Cost-Effectiveness of Closed Incision Negative Pressure Therapy for Surgical Site Management After Revision Total Knee Arthroplasty: Secondary Analysis of a Randomized Clinical Trial

Closed-Incision Negative Pressure Wound Therapy Improves Outcomes in Obese Aseptic Revision Total Hip and Knee Arthroplasty

BACKGROUND

The burden of revision total joint arthroplasty (rTJA) is increasing. Revision procedures are associated with an increased risk of perioperative complications. Obese patients undergoing rTJA may have a higher risk of wound complications due to their soft-tissue envelope. Closed-incision negative pressure wound therapy (ciNPWT) has been rigorously investigated for its effect on reducing wound complications; however, the literature is limited to primary total joint arthroplasty. The purpose of the current study was to investigate the association between ciNPWT and clinical outcomes for obese patients undergoing aseptic revision total hip and knee arthroplasty.

METHODS

This was a retrospective study examining aseptic rTJA procedures from January 2017 to December 2021 at a high-volume institution. Patients were included if their body mass index was > 35 and had a minimum follow-up of 2 years. The cohorts were rTJA procedures that used ciNPWT versus procedures without ciNPWT use. A total of 214 rTJA (Hip, n = 61; Knee, n = 153) patients qualified for analysis. After surgery, ciNPWT was applied on 130 (60.7%) patients (92 knees and 38 hips), and standard dressing was used on 84 (39.3%) patients (61 knees and 23 hips). There were no significant baseline differences between the groups. Outcomes evaluated were as follows: (1) revision for infection; (2) superficial wound complications; (3) overall complications; (4) all-cause revision; and (5) all-cause readmissions. The association between ciNPWT use and outcomes was evaluated using Chi-square tests.

RESULTS

When controlling for all variables, ciNPWT use was associated with significantly fewer revisions for infection (0.8 versus 8.3%), overall complications (3.8 versus 11.9%), all-cause revisions (3.1 versus 13.1%), and readmissions (10.8 versus 21.7%) compared to those who did not use ciNPWT. Secondary superficial wound complication-specific outcomes did not show significant differences.

CONCLUSIONS

To our knowledge, this study is the largest retrospective study to date examining the effect of ciNPWT on outcomes in obese aseptic revision rTJA patients. Our results demonstrated major benefits associated with the use of ciNPWT in obese patients undergoing aseptic rTJA in reference to infection-related revision, overall complications, all-cause revisions, and early readmission for any reason.

PICO™ (Closed-Incision Negative-Pressure Wound Therapy) Dressing Use as Postoperative Prophylaxis for Preventing Surgical Site Infections in Spinal Surgery: A Retrospective Single-Centre Study

Introduction Surgical site infections (SSIs) are one of the dreaded complications of spinal surgery. These typically develop within the first 30 days following surgery. The overall pooled incidence of SSIs is reported at 3.1%. Negative pressure wound therapy (NPWT) has been employed for the management of open wounds and soft tissue injury. There has been a recent trend towards the use of closed incision NPWT (ciNPT), such as PICO. There are only a few studies evaluating the prophylactic use of ciNPT in spinal surgery. The aim of this study was to evaluate whether prophylactic use of PICO dressings can reduce SSI incidence and complications in spinal surgery. Methods Data were collected retrospectively for patients undergoing spinal surgery, with a PICO dressing used for closed surgical incisions, from February 2021 to October 2022. Each patient was followed up for 30 days. The results were compared with local hospital infection control statistics for previous years. Results A total of 50 patients underwent spinal surgery and had PICO dressings post-operatively. None of the patients developed a seroma. Two out of 50 (4.0%) patients developed wound dehiscence and then subsequent SSI (1 superficial, 1 deep). These were managed conservatively with the use of antibiotics and prolonged ciNPT. None of these patients returned to the theatre. The average SSI incidence from previous years was 9.27 ± 4.14 per annum (1.15%), but with an average of 77.3% of these requiring a return to theatres. Conclusion Our study reflects that there is no difference in the incidence rates for SSIs for patients who have PICO dressings versus those having standard occlusive dressings as post-operative closed surgical incision site wound closure following spinal surgery. For those who do develop SSIs, there was no difference in the rates of return to theatres among the two patient populations.

The effectiveness of prophylactic closed incision negative pressure wound therapy compared to conventional dressings in the prevention of periprosthetic joint infection post hip and knee revision arthroplasty surgery: A systematic review

OBJECTIVE

To evaluate the effectiveness of prophylactic closed incision negative pressure wound therapy (ciNPWT) compared to conventional dressings in the prevention of periprosthetic joint infection (PJI) post hip and knee revision arthroplasty surgery.

