Special Issues
Published: 2022-09-28

The application of negative pressure wound therapy in orthopedics: current concepts

Unit of Orthopedics and Traumatology, “Santa Maria Incoronata dell’Olmo” Hospital, AOU San Giovanni di Dio e Ruggi d’Aragona, Cava de’ Tirreni (NA), Italy
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy;
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy; Unit of Orthopedics and Traumatology, Ospedale del Mare, Naples, Italy
https://orcid.org/0000-0001-5366-5733
Unit of Orthopaedics and Traumatology, AORN “San Giuseppe Moscati”, Avellino, Italy
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy; Unit of Orthopaedics and Traumatology, “Santa Maria delle Grazie” Hospital, Pozzuoli, Italy
https://orcid.org/0000-0003-0548-5767
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
https://orcid.org/0000-0002-8560-721X
Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
negative pressure wound therapy vacuum assisted closure therapy wound healing osteomyelitis periprosthetic joint infection

Abstract

We conducted a literature review to better understand the correct application and indications of negative pressure wound therapy (NPWT) in orthopedics and traumatology. A literature search was conducted on PubMed and all articles in English, Spanish, and Italian were included. Relevant articles, references, data, and relevant findings were identified, reviewed, extracted, and accepted by consensus of at least 66% of the researchers. Relevant articles were discussed by the research group. NPWT has several beneficial effects on the wound that contribute to the maintenance of a favorable biochemical and cellular environment, to the formation of granulation tissue and to faster healing. NWPT can be useful in the treatment of septic wounds after initial debridement surgery and removal of the septic foci, and in necrotizing fasciitis in the presence of gas gangrene, venous or pressure ulcers. NPWT can also be used “for prophylactic purposes” (incisional NPWT) in patients with risk factors for skin dehiscence and with a high risk of wound drainage in the post-operative period and after prosthetic surgery or internal fixation to protect the surgical scar. However, the available evidence is mostly unclear. The appropriate use of NPWT seems to reduce the number of dressing changes in complex wounds, reduce hospitalization times, and offer greater comfort to the patient; when applied on surgical incisions, it may reduce the risk of delayed healing and the risk of infections.

Introduction

The term negative pressure wound therapy (NPWT) refers to a controlled negative/sub-atmospheric pressure system topically applied on a wound to improve its healing 1. It is also commonly referred to with the term vacuum-assisted closure (VAC) therapy.

NPWT was introduced in the early 1990s in Germany for treatment of exposed fractures 2. Later, Argenta and Morykwas described its use for the treatment of ulcerative lesions, and with echo-Doppler demonstrated its NPWT effectiveness in increasing blood flow around the wound. Moreover, the authors reported rapid formation of granulation tissue and reduction of bacterial load 3. Since its introduction, several studies have compared NPWT with conventional dressing methods, reporting improved wound healing rate and time 4-12, especially in general surgery. The promising effects of NPWT in complex wound healing led to a broadening of its indications 1. We conducted a literature review to better understand the correct application and indications of NPWT in orthopedics and traumatology.

Materials and methods

During a preliminary meeting, the research group posed three fundamental questions that can guide the orthopedic in the management of complex wound issues using NPWT in orthopedics and traumatology: (1) How to appropriately use NPWT?; (2) What is the current knowledge of NPWT in orthopedics and traumatology?; and (3) What are the future perspectives of NPWT in orthopedics and traumatology? To answer these questions, a PubMed search was conducted by three independent researchers using as keywords: “negative pressure wound therapy”, “orthopedics”, “osteomyelitis”, “open fractures”; “traumatology”; “prophylaxis”, and “periprosthetic joint infections”.

The literature research was conducted only on PubMed considering that 90% of high-quality studies can be retrieved from this database as reported by Rollin et al. 13. Therefore, searching on PubMed should be considered cost-effective and a practitioner can efficiently retrieve the majority of the literature on a given topic 13,14.

All articles in English, Spanish, and Italian were included. References of the included articles were also reviewed. Relevant articles were identified by consensus of at least 2 of 3 researchers. Data from the studies included were extracted, and relevant findings were discussed by the research group and accepted if a consensus was obtained between at least 66.6% of researchers.

Discussion

1) How to appropriately use NPWT?

