgeries for resection of bone tumors associated with modular endoprosthesis reconstruction.

Methods

Retrospective case series of 16 patients diagnosed with osteosarcoma, who underwent resection and reconstruction with endoprosthesis associated with iNPT during the postoperative period. Follow-up was performed for a period of six months, and the evaluated outcomes were the incidence of postoperative infection and complications of the surgical wound.

Results

The use of iNPT for a postoperative period of seven days resulted in only three (18.7%) cases of postoperative infection. No cases of wound dehiscence, seroma formation, or hematoma at the surgical site were observed.

Conclusion

The rate of surgical wound complications in our case series is lower than that reported in most of the literature, and iNPT appears to be an efficient way to reduce the rate of local complications in reconstructive surgeries with endoprosthesis after resection of bone malignancies. Level of Evidence III, Retrospective Study.

The Cost-Effectiveness of Closed Incisional Negative Pressure Wound Therapy for Infection Prevention after Revision Total Knee Arthroplasty

Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses.

The Utility of Closed Incision Negative Pressure Wound Therapy following Spinal Fusion: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence following spinal fusion.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic review and meta-analysis was conducted to identify studies utilizing ciNPWT following spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT following spinal fusion.

RESULTS

A total of 8 studies comprising 1,061 patients who received ciNPWT or a standard postoperative dressing following spinal fusion were included. The rate of SSI [ciNPWT: 4.49% (95% CI: 2.48, 8.00) vs. control: 11.32% (95% CI: 7.51, 16.70), p=0.0103] was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (OR: 1.25, 95% CI: 0.64, 2.41). Additionally, wound dehiscence was not significantly different between the two groups although it was non-significantly lower in ciNWPT-treated patients [ciNPWT: 4.59% (95% CI: 2.49, 8.31) vs control: 7.48% (95% CI: 4.38, 12.47), p=0.23].

CONCLUSION

Closed incision NPWT may reduce the rates of SSI following spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional, studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications.

Evolution of Negative Pressure Wound Therapy in Orthopaedic Trauma

Negative Pressure Wound Therapy (NPWT) has evolved from open wound management to now include closed incision management. It has been a major advance in the management of open wounds and closed incisional wounds especially in orthopaedic trauma surgery. Because of the success of NPWT in the late 1990s and early 2000s, surgeons began using NPWT with adjuncts on closed incisions as a way to help prevent surgical wound dehiscence especially in at-risk patients for wound problems. It has been well established that obesity, diabetes, and smoking in addition to other comorbidities increase the risk of wound dehiscence and surgical site infections in orthopaedic patients. It is widely used for open wound management, often associated with open fractures, and in the mitigation of risk of surgical site infections over closed incisions (incisional negative pressure wound therapy). Newer systems allow the use of various topical wound solutions to be instilled in conjunction with NPWT, termed NPWTi-d. This has shown promising results in difficult wounds that may be resistant to standard NPWT. This article reviews the evolution and use of NPWT in orthopaedic trauma.

Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty

BACKGROUND

The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA.

METHODS

This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m², diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications.

RESULTS

One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ² = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ² = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI.

CONCLUSION

Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

Negative pressure wound therapy reduces the incidence of postoperative wound dehiscence and surgical site infections after total knee arthroplasty in patients with obesity

Obesity is a risk factor for total knee arthroplasty (TKA). Wound dehiscence and surgical site infections (SSIs) are the main complications of TKA in patients with obesity. They can profoundly affect patients because they often require readmission, additional surgical interventions, lengthy intravenous antibiotic administration, and delayed rehabilitation. Negative pressure wound therapy (NPWT) exposes the wound site to negative pressure, resulting in the improvement of blood supply, removal of excess fluid, and stimulation of cellular proliferation of granulation tissue. This study aims to assess the incidence of wound dehiscence and SSIs in patients with obesity undergoing TKA after the routine use of NPWT. This sduty enrolled adult patients with obesity who underwent TKA within 8 years. A total of 360 adult patients with obesity (NPWT: 150, non-NPWT: 210) underwent TKA, and the baseline characteristics were similar between the 2 groups. Compared with the non-NPWT group, the NPWT group had a 50% lower incidence of wound dehiscence (3.33% vs 9.52%; P < .05) and a significantly lower incidence of SSIs (11.33% vs 25.24%; P < .05), including prosthetic joint infection (4.0% vs 10.0%; P < .05) and superficial wound infection (7.33% vs 15.24%; P < .05). In addition, the NPWT group had a lower need to return to the operating room for new interventions for any reason (2.67% vs 9.05%; P = .0107) than the non-NPWT group. Conventional incision NPWT can significantly reduce the incidence of wound dehiscence and SSIs in patients with obesity after TKA.

