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Wang J, Williams B, Wlodarczyk JR, Gupta A, Kim D, Cologne KG, Koller SE, Hsieh C, Duldulao MP, Shin J. First Experience with the NPseal®: A Novel Mechanically Powered Negative Pressure Dressing Applied to Colorectal Surgery Wounds. Surg Innov 2025; 32:127-140. [PMID: 39653591 DOI: 10.1177/15533506241307729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BackgroundThe use of prophylactic closed-incisional negative pressure wound therapy after colorectal procedures has been shown to reduce postoperative wound complications and surgical site infection. We present our experience with a novel, closed-incision, mechanically powered negative pressure (MP-NPD) dressing after colorectal procedures.MethodsThis was a prospective, single-center, single-arm observational study assessing patient reported and wound healing outcomes of colorectal surgical incisions dressed with a MP-NPD. Consecutive patients, 18 years and older, that met inclusion criteria were enrolled between May 2021 and December 2021.ResultsThirty patients were included (13 male/17 female) with a mean age of 62.7 ± 11.8 years and mean body mass index of 25.5 ± 4.4 kg/m2. The mean incision length covered was 3.0 ± 1.8 cm. The median number of manual pinches required to initially activate the dressing with negative pressure within -75 to -125 mmHg was 12 (range 7-20). Four dressings were changed (13.3%) after drainage was noted inside the pump; not including these, 88.5% (23/26) of dressings held pressure consistently without any re-pinching during the 72-h period since they were first applied in the operating room. 75.9% of patients reported the dressing was "very comfortable" and none reported the dressing restricted mobility. 79.3% of patients reported the dressing was "very easy" to use. There were no cases of major wound complication or surgical site infection within 30 days.ConclusionThe use of MP-NPD appears to be feasible on primarily-closed colorectal incisions. Further randomized controlled study is warranted to ascertain its clinical efficacy.
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Affiliation(s)
- Johnny Wang
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Brian Williams
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jordan R Wlodarczyk
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Abhinav Gupta
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Debora Kim
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Kyle G Cologne
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Sarah E Koller
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Christine Hsieh
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Marjun P Duldulao
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Joongho Shin
- Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA, USA
- Keck School of Medicine of USC, Los Angeles, CA, USA
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Woldesenbet A, McGinley C, Fossett D. Negative Pressure Wound Therapy: An Analysis of Its Effectiveness on the Reduction of Postoperative Infection in Posterior Spine Surgery. World Neurosurg 2025; 194:123591. [PMID: 39725287 DOI: 10.1016/j.wneu.2024.123591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 12/15/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) has been used for postsurgical wound management across various disciplines, including spinal surgery. However, its efficacy in reducing wound infection rates after posterior thoracolumbar spine surgery remains uncertain. METHODS A retrospective review was conducted at a single institution, examining 266 patients who underwent posterior thoracic, lumbar, or thoracolumbar spine surgery performed by 1 neurosurgeon. Data included NPWT usage, type of surgery, infection rates, prior spinal surgeries, demographics, comorbidities, smoking status, and immune profiles. Statistical analysis was performed to evaluate correlations. RESULTS Of the 266 patients, 122 (46%) were males, 144 (54%) were females, and 213 (80%) were Black. Patients had a mean age of 56.4 years and an average body mass index of 29.6 kg/m2. NPWT was applied to 153 patients (57.5%). Postoperative wound infections occurred in 35 patients (13%), with 19 (54%) in the NPWT group. Overall, NPWT use was not associated with a statistically significant reduction in infection rates (P = 0.69). However, analysis of patients with multiple comorbidities showed a significant decrease in infections with NPWT (P < 0.01). A total of 198 patients (74.4%) had at least 1 comorbidity, and 10.1% (n = 20) had 2 or more major comorbidities. CONCLUSIONS NPWT significantly reduced infection rates in patients with multiple comorbidities, suggesting its potential benefit in managing wound infections in this subgroup. This finding is particularly relevant for an urban, minority patient population, highlighting the importance of tailored wound care strategies.
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Affiliation(s)
- Amanuel Woldesenbet
- Department of Neurosurgery, Howard University College of Medicine, Washington, DC, USA.
| | - Christopher McGinley
- Department of Neurosurgery, Howard University College of Medicine, Washington, DC, USA
| | - Damirez Fossett
- Division of Neurosurgery, Department of Surgery, Howard University Hospital, Washington, DC, USA
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Williams B, Gupta A, Martucci J, Swinford A, Cologne KG, Koller SE, Shin J. Mechanically Powered Negative Pressure Dressing Enhances Surgical Incision Cosmesis: A Randomized Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2025; 13:e6549. [PMID: 39958717 PMCID: PMC11828027 DOI: 10.1097/gox.0000000000006549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Accepted: 12/17/2024] [Indexed: 02/18/2025]
Abstract
Background Cosmetic appearance of incisions remains one of the most important aspects of the patient recovery experience. Despite advances in surgery, scar prevention is the gold standard in improved results. Closed-incision negative pressure wound therapy has shown promise in decreasing surgical site infection and healing time. This study aimed to assess outcomes of primarily closed surgical incisions with mechanically powered negative pressure dressings (MP-NPDs) compared with standard dressings. Methods This study was a single-center, within-subjects, randomized controlled trial, in which each patient served as both the control and experimental arms. Laparoscopic/robotic port site incisions were randomized to control dressing or MP-NPD. Primary outcomes were cosmetic results at first clinic visit by blinded physicians and nonphysician observers. Results Forty patients with a total of 80 incisions were included in the analysis. The average scores for scar spread, erythema, dyspigmentation, scar hypertrophy, and overall impression were lower for the MP-NPD wounds. The only individual variable of the Scar Cosmesis Assessment Rating scale, in which there was no difference noted between the 2 groups, was the presence of suture marks. The average total Scar Cosmesis Assessment Rating score was significantly lower (more favorable) for the MP-NPD wounds compared with the control wounds (3.39 ± 3.18 versus 4.79 ± 3.18, respectively; P < 0.001). Conclusions The use of closed-incision negative pressure wound therapy with the application of a novel MP-NPD over surgical incisions resulted in clinical and statistically significant improvement in scar cosmesis in the early/intermediate postoperative period according to both physician and nonphysician observers.
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Affiliation(s)
- Brian Williams
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Abhinav Gupta
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Jordan Martucci
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Aubrey Swinford
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Kyle G. Cologne
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
| | - Sarah E. Koller
- Division of Colorectal Surgery, Los Angeles General Medical Center, Los Angeles, CA
| | - Joongho Shin
- From the Division of Colorectal Surgery, Keck Hospital of USC, Los Angeles, CA
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4
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Williams B, Swinford A, Martucci J, Wang J, Wlodarczyk JR, Gupta A, Cologne KG, Koller SE, Hsieh C, Duldulao MP, Shin J. Mechanically powered negative pressure dressing reduces surgical site infection after stoma reversal. Surg Open Sci 2025; 23:69-74. [PMID: 39906220 PMCID: PMC11791243 DOI: 10.1016/j.sopen.2025.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Revised: 01/08/2025] [Accepted: 01/09/2025] [Indexed: 02/06/2025] Open
Abstract
Background The use of closed-incision negative pressure wound therapy (ci-NPWT) has been shown to reduce postoperative wound complications and surgical site infections (SSI) after stoma closures. However, use of this approach has not been widely adopted due to high cost of the devices. We present a novel approach to stoma closure in which a self-contained mechanically powered negative pressure dressing (MP-NPD) is applied to primarily closed stoma reversal wounds. We hypothesized that SSI and wound complication rates would be improved compared to traditional stoma closure methods. Methods This was a prospective investigator-initiated study, in which consecutive patients that underwent stoma reversal with primary stoma wound closure dressed with MP-NPD from May 2021-March 2022. 30-day outcomes from the study group, including surgical site infection, other wound complications, hospital length of stay (LOS), and readmission rates, were then reported. Results Forty-six patients undergoing local ileostomy or colostomy closure were identified for the study group. Patient demographics and surgical variables were reported. One (2.2 %) patient in the study cohort developed superficial SSI within 30 days of their surgery. Post-op LOS in the study group versus was 4.1 days. Conclusion Intestinal stoma reversal wounds closed primarily and dressed with the MP-NPD dressings had very low stoma site SSI rates. These results are promising as they pertain to the use of MP-NPD in stoma reversal procedures, however further large prospective RCTs with a matched control group could help better corroborate these findings.
