Closed incision negative pressure wound therapy may decrease wound complications in major lower extremity amputations

Systematic Review and Meta-analysis of Prophylactic Negative Pressure Wound Therapy Devices for Major Lower Extremity Amputations

OBJECTIVE

Major lower extremity amputations are commonly performed for limb threatening ischaemia and uncontrollable infection. The dysvascular and diabetic cohort have multiple risk factors for post-operative wound complications. Prophylactic incisional negative pressure wound therapy (NPWT) has been associated with significantly lower rates of surgical site infection (SSI). The aim of this updated systematic review was to examine the impact of NPWT on outcomes after major amputations.

DATA SOURCES

PubMed, Scopus, Embase, conference abstracts, and trial registries were searched.

REVIEW METHODS

Studies of all methodologies comparing NPWT applied to closed incisions with dry dressings after major amputations were eligible. The meta-analyses compared the relative risk (RR) of overall wound complications and SSIs between NPWT and standard care. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria and Cochrane Risk of Bias 2 tool. Outcome certainty was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Nine studies were identified, including three randomised controlled trials (RCTs) and six cohort studies. Overall study quality was moderate to poor, with very low outcome certainty on GRADE analyses. Seven hundred and forty-nine patients were included, with 336 receiving NPWT and 413 standard care. The pooled rate of wound complications was 16.0% (95% confidence interval [CI] 9.5 - 24.0%) for NPWT and 44.6% (95% CI 29.0 - 60.9%) for standard care. Prophylactic NPWT was associated with a statistically significantly lower composite complication rate (RR 0.42, 95% CI 0.29 - 0.60; p < .001; I2 = 0%) and SSI rate (RR 0.51, 95% CI 0.31 - 0.83; p = .007; I2 = 0%) compared with standard care.

CONCLUSION

Although the quality of the included studies was variable, prophylactic NPWT may reduce wound complications after major amputation. Further adequately powered RCTs are needed to clarify the benefits and cost effectiveness of NPWT in this cohort, including whether it should be used routinely or selectively.

Negative-pressure wound therapy compared with advanced moist wound therapy: A comparative study on healing efficacy in diabetic foot ulcers

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy of negative-pressure wound therapy with advanced moist wound therapy in managing diabetic foot ulcers.

METHODS

A total of 450 participants with diabetic foot ulcers were randomized to receive either negative-pressure wound therapy (n = 204) or advanced moist wound therapy (n = 246) over 18 months. The primary outcome was complete ulcer closure, with secondary outcomes including time to closure, wound size reduction, infection rates, recurrence, and amputation rates. Wound dimensions were measured using digital planimetry, and Kaplan-Meier survival analysis was applied to assess time to closure.

RESULT

Analysis revealed statistically significant differences in clinical outcomes between treatment modalities. In the negative-pressure wound therapy group (n = 204), complete ulcer closure was achieved in 177 patients (87%), which was significantly greater than the advanced moist wound therapy group (n = 246) with 72 patients (29%) (P < .001). Although the mean time to wound closure was marginally extended in the negative-pressure wound therapy group (73 ± 45 days vs 64 ± 49 days; P = .045), this cohort demonstrated substantially more significant wound area reduction (48% ± 15 vs 25% ± 30; P < .001). Secondary outcome analysis revealed that negative-pressure wound therapy was associated with markedly reduced adverse events: wound infection (40 patients [20%] vs 95 patients [39%]; P < .001), ulcer recurrence (40 patients [20%] vs 113 patients [46%]; P < .001), and amputation rates (30 patients [15%] vs 132 patients [54%]; P < .001). Longitudinal assessment through Kaplan-Meier survival analysis demonstrated significantly greater wound closure probability and reduced complication risk in the negative-pressure wound therapy group throughout the follow-up period (log-rank P < .001).

CONCLUSION

Negative-pressure wound therapy is significantly more effective than advanced moist wound therapy in treating diabetic foot ulcers, demonstrating superior outcomes in wound closure, infection control, and amputation prevention. This study highlights negative-pressure wound therapy as the preferred treatment option for complex diabetic foot ulcers, warranting further research into its long-term benefits and cost-effectiveness.

