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 Table of Contents  
REVIEW
Year : 2017  |  Volume : 2  |  Issue : 4  |  Page : 153-159

Use of incisional negative pressure wound therapy in orthopedics


1 Department of Surgery, Division of Orthopeadics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
2 Lawson Health Research Institute, London, Ontario, Canada
3 Department of Surgery, Division of Orthopeadics, Schulich School of Medicine and Dentistry, Western University, London, Ontario; Lawson Health Research Institute, London, Ontario; London Health Sciences Centre, London, Ontario, Canada

Date of Web Publication5-Dec-2017

Correspondence Address:
Parham Rasoulinejad
Department of Surgery, Division of Orthopeadics, Schulich School of Medicine and Dentistry, Western University, London, Ontario; Lawson Health Research Institute, London, Ontario; London Health Sciences Centre, London, Ontario
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2542-4157.219376

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  Abstract 

This review article summarizes the results of currently available literature on use of incisional negative pressure wound therapy for primary closure of orthopedic incisions. Post-operative wound complications place a heavy toll on patients and the health care system. Patients with post-operative wound complications often require readmission, repeat surgery, prolonged hospitalization, and diminished outcomes. The financial burden on the health care system for surgical site infection, the most common post-operative wound complication, varies from $27,969 to over $100,000 per patient, representing a nearly 300% increase in health care costs.The role of incisional negative pressure wound therapy is currently being investigated in reducing post-operative wound complications. However, the subject is still novel and based on our literature search, only 11 papers discuss the role of incisional negative pressure wound therapy in orthopedic surgery, with only one paper providing level 1 evidence. However, despite the paucity of sufficient clinical trials, it appears that most reports suggest positive outcomes with use of negative pressure wound therapy.

Keywords: incisional negative pressure wound therapy; incisions; orthopaedic surgery; infection; traumatic wounds; wound complications


How to cite this article:
Singh S, Urquhart JC, Bailey CS, Rasoulinejad P. Use of incisional negative pressure wound therapy in orthopedics. Clin Trials Orthop Disord 2017;2:153-9

How to cite this URL:
Singh S, Urquhart JC, Bailey CS, Rasoulinejad P. Use of incisional negative pressure wound therapy in orthopedics. Clin Trials Orthop Disord [serial online] 2017 [cited 2019 Nov 22];2:153-9. Available from: http://www.clinicalto.com/text.asp?2017/2/4/153/219376


  Introduction Top


Post-operative wound complications place a heavy toll on patients, as well as, the health care system. Patients with post-operative wound complications often require readmission, repeat surgery, prolonged hospitalization, additional nursing care, and diminished outcomes. The financial burden, in North America, on the health care system for surgical site infection, the most common post-operative wound complication, varies from $27,969 to over $100,000 per patient depending on the indication and procedure; representing a nearly 300% increase in health care costs.[1] Even in elective arthroplasty surgery, wound infections although rare at 1–2.4% in primary surgery lead to significant patient morbidity and potential mortality with a prolonged treatment course.[2]

The use of negative pressure wound therapy (NPWT) has been successfully utilized for a variety of indications including the management of open abdominal wounds,[3] wounds of varying chronicity,[4] wound dehiscence,[5] burn wound settings,[6] ulcer management,[7] flaps and grafts,[8],[9] as well as incisional wound.[10],[11] NPWT works locally at the site of the wound to increase blood flow,[12] increase the formation of granulation tissue and the rate of epithelialisation,[13] as well as remove excess interstitial fluid from the wound.[4] Animal studies have demonstrated the promotion of angiogenesis at the microcirculatory level.[14],[15],[16],[17]