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Affiliation(s)
- Brian Williams
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Aubrey Swinford
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Jordan Martucci
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Johnny Wang
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | - Abhinav Gupta
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Kyle G. Cologne
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Sarah E. Koller
- Los Angeles General Medical Center, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Christine Hsieh
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Marjun P. Duldulao
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
| | - Joongho Shin
- Keck Medicine of USC, Division of Colorectal Surgery, Los Angeles, CA, USA
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5
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Fiocco A, Dini M, Lorenzoni G, Gregori D, Colli A, Besola L. The prophylactic use of negative-pressure wound therapy after cardiac surgery: a meta-analysis. J Hosp Infect 2024; 148:95-104. [PMID: 38677481 DOI: 10.1016/j.jhin.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
Surgical site infections (SSIs) pose a frequent complication in cardiac surgery patients and lead to increased patient discomfort and extended hospitalization. This meta-analysis aimed to evaluate the protective role of single-use negative-pressure wound therapy (sNPWT) devices on closed surgical wounds after cardiac surgery, and explored their potential preventive application across all cardiac surgery patients. A comprehensive literature search was conducted on ScienceDirect, focusing on studies related to "negative pressure wound therapy" or "PICO negative pressure wound therapy" combined with "cardiac surgery" or "sternotomy," published between 2000 and 2022. Inclusion criteria encompassed case-control studies comparing sNPWT with traditional dressings on closed cardiac surgical incisions in adult patients undergoing median sternotomy without immediate postoperative infective complications, with available details on SSIs. A retrospective analysis of cases treated with sNPWT in our centre was also performed. The meta-analysis revealed a protective role of sNPWT, indicating a 44% risk reduction in overall SSIs (odds ratio 0.56) and a 40% risk reduction in deep wound infections (odds ratio 0.60). Superficial wound infections, however, showed non-significant protective effects. A single-centre study aligned with the meta-analysis findings, confirming the efficacy of sNPWT and was included in the meta-analysis. In conclusion, the meta-analysis and the single-centre study collectively support the protective role of negative pressure wound therapy against overall and deep SSIs, suggesting its potential prophylactic use on all cardiac surgery populations.
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Affiliation(s)
- A Fiocco
- Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - M Dini
- Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - G Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova, Italy
| | - D Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova, Italy
| | - A Colli
- Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.
| | - L Besola
- Cardiac Surgery Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
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6
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Suelo-Calanao RL, D’Alessio A, Hutton S, Krasopoulos G, Muppiri V, Cartwright C, Parvez A, Nikolaidis N, Loubani M. Closed-incision negative pressure therapy as a strategy to reduce sternal wound infection in identified high-risk patients: a multicentre propensity matched study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae056. [PMID: 38588571 PMCID: PMC11091424 DOI: 10.1093/icvts/ivae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/04/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES The premise of this retrospective study was to evaluate the intraoperative use of closed-incision negative pressure therapy (ciNPT) to help reduce the incidence of postoperative sternal wound infections in multimorbid patients with an elevated risk of developing a sternal wound infection post cardiac surgery versus a cohort that received standard-of-care dressings. METHODS Data for all adult patients were collected from each cardiothoracic surgery unit across 3 hospitals in the United Kingdom. High-risk patients had 2 or more recognized risk factors. Fisher's exact test (two-tailed) and unpaired t-test were used to help analyse categorical and continuous data. Propensity matching was performed to compare the 2 groups. RESULTS A total of 5,288 patients who had cardiac surgery were included. Propensity matching led to 766 matched cases. There were significantly fewer sternal wound infections in the ciNPT group [43 (5.6%) vs 119 (15.5%) cases; P = 0.0001], as well as fewer deep sternal wound infections [14 (1.8%) vs 31 (4.0%) cases; P = 0.0149] and superficial sternal wound infections [29 (3.8%) vs 88 (11.4%) cases; P = 0.0001]. A higher mean length of stay in the ciNPT group was statistically significant (11.23 ± 13 vs 9.66 ± 10 days; P = 0.0083) as was a significantly higher mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (11.143 ± 13 vs 8.094 ± 11; P = 0.0001). A statistically significant higher readmission to the intensive care unit due to sternal wound infection was noted for the controls [16 (2.08%) vs 3 (0.39%) readmissions; P = 0.0042]. CONCLUSIONS The ciNPT appears to be an effective intervention to help reduce the incidence of sternal wound infection in high-risk individuals undergoing cardiac surgery.
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Affiliation(s)
| | | | | | | | | | - Carly Cartwright
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Ahmed Parvez
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Mahmoud Loubani
- Castle Hill Hospital, Hull University Teaching Hospital, Hull, United Kingdom
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7
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Mankarious MM, Eng NL, Portolese AC, Deutsch MJ, Lynn P, Kulaylat AS, Scow JS. Closed-incision negative-pressure wound therapy reduces superficial surgical site infections after open colon surgery: an NSQIP Colectomy Study. J Hosp Infect 2024; 145:187-192. [PMID: 38272123 DOI: 10.1016/j.jhin.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/22/2023] [Accepted: 01/06/2024] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- M M Mankarious
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - N L Eng
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - A C Portolese
- Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - M J Deutsch
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - P Lynn
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - A S Kulaylat
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - J S Scow
- Division of Colon and Rectal Surgery, Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA.
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8
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Elhassan H, Amjad R, Palaniappan U, Loubani M, Rose D. The negative pressure wound therapy for prevention of sternal wound infection: Can we reduce infection rate after the use of bilateral internal thoracic arteries? A systematic literature review and meta-analysis. J Cardiothorac Surg 2024; 19:87. [PMID: 38342923 PMCID: PMC10860270 DOI: 10.1186/s13019-024-02589-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 01/30/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) is traditionally used to treat postoperative wound infections. However, its use in closed wound sternotomy post cardiac surgery in high-risk patients has become increasingly popular. The potential preventive benefit of reducing sternal wound infections has been recently acknowledged. Bilateral internal mammary artery (BIMA) grafts are used in coronary artery bypass grafting but have been associated with an increased risk of sternal wound infections (SWIs). OBJECTIVES This systematic analysis examines whether NPWT can reduce the incidence of SWI following BIMA grafts, leading to more patients benefiting from the better survival outcome associated with BIMA grafting. METHOD A comprehensive systematic search and meta-analysis were performed to identify studies on the use of NPWT in closed wound sternotomy. Ovid MEDLINE (in-process and other nonindexed citations and Ovid MEDLINE 1990 to present), Ovid EMBASE (1990 to present), and The Cochrane Library (Wiley), PubMed, and Google Scholar databases were searched from their inception to May 2022 using keywords and MeSH terms. Thirty-four articles from 1991 to May 2022 were selected. RESULT Three studies reported on the outcome of NPWT following BIMA grafting. The pooled analysis did not show any significant difference in the incidence of sternal wound infection between NPWT and standard dressing (RR 0.48 95% CI 0.17-1.37; P = 0.17) with substantial heterogeneity (I2 65%). Another seven studies were found comparing the outcome of SWI incidence of negative pressure closed wound therapy with conventional wound therapy in patients undergoing adult cardiac surgery. The pooled analysis showed that NPWT was associated with a low risk of SWIs compared to conventional dressing (RR 0.47 95% CI 0.36-0.59; P < 0.00001), with low heterogeneity (I2 1%). CONCLUSION The literature identified that NPWT significantly decreased the incidence of sternal wound complications when applied to sutured sternotomy incisions in high-risk patients, and in some cases, it eliminated the risk. However, the inadequate number of randomized controlled trials assessing the effectiveness of NPWT in BIMA grafting emphasizes the need for further, robust studies.
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Affiliation(s)
- Hind Elhassan
- Cardiothoracic Department, Hull University Teaching Hospital NHS Foundation Trust, Castle Rd, Cottingham, East Riding of Yorkshire, HU16 5JQ, UK.
| | - Ridha Amjad
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Mahmoud Loubani
- Cardiothoracic Department, Hull University Teaching Hospital NHS Foundation Trust, Castle Rd, Cottingham, East Riding of Yorkshire, HU16 5JQ, UK
| | - David Rose
- Cardiothoracic Department, Lancashire Cardiac Centre, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool, UK
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9
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Cauley RP, Slatnick BL, Truche P, Barron S, Kang C, Morris D, Chu L. Development of a risk score to predict occurrence of deep sternal dehiscence requiring operative debridement. J Thorac Cardiovasc Surg 2024; 167:757-764.e8. [PMID: 35618530 DOI: 10.1016/j.jtcvs.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence. METHODS A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates. RESULTS One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score. CONCLUSIONS This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.