Effectiveness of Specific Single-Use Incisional Negative Pressure Wound Therapy (PICO System) After Major Lower Extremity Amputation

Lower extremity amputation (LEA), particularly in patients with diabetes or peripheral vascular disease, often results in complications such as surgical site infections (SSIs) and wound dehiscence. This study examined whether utilizing the portable and user-friendly PICO system (Smith and Nephew Medical Ltd, Hull, UK) as incisional negative-pressure wound therapy can reduce post-LEA complications. This study was conducted at a Japanese tertiary medical center and involved a retrospective analysis of LEA cases (n = 32) between January 2021 and December 2022. The PICO dressing group (n = 16) was compared to the conventional dressing group (n = 16) for post-LEA wound management. The primary outcome was the incidence of postoperative wound complications, including SSI and wound dehiscence, within 15 days of LEA. Superficial/deep SSI and wound dehiscence occurred less frequently in the PICO dressing group than in the conventional dressing group (12.5% vs 43.8%; p = .054). There were no cases of deep SSIs in the PICO dressing group. Although this study has limitations owing to its retrospective design and small sample size, the results suggest the potential of the PICO system for improving outcomes in post-LEA wound management.

Surgical site infection following incisional negative pressure wound therapy in lower limb amputation closure: A randomized controlled trial

BACKGROUND

Major amputations are a standard procedure being done for various etiologies of the lower limb. Surgical site infections often complicate the postoperative outcome of patients. Negative pressure wound therapy has evolved to have a preventive role in SSI. According to the best of our knowledge, this is the first study that compared the wound and overall outcomes of incisional application of NPWT against standard dressing in patients undergoing stump closure following major lower limb amputations. The primary goal was to compare the rate of surgical site infections. The secondary objectives were to compare the postoperative hospital stay, reinterventions, readmission, and mortality.

MATERIALS AND METHODS

A randomized controlled trial was conducted in a healthcare institute and included 62 patients who underwent closure of major lower limb amputation stumps. After stump closure, patients were randomized into iNPWT and standard groups for the dressing over the suture line. Surgical site infection and other outcomes were assessed.

RESULTS

A statistically significant difference was found in the rate of surgical site infection (16% vs 51%, P = 0.003). Also, it appreciated a significant reduction in the number of patients needing reinterventions (26% vs 52%, P = 0.037) and the duration of postoperative hospital stay (5.8 days vs 8.2 days, P = 0.043) in the iNPWT group.

CONCLUSION

Incisional application of NPWT following lower limb amputations is an effective tool to reduce surgical site infections, the need of multiple reinterventions, the cost of treatment, and hospital stay. We should use this special dressing as a standard protocol for the high-risk patients undergoing stump closure following major amputations; therefore, it can reduce the morbidity of patients.

The incidence of surgical site infection following major lower limb amputation: A systematic review

Surgical site infections (SSIs) following major lower limb amputation (MLLA) in vascular patients are a major source of morbidity. The objective of this systematic review was to determine the incidence of SSI following MLLA in vascular patients. This review was prospectively registered with the International Prospective Register of Systematic Reviews (CRD42023460645). Databases were searched without date restriction using a pre-defined search strategy. The search identified 1427 articles. Four RCTs and 21 observational studies, reporting on 50 370 MLLAs, were included. Overall SSI incidence per MLLA incision was 7.2% (3628/50370). The incidence of SSI in patients undergoing through-knee amputation (12.9%) and below-knee amputation (7.5%) was higher than the incidence of SSI in patients undergoing above-knee amputation, (3.9%), p < 0.001. The incidence of SSI in studies focusing on patients with peripheral arterial disease (PAD), diabetes or including patients with both was 8.9%, 6.8% and 7.2%, respectively. SSI is a common complication following MLLA in vascular patients. There is a higher incidence of SSI associated with more distal amputation levels. The reported SSI incidence is similar between patients with underlying PAD and diabetes. Further studies are needed to understand the exact incidence of SSI in vascular patients and the factors which influence this.