"Negative Pressure Wound Therapy (NPWT) Yields Lower Wound Complication and Surgical Site Infection Rates Compared to Standard Surgical Dressings (SSDs) after Resection of a Malignancy: A Systematic Review and Meta-Analysis"

BACKGROUND

Negative Pressure Wound Therapy (NPWT) offers many advantages over Standard Surgical Dressings (SSDs) in the treatment of open wounds including accelerated wound healing (72.3% vs 30.8%), cost savings (up to $1,607), and reduced complication rates (35% vs 53%).2-4 Contraindicated by device manufacturers in malignancy-resected wounds for hypothesized risk of tumor recurrence, NPWT is still applied post-operatively due to limited clinical support. A systematic review with meta-analysis was performed to compare NPWT outcomes with SSDs on open wounds with our null hypotheses stating there would be no outcome differences.

METHODS

A systematic review of the literature on NPWT and SSDs on malignancy-resected wounds was conducted following PRISMA guidelines using PubMed, EMBASE, CINAHL, and Cochrane Central databases. Meta-analysis compared group outcomes, including malignancy recurrence, wound complication, and surgical site infection (SSI) rates, with random effects model.

RESULTS

1,634 studies were identified and 27 met eligibility criteria, including 4 randomized control trials (RCTs), 4 prospective cohort studies, and 19 retrospective reviews. Eighty-one percent of papers (n = 22) recommended NPWT use in malignancy-resected wounds. Meta-analysis determined NPWT yielded significantly lower overall SSI (P = 0.004) and wound complication rates (P = 0.01) than SSDs; however, there were no statistically significant differences found for other outcomes between the two groups.

CONCLUSIONS

This review demonstrates favorable outcomes of NPWT over SSDs for malignancy-resected wounds without an increased risk of malignancy recurrence. However, with limited RCTs (detailing only incisional wounds for limited malignancies and anatomic regions), additional high-power RCTs are recommended.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence.

MAIN RESULTS

In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I² = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I² = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I² = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I² = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I² = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I² = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I² = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I² = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs  than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Postoperative Fluid Collections in Total Joint Arthroplasty: A Narrative Review

A post-operative fluid collection (POFC) represents a common finding in both primary and revision total joint arthroplasty (TJA). Fortunately, most resolve on their own, but in instances where they become symptomatic, prompt identification and management are paramount, especially when they occur adjacent to a joint arthroplasty because of the increased the risk of developing a periprosthetic joint infection. A strong clinical suspicion with appropriate clinical exam is required along with select imaging modalities to arrive at a diagnosis. Meticulous surgical technique is crucial to prevent POFC, but new emerging treatments continue to evolve. This article presents an updated overview of incidence, pathophysiology, diagnosis, and management of POFC in the setting of TJA. We review the role of select imaging modalities as well as summarize current literature regarding new treatments such as sclerotherapy agents, acellular dermal matrices, and negative pressure wound therapy. Future studies are necessary to explore the interplay of inflammatory mediators in POFC formation and to define their role in fluid collection resolution.

The application of close incisional negative pressure wound therapy in revision arthroplasty among asian patients: a comparative study

INTRODUCTION

Peri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order to reduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT) has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of ciNPWT in revision arthroplasty.

METHODS

This was a single-centre retrospective comparative study approved by the Institutional Review Board. Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author's institution from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients, who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts.