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Affiliation(s)
- Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| | - Brianna L Slatnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Paul Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Mass
| | - Sivana Barron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Christine Kang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Donald Morris
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Louis Chu
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
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10
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Narayan P. Commentary: Negative pressure wound therapy: Not so negative! J Thorac Cardiovasc Surg 2024; 167:269-270. [PMID: 35181002 DOI: 10.1016/j.jtcvs.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, India.
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11
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Loubani M, Cooper M, Silverman R, Bongards C, Griffin L. Surgical site infection outcomes of two different closed incision negative pressure therapy systems in cardiac surgery: Systematic review and meta-analysis. Int Wound J 2024; 21:e14599. [PMID: 38272801 PMCID: PMC10794080 DOI: 10.1111/iwj.14599] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/08/2023] [Indexed: 01/27/2024] Open
Abstract
Closed incision negative pressure therapy (ciNPT) system use compared with standard of care dressings (SOC) on surgical site infection (SSI) in cardiac surgery was assessed. A systematic literature review was conducted. Risk ratios (RR) and random effects models were used to assess ciNPT with foam dressing (ciNPT-F) or multilayer absorbent dressing (ciNPT-MLA) versus SOC. Health economic models were developed to assess potential per patient cost savings. Eight studies were included in the ciNPT-F analysis and four studies were included in the ciNPT-MLA analysis. For ciNPT-F, a significant reduction in SSI incidence was observed (RR: 0.507, 95% confidence interval [CI]: 0.362, 0.709; p < 0.001). High-risk study analysis reported significant SSI reduction with ciNPT-F use (RR: 0.390, 95% CI: 0.205, 0.741; p = 0.004). For ciNPT-MLA, no significant difference in SSI rates were reported (RR: 0.672, 95% CI: 0.276, 1.635; p = 0.381). Health economic modelling estimated a per patient cost savings of $554 for all patients and $3242 for the high-risk population with ciNPT-F use. Health economic modelling suggests ciNPT-F may provide a cost-effective solution for sternotomy incision management. However, limited high-quality literature exists. More high-quality evidence is needed to fully assess the impact of ciNPT use following cardiac surgery.
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Affiliation(s)
- Mahmoud Loubani
- Department of Cardiothoracic SurgeryCastle Hill Hospital, Hull University Teaching HospitalHullUK
| | - Matthew Cooper
- Medical Solutions Division3M Health CareSt. PaulMinnesotaUSA
| | | | | | - Leah Griffin
- Medical Solutions Division3M Health CareSt. PaulMinnesotaUSA
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12
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Jenkins S, Komber M, Mattam K, Briffa N. Negative pressure wound therapy in patients with diabetes undergoing left internal thoracic artery harvest: A randomized control trial. J Thorac Cardiovasc Surg 2024; 167:256-268. [PMID: 35550716 DOI: 10.1016/j.jtcvs.2022.01.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 11/28/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with diabetes undergoing CABG are at risk of wound infection. Incisional negative pressure wound therapy has been shown to be effective in decreasing incidence of infection in high-risk wounds. Near infrared spectroscopy (NIRS) can be used to assess wound oxygenation and low values can predict infection. OBJECTIVES To evaluate utility of NIRS to assess wound oxygenation, to assess effect of sternotomy, left internal thoracic artery harvest, and wound dressing type on wound edge oxygenation. METHODS In this blinded randomized control trial, patients with diabetes undergoing isolated coronary artery bypass grafting with a left internal thoracic artery were randomized to receive either incisional negative pressure wound therapy dressing or a standard dressing. NIRS measurements were made on the left upper arm (control), and left and right parasternal regions on day -1 (preoperative), day 5, and week 6 after surgery. Results were analyzed using repeated measures parametric methods. RESULTS Eighty patients with diabetes were recruited, 40 to the incisional negative pressure wound therapy group and 40 to the standard dressing group. Adjusted NIRS readings dropped significantly in all patients by day 5 and partially recovered by week 6. In both groups, there was no difference between readings on the left and right. At all time points and on both sides, there was no difference in readings between patients in the 2 groups. CONCLUSIONS NIRS can be used to assess oxygenation adjacent to a sternotomy wound. Adjusted tissue oxygen levels change with time after sternotomy and left internal thoracic artery harvest in patients with diabetes. Wound dressing type does not influence day 5 wound edge oxygenation.
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Affiliation(s)
- Sam Jenkins
- Department of Infection, Immunity, and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Mohamed Komber
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Kavitha Mattam
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Norman Briffa
- Department of Infection, Immunity, and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom; Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom.
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13
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Traylor LB, Bhatia G, Blackhurst D, Wallenborn G, Ewing A, Bolton W, Davis B. Efficacy of incisional negative pressure therapy in preventing post-sternotomy wound complications. Am J Surg 2023; 226:762-767. [PMID: 37453803 DOI: 10.1016/j.amjsurg.2023.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Sternal wound infections represent a source of significant morbidity and mortality following median sternotomy. The use of incisional negative pressure wound therapy in prevention has yet to be elucidated. METHODS A retrospective study was conducted before and after a universal wound care protocol was implemented including the prophylactic use of negative pressure wound therapy (NPWT). The primary endpoint was sternal infections within 90 days of the index operation. RESULTS In the control period, there was a 3.0% rate of sternal infection within 90 days compared to 0.8% in the intervention period (p < 0.001). An odds ratio of 0.25 (95% confidence interval 0.11, 0.57; p < 0.001) in the intervention period as compared to the control period was demonstrated. CONCLUSIONS The use of a standardized wound care protocol including the universal application of NPWT for patients undergoing cardiac surgery with median sternotomy was an independent predictor of decreased rates of sternal infection.
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Affiliation(s)
- L B Traylor
- University of South Carolina School of Medicine Greenville, Greenville, SC, 29605, USA
| | - G Bhatia
- Prisma Health - Upstate, Greenville, SC, 29605, USA.
| | - D Blackhurst
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - G Wallenborn
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - A Ewing
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - W Bolton
- Prisma Health - Upstate, Greenville, SC, 29605, USA
| | - B Davis
- Prisma Health - Upstate, Greenville, SC, 29605, USA
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14
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Tao Y, Zhang Y, Liu Y, Tang S. Effects of negative pressure wound therapy on surgical site wound infections after cardiac surgery: A meta-analysis. Int Wound J 2023; 21:e14398. [PMID: 37740679 PMCID: PMC10824598 DOI: 10.1111/iwj.14398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/25/2023] Open
Abstract
We conducted a comprehensive analysis to evaluate the benefits of negative pressure wound therapy (NPWT) versus traditional dressings in preventing surgical site infections in patients undergoing cardiac surgery. We thoroughly examined several databases, including PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Chinese Biomedical Literature Database (CBM) and Wanfang, from inception until July 2023. Two independent researchers were responsible for the literature screening, data extraction and quality assessment; analyses were performed using RevMan 5.4 software. Thirteen studies comprising 8495 patients were deemed relevant. A total of 2685 patients were treated with NPWT, whereas 5810 received conventional dressings. The findings revealed that NPWT was more effective in reducing surgical site infections after cardiac surgery than conventional dressings (4.88% vs. 5.87%, odds ratio [OR]: 0.50, 95% confidence intervals [CIs]: 0.40-0.63, p < 0.001). Additionally, NPWT was more effective in reducing deep wound infections (1.48% vs. 4.15%, OR: 0.36, 95% CI: 0.23-0.56, p < 0.001) and resulted in shorter hospital stays (SMD: -0.33, 95% CIs: -0.54 to -0.13, p = 0.001). However, the rate of superficial wound infections was not significantly affected by the method of wound care (3.72% vs. 5.51%, OR: 0.63, 95% CI: 0.32-1.23, p = 0.180). In conclusion, NPWT was shown to be advantageous in preventing postoperative infections and reducing hospital stay durations in patients undergoing cardiac surgery. Nonetheless, given the limitations in the number and quality of the included studies, further research is recommended to validate these findings.