The beneficial effects on the wound have been demonstrated by the reduction of wound area, which is related to the stimulation of angiogenesis, constant aspiration and mechanical cleaning of small debris and necrotic tissue, removal of protease-containing fluids, reduction of interstitial edema with improvement of microcirculation, and increase in blood flow and oxygenation 1,3,15,16. All these conditions contribute to a favorable biochemical and cellular environment and formation of granulation tissue and therefore to faster wound healing (Fig. 1).

From a technical point of view, the system is characterized by a vacuum generator, a fluid collection container (canister), a wound filler material, and a wound sealing material 1. The vacuum generator creates the suction pressure of variable intensity which is electrically powered. The suction pressure ranges between -50 and -150 mmHg, with an optimum of -125 mmHg 1,17-21. However, a lower pressure is recommended in patients with vascular disorders, ischemic areas, skin transplants, or pain during the treatment 21-26. The suction can be continuous or intermittent. Continuous suction theoretically offers better wound cleaning, and reduces bacterial proliferation and the risk of secretion leakage 1. The canister collects all the fluids and secretions. In some of the handiest NPWT devices, the canister is replaced by a highly breathable dressing that favors evaporation rather than the simple collection of material 27. The filler material can be either polyurethane foam or gauze. The former is most suitable to deep wounds with regular and wet edges and in cases where a high granulation is desired 1,27. The latter, instead, is especially useful for superficial or irregular wounds, and in case of local ischemia or severe pain 1,27. The latest generation of fillers available on the market contains also bactericidal substances like silver. The sealing material, which hermetically covers and isolates the wound, can be in polyurethane or hydrocolloid. This latter is particularly useful in case of suffering of the wound edges. The wound is connected to the vacuum generator by a drainage tube. When the vacuum is appropriately generated, collapse of the filler material, mechanical retraction of the wound, and drainage with the collection of secretions from the canister can be observed. To appropriately use the NPWT requires that the filler perfectly follows the geometry of the wound, and the absence of any leakage from the sealing material 1. NPWT should be applied for at least 22 hours per day. In case of battery failure or insufficient suction for more than 2 hours, the device should be removed, and the dressage reapplied 1,26,27. Dressings should be changed at least every 48 to 72 hours. In fact, a lower frequency easily results in foam saturation which decreases the effectiveness of treatment while increasing the risk of infection 28. The canister must be changed when it is full or at least once a week 1,26,27.

In case of infections, the NPWT can be associated with the instillation of substances such as antiseptics and antibiotics inside the wound (NWPTi) 1,27. These latter systems allow controlled and automatic instillation of a defined fluid quantity, duration, and number of cycles 1,27. Generally, instillation with a duration between 10 and 30 seconds, represents the first of the three phases, and is followed by a stationary phase that lasts from 5 to 30 minutes after the instillation. The third phase is suction, which lasts about 2-3 hours. The instillation cycle is repeated several times a day depending on the type and pharmacodynamic properties of the instilled substance 1,27.

2) What is the current knowledge of use NPWT in orthopedics and traumatology?

NWPT may be used in several scenarios, including the treatment of septic wounds, necrotizing fasciitis, gas gangrene, and venous or pressure ulcers. In the orthopedic fields it can be used especially in open fractures, infections (including osteomyelitis and periprosthetic joint infections), and fasciotomy 27.

Although the quality of the available literature is mostly poor 29, there are several studies that support the effectiveness of negative pressure therapy in reducing the risk of infection, accelerating the wound healing process, and reducing hospitalization length, at least in open fractures 30-32.

In particular, good outcomes in terms of hospital stay, wound size reduction, wound healing time, and deep infection rate were reported by Kumaar et al. in their randomized controlled trial comparing NPWT with standard dressing in open fractures 33. A safer delayed free flap repair was reported by Mastumine et al. in their case series of Gustilo IIIb tibial injuries 34.

Liu et al. conducted a systematic review on the use of NPWT in open fractures, reporting that VAC therapy was able to accelerate the wound healing process (in terms of shorter wound coverage time, shorter wound healing time) and reduces the length of stay as well as the rates of infection and amputation. However, NPWT was not demonstrated to be able to act on the need for flap surgery, free flap size, flap failure, and nonunion rate 30. Similar results were also reported in a recent meta-analysis 31. However, other reports have questioned the usefulness of NPWT in open fractures 35-37. For example, the WOLLF randomized controlled trial, conducted on 460 adults with open fractures, failed to identify substantial differences between NPWT and standard dressage at both 12 months and 5 years of follow-up 35,36. These observations raised some questions of the cost-utility of the routine use of NPWT in open fractures 37.