RESULTS

There was a statistically significant difference in the rate of superficial surgical site infection (SSI) between control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statistically significance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504).

CONCLUSIONS

The application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties.

TRIAL REGISTRATION

UW19-706.

Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study

BACKGROUND

Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing.

METHODS

One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m², autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation.

RESULTS

Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications.

CONCLUSION

Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.

Effectiveness of Different Wound Dressings in the Reduction of Blisters and Periprosthetic Joint Infection After Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis

BACKGROUND

The optimal type of dressing in the setting of total joint arthroplasty (TJA) remains uncertain. The aim of this network meta-analysis was to compare various wound dressings and identify the optimal type of dressings for blister reduction and prevention of periprosthetic joint infection (PJI) in patients after TJA.

METHODS

Studies comparing 2 or more dressing groups after TJA (hip or knee) were systematically searched on PubMed, Embase, and Scopus. Two authors performed the study selection, risk of bias assessment, and data extraction. Both outcomes were assessed using odds ratios (OR) with 95% confidence intervals (CI) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of dressings. A sensitivity analysis was performed to reduce the effect of intransitivity between studies.

RESULTS

A total of 21 studies, consisting of 12 dressing types in 7293 TJAs, were included in the final analysis. The highest incidence of blisters occurred when using negative-pressure wound therapy (OR 9.33, 95% CI 3.51-24.83, vs gauze). All dressings ranked better than gauze in infection rate except for hydrofiber (OR 1.46, 95% CI 0.02-112.53) and fabric dressings (OR 1.46, 95% CI 0.24-9.02). For blister reduction, alginate (SUCRA = 87.7%) and hydrofiber with hydrocolloid (SUCRA = 92.3%) were ranked as the optimal dressings before and after a sensitivity analysis, respectively. Antimicrobial dressing (SUCRA = 83.7%) demonstrated the most efficacy for preventing PJI.

CONCLUSION

Based on the evidence from our analysis, an antimicrobial dressing is the optimal dressing to prevent PJI. If negative-pressure wound therapy is used, surgeons should be aware of an increased incidence of blister formation. Further studies should focus on the alginate versus hydrofiber and hydrocolloid dressing to determine the optimal dressing to reduce blisters.

Single-use negative pressure wound therapy reduces costs in closed surgical incisions: UK and US economic evaluation

OBJECTIVE

Single-use negative pressure wound therapy (sNPWT) following closed surgical incisions has a demonstrable effect in reducing surgical site complications (SSC). However, there is little health economic evidence to support its widespread use. We sought to evaluate the cost-effectiveness of sNPWT compared with standard care in reducing SSCs following closed surgical incisions.

METHOD

A decision analytic model was developed to explore the total costs and health outcomes associated with the use of the interventions in patients following vascular, colorectal, cardiothoracic, orthopaedic, C-section and breast surgery from the UK National Health Service (NHS) and US payer perspective over a 12-week time horizon. We modelled complications avoided (surgical site infection (SSI) and dehiscence) using data from a recently published meta-analysis. Cost data were sourced from published literature, NHS reference costs and Centers for Medicare and Medicaid Services. We conducted subgroup analysis of patients with diabetes, an American Society of Anesthesiologists (ASA) score ≥3 and body mass index (BMI) ≥30kg/m². A sensitivity analysis was also conducted.

RESULTS

sNPWT resulted in better clinical outcomes and overall savings of £105 per patient from the UK perspective and $637 per patient from the US perspective. There were more savings when higher-risk patients with diabetes, or a BMI ≥30kg/m² or an ASA≥3 were considered. We conducted both one-way and probabilistic sensitivity analysis, and the results suggested that this conclusion is robust.

CONCLUSION

Our findings suggest that the use of sNPWT following closed surgical incisions saves cost when compared with standard care because of reduced incidence of SSC. Patients at higher risk should be targeted first as they benefit more from sNPWT. This analysis is underpinned by strong and robust clinical evidence from both randomised and observational studies.

