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Schröder TA, Karasavvas A, Bauckloh M, Schulz MC, Lauer G, Kroschwald LM. Influence of Unidirectional Vacuum Application on Bone Healing in Maxillofacial Surgery. Cells 2025; 14:751. [PMID: 40422254 DOI: 10.3390/cells14100751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2025] [Revised: 05/02/2025] [Accepted: 05/11/2025] [Indexed: 05/28/2025] Open
Abstract
Negative-pressure wound therapy (NPWT) using vacuum-assisted closure (VAC) is a well known tissue defect bridging method that applies a vacuum pump to sterile, open-cell foam dressings via suction tubes. Although it has mostly been described for soft tissue use, there are also a few studies concerning its use on hard tissue. However, as oral and maxillofacial surgery has to deal with both soft and hard tissue, which lie next to each other in these regions, there is a particular need to assess the influence of negative pressure on bone. Therefore, the effects of different negative pressure levels (530 mbar and 725 mbar) and atmospheric pressure (1013 mbar) on bone tissue cultures and osteoblast cell cultures were investigated over periods of 1, 3, and 6 weeks. During the culture period, osteoblast growth and the tissue regeneration of bone defects were studied in vitro using tissue cultures that were histologically supplemented by cytological investigations and quantitative RNA expression studies. In the bone defect model, there was a faster defect reduction using NPWT; the effect was especially strong for 530 mbar. Compared to the control group, up to 30% more newly generated bone tissue was detected. This effect on the mineralization capacity was assessed by the mRNA expression of osteogenic marker genes, as well as the receptor activator of nuclear factor κB ligand (RANKL) and osteoprotegerin (OPG), two multifaceted cytokines that regulate bone metabolism. The influence of negative pressure consequently resulted in a decreased RANKL/OPG ratio in osteoblasts. Associated with the upregulation of marker genes to up to 400%, including Col1, BMP4, OCN, and RUNX2, the decrease in the RANKL/OPG ratio to 41% indicates the stimulation of osteogenesis. Since VAC has been shown to be a safe and effective method to close wounds in general, these data suggest that patients suffering from compound bone and soft tissue defects in the maxillofacial area may benefit from an adapted therapy approach accelerating both soft and hard tissue regeneration.
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Affiliation(s)
- Tom Alexander Schröder
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Athanasios Karasavvas
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Maximilian Bauckloh
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Matthias C Schulz
- Department of Oral and Maxillofacial Surgery, University Hospital Tübingen, Eberhard Karls Universität Tübingen, Osianderstraße 2-8, 72076 Tübingen, Germany
| | - Günter Lauer
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Lysann Michaela Kroschwald
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
- Centre for Translational Bone, Joint and Soft Tissue Research, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Millán-Reyes MJ, Afanador-Restrepo DF, Carcelén-Fraile MDC, Aibar-Almazán A, Sánchez-Alcalá M, Cano-Sánchez J, Mesas-Aróstegui MA, Castellote-Caballero Y. Reducing Infections and Improving Healing in Complex Wounds: A Systematic Review and Meta-Analysis. J Clin Med 2025; 14:3237. [PMID: 40364268 PMCID: PMC12072239 DOI: 10.3390/jcm14093237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2025] [Revised: 04/19/2025] [Accepted: 05/05/2025] [Indexed: 05/15/2025] Open
Abstract
Background and Objectives: Wound management in complex and traumatic injuries remains a significant clinical challenge, with a high risk of surgical site infections (SSIs) and associated complications. This systematic review and meta-analysis aim to evaluate the effectiveness of diverse interventions, including Negative Pressure Wound Therapy (NPWT), advanced dressings, irrigation techniques, antibiotic regimens, and innovative therapies, in improving wound healing outcomes and reducing infection rates. Materials and Methods: An exhaustive literature search focused on the use of NPWT, dressings, and antibiotics in the care of chronic wounds was conducted following PRISMA guidelines in the PubMed, Scopus, Web of Science, and CINAHL databases. Eligible studies included randomized controlled trials and prospective cohorts assessing interventions for wound care in trauma, surgical, and chronic wound settings. The risk of bias was assessed using the ROB2 tool. Subgroup analyses were performed to evaluate the relative risk (RR) of infections based on the intervention type. Results: The analysis included 17 studies spanning diverse geographical and clinical settings. NPWT demonstrated significant benefits in reducing infection rates compared to control groups (RR: 0.590, 95% CI: 0.458-0.760, and p < 0.001). Although advanced dressings demonstrated clinically relevant benefits as reported across the included studies, the meta-analysis did not reveal statistically significant differences (RR: 0.516, 95% CI: 0.242-1.100, and p = 0.087). Antibiotic therapies significantly reduced infections when administered within 24 h of injury, while low-pressure irrigation techniques effectively minimized bacterial contamination without causing tissue damage. Growth factors and honey-based treatments exhibited promising results in accelerating wound healing and reducing infection risks in chronic wounds. Conclusions: NPWT emerges as a highly effective intervention for infection prevention and wound healing, supported by robust evidence. Advanced dressings and innovative therapies show potential but require further research for conclusive evidence. These findings underscore the importance of tailoring wound care strategies to the clinical context and patient needs. Future research should focus on long-term outcomes and cost-effectiveness analyses to enhance the integration of these therapies into clinical practice.