The use of NPWT has more recently been applied to closed, clean surgical incision sites, for high risk patient populations. This has been a novel approach to management of clean and closed wounds. In this way, NPWT is utilized with the purpose of reducing post-operative surgical site complications such as infections, seromas, hematomas, wound dehiscence and delayed healing.[18] Majority of reports focus on use of incisional NPWT for management of high risk surgical incisions with the classification of “high risk” based on the increased chance of developing a post-operative wound infection or dehiscence. Risk factors for post-operative wound complications are based on the initial trauma (i.e., soft tissue compromise, open fracture, contamination of wound), type of surgery (i.e., length of surgery, type of incision, area of incision), as well as patient attributes (i.e., medical comorbidities, age, BMI, immunosuppressive medications, immunocompromised states).[19],[20] No specific contraindications have been highlighted in the use of incisional NPWT.[21] Traditional NPWT dressings utilized for open wounds have been applied to closed surgical incisions with the addition of a non-adherent barrier layer to protect the skin.[22],[23] The ideal length of time for the application of incisional NPWT in the post-operative period is controversial with variations in duration of therapy from 24 hours up to 2 weeks.

The purpose of this paper is to review and summarize the evidence for the role of incisional NPWT specifically in orthopedic surgery.

Our goal was to identify any publications discussing the use of NPWT in management of orthopedic wounds used to prevent infection on primarily closed incisions. Due to the novelty of this technique and the overall paucity of publications, the search had to be broad and focus on orthopedics in general. We performed a literature search of the PubMed and Medline databases from 2006 to present using the key words NPWT and incisional [Figure 1]. Totally 167 articles were identified. A review of the title and abstract further refined the search to 11 articles that were specific to the use of incisional NPWT in primarily closed orthopedic surgery wounds. Animal studies were excluded from this review. Of these 11 orthopedic studies reviewed,[4] were prospective randomized controlled trials, including one multicentre trial,[4] were retrospective cohort reviews,[2] were descriptive studies and one was a case series report [Table 1]. Furthermore, two systematic reviews were identified exploring the use of incisional NPWT on closed, clean surgical sites. However, these papers include all types of surgery. No other systematic reviews were identified focusing on use of NPWT on cleaned closed incisions in Orthopedics.
Figure 1: Literature selection flowchart.
Note: NPWT: Negative pressure wound therapy.


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Table 1: Summary of post-operative incisional negative pressure wound therapy literature

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  Wound Infection and Dehiscence Top


Two systematic reviews have been done examining the role of incisional NPWT on closed, clean surgical sites. However, these reviews are broad including data from multiple surgical specialties such as general surgery, plastic surgery, orthopedic surgery, cardiothoracic surgery and vascular surgery.[24],[25] These included studies are fairly heterogeneous and represent varying levels of evidence and compare multiple patient cohorts with varying comorbidities and risk factors for surgical wound infections. Ingargiola et al. [24] concluded that there is not enough evidence to support the generalized use of incisional NPWT to all surgical wounds. No specific recommendations were made for particular patient groups or high risk surgeries. Scalise et al. [25] concluded similarly that widespread use of incisional NPWT is not recommended based on the available evidence. However, the authors reported a decrease in the incidence of infection, sero-heamatoma formation and reoperation rates when using incisional NPWT in patient populations at high risk of developing wound complications. Such patient populations may include certain lower extremity trauma cohorts, such as calcaneal, tibial plateau and pilon fratures,[32],[33] and posterior open spinal procedures which have infection rates up to 13%.[35] As such, previously published review articles, focusing on surgery in general, concluded that NPWT did not have sufficient support in literature with the exception of particular orthopedic procedures.

The most robust evidence available on incisional NPWT comes from a prospective randomized control trial performed by Stannard et al., who examined the use of this therapy after high risk lower extremity fractures. It is the first and only multicentre, prospective randomized controlled clinical trial involving four level-1 trauma centres. This study examined post-operative infection rates after tibial plateau, pilon and calcaneus fractures treated by open reduction and internal fixation. It included 263 fractures in total, 122 fractures were randomized to the control group which included routine dry gauze dressings, and 141 fractures were randomized to post-operative incisional NPWT. There were no significant differences between the groups in terms of demographics or fracture type. In this study, the authors identified a significant reduction in post-operative wound infections (9.9% vs. 18.9%) in favor of incisional NPWT, with the relative risk of developing an infection in the control group being 1.9 times higher than the incisional NPWT group. Stannard et al. also evaluated risk of wound dehiscence after lower extremity trauma surgery, in addition to post-operative wound infection rates. Their multicentre, prospective randomized controlled trial showed a statistically significant reduction in wound dehiscence in the incisional NPWT group after tibial plateau, pilon and calcaneus fractures. The control group with standard post-operative wound dressing had 20 out of 122 wounds dehiscing in comparison to the incisional NPWT dressing group, which had only 14 out of 141 wounds dehiscing. This prospective randomized trial provides the best available evidence to support use of incisional negative pressure therapy in management of calcaneal, tibial plateau and pilon fractures. The relative risk reduction for both wound infections and wound dehiscence is convincing. The study was appropriately randomized and cofounders well controlled for. As such the data is likely valid, though it has not been reproduced to date.