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Affiliation(s)
- Yixi Tao
- Department of Cardiovascular MedicineThe First Affiliated Hospital of Guizhou University of Traditional Chinese MedicineGuiyangChina
| | - Yusui Zhang
- Interventional Surgery of RadiologyThe First Affiliated Hospital of Guizhou University of Traditional Chinese MedicineGuiyangChina
| | - Yang Liu
- Department of Scientific Research DivisionThe First Affiliated Hospital of Guizhou University of Traditional Chinese MedicineGuiyangChina
| | - Songjiang Tang
- Department of AnaesthesiaThe First Affiliated Hospital of Guizhou University of Traditional Chinese MedicineGuiyangChina
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15
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Singh H, Avudaiappan M, Kharel J, Irrinki S, Kumar H, Savlania A, Sharma V, Gupta V, Yadav TD, Gupta R. Negative pressure wound therapy versus standard care for incisional laparotomy subcutaneous wounds in gastrointestinal perforations: A randomized controlled study. Surgery 2023; 174:291-295. [PMID: 37183134 DOI: 10.1016/j.surg.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/25/2023] [Accepted: 04/09/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Surgical site infections after gastrointestinal perforation with peritonitis have significant morbidity, increased hospital stays, and cost of treatment. The appropriate management of these wounds is still debatable. METHODS Patients undergoing surgery for gastrointestinal perforation with peritonitis via midline incision were screened for inclusion. After the closure of the midline fascia, patients were randomized into an open negative pressure wound therapy group (application of negative pressure wound therapy and attempted delayed closure at day 4) or a standard care group (no negative pressure wound therapy and attempted delayed closure at day 4). Postoperative outcomes, including surgical site infection till 30 days, were compared between the groups. This was assessed by an independent assessor not involved in the study for delayed closure. Although a priori sample size was calculated, an interim analysis was performed due to slow recruitment during the COVID pandemic. After interim analysis, a continuation of the trial was deemed unethical and terminated. RESULTS Ninety-six patients were assessed, and 69 were randomized (34 in the negative pressure wound therapy group and 31 in the standard care group). The age, body mass index, comorbidities, blood loss, operative time, and stoma formation were comparable. The surgical site infection was significantly lower in the negative pressure wound therapy group compared to the standard care group (6 [18%] vs 19 [61%], P < .01). The number needed to prevent 1 surgical site infection was 2.3. In a subgroup analysis, the use of negative pressure wound therapy also significantly decreased the rate of surgical site infection in stoma patients (4 [30.7%] vs 9 [69.3%], P = .03). CONCLUSION Open negative pressure wound therapy significantly decreases the incisional surgical site infection rate in patients with a dirty wound secondary to gastrointestinal perforation with peritonitis.
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Affiliation(s)
- Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Mohanasundaram Avudaiappan
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jyoti Kharel
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Santosh Irrinki
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Kumar
- Department of Surgical Gastroenterology, Manipal Hospital, Bangalore, India
| | - Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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16
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Tsuji M, Kakuda N, Bujo C, Saito A, Ishida J, Amiya E, Hatano M, Shimada A, Imai H, Kimura M, Ando M, Kinoshita O, Yamauchi H, Komuro I, Ono M. Prophylactic negative pressure wound therapy is not effective for preventing driveline infection following left ventricular assist device implantation. Artif Organs 2023; 47:566-573. [PMID: 36300650 DOI: 10.1111/aor.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/10/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Driveline infection (DLI) following left ventricular assist device (LVAD) implantation remains an unresolved problem. Negative pressure wound therapy (NPWT) promotes wound healing by applying negative pressure on the surface of the wound. Recently, the prophylactic application of NPWT to closed surgical incisions has decreased surgical site infections in various postsurgical settings. Therefore, we evaluated the efficacy and safety of prophylactic NPWT for preventing DLI in patients with LVAD implantation. METHODS Prophylactic NPWT was provided to 50 patients who received continuous-flow LVADs as bridge-to-transplant therapy at our institution between May 2018 and October 2020 (NPWT group). The negative pressure dressing was applied immediately after surgery and retained on the driveline exit site for 7 days with a continuous application of -125 mm Hg negative pressure. The primary outcome was DLI within 1 year of LVAD implantation. We compared the rate of DLI incidence in the NPWT group with that in the historical control cohort (50 patients) treated with the standard dressing (SD) who received LVAD implantation between July 2015 and April 2018 (SD group). RESULTS No severe complications were associated with the NPWT. During the follow-up period, DLI was diagnosed in 16 participants (32%) in the NPWT group and 21 participants (42%) in the SD group. The rates of DLI incidence and freedom from DLI did not differ between groups (p = 0.30 and p = 0.63). CONCLUSIONS Prophylactic NPWT at the driveline exit site was safe following LVAD implantation. However, it did not significantly reduce the risk of DLI.
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Affiliation(s)
- Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Akihito Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Advanced Medical Center for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Asako Shimada
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroko Imai
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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17
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Cooper HJ, Singh DP, Gabriel A, Mantyh C, Silverman R, Griffin L. Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4722. [PMID: 36936465 PMCID: PMC10019176 DOI: 10.1097/gox.0000000000004722] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/26/2022] [Indexed: 03/18/2023]
Abstract
Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes. Methods A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments. Results The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05). Discussion For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.
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Affiliation(s)
- H. John Cooper
- From the Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, N.Y
| | - Devinder P. Singh
- Department of Plastic Surgery, University of Miami Health System and Miller School of Medicine, Miami, Fla
| | | | | | - Ronald Silverman
- Department of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Md
- Medical Solutions Division, 3M, St Paul, Minn
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18
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Using Closed Incision Negative Pressure Therapy Specialty Dressings over Incisions following Sternal Dehiscence Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4623. [DOI: 10.1097/gox.0000000000004623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022]
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19
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White AJ, Gilad R, Motivala S, Fiani B, Rasouli J. Negative Pressure Wound Therapy in Spinal Surgery. Bioengineering (Basel) 2022; 9:614. [PMID: 36354525 PMCID: PMC9687616 DOI: 10.3390/bioengineering9110614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 10/30/2023] Open
Abstract
Negative pressure wound therapy (NPWT) has demonstrated promise in the management of surgical site infections as well as assisting in surgical wound healing. In this manuscript, we describe the mechanisms and applications of NPWT for surgical wounds and existing evidence for NPWT in cardiac, plastic, and general surgery, followed by a discussion of the emerging evidence base for NPWT in spinal surgery. We also discuss the different applications of NPWT for open wounds and closed incisions, and the promise of newer closed-incision NPWT (ciNPWT) devices. There is nominal but promising prospective evidence on NPWT's efficacy in select at-risk populations for post-operative wound complications after spinal surgery. As there is currently a paucity of robust clinical evidence on its efficacy, rigorous randomized prospective clinical trials are needed.
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Affiliation(s)
- Alexandra Jeanne White
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
| | - Ronit Gilad
- Northwell Health—Staten Island University Hospital, Staten Island, NY 10301, USA
| | - Soriaya Motivala
- Northwell Health—Staten Island University Hospital, Staten Island, NY 10301, USA
| | - Brian Fiani
- Department of Neurosurgery, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, NY 10065, USA
| | - Jonathan Rasouli
- Northwell Health—Staten Island University Hospital, Staten Island, NY 10301, USA
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20
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Rankin KA, Gibson D, Schwarzkopf R, O’Connor MI, Wiznia DH. Operative Techniques to Reduce Hip and Knee Arthroplasty Complications in Morbidly Obese Patients. Arthroplast Today 2022; 17:120-125. [PMID: 36082285 PMCID: PMC9445224 DOI: 10.1016/j.artd.2022.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/05/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Obesity, defined as a body mass index (BMI) >30, is associated with an increased likelihood of osteoarthritis and need for total joint arthroplasty (TJA). Unfortunately, the morbidly obese population has a higher risk of postoperative complications. For some surgeons, patient selection criteria for TJA includes BMI<40. The associated risks are recognized by The American Association of Hip And Knee Surgeons, and many surgeons follow these guidelines. Importantly, as obese patients have been demonstrated to have equal or greater gains in functional outcomes and quality of life metrics, it is important for obese patients to have access to TJA. Through a comprehensive literature review and structured interviews with leading surgeons in the field, we provide guidance for orthopedic surgeons treating patients with BMI>40 to minimize risks, including tailored preoperative, intraoperative, and postoperative considerations.
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Affiliation(s)
- Kelsey A. Rankin
- Yale School of Medicine, New Haven, CT, USA
- Corresponding author. Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA. Tel.: +1 617 285 4102.