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Affiliation(s)
- María Juana Millán-Reyes
- University Hospital of Jaén, 23007 Jaen, Spain;
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaen, Spain
| | - Diego Fernando Afanador-Restrepo
- Faculty of Health Sciences and Sport, University Foundation of the Área Andina—Pereira, Pereira 660004, Colombia
- Faculty of Distance and Virtual Education, Antonio José Camacho University Institution, Santiago de Cali 760016, Colombia
| | - María del Carmen Carcelén-Fraile
- Department of Education Sciences, Faculty of Social Sciences, University of Atlántico Medio, 35017 Las Palmas de Gran Canaria, Spain
| | - Agustín Aibar-Almazán
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaen, Spain
| | - Marcelina Sánchez-Alcalá
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaen, Spain
| | - Javier Cano-Sánchez
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaen, Spain
| | - María Aurora Mesas-Aróstegui
- Pediatric Endocrinology Department, Instituto Hispalense de Pediatría, Hospital Quirón Marbella, 29603 Malaga, Spain
- Pediatrics Department, Hospital of Guadix, 18500 Granada, Spain
| | - Yolanda Castellote-Caballero
- Department of Health Sciences, Faculty of Health Sciences, University of Atlántico Medio, 35017 Las Palmas de Gran Canaria, Spain
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Izawa Y, Nishida M, Futamura K, Murakami H, Sato K, Tsuchida Y. Staged wound closure using tension-reducing taping technique with negative pressure wound therapy in lower extremity open fractures: A retrospective review. J Orthop Sci 2025:S0949-2658(25)00075-2. [PMID: 40122733 DOI: 10.1016/j.jos.2025.03.002] [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: 09/12/2024] [Revised: 03/05/2025] [Accepted: 03/07/2025] [Indexed: 03/25/2025]
Abstract
BACKGROUND In the treatment of lower extremity open fractures Gustilo-Anderson classification types IIIA/IIIB borderline cases, closing open wound under strong tension may lead to wound edge necrosis and the need for soft tissue reconstruction. The purpose of this study is to examine whether staged wound closure using tension-reducing taping with negative pressure wound therapy (NPWT) could prevent wound edge necrosis in borderline type lower extremity open fractures. MATERIALS AND METHODS Patients with ⅢA/ⅢB borderline type lower extremity open fractures who were treated at our institution were included. The patients were divided into two groups: those who underwent conventional wound closure (Group 1) and those who underwent staged closure using tension-reducing taping (Group 2). Characteristics of patients and their injuries were compared between the two groups. In addition, the presence or absence of wound edge necrosis after wound closure, soft tissue reconstruction, and wound infection were compared between the two groups. RESULTS Twenty-six patients were included in Group 1 and 21 patients were included in Group 2. There were no significant differences in characteristics of patients and their injuries between the two groups. The rate of wound edge necrosis and the need for local flaps were significantly higher in Group 1 (p = 0.002, 0.027). There was no significant difference in infection rates between the two groups (p = 0.495). CONCLUSION For ⅢA/ⅢB borderline type lower extremity open fractures, staged wound closure using tension-reducing taping technique with NPWT can reduce wound edge necrosis and prevent the transition to iatrogenic type ⅢB.