Effectiveness of incisional negative pressure wound therapy after major lower extremity amputation: a randomised controlled trial

INTRODUCTION

The aim was to study the effect of incisional negative pressure wound therapy (iNPWT) in wound healing compared with standard sterile gauze dressings after major lower extremity amputation in patients with peripheral arterial disease (PAD).

METHODS

This prospective, randomised controlled trial included 50 patients undergoing major lower extremity amputations for PAD. Patients were randomised into iNPWT and standard dressing groups. The patency of blood vessels at the level of the stump was ensured with or without revascularisation. The primary outcome was wound-related complications such as surgical site infection (SSI), wound dehiscence, seroma/haematoma formation or the need for revision amputation. The secondary outcome was the time taken for the eligibility of prosthesis placement.

RESULTS

It was found that only 12% of the patients in the iNPWT group had SSI compared with 36% in the standard dressing group (p = 0.047). Rates of wound dehiscence, seroma/haematoma formation and revision amputation were decreased in the iNPWT group but this was not statistically significant (p > 0.05). There was a significant reduction in the time taken for eligibility of prosthesis placement in the iNPWT group (5.12 ± 1.53 vs 6.8 ± 1.95 weeks, p = 0.002).

CONCLUSIONS

iNPWT is effective in reducing the incidence of SSI and the time taken for rehabilitation in patients undergoing major lower limb amputation due to PAD.

The wound adjuncts effect of closed incision negative pressure wound therapy on stopping groin surgical site wound infection in arterial surgery: A meta-analysis

A meta-analysis study was conducted to assess the influence of the wound adjuncts therapy of closed incision negative pressure wound therapy (ciNPWT) on stopping groin site wound infection (SWSI) in arterial surgery. A comprehensive literature examination till January 2023 was implemented and 2186 linked studies were appraised. The picked studies contained 2133 subjects with groin surgical wounds of arterial surgery in the picked studies' baseline, 1043 of them were using ciNPWT, and 1090 were using standard care. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of the wound adjuncts therapy of ciNPWT on stopping groin SWSI in arterial surgery by the dichotomous and continuous styles and a fixed or random model. The ciNPWT had a significantly lower SWSI (OR, 0.42; 95% CI, 0.33-0.55, P < .001), superficial SWSI (OR, 0.46; 95% CI, 0.33-0.66, P < .001), and deep SWSI (OR, 0.39; 95% CI, 0.25-0.63, P < .001) compared with the standard care in groin surgical wound of arterial surgery. The ciNPWT had a significantly, lower SWSI, superficial SWSI, and deep SWSI compared with the standard care in groin surgical wounds of arterial surgery. Although precautions should be taken when commerce with the consequences because some of the picked studies for this meta-analysis was with low sample sizes.

Negative pressure wound therapy: Where are we in 2022?

The use of negative pressure wound therapy (NPWT) continues to be an important tool for surgeons. As the use and general acceptance of NPWT have grown, so have the indications for its use. These indications have expanded to include soft tissue defects in trauma, infection, surgical wound management, and soft tissue grafting procedures. Many adjuvants have been engineered into newer generations of NPWT devices such as wound instillation of fluid or antibiotics allowing surgeons to further optimize the wound healing environment or aid in the eradication of infection. This review discusses the recent relevant literature on the proposed mechanisms of action, available adjuvants, and the required components needed to safely apply NPWT. The supporting evidence for the use of NPWT in traumatic extremity injuries, infection control, and wound care is also reviewed. Although NPWT has a low rate of complication, the surgeon should be aware of the potential risks associated with its use. Furthermore, the expanding indications for the use of NPWT are explored, and areas for future innovation and research are discussed.

Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis

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.

Effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery. A systematic literature search up to April 2022 was performed and 1537 total number of groin vascular surgery incisions at the baseline of the studies; 729 of them were using the prophylactic negative pressure treatment, and 808 were using control. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery using the dichotomous, and contentious methods with a random or fixed-effect model. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection (OR, 0.26; 95% CI, 0.16-0.42, P < .001) in subjects after vascular surgery compared with control. However, prophylactic negative pressure treatment did not show any significant difference in revision surgery (OR, 0.73; 95% CI, 0.52-1.00, P = .05), readmission (OR, 0.93; 95% CI, 0.66-1.32, P = .69), mortality in hospital (OR, 0.54; 95% CI, 0.29-1.01, P = .05), and length of hospital stay (MD, -0.24; 95% CI, -0.91-0.44, P = .49) compared with control in subjects after vascular surgery. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection and no significant difference in revision surgery, readmission, mortality in hospital, and length of hospital stay compared with control in subjects after vascular surgery. The analysis of outcomes should be with caution because of the low sample size of 2 out of 10 studies in the meta-analysis and a low number of studies in certain comparisons.

Incisional negative pressure wound therapy to reduce surgical-site infections in major limb amputations: a meta-analysis

Purpose

Incisional negative pressure wound therapy (iNPWT) has shown effectiveness in the treatment of high-risk surgical wounds. Especially patients with diabetes-induced peripheral arterial disease undergoing major limb amputation have a high intrinsic risk for post-surgical wound infections. While normal gauze wound dressings do not cause stimulation of microvasculature, iNPWT might improve wound healing and reduce wound complications. The purpose of this study was to systematically review the literature for rates of wound complications and readmissions, as well as post-surgical 30-day mortality.

Methods

We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score >60, non-traumatic major limb amputation, and adult patients. Traumatic amputations and animal studies were excluded. Relevant articles were reviewed independently by referring to the title and abstract. In a meta-analysis, we compared 3 studies and 457 patients.

Results

A significantly overall lower rate of postoperative complications is associated with usage of iNPWT (odds ratio (OR) = 0.52; 95% CI: 0.30-0.89; P = 0.02). There was no significant improvement for 30-day mortality, when iNPWT was used (OR= 081; 95% CI: 0.46 - 1.45; P = 0.48). Nevertheless, we did not note a significant difference in the readmission rate or revision surgery between the two groups.

Conclusion

Overall, the usage of iNPWT may reduce the risk of postoperative wound complications in major lower limb amputations but does not improve 30-day mortality rates significantly. However, to anticipate surgical-site infection, iNPWT has shown effectiveness and thus should be used whenever applicable.

Comparison of vacuum sealing drainage and conventional drainage for postoperative drainage in closed calcaneal fracture: A randomized controlled trial

BACKGROUND

The objective of this study was to compare the outcomes of vacuum sealing drainage (VSD) and conventional drainage after surgery in the treatment of closed calcaneal fracture. We hypothesize that VSD is superior to conventional drainage in reducing volume of drainage, time of wound drying, time of skin fold, time of wound healing, VAS at day 3 postoperatively, wound complications and increasing wound healing grade.

METHODS

120 patients with closed calcaneal fractures from January 2016 to December 2018 were enrolled in our study. They were divided randomly into VSD group (n = 60) and conventional (n = 60). The volume of drainage, duration of drainage, time of wound drying, time of skin fold, time of wound healing and VAS at day 3 postoperatively were recorded. Furthermore, the wound complications of the two groups were also evaluated. Besides, wound healing grade was used to assess the degree of wound healing. The functional outcome American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores and visual analog scale (VAS) pain scores was also evaluated.

RESULTS

A total of 10 patients were lost to follow-up for various reasons, VSD group remained 55 cases while conventional group remained 53 cases. Our results showed that VSD group exhibited significantly more volume of drainage (P< 0.0001), longer duration of drainage (P< 0.0001), shorter time of wound drying (P = 0.0086), shorter time of skin fold (P = 0.0158), shorter time of wound healing (P = 0.0240) and lower VAS at day 3 postoperatively (P = 0.0019) compared with conventional group. Moreover, VSD group was demonstrated to have significantly lower wound complications (P = 0.025) and higher rate grade A of wound healing (P = 0.031). However, no significant difference was noted in time of fracture union (P = 0.754), VAS (P = 0.407) and AOFAS score (P = 0.512) at final follow-up between the two groups.