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21
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Morrell Scott N, Lotto RR, Spencer E, Grant MJ, Penson P, Jones ID. Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature. Heart Lung 2022; 55:89-101. [PMID: 35504241 DOI: 10.1016/j.hrtlng.2022.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Around 36,000 cardiac operations are undertaken in the United Kingdom annually, with most procedures undertaken via median sternotomy. Wound complications occur in up to 8% of operations, with an associated mortality rate of around 47% in late or undetected cases. OBJECTIVE To undertake a systematised literature review to identify pre-operative, peri-operative and post-operative risk factors associated with sternal wound complications. METHODS Healthcare databases were searched for articles written in the English language and published between 2013 and 2021. Inclusion criteria were quantitative studies involving patients undergoing median sternotomy for cardiac surgery; sternal complications and risk factors. RESULTS 1360 papers were identified, with 25 included in this review. Patient-related factors included: high BMI; diabetes; comorbidities; gender; age; presenting for surgery in a critical state; predictive risk scores; vascular disease; severe anaemia; medication such as steroids or α-blockers; and previous sternotomy. Peri-operative risk increased with specific types and combinations of surgical procedures. Sternal reopening was also associated with increased risk of sternal wound infection. Post-operative risk factors included a complicated recovery; the need for blood transfusions; respiratory complications; renal failure; non-diabetic hyperglycaemia; sternal asymmetry and sepsis. CONCLUSION Pre, peri and post-operative risk factors increase the risk of sternal wound complications in cardiac surgery. Generic risk assessment tools are primarily designed to provide mortality risk scores, with their ability to predict risk of wound infection questionable. Tools that incorporate factors throughout the operative journey are required to identify patients at risk of surgical wound infection.
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Affiliation(s)
- N Morrell Scott
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
| | - R R Lotto
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom.
| | - E Spencer
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom
| | - M J Grant
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom
| | - P Penson
- School of Pharmacy and Biomolecular Sciences, Faculty of Science, Liverpool John Moores University, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
| | - I D Jones
- School of Nursing and Allied Health, Faculty of Health, Liverpool John Moores University, Liverpool L2 2ER, United Kingdom; Liverpool Centre for Cardiovascular Sciences, United Kingdom
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22
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Incisional and Surrounding Periarticular Soft Tissue Management With Negative Pressure Therapy. J Orthop Trauma 2022; 36:S26-S30. [PMID: 35994306 DOI: 10.1097/bot.0000000000002429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 02/02/2023]
Abstract
Periarticular injuries of the lower extremity are known for wound healing and infection complications. The role for incisional negative pressure wound therapy for lower extremity periarticular fractures has expanded over the last 10 years in hopes of minimizing complications. To date, there is no standardized published protocol of how negative pressure wound therapy is best used in lower extremity periarticular fractures. A review of strategies to decrease complications associated with the operative management of lower extremity periarticular fractures to include the use of incisional negative pressure wound therapy is presented.
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23
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Cooper HJ, Santos WM, Neuwirth AL, Geller JA, Rodriguez JA, Rodriguez-Elizalde S, Shah RP. Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty. J Arthroplasty 2022; 37:S931-S936. [PMID: 35304299 DOI: 10.1016/j.arth.2022.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- H John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Walkania M Santos
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jose A Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | | | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Cooper HJ, Bongards C, Silverman RP. Cost-Effectiveness of Closed Incision Negative Pressure Therapy for Surgical Site Management After Revision Total Knee Arthroplasty: Secondary Analysis of a Randomized Clinical Trial. J Arthroplasty 2022; 37:S790-S795. [PMID: 35288248 DOI: 10.1016/j.arth.2022.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 03/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The PROMISES (Post-market, Randomized, Open-Label, Multicenter, Study to Evaluate the Effectiveness of Closed Incision Negative Pressure Therapy Versus Standard of Care Dressings in Reducing Surgical Site Complications in Subjects With Revision of a Failed Total Knee Arthroplasty) randomized controlled trial compared closed incision negative pressure therapy (ciNPT) to standard of care (SOC) after revision total knee arthroplasty in high-risk patients. We assessed the costs associated with 90-day surgical site complications (SSCs) to determine the cost-benefit of ciNPT. METHODS A health economic model was used to determine mean per-patient costs to manage the surgical site, including the costs of postoperative dressings, surgical and non-surgical interventions, and readmission. A subanalysis was performed to examine cost-benefit in "lower risk" (Charlson Comorbidity Index < 2) and "higher risk" (Charlson Comorbidity Index ≥ 2) patients. RESULTS Patients with ciNPT experienced fewer SSCs (3.4% vs 14.3%; P = .0013) and required fewer surgical (0.7% vs 4.8%; P = .0666) and non-surgical (2.7% vs 12.9%; P = .0017) interventions compared to those with SOC. Readmission rates were significantly higher when patients experienced SSC (31% vs 4%; P = .0001). Using the economic model, respective per-patient costs for the ciNPT and SOC groups were $666 and $52 for postoperative dressings, $135 and $994 for surgical interventions, $231 and $970 for readmissions, and $15 and $70 for non-surgical interventions. Total per-patient costs for surgical site management were $1,047 for ciNPT and $2,036 for SOC. Among the lower risk population, mean per-patient cost was $1,066 for ciNPT and $1,474 for SOC. Among the higher risk population, mean per-patient cost was $676 for ciNPT and $3,212 for SOC. CONCLUSION Despite higher upfront costs for postoperative dressings, ciNPT was cost-effective in this health economic model, decreasing the costs of surgical site management after revision total knee arthroplasty by 49% in this study population and 79% in higher risk subgroup.
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Affiliation(s)
- Herbert J Cooper
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY
| | | | - Ronald P Silverman
- 3M Company, St. Paul, MN; University of Maryland School of Medicine, Baltimore, MD
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Negative-Pressure Wound Therapy for Prevention of Sternal Wound Infection after Adult Cardiac Surgery: Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11154268. [PMID: 35893360 PMCID: PMC9330054 DOI: 10.3390/jcm11154268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023] Open
Abstract
The results of current studies are not conclusive on the efficacy of incisional negative-pressure wound therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery. A systematic review of the literature was performed through PubMed, Scopus and Google to identify studies which investigated the efficacy of NPWT to prevent SWI after adult cardiac surgery. Available data were pooled using RevMan and Meta-analyst with random effect models. Out of 191 studies retrieved from the literature, ten fulfilled the inclusion criteria and were included in this analysis. The quality of these studies was judged fair for three of them and poor for seven studies. Only one study was powered to address the efficacy of NPWT for the prevention of postoperative SWI. Pooled analysis of these studies showed that NPWT was associated with lower risk of any SWI (4.5% vs. 9.0%, RR 0.54, 95% CI 0.34–0.84, I2 48%), superficial SWI (3.8% vs. 4.4%, RR 0.63, 95% CI 0.29–1.36, I2 65%), and deep SWI (1.8% vs. 4.7%, RR 0.46, 95% CI 0.26–0.74, I2 0%), but such a difference was not statistically significant for superficial SWI. When only randomized and alternating allocated studies were included, NPWT was associated with a significantly lower risk of any SWI (3.3% vs. 16.5%, RR 0.22, 95% CI 0.08–0.62, I2 0%), superficial SWI (2.6% vs. 12.4%, RR 0.21, 95% CI 0.06–0.69, I2 0%), and deep SWI (1.2% vs. 4.8%, RR 0.17, 95% CI 0.03–0.95, I2 0%). This pooled analysis showed that NPWT may prevent postoperative SWI after adult cardiac surgery. NPWT is expected to be particularly useful in patients at risk for surgical site infection and may significantly reduce the burden of resources needed to treat such a complication. However, the methodology of the available studies was judged as poor for most of them. Further studies are needed to obtain conclusive results on the potential benefits of this preventative strategy.
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The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis. Plast Reconstr Surg Glob Open 2022; 10:e4233. [PMID: 35506023 PMCID: PMC9053136 DOI: 10.1097/gox.0000000000004233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
Abstract
Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.
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Nguyen KA, Taylor GA, Webster TK, Jenkins RA, Houston NS, Kahler DL, Gassman AA, Jones CM. Incisional Negative Pressure Wound Therapy Is Protective Against Postoperative Cardiothoracic Wound Infection. Ann Plast Surg 2022; 88:S197-S200. [PMID: 35513319 DOI: 10.1097/sap.0000000000003196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sternal wound infections are a rare but life-threatening complication of cardiothoracic surgery. Prior literature has supported the use of negative pressure wound therapy to decrease sternal wound infections and promote healing. This study sought to determine whether closed incision negative pressure therapy reduced wound infection and improved outcomes in cardiothoracic surgery. METHODS A retrospective cohort study was performed including all adult patients who underwent nontraumatic cardiothoracic surgery at a single institution between 2016 and 2018 (n = 1199). Patient characteristics, clinical variables, and surgical outcomes were compared between those who did and did not receive incisional negative pressure wound therapy intraoperatively. Multivariable logistic regression analysis determined factors predictive or protective of the development of complications. RESULTS Incisional negative pressure wound therapy was used in 58.9% of patients. Patients who received this therapy were older with statistically higher rates of hyperlipidemia, statin, and antihypertensive use. The use of negative pressure wound therapy was found to significantly reduce rates of both wound infection (3.0% vs 6.3%, P = 0.01) and readmission for wound infection (0.7% vs 2.6%, P = 0.01). After controlling for confounding variables, negative pressure wound therapy was found to be a protective factor of surgical wound infection (odds ratio, 0.497; 95% confidence interval, 0.262-0.945). CONCLUSIONS In the largest population studied to date, this study supported the expanded use of negative pressure therapy on sternal wound incisions to decrease infection rates.