However, as reported by Zhang et al. in their series of 21 patients, NPWT may be part of an effective protocol for the treatment of osteomyelitis with severe soft tissue impairment 38. Figure 2 shows the staged application of NPWT in a case of osteomyelitis at our institution.

When using a NPWT there are some contraindications to consider. It should be avoided in case of coagulation disorders, active bleeding of the wound, exposure of organs, vessels, nerves, vascular anastomoses, in the presence of neoplastic tissue in the wound region (except as a palliative measure), or as an alternative for surgical debridement in case of osteomyelitis, or necrotic tissue.

3) What are the future perspectives of NPWT in orthopedics and traumatology?

Incisional NPWT (INPWT) can be used “for prophylactic purposes” on several occasions, especially in high risk patients (diabetes, glucocorticoid therapy, very elderly, revision surgery) 39-42. Several studies support this kind of approach. In particular, a meta-analysis conducted by Ailaney et al. supported the efficacy of INPWT in revision total hip arthroplasty, decreasing hospital stay and reoperation rates 39. Similar results were also reported by DeCarbo et al. in ankle replacement and calcaneal fractures 43. Moreover, in a randomized controlled trial on over 263 extremity fractures a reduction in the infection rate was reported with INPWT compared with traditional dressing 44. This reduction of surgical site infections with the use of preventive NPWT was also suggested in a recent Cochrane review 8. The reason for these promising results may be related to the inhibitory effects on bacterial proliferation observable for 48 hours after its application 45.

Conclusions

NPWT is a valuable aid in the management of complex wounds in both acute and chronic phases. It allows to reduce the number of dressing changes, thus decreasing hospitalization time, and offers greater comfort to the patient; applied on surgical incisions it may reduce the risk of delayed healing and the risk of infections, especially in patients with comorbidities. The stratification of the patient’s risk, therefore, is fundamental for optimization of the cost-benefit ratio.

Acknowledgements

None.

Conflict of interest

The Authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors’ contributions

GL, GT, ASP: conceived the study; ADC, AB, RP: performed the literature review; ADC, AB, RP, GC: extract data; all Authors analyzed the extracted data; GL, LM: wrote the first draft of the manuscript; all Authors wrote and approved the final draft of the manuscript; GT, ASP: supervised the entire process.

Ethical consideration

As a standard protocol, all patients provided written and informed consent allowing to undergo surgery and to have their data collected for scientific and audit purposes. The present study has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. According to Italian law, formal ethics approval was not required for this study, as it involved routine tests and clinical evaluations.

Figures and tables

Figure 1.NPWT: mechanism of action.

Figure 2.Clinical case of a female with a distal tibia osteomyelitis. A) clinical picture prior to surgical treatment. The patient was scheduled for bridging therapy based on wide debridement, application of an external fixator; B) and NPWTi (VAC Veraflo™, 3M, Milan, Italy); C-D) after three weeks, the soft tissues significatively improved and the patient underwent a bone transport using an Ilizarov external fixator (G).

Figure 3.Male with a pelvic fracture (A) treated with plate and screws (B). At two weeks after the surgery a wound dehiscence was observed (C) and an INPWT (Prevena™, 3M, Milan, Italy) was applied. In (D) clinics after 2 weeks of application.

Figure 4.Clinical case of an obese patient with a periprosthetic joint infection who underwent to a one stage revision (A). At three days after the surgery because of a persistent seroma some staples were removed and an INPWT applied (PICO™, Smith&Nephew, London, UK) (C). Clinics at 2 weeks after the application. At 1 year after the surgery the patient still have no clinical or laboratory signs of infection.