METHOD

Five databases (MEDLINE, Embase., Emcare, CINAHL and Scopus) were searched with no date or language limits. Two independent reviewers assessed articles against the inclusion criteria and methodological quality of the 3 included studies. Data was extracted using a customised data tool and included the intervention, study methods and outcomes of interest. A meta-analysis was performed, and results presented in narrative form with forest plots.

FINDINGS

The three studies, one randomized control trial and two quasi-experimental studies, included 136 intervention and 228 control participants (Sample 364). The PJI rate decreased in the ciNPWT cohort compared to the conservative dressing cohort (2 [1.47%] vs 27 [11.84%]). The reoperation rate was lower in the ciNPWT cohort versus the conventional cohort (4 [2.94%] vs 35 [15.35%]). The rate of wound complications was significantly decreased in the ciNPWT cohort compared to the conventional dressing cohort (14 [10.29%] v 85 [37.28), p=<0.001).

CONCLUSION

Prophylactic application of ciNPWT may be effective in reducing wound complications, PJI and reoperation post hip and knee revision arthroplasty surgery. The added cost of ciNPWT may be justified in the reduction of wound complications, PJI and reoperation. Ongoing trials determining if the prophylactic application of ciNPWT post hip and knee revision arthroplasty surgery is beneficial in preventing PJI particularly in high risk patients with additional comorbidities are warranted.

A Health Economic Analysis Exploring the Cost Consequence of Using a Surgical Site Infection Prevention Bundle for Hip and Knee Arthroplasty in Germany

Background

According to the European Centre for Disease Prevention and Control, surgical site infections (SSIs) constitute over 50% of all hospital-acquired infections. Reducing SSIs can enhance healthcare efficiency.

Objective

This study explores the cost consequences of implementing an SSI prevention bundle (SPB) in total hip and knee arthroplasty (THKA).

Methods

A health-economic model followed a cohort of THKA patients from admission to 90 days postdischarge. The perioperative process was modeled using a decision tree, and postoperative recovery and potential SSI evaluated using a Markov model. The model reflects the hospital payers' perspective in Germany. The SPB includes antimicrobial incision drapes, patient warming, and negative pressure wound therapy in high-risk patients. SSI reduction associated with these interventions was sourced from published meta-analyses. An effectiveness factor of 70% was introduced to account for potential overlap of effectiveness when interventions are used in combination. Sensitivity analyses were performed to assess the robustness of model outcomes.

Results

The cost with the SPB was €4274.32 per patient, €98.27, or 2.25%, lower than that of the standard of care (€4372.59). Sensitivity analyses confirmed these findings, indicating a median saving of 2.22% (95% credible interval: 1.00%-3.79%]). The SPB also reduced inpatient SSI incidence from 2.96% to 0.91%. The break-even point for the SPB was found when the standard of care had an SSI incidence of 0.938%. Major cost drivers were the cost of inpatient SSI care, general ward, and operating room, and the increased risk of an SSI associated with unintended, intraoperative hypothermia. Varying the effectiveness factor from 10% to 130% did not substantially impact model outcomes.

Conclusions

Introducing the SPB is expected to reduce care costs if the inpatient SSI rate (superficial and deep combined) in THKA procedures exceeds 1%. Research into how bundles of measures perform together is required to further inform the results of this computational analysis.

Impact of negative pressure wound treatment on incidence of surgical site infection in varied orthopedic surgeries: A systematic review and meta-analysis

Negative pressure wound therapy (NPWT) is a popular treatment to heal infected wounds. This meta-analysis aimed to determine if NPWT was more effective than conventional wound dressings for surgical site infections (SSI) in varied orthopaedic surgeries. Literature was retrieved from seven electronic databases (Medline, Web of Science, PubMed, Embase, Google Scholar, Cochrane Library, and CNKI). Randomised control trials (RCT) and retrospective cohort studies (RS) involving arthroplasty, fracture, and spinal surgery were extracted. SSI was our primary outcome, while total complications and length of hospital stay were secondary outcomes. We carried out the risk of bias assessment and meta-analysis using the Cochrane Risk of Bias 2.0 tool and Stata 17.0. Among the 798 studies retrieved, 18 of them met our inclusion criteria. We identified 13 RCTs and 5 RSs. The results of meta-analysis showed that the incidence of SSI in the NPWT group was significantly lower relative to the control group (OR = 0.60, 95% CI 0.47 to 0.77, P < 0.001). Subgroup analyses revealed that the incidences of SSI involving arthroplasty, fracture, and spinal surgery in the NPWT group accounted for 46%, 69%, and 37% relative to the control group, respectively. The incidence of SSI in RS (OR = 0.27, 95% CI 0.13 to 0.56) was significantly lower than that in RCT (OR = 0.69, 95% CI 0.54 to 0.90) (P = 0.02). Moreover, patients in the NPWT group had a lower total complication rate (OR = 0.51, 95% CI 0.34 to 0.76) and shorter hospital stays (SMD = -0.42, 95% CI -0.83 to -0.02), although high heterogeneity existed. NPWT may be an efficient alternative to help prevent the incidence of SSI and total complications as well as achieved shorten hospital stay in varied orthopaedic surgeries. The rational use of NPWT should be based on the presence of patients' clinical conditions and relevant risk factors.