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Affiliation(s)
- Kaitlin A Nguyen
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - George A Taylor
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Theresa K Webster
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Rachel A Jenkins
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Nicklaus S Houston
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Dylan L Kahler
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
| | - Andrew A Gassman
- PRMA Plastic Surgery Center for Advanced Reconstruction, San Antonio, TX
| | - Christine M Jones
- From the Department of Surgery, Temple University Hospital, Philadelphia, PA
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Norman G, Shi C, Goh EL, Murphy EM, Reid A, Chiverton L, Stankiewicz M, Dumville JC. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2022; 4:CD009261. [PMID: 35471497 PMCID: PMC9040710 DOI: 10.1002/14651858.cd009261.pub7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
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.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Elizabeth Ma Murphy
- Ward 64, St. Mary's Hospital, Manchester Foundation NHS Trust, Manchester, UK
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Ryu JY, Lee JH, Kim JS, Lee JS, Lee JW, Choi KY, Chung HY, Cho BC, Yang JD. Usefulness of Incisional Negative Pressure Wound Therapy for Decreasing Wound Complication Rates and Seroma Formation Following Prepectoral Breast Reconstruction. Aesthetic Plast Surg 2022; 46:633-641. [PMID: 33474573 DOI: 10.1007/s00266-020-02115-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Seroma is a common complication in prepectoral breast reconstruction. PICOTM dressing, a type of incisional negative pressure wound therapy (iNPWT), was used to reduce complications postoperatively. METHODS This study was a retrospective cohort study that included patients who underwent prepectoral breast reconstruction between February 2017 and July 2019. There were two groups: one that received PICOTM dressing and a control group. The frequencies of overall complications, major seromas, and reoperations were analyzed. The durations and total amounts of seromas were also analyzed. RESULT Sixty patients were included in this study (PICOTM : 37 and non-PICOTM patients: 23). The overall incidence of complications, major seromas, and frequency of reoperations were lower in the PICO group compared to the non-PICOTM group (18.9% vs. 52.2%, p = 0.007; 16.2% vs. 43.5%, p = 0.020; 2.7% vs. 26.1%, p = 0.006, respectively). Univariate analysis was used to analyze the risk factors for complications due to the application of PICOTM dressing and showed statistically significant results for any complication. When univariate analysis was performed on risk factors for seroma, the duration of seroma showed statistical significance in association with PICOTM dressing status and mastectomy volume. The total number of patients who developed seroma was statistically correlated with age, PICOTM dressing status, and mastectomy volume. CONCLUSIONS PICOTM dressing after prepectoral breast reconstruction could be a useful tool for reducing the frequency of complications and major seroma, as well as the duration and total incidences of seroma. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Jeong Yeop Ryu
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Jung Ho Lee
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Jong Seong Kim
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Joon Seok Lee
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Jeong Woo Lee
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Kang Young Choi
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Ho Yun Chung
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Byung Chae Cho
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea
| | - Jung Dug Yang
- Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Korea.
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Wound Closure Following Intervention for Closed Orthopedic Trauma. Injury 2022; 53:313-322. [PMID: 34865820 DOI: 10.1016/j.injury.2021.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/24/2021] [Indexed: 02/02/2023]
Abstract
The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.
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Borejsza-Wysocki M, Bobkiewicz A, Francuzik W, Krokowicz L, Walczak D, Szmeja J, Banasiewicz T. Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study. Wideochir Inne Tech Maloinwazyjne 2021; 16:686-696. [PMID: 34950263 PMCID: PMC8669980 DOI: 10.5114/wiitm.2021.106426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/20/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI. AIM To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery. MATERIAL AND METHODS As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed. RESULTS The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03-3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group. CONCLUSIONS CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.
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Affiliation(s)
- Maciej Borejsza-Wysocki
- Department of General, Endocrinological and Gastroenterological Oncology Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Adam Bobkiewicz
- Department of General, Endocrinological and Gastroenterological Oncology Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Francuzik
- Department of Dermatology, Venerology and Allergology Charité – Universitätsmedizin, Berlin, Germany
| | - Lukasz Krokowicz
- Department of General, Endocrinological and Gastroenterological Oncology Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Dominik Walczak
- Department of Oncological and Reconstructive Surgery, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Gliwice, Poland
| | - Jacek Szmeja
- Department of General, Endocrinological and Gastroenterological Oncology Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological and Gastroenterological Oncology Surgery, Poznan University of Medical Sciences, Poznan, Poland
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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Doman DM, Young AM, Buller LT, Deckard ER, Meneghini RM. 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. J Arthroplasty 2021; 36:3437-3442. [PMID: 34140207 DOI: 10.1016/j.arth.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- David M Doman
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA
| | | | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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The utility of incisional vacuum-assisted closure in surgical Management of Hidradenitis Suppurativa: a retrospective cohort study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01788-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Myllykangas HM, Halonen J, Husso A, Väänänen H, Berg LT. Does Incisional Negative Pressure Wound Therapy Prevent Sternal Wound Infections? Thorac Cardiovasc Surg 2021; 70:65-71. [PMID: 34521138 DOI: 10.1055/s-0041-1731767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Incisional negative pressure wound therapy has been described as an effective method to prevent wound infections after open heart surgery in several publications. However, most studies have examined relatively small patient groups, only a few were randomized, and some have manufacturer-sponsorship. Most of the studies have utilized Prevena; there are only a few reports describing the PICO incisional negative pressure wound therapy system. METHODS We conducted a prospective cohort study involving a propensity score-matched analysis to evaluate the effect of PICO incisional negative pressure wound therapy after coronary artery bypass grafting. A total of 180 high-risk patients with obesity or diabetes were included in the study group. The control group included 772 high-risk patients operated before the initiation of the study protocol. RESULTS The rates of deep sternal wound infections in the PICO group and in the control group were 3.9 and 3.1%, respectively. The rates of superficial wound infections needing operative treatment were 3.1 and 0.8%, respectively. After propensity score matching with two groups of 174 patients, the incidence of both deep and superficial infections remained slightly elevated in the PICO group. None of the infections were due to technical difficulties or early interruption of the treatment. CONCLUSION It seems that incisional negative pressure wound therapy with PICO is not effective in preventing wound infections after coronary artery bypass grafting. The main difference in this study compared with previous reports is the relatively low incidence of infections in our control group.
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Affiliation(s)
- Heidi-Mari Myllykangas
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland.,University of Eastern Finland School of Medicine, Kuopio, Pohjois-Savo, Finland
| | - Jari Halonen
- University of Eastern Finland School of Medicine, Kuopio, Pohjois-Savo, Finland.,Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Annastiina Husso
- Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Helli Väänänen
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Leena T Berg
- Department of Plastic Surgery, Kainuu Central Hospital, Kajaani, Kainuu, Finland
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Mueller KB, D'Antuono M, Patel N, Pivazyan G, Aulisi EF, Evans KK, Nair MN. Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection after Spinal Surgery: A Prospective Observational Study. Neurosurgery 2021; 88:E445-E451. [PMID: 33611587 DOI: 10.1093/neuros/nyab040] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Use of a closed-incisional negative pressure therapy (ci-NPT) dressing is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery that lacks robust data. OBJECTIVE To determine the impact of a ci-NPT, as compared with a standard dressing, on the development of SSIs after spine surgery. METHODS This was a prospective observational study over a 2-yr period. Indications for surgery included degenerative disease, deformity, malignancy, and trauma. Exclusion criteria included anterior and lateral approaches to the spine, intraoperative durotomy, or use of minimally invasive techniques. SSIs up to 60 d following surgery were recorded. RESULTS A total of 274 patients were included. SSI rate was significantly lower with ci-NPT dressing (n = 118) as compared with the standard dressing (n = 156) (3.4 vs 10.9%, P = .02). There was no statistical difference in infection rate for decompression alone procedures (4.2 vs 9.1%, P = .63), but there was a statistically significant reduction with the use of a negative-pressure dressing in cases that required instrumentation (3.2 vs 11.4%, P = .03). Patients at higher risk (instrumentation, deformity, and malignancy) had less SSIs with the use of ci-NPT, although this did not reach statistical significance. There were no complications in either group. CONCLUSION SSI rates were significantly reduced with a ci-NPT dressing vs a standard dressing in patients who underwent spinal surgery. The higher cost of a ci-NPT dressing might be justified with instrumented cases, as well as with certain high-risk patient populations undergoing spine surgery, given the serious consequences of an infection.