Improving Postoperative Outcomes in Lower Extremity Amputees Utilizing a Quality Improvement Approach

This project focused on adult lower extremity amputees from March 2017 through March 2019. The aim was to improve 30-day surgical site infection (SSI) rates by 10% in two orthopaedic populations. Subaims focused on 30-day readmission rates, length of stay, and 30-day mortality rates. The primary intervention of incisional negative pressure wound vac therapy (iNPWT) device application was instituted. This was supported by World Health Organization recommendations, meta-analyses, and consensus statements advising the utilization of iNPWT devices. Plan-Do-Study-Act cycles were aimed at education, operation efficiency, and patient engagement. By March 2019, goals were met for SSI and 30-day readmission rates in each division. Cost analysis showed a savings of $38,500. Improved clinical significance was noted in SSI rates, 30-day readmission rates, and cost in lower extremity amputees. It is unclear whether the innovation led to improvement in the other subaims; however, this revealed areas for additional areas for improvement.

Cellular benefits of single-use negative pressure wound therapy demonstrated in a novel ex vivo human skin wound model

Negative pressure wound therapy is a widely used treatment for chronic, nonhealing wounds. Surprisingly, few studies have systematically evaluated the cellular and molecular effects of negative pressure treatment on human skin. In addition, no study to date has directly compared recently available single-use negative pressure modalities to traditional negative pressure devices in a controlled setting. Here we developed a novel large-scale ex vivo human skin culture system to effectively evaluate the efficacy of two different negative pressure wound therapy modalities. Single-use and traditional negative pressure devices were applied to human ex vivo wounded skin sheets cultured over a period of 48 hours. Cellular tissue response to therapy was evaluated via a combination of histological analysis and transcriptional profiling, in samples collected from the wound edge, skin adjacent to the wound, and an extended skin region. Single-use negative pressure wound therapy caused less damage to wound edge tissue than traditional application, demonstrated by improved skin barrier, reduced dermal-epidermal junction disruption and a dampened damage response. Transcriptional profiling confirmed significantly less activation of multiple pro-inflammatory markers in wound edge skin treated with single-use vs traditional negative pressure therapy. These findings may help to explain the greater efficacy of sNPWT in the clinic, while offering a noninvasive system to develop improved NPWT-based therapies.

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy

BACKGROUND AND AIM OF THE WORK

complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

METHODS

The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

RESULTS

65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

CONCLUSIONS

INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Clinical and Health-Care Cost Analysis of Negative Pressure Dressing in Primary and RevisionTotal Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Negative pressure wound therapy (NPWT) has been used because of its perceived advantages in reducing surgical site infections, wound complications, and the need for further surgery. The purpose of this study was to assess the infection rates, wound complications, length of stay, and financial burden associated with NPWT use in primary and revision total knee arthroplasty (TKA).

METHODS

We performed a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) systematic review of the existing literature on using NPWT in primary and revision TKA. PubMed, Embase, Science Direct, and the Cochrane Library were utilized. The risk of bias was evaluated using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool, and the quality of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twelve articles that evaluated 1,403 primary TKAs and 279 revision TKAs were reviewed. NPWT significantly reduced complication rates in revision TKA. However, there was no significant difference in infection rates between NPWT and regular dressings in primary or revision TKA. NPWT use in primary TKA significantly increased the risk of blistering, although no increase in reoperations was noted. The analysis showed a possible reduction in length of stay associated with NPWT use for both primary and revision TKA, with overall health-care cost savings.

CONCLUSIONS

Based on a meta-analysis of the existing literature, we do not recommend the routine use of NPWT. However, in high-risk revision TKA and selected primary TKA cases, NPWT reduced wound complications and may have health-care cost savings.

LEVEL OF EVIDENCE

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

Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra- and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.

The use of negative-pressure wound therapy after total knee arthroplasty is effective for reducing complications and the need for reintervention

BACKGROUND

Wound healing complications are causal factors of prosthesis infection and poor postoperative evolution of patients after total knee arthroplasty (TKA). Negative-pressure wound therapy (NPWT) can be an option to minimize these complications. The aim of this study is to compare the complications of patients undergoing TKA who used a portable NPWT device in the immediate postoperative period with those of a control group.