Reddix et al. [26] evaluated the effect of incisional NPWT on wound complications after acetabular fracture surgery in a large, retrospective study. Two hundred and thirty-five patients were treated with incisional NPWT dressings between 2001 and 2005 at a single level-1 trauma centre in the United States. They compared this group to 66 control patients receiving standard dry gauze dressing, during the 5 years prior (1996–2001). The primary outcomes of this study were wound dehiscence and wound infection rates among acetabular fracture patients. For the incisional NPWT group, they reported a 1.27% infection rate which was significantly lower than their control group (~6%) as well as, the published infection rate for acetabular fractures (~5%).

Reddix et al. [26] also evaluated wound dehiscence in their retrospective review of acetabular fractures. This study had only 1/235 wound dehiscence in the incisional NPWT group and 2/66 wound dehiscence in the control group. Although statistical significance was not found, all wounds that dehisced occurred in patients who developed wound infections. The study by Reddix et al. is the largest of its kind for use of incisional negative pressure therapy in the setting of acetabular fractures. It provides strong evidence that NPWT is safe to use under these circumstances and maybe effective in reducing wound infections. However, the groups are separated by substantial time gap and it is difficult to know if other policy changes in the hospital were set into place and controlled for. It was not reported if infections rates altered for other types of surgery at this hospital comparing the 1996–2001 to 2001–2005. Also the number of patients who underwent surgery during the same time period of 4 years was substantially different between the two introducing a possible bias. As such it would be difficult to exclude the possibility of multiple confounders. However, these results have yet to be reproduced.

In summary, there is evidence to support the use of incisional NPWT in prevention of wound dehiscence for high risk lower extremity fractures, however, only single individual studies have been reported.


  Wound Exudate Top


A recent prospective randomized controlled trial examined the use of incisional NPWT dressings in post-operative total hip and knee replacement surgery.[27] One of the primary outcomes of this study was evaluating wound exudate, as this has a correlation with risk of wound infection. This study compared 102 patients who received incisional NPWT to 107 patients who received standard gauze dressing and found a significant reduction in post-surgical wound exudate in the study group. The majority of patients in both groups had grade 0–2 peak level of exudate [Table 2]. In the incisional NPWT group only 4% of patients had grade 4 exudate as compared to the control group, which had 16% grade 4 exudate. There was a 4-fold statistically significant reduction in wound exudate. It appears that NPWT is effective in reducing wound exudate after joint replacement surgery. This has been the authors anecdotal experience. However, the correlation of reduction in exudate and wound complication is still an assumption. Previous finite element analysis models have shown a decrease in wound tension of up to 50% with the use of NPWT. It is likely this process that results in reduced exudate formation. However, it is unclear if this will also result in decreased wound infections or complications otherwise.
Table 2: Grading of wound exudate levels

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  Wound Complications Top


A study was done evaluating the use of NPWT on closed surgical incisions after total ankle arthroplasty.[28] This was a retrospective cohort study design from a single surgeon, at one institution (Duke University) from 2009–2013. All patients from 2012–2013 who underwent total ankle replacement surgery received 6 days of post-operative incisional NPWT. The control group for comparison from 2009–2012 had conventional gauze and tape used on their incisions post operatively. This study looked at 74 patients in total, with 37 patients in the control group and 37 in the incisional NPWT group. There was no significant difference between the two groups in terms of age, sex, body mass index, comorbidities, implants used, surgical time or type of closure. All patients were followed up at the 3 week post-operative mark for wound complications including wound dehiscence, wound necrosis and/or wound drainage. The results of this study showed a statistically significant reduction in wound complications from 24% in the control group to 3% in the incisional NPWT group. The results of this study are notable and despite small numbers, a statistically significant reduction in wound complications was achieved. However, it does appear that early sampling of the control group had a higher than expected infection rate and due to small number of patients it is difficult to exclude the possibility of a sampling bias. A multi-centre trial is needed to identify if NPWT can substantially reduce wound complication of ankle arthroplasty.