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Affiliation(s)
- Yuta Izawa
- Department of Trauma Centre, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan; Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 Chome 3-1, Higashiku, Sapporo, Hokkaido, Japan.
| | - Masahiro Nishida
- Department of Trauma Centre, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan.
| | - Kentaro Futamura
- Department of Trauma Centre, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan.
| | - Hiroko Murakami
- Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 Chome 3-1, Higashiku, Sapporo, Hokkaido, Japan.
| | - Kazuo Sato
- Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 Chome 3-1, Higashiku, Sapporo, Hokkaido, Japan.
| | - Yoshihiko Tsuchida
- Department of Trauma Centre, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan; Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Kita 33 Jou Higashi 14 Chome 3-1, Higashiku, Sapporo, Hokkaido, Japan.
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Adegboye O, Pillay K, Adams S. Acellular Dermal Matrices in Reconstructive Pediatric Complex Lower Limb Trauma: An Observational Study. J Trauma Nurs 2025; 32:23-29. [PMID: 39879269 DOI: 10.1097/jtn.0000000000000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
BACKGROUND Contemporary research has shown that acellular dermal matrices can benefit adult lower extremity traumatic injuries; however, its use in children has not been explored. OBJECTIVE This study aims to explore the use of acellular dermal matrices in pediatric complex lower extremity trauma. METHODS This single-center retrospective observational cohort study of children with complex lower extremity trauma treated with Pelnac™, commercial acellular dermal matrices, was conducted at a tertiary hospital in South Africa from 2010 to 2017. Demographic and clinical data were collected from medical records. The primary outcome was the rate and type of acellular dermal matrices-related complications. Secondary outcomes included the usage of negative pressure wound therapy. RESULTS A total of 54 children were studied; 30 (55%) were male, and the median age was six. Forty-five children healed without complications, while nine experienced complications - four acute and five chronic. Four patients had complete loss of acellular dermal matrices, and three developed acute infections. More than 30 days post-acellular dermal matrices application, five patients had hypertrophic scarring, four had joint contractures, and two had non-healing wounds. All patients who healed without complication received negative pressure wound therapy (n = 45), while those who did not (n = 5) developed complications. Three of the five patients without negative pressure wound therapy had acute acellular dermal matrices loss, compared to only one of the 49 patients who received negative pressure wound therapy. CONCLUSION Our findings suggest that acellular dermal matrices may be an effective and safe reconstructive adjunct or alternative when used with negative pressure wound therapy.
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Affiliation(s)
- Oluwatobi Adegboye
- Author Affiliations: St Andrew's Anglia Ruskin (StAAR) Research Group, Faculty of Health, Education, Medicine, and Social Care, Anglia Ruskin University, Chelmsford, UK (Dr Adegboye); Division of Plastic and Reconstructive Surgery, Red Cross War Memorial Children's Hospital; and Division of Plastic & Reconstructive Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa (Dr Pillay and Prof Adams)
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Hakim AM, Khalifa AA, Abubeih H, El-Gafary KA, Farouk O. Early experience using vacuum-assisted closure for managing soft tissue injuries in open type IIIB tibial fractures, a non-randomised controlled trial from a North African level one trauma centre. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2024. [DOI: 10.1177/22104917241280288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2024] Open
Abstract
Purpose: The primary objective was to investigate our early results of using vacuum-assisted closure (VAC) for wound management in patients with open IIIB tibial fractures and compare the results with a group subjected to conventional daily dressing. Methods: A prospective non-randomised clinical trial (NRCT) with a parallel design and allocation ratio of 1:1 was conducted after obtaining ethical committee approval. Forty skeletally mature patients with unilateral type IIIB open tibia fractures were included over two years, starting from April 2019. In group A, patients were treated with VAC, which was changed every four days if needed, and in group B, patients had daily conventional dressings. Results: Both groups had no differences in the basic demographic, comorbidities, injury mechanism, and associated injuries. The need for secondary debridement surgeries was significantly lower in Group A than in Group B, 1 ± 0.50 versus 2.50 ± 0.85, respectively ( P < 0.001). The time till definitive coverage was significantly lower in Group A than in Group B, 12.22 ± 2.90 versus 23.56 ± 8.68 (days); P < 0.001. All coverage procedures succeeded in Group A, while four (20%) failed in Group B, P = 0.04. Infection was higher in Group B, with six (30%) patients compared to one (5%) in Group A, P = 0.01. Conclusion: Reports on VAC's role in managing severe open fracture wounds are rare in our area, and the initial results we obtained are encouraging, with lower infection rates and less cumbersome reconstruction procedures; however, further evaluation of the procedure's cost-effectiveness is mandatory.