METHODS

A total of 296 patients were evaluated. Patients were divided into two groups: those who used NPWT for seven days in the postoperative period (Group 1 - prospective evaluated) and those who used conventional dressings (Group 2 - historical control group). Epidemiological data, comorbidities, local parameters related to the surgical wound and complications were evaluated.

RESULTS

The groups did not differ in regard to sex, age and clinical comorbidities. Overall, 153 (51.7%) patients had at least one risk factor for wound complications. Patients who used NPWT had a lower rate of complications (28.5% vs. 45.7%, p = 0.001) and a lower rate of reintervention in the operating room (2% vs. 8.5%, p = 0.001). Patients in group 1 had a lower incidence of hyperaemia (14.7% vs. 40.2%, p = 0.01), skin necrosis (2.1% vs. 8.5%, p = 0.04) and wound dehiscence (3.1% vs 10.1%, p = 0.03). The use of NPWT was a protective factor for the presence of complications, with an odds ratio of 0.36 (95% CI 0.206-0.629).

CONCLUSION

The number of complications related to the wound after TKA is high; however, most of them are minor and have no impact on the treatment and clinical evolution of patients. The use of NPWT decreased the number of surgical wound complications, especially hyperaemia, dehiscence and necrosis, and reduced the need for reintervention.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.

MAIN RESULTS

In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I² = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I² = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I² = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I² = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I² = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I² = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I² = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Are high-risk patient and revision arthroplasty effective indications for closed-incisional negative-pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta-analysis

To determine the effective indications of closed-incisional negative-pressure wound therapy (ciNPWT) following total hip or knee arthroplasty, this systematic review and meta-analysis was conducted. The systematic search was performed on MEDLINE, Embase, and Cochrane Library, and 11 studies were included. The studies comparing between ciNPWT and conventional dressings were categorised into following subgroups based on patient risk and revision procedures: routine vs high-risk patient; primary vs revision arthroplasty. Pooled estimates were calculated for wound complication and surgical site infection (SSI) rates in the subgroup analyses using Review Manager. In high-risk patients, the overall rates of wound complication (odds ratio [OR] = 0.38; 95% confidence interval [CI] 0.15-0.93; P = .030) and SSI (OR = 0.24; 95% CI = 0.09-0.64; P = .005) were significantly lower in the ciNPWT; however, there were no differences in routine patients. In cases involving revision arthroplasties, the overall rates of wound complication (OR = 0.33; 95% CI = 0.18-0.62; P < .001) and SSI (OR = 0.26; 95% CI = 0.11-0.66; P = .004) were significantly lower in the ciNPWT; however, there were no differences in cases involving primary arthroplasties. In summary, ciNPWT showed a positive effect in decreasing the rates of wound complication and SSI in high-risk patients and in revision arthroplasties.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.

MAIN RESULTS

In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I² = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I² = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I² = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I² = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I² = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I² = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I² = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Negative Pressure Wound Therapy Reduces Wound Breakdown and Implant Loss in Prepectoral Breast Reconstruction

Background:

Single-use negative pressure wound therapy (NPWT) has been shown to encourage wound healing. It is often used when patient factors impair wound healing, or in more complex wounds, such as in implant-based breast reconstruction. We report the findings of a prospective cohort study comparing the use of NPWT with standard dressings in prepectoral breast reconstruction.

Methods:

A prospective database of implant-based reconstruction from a single institution was mined to identify patients who underwent prepectoral reconstruction. Patient demographics, operative data, surgical complications, and 90-day outcomes were compared between patients who had NPWT and those who had standard dressings.

Results:

Prepectoral implant-based breast reconstruction was performed on 307 breasts. NPWT dressings were used in 126 cases, with standard dressings used in 181 cases. Wound breakdown occurred in 10 cases after standard dressings versus 1 where NPWT was utilized. Of the standard dressing cases, only 3 implants were salvaged, while 7 cases led to implant loss. The 1 case of wound breakdown in the NPWT cohort settled with conservative measures. The cost of a reconstructive failure was £14,902, and the use of NPWT resulted in a cost savings of £426 per patient.