CONCLUSIONS

Our hypothesis was confirmed that VSD was superior in terms of some aspects than conventional drainage. Therefore, VSD is a safe and effective postoperative wound drainage method in the treatment of closed calcaneal fracture. However, more and higher evidence needs to be carried to demonstrate the results.

Clinical Relevance of Closed-Incision Negative Pressure Therapy (ciNPT) for SSI-Risk Reduction in Vascular Surgery Through a Groin Incision

BACKGROUND

Vascular surgery, especially lower limb revascularization surgery, has one of the highest rates of surgical complications, predominantly surgical site infections (SSI). Resulting in a significant burden of additional costs due to longer hospital stays, re-admissions and re-interventions, mainly attributable to deep incisional SSIs. Closed incisional negative pressure therapy (ciNPT) is a relatively new strategy in the postoperative management surgical wounds, aiming to reduce surgical wound complications. When discussing the clinical relevance of ciNPT, it is crucial to take into account the outcome of therapy as well as the additional costs related to ciNPT. Since, the additional costs must be justified by an associated decrease in the morbidity and costs associated with groin wound complications, which are particularly attributable to deep incisional SSIs. The current literature evaluating the beneficial effect of ciNPT in groin incisional vascular surgery, predominantly focusses on the decrease in superficial SSIs. Whereas this study aims to address and discuss the clinical relevance of ciNPT over conventional wound dressings, by separately evaluating and comparing the incidence of superficial and deep SSIs and their related re-admissions and re-interventions.

METHODS

In this single center prospective cohort study performed in a non-academic hospital in The Netherlands, 59 consecutive patients (67 incisions) were included between January and October 2019. All underwent elective vascular surgery with groin (access) incisions for either lower limb revascularization surgery or abdominal aortic aneurysm surgery. The study group was treated with six days ciNPT (PREVENA Incision Management System; KCI/3M, San Antonio, TX, USA) and matched for equal comparison to a historical retrospectively analysed cohort of 54 consecutive patients (60 incisions), all of whom have undergone elective vascular surgery for equal indications with groin (access) incisions in our center between January and October 2018. The standard-care group was treated following standard surgical wound care protocol with conventional surgical self-adhesive plaster (10 × 15cm, Mepore, Mölnlycke Health Care AB, Gothenburg, Sweden).

RESULTS

Study groups were comparable at baseline, except for Body Mass Index (BMI), which was significantly higher in the ciNPT-group (P =.021). No significant differences for formation of seroma, hematoma, as well as wound dehiscence and SSIs were found between both groups. Groin SSIs were seen in 12.1% of the patients in the ciNPT-group and in 13.0% in the Standard-care group (OR 0.80, CI ((0.26, 2.48)), deep SSI contributed for 4 out of 7 patients of total SSIs in the ciNPT-group and for 2 out of 7 patients in the standard of care group (P-value >0.05). Analysis for incidence of hospital re-admission and re-intervention in both study groups showed no significant difference. Subset analysis in both study groups for SSIs differentiated in superficial and deep SSIs showed that only deep SSIs resulted in re-interventions.

CONCLUSIONS

Based on the findings in the population of our single center study, we conclude that routine use of ciNPT was not effective in reducing groin wound complications, and therefore could not replicate the promising findings from some previous studies. Furthermore, we did not find a reduction in the incidence of deep SSIs, which comprise the highest morbidity and costs. Considering our findings as well as the associated additional expenses related to ciNPT, it might be superfluous at this stage to use ciNPT as the new standard of post-operative groin incision care for all lower limb revascularization and abdominal aortic aneurysm surgeries. In our opinion further research is warranted for establishing a risk-factor based model for determination of the indication of ciNPT. To be able to achieve a more substantiated decision for utilizing ciNPT compared to standard surgical wound care in groin incisional vascular surgical interventions.