References

  1. Apelqvist J, Willy C, Fagerdahl A-M. EWMA document: negative pressure wound therapy. J Wound Care. 2017; 26:S1-S154. DOI
  2. Fleischmann W, Becker U, Bischoff M. Vacuum sealing: indication, technique, and results. Eur J Orthop Surg Traumatol. 1995; 5:37-40. DOI
  3. Morykwas MJ, Argenta LC, Shelton-Brown EI. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997; 38:553-562. DOI
  4. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997; 38:563-576. DOI
  5. Joseph E, Hamori CA, Bergman S. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. Wounds. 2000; 12:60-67. DOI
  6. McCallon SK, Knight CA, Valiulus JP. Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage. 2000; 46:28-32, 34.
  7. ECM. Effective management of incisional and cutaneous fistulae with closed suction wound drainage. Contemp Surg. 1989; 34:59-63.
  8. Norman G, Shi C, Goh EL. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2022; 4:CD009261. DOI
  9. Cheng Y, Wang K, Gong J. Negative pressure wound therapy for managing the open abdomen in non-trauma patients. Cochrane Database Syst Rev. 2022; 5:CD013710. DOI
  10. Pappalardo V, Frattini F, Ardita V. Negative Pressure Therapy (NPWT) for management of surgical wounds: effects on wound healing and analysis of devices evolution. Surg Technol Int. 2019; 34:56-67.
  11. Low EZ, Nugent TS, O’Sullivan NJ. Application of PREVENA (Surgical Incision Protection System) in reducing surgical site infections following reversal of ileostomy or colostomy: the PRIC study protocol. Int J Colorectal Dis. 2022; 37:1215-1221. DOI
  12. Nguyen KA, Taylor GA, Webster TK. Incisional negative pressure wound therapy is protective against post-operative cardiothoracic wound infection. Ann Plast Surg. 2022; 88:S197-S200. DOI
  13. Rollin L, Darmoni S, Caillard J-F. Searching for high-quality articles about intervention studies in occupational health – what is really missed when using only the Medline database?. Scand J Work Environ Health. 2010; 36:484-487. DOI
  14. Pillastrini P, Vanti C, Curti S. Using PubMed search strings for efficient retrieval of manual therapy research literature. Journal of Manipulative and Physiological Therapeutics. 2015; 38:159-166. DOI
  15. Stannard J. Complex orthopaedic wounds: prevention and treatment with negative pressure wound therapy. Orthop Nurs. 2004; 23:3-10. DOI
  16. Falabella AF, Carson P, Eaglstein WH. The safety and efficacy of a proteolytic ointment in the treatment of chronic ulcers of the lower extremity. J Am Acad Dermatol. 1998; 39:737-740. DOI
  17. Coutin JV, Lanz OI, Magnin-Bissel GC. Cefazolin concentration in surgically created wounds treated with negative pressure wound therapy compared to surgically created wounds treated with nonadherent wound dressings. Vet Surg. 2015; 44:9-16. DOI
  18. Borgquist O, Gustafson L, Ingemansson R. Tissue ingrowth into foam but not into gauze during negative pressure wound therapy. Wounds. 2009; 21:302-309.
  19. Nease C. Using low pressure, NPWT for wound preparation & the management of split-thickness skin grafts in 3 patients with complex wound. Ostomy Wound Manage. 2009; 55:3242.
  20. Zhou M, Yu A, Wu G. Role of different negative pressure values in the process of infected wounds treated by vacuum-assisted closure: an experimental study. Int Wound J. 2013; 10:508-515. DOI
  21. Bollero D, Carnino R, Risso D. Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy. Wound Repair Regen. 2007; 15:589-594. DOI
  22. Borgquist O, Ingemansson R, Malmsjö M. Individualizing the use of negative pressure wound therapy for optimal wound healing: a focused review of the literature. Ostomy Wound Manage. 2011; 57:44-54.
  23. Hurd T, Chadwick P, Cote J. Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds. Int Wound J. 2010; 7:448-455. DOI
  24. Jeffery SLA. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty. 2009; 9:e28.
  25. Kairinos N, Voogd AM, Botha PH. Negative-pressure wound therapy II: negative-pressure wound therapy and increased perfusion. Just an illusion?. Plast Reconstr Surg. 2009; 123:601-612. DOI
  26. Mendez-Eastman S. Guidelines for using negative pressure wound therapy. Adv Skin Wound Care. 2001; 14:314-322. DOI
  27. Robert N. Negative pressure wound therapy in orthopaedic surgery. Orthop Traumatol Surg Res. 2017; 103:S99-S103. DOI
  28. Anagnostakos K, Thiery A, Sahan I. Retained negative pressure wound therapy foams as a cause of infection persistence. Advances in Wound Care. 2021; 10:699-710. DOI
  29. Johal H, Kreder H. Cochrane in CORR®: Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Clin Orthop Relat Res. 2018; 476:463-465. DOI
  30. Liu X, Zhang H, Cen S. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: a systematic review and meta-analysis. Int J Surg. 2018; 53:72-79. DOI
  31. Qian H, Lei T, Hu Y. Negative pressure wound therapy versus gauze dressings in managing open fracture wound of lower limbs: a meta-analysis of randomized controlled trials. Foot Ankle Surg. 2022;S126877312200073X.
  32. Kim J-H, Lee D-H. Negative pressure wound therapy vs conventional management in open tibia fractures: systematic review and meta-analysis. Injury. 2019; 50:1764-1772. DOI
  33. Kumaar A, Shanthappa AH, Ethiraj P. A comparative study on efficacy of negative pressure wound therapy versus standard wound therapy for patients with compound fractures in a tertiary care hospital. Cureus. 2022; 14:e23727. DOI
  34. Matsumine H, Giatsidis G, Fujimaki H. NPWTi allows safe delayed free flap repair of Gustilo IIIb injuries: a prospective case series. Regen Ther. 2021; 18:82-87. DOI
  35. Costa ML, Achten J, Parsons NR. Five-year outcomes for patients sustaining severe fractures of the lower limb: mid-term results from the Wound management for Open Lower Limb Fracture (WOLLF) trial. Bone Joint J. 2022; 104-B:633-639. DOI
  36. Costa ML, Achten J, Bruce J. Effect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: the WOLLF randomized clinical trial. JAMA. 2018; 319:2280-2288. DOI
  37. Älgå A, Löfgren J, Haweizy R. Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial. World J Emerg Surg. 2022; 17:9. DOI
  38. Zhang X, Yang X, Chen Y. Clinical study on orthopaedic treatment of chronic osteomyelitis with soft tissue defect in adults. Int Wound J. 2021. DOI
  39. Ailaney N, Johns WL, Golladay GJ. Closed incision negative pressure wound therapy for elective hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty. 2021; 36:2402-2411. DOI
  40. Brem MH, Bail HJ, Biber R. Value of incisional negative pressure wound therapy in orthopaedic surgery. Int Wound J. 2014; 11:3-5. DOI
  41. Kim PJ, Attinger CE, Constantine T. Negative pressure wound therapy with instillation: International consensus guidelines update. Int Wound J. 2020; 17:174-186. DOI
  42. Siqueira MB. Role of negative pressure wound therapy in total hip and knee arthroplasty. WJO. 2016; 7:30. DOI
  43. DeCarbo WT, Hyer CF. Negative-pressure wound therapy applied to high-risk surgical incisions. J Foot Ankle Surg. 2010; 49:299-300. DOI
  44. Stannard JP, Volgas DA, McGwin G. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. 2012; 26:37-42. DOI
  45. Li Z, Yu Q, Wang S. Impact of negative-pressure wound therapy on bacterial behaviour and bioburden in a contaminated full-thickness wound. Int Wound J. 2019; 16:1214-1221. DOI