Conclusions:

The utilization of single-use NPWT reduces the rate of wound breakdown and implant loss in prepectoral implant-based reconstruction. In addition to the significant clinical benefits, this approach is cost-saving compared with standard dressings. These data suggest that prepectoral implant reconstruction should be considered as an indication for the use of NPWT.

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

OBJECTIVES

To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

DESIGN

Systematic review of cost-utility analyses.

DATA SOURCES

Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.

ELIGIBILITY CRITERIA

English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

DATA EXTRACTION AND SYNTHESIS

Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken.

RESULTS

We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

CONCLUSIONS

Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

PROSPERO REGISTRATION NUMBER

CRD42017059473.

Barbed suture and glue in skin closure during lower limb arthroplasty: reduced delayed discharge due to wound exudate

Objective:

The number of hip and knee replacement performed is rising, causing increased pressure for the timely management of these patients. A dry incision is considered a prerequisite for discharge. This is a retrospective cohort study comparing two treatments for skin closure during elective hip and knee arthroplasty.

Methods:

A barbed monofilament absorbable 3.0 subcuticular suture (Quill), with the additional surface application of n-butyl-2-cyanoacrylate glue, was used for the study group and metal clips or a smooth monofilament absorbable 3.0 subcuticular suture (Monocryl) for the control group. Each group comprised 46 hip and 27 knee replacement patients and data on predisposing risk factors for prolonged wound exudate were collected. We have calculated the proportion of patients who have exceeded their expected length of stay due to a wound exudate, the additional days required for the wound to dry and the derived cost.

Results:

No significant differences were identified with regards to risk factors. The study group demonstrated a significantly lower incidence of exudating wounds of excessive duration (1% versus 14%, p=0.005, relative risk: 10; 95% confidence interval: 1.31–76.13). The combined additional stay was 22 days more for the control group, producing an average financial benefit of £80 per patient for the study group. There were seven knee replacement and two hip replacement patients treated with a nozzled glue applicator who presented with delayed (> 2 weeks) wound healing issues.

Conclusion:

Barbed subcuticular suture with surface glue application is a viable option for skin closure after elective lower limb joint arthroplasty and can reduce the incidence of prolonged wound discharge. A brushed glue applicator should be preferred over the nozzled one.

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial

Aims

The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb.

Patients and Methods

An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation.

Results

The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses.

Conclusion

This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392–1401.

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis

BACKGROUND

Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).

METHODS

Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.

RESULTS

Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).

CONCLUSION

Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.

Using negative pressure wound therapy to prevent surgical site infection

It is estimated that, at the very least, 5% of patients who undergo surgery develop a surgical site infection (SSI). There has been much interest in the use of negative pressure wound therapy (NPWT) as a prophylactic treatment to reduce the risk of SSI. Evidence suggests it can accelerate healing times, reduce both the length of hospital stay and the frequency of dressing changes, and improve patients' quality of life. The efficacy of traditional and portable NPWT systems is similar. However, the latter has an advantage in that it increases patient mobility and does not hinder individuals from carrying out activities of daily living. There are also economic data suggesting that portable NPWT devices are associated with long-term cost savings.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). While existing evidence for the effectiveness of NPWT remains uncertain, new trials necessitated an updated review of the evidence for the effects of NPWT on postoperative wounds healing by primary closure.

OBJECTIVES

To assess the effects of negative pressure wound therapy for preventing surgical site infection in wounds healing through primary closure.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in February 2018. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions on language, publication date, or setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to GRADE methodology.