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Affiliation(s)
- Albair Malaka Hakim
- Orthopaedic Department, Faculty of Medicine, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Ahmed A Khalifa
- Orthopaedic Department, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt
| | - Hossam Abubeih
- Orthopaedic Department, Faculty of Medicine, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Kamal A El-Gafary
- Orthopaedic Department, Faculty of Medicine, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Osama Farouk
- Orthopaedic Department, Faculty of Medicine, Assiut University Hospitals, Assiut University, Assiut, Egypt
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Liu H, Zhang G, Wei A, Xing H, Han C, Chang Z. Effect of negative pressure wound therapy on the incidence of deep surgical site infections after orthopedic surgery: a meta-analysis and systematic review. J Orthop Surg Res 2024; 19:555. [PMID: 39252068 PMCID: PMC11385841 DOI: 10.1186/s13018-024-05038-7] [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: 07/01/2024] [Accepted: 08/27/2024] [Indexed: 09/11/2024] Open
Abstract
OBJECTIVE This meta-analysis aimed to explore the impact of prophylactic negative pressure wound therapy (NPWT) on the occurrence of deep surgical site infections (SSIs) following orthopedic surgery. METHODS A systematic search was conducted across Medline, Embase, Cochrane Library, and Web of Science databases for articles concerning NPWT in patients who underwent orthopedic surgery up to May 20, 2024. Using Stata 15.0, the combined odds ratios (ORs) were calculated with either a random-effects model or a fixed-effects model, depending on the heterogeneity values. RESULTS From a total of 440 publications, studies that utilized NPWT as the experimental group and conventional dressings as the control group were selected to analyze their impact on SSIs. Ultimately, 32 studies met the inclusion criteria. These included 12 randomized controlled trials and 20 cohort studies, involving 7454 patients, with 3533 of whom received NPWT and 3921 of whom were treated with conventional dressings. The results of the meta-analysis demonstrated that the NPWT group had a lower incidence of deep SSIs in orthopedic surgeries than did the control group [OR 0.64, 95% CI (0.52, 0.80), P = 0.0001]. Subgroup analysis indicated a notable difference for trauma surgeries [OR 0.65, 95% CI (0.50, 0.83), P = 0.001], whereas joint surgeries [OR 0.65, 95% CI (0.38, 1.12), P = 0.122] and spine surgeries [OR 0.61, 95% CI (0.27, 1.35), P = 0.221] did not show significant differences. Additionally, when examined separately according to heterogeneity, trauma surgeries exhibited a significant difference [OR 0.50, 95% CI (0.31, 0.80), P = 0.004]. CONCLUSION The results of our study indicate that the prophylactic use of NPWT reduces the incidence of deep SSIs following orthopedic trauma surgery when compared to the use of conventional dressings. We postulate that the prophylactic application of NPWT in patients at high risk of developing complications from bone trauma may result in improved clinical outcomes and an enhanced patient prognosis.
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Affiliation(s)
- Huan Liu
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053, Shandong, China
| | - Ge Zhang
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - An Wei
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - Hao Xing
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053, Shandong, China
| | - Changsheng Han
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - Zhengqi Chang
- Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China.
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Barone N, Ziolkowski N, Haykal S. The Role of Negative Pressure Wound Therapy in Temporizing Traumatic Wounds before Lower Limb Soft Tissue Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6003. [PMID: 39071768 PMCID: PMC11281775 DOI: 10.1097/gox.0000000000006003] [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: 10/18/2023] [Accepted: 05/31/2024] [Indexed: 07/30/2024]
Abstract
Background In practice, there is often a delay from initial debridement and temporary fixation to definitive soft tissue coverage of traumatic leg wounds. Without clear evidence, conservative negative pressure wound therapy (NPWT) is increasingly used to temporize these wounds. This systematic review summarizes and synthesizes the literature on using NPWT to temporize traumatic leg wounds before surgery in adult surgical patients. Methods A comprehensive search of Medline, Embase, and Cochrane Library was performed from inception until July 2022, inclusively. Two independent reviewers performed screening, data extraction, and risk of bias assessment. Primary English studies, including adult patients (≥16 years old) with a fracture below the knee up to and including the ankle that received NPWT to temporize wounds before definitive soft tissue reconstruction with a flap and/or graft, were included. Results Thirty-four studies, including 804 patients who received NPWT, were included. The partial/total flap loss rate was 6.95% (n = 9 studies), the infection rate was 19.5% (n = 25 studies), the nonunion rate was 18% (n = 15 studies), the delayed union rate was 9.31% (n = 3 studies), and the amputation rate was 15.4% (n = 6 studies). The mean late stay was 43.1 days (n = 9 studies), and the follow-up length was 23.7 months (n = 9 studies). The mean time to wound healing was 5.63 months (n = 2 studies), and the time to soft tissue coverage was 40.8 days (n = 12 studies). The mean time to achieve bone union was 7.26 months (n = 6 studies). Conclusion NPWT can be used to temporize traumatic wounds while awaiting soft tissue reconstruction.