Closed Incision Negative Pressure Therapy vs Standard of Care Over Closed Knee and Hip Arthroplasty Surgical Incisions in the Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis of Comparative Studies

Background

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common surgical procedures but carry a risk of harmful and costly surgical site complications (SSCs). This systematic review and meta-analysis examined the impact of closed incision negative pressure therapy (ciNPT) on the risk of SSCs following THA and TKA.

Methods

A systematic literature review identified studies published between January 2005 and July 2021 comparing ciNPT (Prevena Incision Management System) to traditional standard-of-care dressings for patients undergoing THA and TKA. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national database.

Results

Twelve studies met the inclusion criteria. Eight studies evaluated SSCs, where a significant difference was seen in favor of ciNPT (relative risk [RR]: 0.332, P < .001). Significant benefits in favor of ciNPT were also observed for surgical site infection (RR: 0.401, P = .016), seroma (RR: 0.473, P = .008), dehiscence (RR: 0.380, P = .014), prolonged incisional drainage (RR: 0.399, P = .003), and rate of return to the operating room (RR: 0.418, P = .001). The estimated cost savings attributed to ciNPT use was $932 per patient.

Conclusions

The use of ciNPT after TKA and THA was associated with a significant reduction in the risk of SSCs, including surgical site infections, seroma, dehiscence, and prolonged incisional drainage. The risk of reoperation was reduced as were the costs of care in the modeled cost analysis, suggesting a potential for both economic and clinical advantages for ciNPT over standard-of-care dressings, particularly in high-risk patients.

Outcomes of Two Different Negative Pressure Therapy Systems for Closed Incision Management in Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis

Closed incision negative pressure therapy (ciNPT) has been adopted into practices of diverse surgical specialties to help reduce postsurgical complication risks. There are two primary commercially available systems that deliver ciNPT through different mechanisms. The purpose of this meta-analysis is to compare the potential effects of two different ciNPT systems on clinical outcomes following hip and knee arthroplasty. A systematic literature search was conducted to identify hip and knee arthroplasty studies comparing the incidence of surgical site infections (SSIs) and surgical site complications (SSCs) versus standard of care (SOC) following the use of two different ciNPT systems. Four meta-analyses were performed by calculating risk ratios (RR) to assess the effect of (1) ciNPT with foam dressing (ciNPT-F) versus SOC and (2) ciNPT with multilayer absorbent dressing (ciNPT-MLA) versus SOC. Comprehensive Meta-Analysis Version 3.0 (Biostat Inc., Englewood, NJ) software was used to perform the analyses. Twelve studies comparing ciNPT-F to SOC and six studies comparing ciNPT-MLAto SOC were analyzed. SSI rates were reported in seven of 12 studies involving ciNPT-F. In those, ciNPT-F significantly reduced the incidence of SSI (RR = .401, 95% confidence interval (CI) = .190, .844; p = .016). Across four of six studies that reported SSI rates, there was no significant difference in SSI rates between ciNPT-MLAvs SOC (RR = .580, 95% CI = .222, 1.513; p = .265). SSC rates were evaluated in eight of 12 ciNPT-F studies that reported SSC rates. This meta-analysis of the eight ciNPT-F studies showed significantly reduced SSC rates with ciNPT-F vs SOC (RR = .332, 95% CI = .236, .467; p < 0.001). For ciNPT-MLA, five of six studies reported SSC rates. In those, there was no significant difference in SSC rates between ciNPT-MLA vs SOC (RR = .798, 95% CI = .458, 1.398; p = .425). These meta-analyses results showed a significant reduction in SSI and SSC rates in the ciNPT-F group vs SOC and no difference in SSI and SSC rates in the ciNPT-MLA group vs SOC. The reasons for these observed differences were not evaluated as part of this study. Future controlled clinical studies comparing outcomes between different ciNPT systems over closed orthopedic incisions would help to validate these study results.