MAIN RESULTS

In this second update we added 25 intervention trials, resulting in a total of 30 intervention trials (2957 participants), and two economic studies nested in trials. Surgeries included abdominal and colorectal (n = 5); caesarean section (n = 5); knee or hip arthroplasties (n = 5); groin surgery (n = 5); fractures (n = 5); laparotomy (n = 1); vascular surgery (n = 1); sternotomy (n = 1); breast reduction mammoplasty (n = 1); and mixed (n = 1). In three key domains four studies were at low risk of bias; six studies were at high risk of bias; and 20 studies were at unclear risk of bias. We judged the evidence to be of low or very low certainty for all outcomes, downgrading the level of the evidence on the basis of risk of bias and imprecision.Primary outcomesThree studies reported mortality (416 participants; follow-up 30 to 90 days or unspecified). It is uncertain whether NPWT has an impact on risk of death compared with standard dressings (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.25 to 1.56; very low-certainty evidence, downgraded once for serious risk of bias and twice for very serious imprecision).Twenty-five studies reported on SSI. The evidence from 23 studies (2533 participants; 2547 wounds; follow-up 30 days to 12 months or unspecified) showed that NPWT may reduce the rate of SSIs (RR 0.67, 95% CI 0.53 to 0.85; low-certainty evidence, downgraded twice for very serious risk of bias).Fourteen studies reported dehiscence. We combined results from 12 studies (1507 wounds; 1475 participants; follow-up 30 days to an average of 113 days or unspecified) that compared NPWT with standard dressings. It is uncertain whether NPWT reduces the risk of wound dehiscence compared with standard dressings (RR 0.80, 95% CI 0.55 to 1.18; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision).Secondary outcomesWe are uncertain whether NPWT increases or decreases reoperation rates when compared with a standard dressing (RR 1.09, 95% CI 0.73 to 1.63; 6 trials; 1021 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision) or if there is any clinical benefit associated with NPWT for reducing wound-related readmission to hospital within 30 days (RR 0.86, 95% CI 0.47 to 1.57; 7 studies; 1271 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision). It is also uncertain whether NPWT reduces incidence of seroma compared with standard dressings (RR 0.67, 95% CI 0.45 to 1.00; 6 studies; 568 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). It is uncertain if NPWT reduces or increases the risk of haematoma when compared with a standard dressing (RR 1.05, 95% CI 0.32 to 3.42; 6 trials; 831 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision. It is uncertain if there is a higher risk of developing blisters when NPWT is compared with a standard dressing (RR 6.64, 95% CI 3.16 to 13.95; 6 studies; 597 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision).Quality of life was not reported separately by group but was used in two economic evaluations to calculate quality-adjusted life years (QALYs). There was no clear difference in incremental QALYs for NPWT relative to standard dressing when results from the two trials were combined (mean difference 0.00, 95% CI -0.00 to 0.00; moderate-certainty evidence).One trial concluded that NPWT may be more cost-effective than standard care, estimating an incremental cost-effectiveness ratio (ICER) value of GBP 20.65 per QALY gained. A second cost-effectiveness study estimated that when compared with standard dressings NPWT was cost saving and improved QALYs. We rated the overall quality of the reports as very good; we did not grade the evidence beyond this as it was based on modelling assumptions.

AUTHORS' CONCLUSIONS

Despite the addition of 25 trials, results are consistent with our earlier review, with the evidence judged to be of low or very low certainty for all outcomes. Consequently, uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well-designed and well-conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients.

Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation

OBJECTIVE

To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section.

DESIGN

A cost-effectiveness analysis conducted alongside a clinical trial.

SETTING

Five obstetric departments in Denmark.

POPULATION

Women with a pregestational body mass index (BMI) ≥30 kg/m² .

METHOD

We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth.

MAIN OUTCOME MEASURES

Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained.

RESULTS

The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m² .

CONCLUSION

Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m² .

TWEETABLE ABSTRACT

Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.

A risk-stratification algorithm to reduce superficial surgical site complications in primary hip and knee arthroplasty

BACKGROUND

Surgical site complications (SSCs) are the most common cause for readmission after total joint arthroplasty (TJA), increasing costs while predisposing to inferior long-term outcomes. Prophylactic use of closed-incision negative pressure therapy (ciNPT) may lower the risk of these complications, especially in high-risk populations, but appropriate-use guidelines are lacking for patients undergoing primary TJA. We sought to develop a risk-stratification algorithm to guide use of ciNPT dressings and test its use in normalizing the rate of superficial SSCs among high-risk groups.