A retrospective comparative study was also performed for revision total hip and knee replacement surgery to examine the value of incisional NPWT on post-operative wound complications.[29] This study evaluated 138 revision arthroplasty surgeries performed by one surgeon at one centre from 2012–2015. Negative pressure wound dressings were applied in 30 patients based on surgeon selection of patients deemed at higher risk of surgical site infections and compared to 108 patients who received standard gauze dressing post operatively. This study showed that there were fewer overall wound complications in terms of wound dehiscence and infection rates but the results were not statistically significant. However, significant bias may have been introduced due to surgeon selection and lack of randomization making it difficult to interpret these results.

There is some level-3 evidence to support the use of incisional NPWT in reducing wound complications.


  Seroma Prevention Top


Seroma formation has previously been associated with wound complications. Seroma development can lead to increased wound tension and thus lead to the risk of skin necrosis and wound dehiscence. As such a reduction in post-operative seroma formation may be associated with improved wound healing.

A prospective, randomized controlled trial was performed in post-operative primary total hip arthroplasty patients, comparing the use of incisional NPWT and standard gauze dressing in developing post-operative incisional seromas.[30] This study involved a small number of patients,[19] in total, with 10 patients being randomized to the standard gauze dressing and with 9 patients being randomized to the incisional NPWT dressing. Both were applied directly on sterile closed wounds in the operating room and seroma formation was measured using ultrasound on post-operative days 5 and 10. There was statistical significance in the difference of seroma formation with the incisional NPWT group having a significant reduction in their post-operative development of a seroma (1.97 mL) as compared to the control group (5.08 mL) on day 10. More recently, a prospective randomized controlled trial evaluated the use of incisional NPWT after hemiarthroplasty for femoral neck fractures.[31] This study included 21 patients, with the average age of 82 years,[11] patients receiving incisional NPWT after surgery and 10 patients receiving standard dry gauze dressings post-operatively. Using an ultrasound, the formation of a post-operative seroma was measured at days 5 and 10. There was a significant reduction in wound secretions and formation of post-operative seromas in the incisional NPWT group (0.256 cm3 vs. 3.995 cm3 on day 5). Evidence exists to support the use of NPWT in seroma prevention which could contradict the results of studies demonstrating reduction in exudate, further studies need to be performed to understand this mechanism of action.

In orthopedic surgery, there is level-1 evidence suggesting a reduction in post-operative seroma formation with the use of incisional NPWT.


  Length of Hospital Stay Top


Karlakki et al. [27] evaluated the use of incisional NPWT dressings in routine post-operative primary total hip and knee arthroplasty surgeries. One of their primary outcomes was measuring length of stay. In this randomized controlled trial, 102 patients received incisional NPWT dressings and 107 patients received routine gauze and tape dressings. This study found no significant change in length of stay between these two groups. They did note that in the study group, the extreme value of length of stay was reduced in comparison to the control group, but overall the use of incisional NPWT did not affect length of stay. Although these study results were favorable in showing no changes in length of stay, it is likely that the results are not generalizable due to different hospital policies and home care availability by region. However, it does demonstrate that negative pressure wound therapy can be utilized without prolonging hospital admission.


  Dressing Care Top


There are two studies that comment indirectly on cost effectiveness of incisional NPWT in post-operative orthopedic surgery patients. Pauser et al. [31] showed that total dressing time was significantly reduced with the use of incisional NPWT after hemiarthroplasty surgery for femoral neck fractures. This small, prospective, randomized controlled trial demonstrated that in the incisional NPWT group, dressing time on average by post-operative day 10 was a total of 12.8 minutes with the incisional negative pressure wound dressing staying in place for 5 days, as compared to the control group, in which total dressing time was 42.9 minutes.