Affiliations

Giovanni Landi

Unit of Orthopedics and Traumatology, “Santa Maria Incoronata dell’Olmo” Hospital, AOU San Giovanni di Dio e Ruggi d’Aragona, Cava de’ Tirreni (NA), Italy

Luciano Mottola

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy;

Adriano Braile

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy; Unit of Orthopedics and Traumatology, Ospedale del Mare, Naples, Italy

Raffaele Pezzella

Unit of Orthopaedics and Traumatology, AORN “San Giuseppe Moscati”, Avellino, Italy

Annalisa De Cicco

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy; Unit of Orthopaedics and Traumatology, “Santa Maria delle Grazie” Hospital, Pozzuoli, Italy

Gianluca Conza

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy

Giuseppe Toro

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy

Alfredo Schiavone Panni

Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy

Copyright

© © Ortopedici Traumatologi Ospedalieri d’Italia (O.T.O.D.i.) , 2022

How to Cite

[1]
Landi, G., Mottola, L., Braile, A., Pezzella, R., De Cicco, A., Conza, G., Toro, G. and Schiavone Panni, A. 2022. The application of negative pressure wound therapy in orthopedics: current concepts. Lo Scalpello - Journal. 36, 2 (Sep. 2022), 116-121. DOI:https://doi.org/10.36149/0390-5276-263.
  • Abstract viewed - 107 times
  • PDF downloaded - 23 times