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Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Matthew D'Antuono
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Nirali Patel
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Gnel Pivazyan
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Edward F Aulisi
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic Surgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - M Nathan Nair
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
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Wang E, Archer L, Foster A, Ballal M. Large abdominal hernia repair with closed incision negative pressure therapy: a case series. J Wound Care 2021; 30:192-196. [PMID: 33729848 DOI: 10.12968/jowc.2021.30.3.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A major challenge of large abdominal incisional hernia repair is the high rates of wound complications. Closed incision negative pressure therapy (CINPT) can offer many treatment advantages in the management of these wounds and has been shown to reduce complications for other postoperative incisions. This study assesses the wound outcomes for hernia repair patients receiving CINPT. METHOD A six-year retrospective case series of patients who had undergone large abdominal incisional hernia repair wounds treated with CINPT was conducted. Outcomes for patients treated with CINPT were compared with patients who had not received CINPT acting as a control. RESULTS A total of 23 patients were treated with CINPT after hernia repair and compared with 12 patients in the control group. A statistically significant decreased rate of return to theatre (odds ratio: 0.12) was found in this study. Non-significant reductions in wound infection, seroma and wound dehiscence were also seen. No adverse events with CINPT therapy were reported. CONCLUSIONS CINPT, when used after large abdominal incisional hernia repair, may help in the prevention of wound complications.
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Affiliation(s)
- Edward Wang
- Department of General Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch 6150 WA, Australia
| | - Leigh Archer
- Department of General Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch 6150 WA, Australia
| | - Amanda Foster
- Department of General Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch 6150 WA, Australia
| | - Mohammed Ballal
- Department of General Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch 6150 WA, Australia.,School of Surgery, The University of Western Australia (M704), 35 Stirling Highway, 6009 Perth, Australia
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Rashed A, Csiszar M, Beledi A, Gombocz K. The impact of incisional negative pressure wound therapy on the wound healing process after midline sternotomy. Int Wound J 2020; 18:95-102. [PMID: 33236860 PMCID: PMC7948622 DOI: 10.1111/iwj.13497] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/15/2020] [Accepted: 08/19/2020] [Indexed: 01/22/2023] Open
Abstract
Previous studies have reported that the use of incisional negative pressure wound therapy (INPWT) might reduce the incidence of wound infections, although its mechanism remains unknown. We designed a prospective study to explore the effects of INPWT on different stages of the wound healing process. After meeting the inclusion criteria, 108 patients were enrolled. Based on exclusion criteria four patients were excluded and 104 patients were randomised into two groups. INPWT was applied after primary closure of the midline sternotomy in the study group (n = 52), while conventional wound dressing was applied in the control group (n = 52). We documented the incidence of deep sternal wound infections and analysed the pre‐ and postoperative inflammatory biomarkers and scar size in both groups. No wound infections were observed in the study group compared with six cases (11.1%) in the control group, (P = .026). No significant differences were observed in the inflammatory biomarkers between the groups. Scar size was significantly smaller in the study group. We concluded that INPWT has less effect on the inflammatory phase and appears to have more effect on the proliferation phase through pronounced scar formation.
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Affiliation(s)
- Aref Rashed
- Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
| | - Marton Csiszar
- Department of Radiology, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
| | - Agnes Beledi
- Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
| | - Karoly Gombocz
- Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary
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Siegwart LC, Sieber L, Fischer S, Maraka S, Kneser U, Kotsougiani-Fischer D. Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction. Microsurgery 2020; 42:32-39. [PMID: 33201541 DOI: 10.1002/micr.30683] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/06/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction. PATIENTS AND METHODS We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality. RESULTS Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups. CONCLUSION The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.
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Affiliation(s)
- Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Laura Sieber
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Medicine, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA.,Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
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Abstract
Summary
Background
Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces.
Materials and methods
We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence.
Results
Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%).
Conclusion
ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.
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Suelo-Calanao RL, Thomson R, Read M, Matheson E, Isaac E, Chaudhry M, Loubani M. The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study. J Cardiothorac Surg 2020; 15:222. [PMID: 32814569 PMCID: PMC7437015 DOI: 10.1186/s13019-020-01265-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing. Objective This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients. Methods A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher’s exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively. Results The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66). Conclusion In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.
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Affiliation(s)
| | - Richard Thomson
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Maxine Read
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | | | - Emmanuel Isaac
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mubarak Chaudhry
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK.
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Kachel E, Moshkovitz Y, Sternik L, Sahar G, Grosman-Rimon L, Belotserkovsky O, Reichart M, Stark Y, Emanuel N. Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology. J Card Surg 2020; 35:2695-2703. [PMID: 32743813 DOI: 10.1111/jocs.14890] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sternal wound infection (SWI) is a devastating postcardiac surgical complication. D-PLEX100 (D-PLEX) is a localized prolonged release compound applied as a prophylactic at the completion of surgery to prevent SWI. The D-PLEX technology platform is built as a matrix of alternating layers of polymers and lipids, entrapping an antibiotic (doxycycline). The objective of this study was to assess the safety profile and pharmacokinetics of D-PLEX in reducing SWI rates postcardiac surgery. METHOD Eighty-one patients were enrolled in a prospective single-blind randomized controlled multicenter study. Sixty patients were treated with both D-PLEX and standard of care (SOC) and 21 with SOC alone. Both groups were followed 6 months for safety endpoints. SWI was assessed at 90 days. RESULTS No SWI-related serious adverse events (SAEs) occurred in either group. The mean plasma Cmax in patients treated with D-PLEX was about 10 times lower than the value detected following the oral administration of doxycycline hyclate with an equivalent overall dose, and followed by a very low plasma concentration over the next 30 days. There were no sternal infections in the D-PLEX group (0/60) while there was one patient with a sternal infection in the control group (1/21, 4.8%). CONCLUSION D-PLEX was found to be safe for use in cardiac surgery patients. By providing localized prophylactic prolonged release of broad-spectrum antibiotics, D-PLEX has the potential to prevent SWI postcardiac surgery and long-term postoperative hospitalization, reducing high-treatment costs, morbidity, and mortality.
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Affiliation(s)
- Erez Kachel
- Department of Cardiac Surgery, Poriya Medical Center, Tiberias, Israel.,Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Yaron Moshkovitz
- Department of Cardiothoracic Surgery, Assuta Medical Center, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Gideon Sahar
- Department of Cardiothoracic Surgery, Soroka Medical Center, Beer Sheva, Israel
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Closed incision negative pressure wound therapy may decrease wound complications in major lower extremity amputations. J Vasc Surg 2020; 73:1041-1047. [PMID: 32707380 DOI: 10.1016/j.jvs.2020.07.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/07/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Wound complications after major lower extremity amputations (LEAs) are a cause of significant morbidity in vascular surgery patients. Recent publications have demonstrated the efficacy of the closed incision negative pressure dressing at preventing surgical site infections (SSIs); however, there are few data on its use in major LEAs. This study sought to assess if closed incision negative pressure wound therapy (NPWT) would decrease the risk of complications as compared with a standard dressing in patients with peripheral vascular disease undergoing major LEA. METHODS Fifty-four consecutive patient limbs with a history of peripheral arterial disease underwent below-knee or above-knee amputations. This was a retrospective review of a prospectively maintained database from January 2018 to December 2019, and it included 23 amputations in the NPWT group and 31 amputations in the standard dressing group. NPWT using the PREVENA system was applied intraoperatively at the discretion of the operating surgeon and removed 5 to 7 days postoperatively. The standard group received a nonadherent dressing with an overlying compression dressing. Amputation incisions were assessed and wound complications were recorded. Student's t-test and two-sample proportion z-test were used for statistical analysis. A P value of less than .05 was considered statistically significant. RESULTS For comorbidities, there was a higher incidence of tobacco use in the NPWT as compared with the standard group (44% vs 13%; P = .011), as well as trends toward increased prior amputations, anemia, hyperlipidemia, and chronic obstructive pulmonary disorder in the NPWT group. For risk factors, there were more dirty wounds in the NPWT as compared with the standard group (52% vs 26%; P = .046). For outcomes, there were fewer wound complications in the NPWT as compared with the standard group (13% vs 39%; P = .037). The types of wound-related complications in the NPWT group included one wound dehiscence with a deep SSI, one superficial SSI, and one incision line necrosis. In the standard group, there were four wound dehiscences with deep SSI, three superficial SSIs, four incision line necroses, and one stump hematoma. The rates of perioperative mortality and amputation revision did not differ significantly between the NPWT and the standard groups (3% vs 4% and 4.3% vs 10%, respectively). CONCLUSIONS Closed incision NPWT may decrease the incidence of wound complications in vascular patients undergoing major LEA. This held true even among a population that was potentially at higher risk. This therapy may be considered for use in lower extremity major amputations.