This finding was confirmed by Karlakki et al. [27] in their randomized controlled trial examining the use of incisional NPWT in primary total joint arthroplasty surgery, which showed a significant reduction in dressing changes in the incisional NPWT dressing group (2.5 in 1 week) as compared to their control group (4.2 in 1 week).

Overall, in orthopedic surgery, use of incisional negative pressure therapy dressings is associated with a significant reduction in dressing changes and time for dressing care, which may indirectly affect post-operative surgical care costs.


  Conclusion Top


The purpose of this paper was to summarize the role of incisional NPWT in primarily closed surgical wounds in orthopedic surgery. Previous review articles have relied on using data from all surgical fields in order to collect sufficient studies. Eleven publications to date have been presented describing the use of incisional NPWT as a method of decreasing wound complication in orthopedics. This article discerns, from currently available evidence, if the use of incisional NPWT can decrease wound complication in orthopedics. Based on the evidence available we can make specific conclusions on the use of incisional NPWT in orthopedics. However, it is important to note that although strong evidence exists to support use of incisional NPWT in orthopedics, there is insufficient number of studies available to make definitive conclusions.

There is level-1 evidence in orthopedic lower extremity trauma literature that supports the use of incisional NPWT in the reduction of post-operative wound infections and wound dehiscence. The use of incisional NPWT has strong evidence from the largest randomized control trial to date. However, it remains to be reproduced. Furthermore, there is level-1 evidence to support the use of incisional NPWT for reduction of post-operative seroma development in management of orthopedic trauma though interestingly evidence also exists to show reduction in postoperative exudate. Further studies are required to confirm these findings. Other level-3 evidence in orthopedic surgery literature shows a role for incisional NPWT to reduce overall wound complications including wound necrosis/dehiscence and infection.

Orthopedic surgery has a wide range of patient population and surgical procedures. It ranges from young, healthy, elective, outpatient surgery to complex acute trauma surgery. Post-operative wound infections can be devastating complications in orthopedic surgery leading to chronic pain and significant morbidity and mortality to the patients. In addition to patient consequences, wound complications have a significant cost burden to our health care system including prolonged hospital admissions, multiple revision surgeries and long term antibiotic treatment. As such the role of incisional NPWT is important to investigate if it can mitigate post-operative wound infections.

Although our literature search was conducted meticulously, there may be studies that were not included. Largest weakness of this review is the variation in the type of surgeries performed. Arguably calcaneal open reduction and internal fixation is a procedure different from total hip arthroplasty. However, insufficient data exists currently to focus on a specific procedure alone. Indeed, previously published review articles focused on all types of surgery in general. Despite our broad approach focusing on all of orthopedics, only 11 articles were identified. It would be preferable to focus on one specific type of orthopedic surgery; however, this review article is the first of its kind to focus on orthopedics alone with literature collected primarily from limb procedures which are much more alike than previous attempts. Evidence on this topic continues to expand and it is a current area of active research. The type of NPWT dressing and the duration of therapy are not clear in the literature and these are current areas of ongoing research. In addition, further research into cost effectiveness of incisional NPWT could be helpful to encourage its use.

There is an important role for the consideration of using incisional NPWT in orthopedic surgery for wounds that are at high risk of infection based on our review of the current available evidence. It is a safe intervention with many potential benefits especially in specific orthopedic patient groups at high risk of post-operative wound infections.

 
  References Top

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Author contributions
SS drafted the manuscript; PR contributed to the concept, draft and writing of the manuscript; CSB edited and critically reviewed the manuscript; JCU edited and prepared the manuscript.
Conflicts of interest
None declared.
Plagiarism check
Checked twice by iThenticate.
Peer review
Externally peer reviewed.


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Abstract
Introduction
Wound Infection ...
Wound Exudate
Wound Complications
Length of Hospit...
Dressing Care
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Seroma Prevention
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