METHODS

We reviewed 323 consecutive primary TJAs, where 38% of those patients considered at elevated risk were risk-stratified to receive ciNPT dressings. An individual risk score was developed, assigning points based on patient-specific risk factors. We identified a historical control population of 643 patients who all received the same postoperative dressing to test the impact of this risk score.

RESULTS

Compared with historical controls, we observed a modest but significant improvement in superficial SSCs after implementation of risk-stratification (12.0% vs 6.8%; P = .013). Among high-risk patients, there was a marked improvement in SSCs when treated prophylactically with ciNPT dressings as compared with historical controls (26.2% vs 7.3%; P < .001). Low-risk patients, who continued to be treated with standard postoperative dressings, demonstrated no significant improvement (8.6% vs 6.5%; P = .344).

CONCLUSIONS

ciNPT dressings are effective at reducing and normalizing risks of superficial SSCs among high-risk primary arthroplasty patients. The proposed risk-stratification algorithm may help identify those patients who benefit most from these dressings.

Cost-effectiveness analysis of single use negative pressure wound therapy dressings (sNPWT) compared to standard of care in reducing surgical site complications (SSC) in patients undergoing coronary artery bypass grafting surgery

Background

There is a growing interest in using negative pressure wound therapy in closed surgical incision to prevent wound complications which continue to persist following surgery despite advances in infection measures.

Objectives

To estimate the cost-effectiveness of single use negative pressure wound therapy (sNPWT) compared to standard of care in patients following coronary artery bypass grafting surgery (CABG) procedure to reduce surgical site complications (SSC) defined as dehiscence and sternotomy infections.

Method

A decision analytic model was developed from the Germany Statutory Health Insurance payer’s perspective over a 12-week time horizon. Baseline data on SSC, revision operations, length of stay, and readmissions were obtained from a prospective observational study of 2621 CABG patients in Germany. Effectiveness data for sNPWT was taken from a randomised open label trial conducted in Poland which randomised 80 patients to treatment with either sNPWT or standard care. Cost data (in Euros) were taken from the relevant diagnostic related groups and published literature.

Results

The clinical study reported an increase in wounds that healed without complications 37/40 (92.5%) in the sNPWT compared to 30/40 (75%) patients in the SC group p = 0.03. The model estimated sNPWT resulted in 0.989 complications avoided compared to 0.952 and the estimated quality adjusted life years were 0.8904 and 0.8593 per patient compared to standard care. The estimated mean cost per patient was €19,986 for sNPWT compared to €20,572 for SC resulting in cost-saving of €586. The findings were robust to a range of sensitivity analyses.

Conclusion

The sNPWT can be considered a cost saving intervention that reduces surgical site complications following CABG surgery compared to standard care. We however recommend that additional economic studies should be conducted as new evidence on the use of sNPWT in CABG patients becomes available to validate the results of this economic analysis.

The Use of Closed Incision Negative-Pressure Wound Therapy in Orthopaedic Surgery

Wound complications and surgical site infections after orthopaedic procedures result in substantial morbidity and costs. Traditional postoperative wound care consists of applying sterile, dry gauze and abdominal pads to the surgical site, with more frequent dressing changes performed in cases in which wound drainage is excessive. Persistent incisional drainage is of particular concern because it increases the risk of deep infection. The use of closed incision negative-pressure wound therapy (ciNPWT) to manage delayed wound healing was first reported a decade ago, and the benefits of this treatment modality include wound contraction with diminished tensile forces, stabilization of the wound environment, decreased edema and improved removal of exudate, and increased blood and lymphatic flow. Numerous trauma, plastic surgery, and general surgery studies have demonstrated that ciNPWT improves wound healing. In orthopaedic surgery, ciNPWT has been shown to be clinically effective for incisions at high risk for perioperative complications. However, specific indications for ciNPWT continue to be defined.

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.