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Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management. Plast Reconstr Surg 2020; 145:839e-854e. [PMID: 32221237 DOI: 10.1097/prs.0000000000006652] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care. SUMMARY Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.
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Ozkan B, Markal Ertas N, Bali U, Uysal CA. Clinical Experiences with Closed Incisional Negative Pressure Wound Treatment on Various Anatomic Locations. Cureus 2020; 12:e8849. [PMID: 32626631 PMCID: PMC7328693 DOI: 10.7759/cureus.8849] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Closed incisional negative pressure wound treatment (ciNPWT) is one of the promising methods for the prevention of complications in surgical incisions. The mechanisms of ciNPWT have previously been elucidated and in this series, we demonstrate various, as of yet, underreported uses for the technology. Our aim is to share our experience with ciNPWT on various anatomic sites with novel indications. Materials and methods ciNPWT was used in 24 patients. The mean age was 49.6. All the incisions were sutured, clean, and non-infected. Patients’ sex, age, comorbidities, anatomic location of the wound, and the indications for ciNPWT were recorded. Results The mean number of applications was three per patient. One suture dehiscence after one session of ciNPWT was encountered in a flap donor site of an infant operated for meningomyelocele. Late-term seroma and hematoma formation were encountered in two patients. No surgical site infection, wound dehiscence, and ciNPWT related complications were seen in other patients. The majority of the applications were on the trunk, lower extremity, pelvis, upper extremity, and scalp respectively. Indications for ciNPWT utilization were preventing dehiscence, seroma, and hematoma formation in the majority of the patients. Conclusion ciNPWT is reliable and effective in the prevention of post-operative wound dehiscence and surgical site infections. It can be used safely in various locations and different indications for preventingcomplications such as preventing dehiscence in revision surgeries, cerebrospinal fluid (CSF) fistula formation in the scalp, and wound breakdown in chronic corticosteroid use,
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Affiliation(s)
- Burak Ozkan
- Plastic and Reconstructive Surgery, Baskent University Faculty of Medicine, Ankara, TUR
| | - Nilgun Markal Ertas
- Plastic and Reconstructive Surgery, Baskent University Faculty of Medicine, Ankara, TUR
| | - Ulas Bali
- Plastic Surgery, Celal Bayar Üniversitesi, Manisa, TUR
| | - Cagri A Uysal
- Plastic and Reconstructive Surgery, Baskent University Faculty of Medicine, Ankara, TUR
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Norman G, Goh EL, Dumville JC, Shi C, Liu Z, Chiverton L, Stankiewicz M, Reid A. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2020; 6:CD009261. [PMID: 32542647 PMCID: PMC7389520 DOI: 10.1002/14651858.cd009261.pub6] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zhenmi Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
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Naalla R, Bhushan S, Abedin MU, Bichpuriya AD, Singhal M. Closed Incisional Negative Pressure Wound Therapy at Flap Suture Line: An Innovative Approach for Improving Outcomes in Suboptimal Wound Conditions. Indian J Plast Surg 2020; 53:90-96. [PMID: 32367922 PMCID: PMC7192709 DOI: 10.1055/s-0040-1709528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background
Persistent dead space following flap cover is a frequently encountered challenge following the reconstruction of complex wounds. It may lead to a hematoma, seroma, wound infection, and wound dehiscence. Wound dehiscence could be a devastating complication. Closed incisional negative pressure wound therapy (ciNPWT) over the surgical incisions was found to reduce surgical site infection (SSI) and wound dehiscence. We applied this principle at the closed flap suture line and through this article, we share the indications, technique, and outcomes.
Methods
A retrospective analysis (January 2018–June 2019), in which selected high-risk patients who underwent ciNPWT at the flap suture following complex reconstruction (pedicled or free flap) were included in the study. The indications include deep incisional/organ SSI after debridement and flap coverage, persistent dead space following flap coverage, chronic osteomyelitis. Patients were analyzed in the follow-up period in terms of complications, wound healing.
Results
Nine patients underwent ciNPWT over the flap suture line. The mean age was 32.2 years (range: 10–48 years). The mean duration of the NPWT application was 7.3 days (range: 3–21 days). Three of the nine patients had flap-related minor complications. One patient had marginal flap necrosis and required skin grafting, one patient had minor wound dehiscence (1 cm) which required secondary skin suturing and one patient had chronic discharging sinus related to osteomyelitis of ischium, which subsequently healed with antibiotics and local wound care. None of the patients had NPWT-related complications.
Conclusion
Closed incisional NPWT decreases the untoward effects of dead space following the reconstruction of complex wounds. The incidence of SSI and wound gaping can be reduced.
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Affiliation(s)
- Ravikiran Naalla
- Department of Plastic Reconstructive & Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Bhushan
- Department of Plastic Reconstructive & Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Minhaj Ul Abedin
- Department of Plastic Reconstructive & Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Dhanraj Bichpuriya
- Department of Plastic Reconstructive & Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Maneesh Singhal
- Department of Plastic Reconstructive & Burns Surgery, All India Institute of Medical Sciences, New Delhi, India
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Norman G, Goh EL, Dumville JC, Shi C, Liu Z, Chiverton L, Stankiewicz M, Reid A. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2020; 5:CD009261. [PMID: 32356396 PMCID: PMC7192856 DOI: 10.1002/14651858.cd009261.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zhenmi Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
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Chang B, Sun Z, Peiris P, Huang ES, Benrashid E, Dillavou ED. Deep Learning-Based Risk Model for Best Management of Closed Groin Incisions After Vascular Surgery. J Surg Res 2020; 254:408-416. [PMID: 32197791 DOI: 10.1016/j.jss.2020.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/13/2020] [Accepted: 02/16/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Reduced surgical site infection (SSI) rates have been reported with use of closed incision negative pressure therapy (ciNPT) in high-risk patients. METHODS A deep learning-based, risk-based prediction model was developed from a large national database of 72,435 patients who received infrainguinal vascular surgeries involving upper thigh/groin incisions. Patient demographics, histories, laboratory values, and other variables were inputs to the multilayered, adaptive model. The model was then retrospectively applied to a prospectively tracked single hospital data set of 370 similar patients undergoing vascular surgery, with ciNPT or control dressings applied over the closed incision at the surgeon's discretion. Objective predictive risk scores were generated for each patient and used to categorize patients as "high" or "low" predicted risk for SSI. RESULTS Actual institutional cohort SSI rates were 10/148 (6.8%) and 28/134 (20.9%) for high-risk ciNPT versus control, respectively (P < 0.001), and 3/31 (9.7%) and 5/57 (8.8%) for low-risk ciNPT versus control, respectively (P = 0.99). Application of the model to the institutional cohort suggested that 205/370 (55.4%) patients were matched with their appropriate intervention over closed surgical incision (high risk with ciNPT or low risk with control), and 165/370 (44.6%) were inappropriately matched. With the model applied to the cohort, the predicted SSI rate with perfect utilization would be 27/370 (7.3%), versus 12.4% actual rate, with estimated cost savings of $231-$458 per patient. CONCLUSIONS Compared with a subjective practice strategy, an objective risk-based strategy using prediction software may be associated with superior results in optimizing SSI rates and costs after vascular surgery.
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Affiliation(s)
| | - Zhifei Sun
- KelaHealth, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Erich S Huang
- KelaHealth, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ellen D Dillavou
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Kunze KN, Hamid KS, Lee S, Halvorson JJ, Earhart JS, Bohl DD. Negative-Pressure Wound Therapy in Foot and Ankle Surgery. Foot Ankle Int 2020; 41:364-372. [PMID: 31833393 DOI: 10.1177/1071100719892962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kamran S Hamid
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Simon Lee
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jason J Halvorson
- Department of Orthopaedic Surgery, Wake Forest Baptist Health Center, Winston Salem, NC, USA
| | | | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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