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Affiliation(s)
- Natasha Barone
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Natalia Ziolkowski
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Siba Haykal
- From the Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science and Toronto General Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, Yale New Haven Hospital, New Haven, Conn
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Mehta DD, Leucht P. Prevention and treatment of osteomyelitis after open tibia fractures. OTA Int 2024; 7:e309. [PMID: 38840709 PMCID: PMC11149744 DOI: 10.1097/oi9.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 06/07/2024]
Abstract
Infection and chronic post-traumatic osteomyelitis of the tibia after open fracture are complex problems that cause significant morbidity and threaten the viability of a limb. Therefore, it is of utmost importance for the orthopaedic surgeon to understand both patient and treatment factors that modify the risk of developing these disastrous complications. Infection risk is largely based on severity of open injury in addition to inherent patient factors. Orthopaedic surgeons can work to mitigate this risk with prompt antibiotic administration, thorough and complete debridement, expedient fracture stabilization, and early wound closure. In the case osteomyelitis does occur, the surgeon should use a systematic multidisciplinary approach for eradication.
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Affiliation(s)
- Devan D. Mehta
- Department of Orthopedic Surgery, NYU Grossman School of Medicine—NYU Langone Orthopedic Hospital, New York, NY
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Grossman School of Medicine—NYU Langone Orthopedic Hospital, New York, NY
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Alves AS, Martineau J, Scampa M, Kalbermatten DF, Oranges CM. Negative Pressure Wound Therapy versus Conventional Dressing in Lower Limb Fractures: Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5806. [PMID: 38752221 PMCID: PMC11095958 DOI: 10.1097/gox.0000000000005806] [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: 11/20/2023] [Accepted: 03/12/2024] [Indexed: 05/18/2024]
Abstract
Gustilo 3 lower limb fractures represent a significant challenge because of high complication risk. Two management strategies are commonly used for wound coverage until final closure: negative pressure wound therapy (NPWT) and conventional wound dressing (CWD), also described as standard wound coverage without subatmospheric pressure. Understanding their relative effectiveness is essential to improve patient outcomes. The aim of this systematic review and meta-analysis was to compare the efficacy of NPWT and CWD in Gustilo 3 lower limb fracture management, with a focus on overall rates, superficial infection, and deep infection rates. A systematic review of medical research databases was conducted in accordance with PRISMA guidelines. Studies comparing NPWT with CWD for Gustilo 3 fractures were included. Data extraction and quality assessment were performed. Treatment with CWD was associated with significantly higher rates of overall infection [pooled risk ratio (RR): 0.33; 95% confidence interval (CI): 0.14-0.51] and pooled risk difference (RD: 0.27; 95% CI: 0.15-0.38), superficial infection (pooled RR: 0.35; 95% CI: 0.04-0.66), and deep infection (pooled RR: 0.20; 95% CI: 0.02-0.38) compared with NPWT treatment. Overall infection rate remained significantly higher in the CWD group after analyzing only open tibia fractures (pooled RR: 0.35; 95% CI: 0.21-0.48). Nonunion rate was significant higher in the CWD group (pooled RR: 0.30; 95% CI: 0.00-0.59). Flap failure rate was similar in both groups (pooled RR: 0.09; 95% CI: -0.05 to 0.23). NPWT appears to be a reasonable option for wound management in Gustilo 3 lower limb fractures in terms of infection rates.
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Affiliation(s)
- André S. Alves
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jérôme Martineau
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Matteo Scampa
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Daniel F. Kalbermatten
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Carlo M. Oranges
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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Farrelly E, Tarapore R, Lindsey S, Wieland MD. Management of the Mangled Extremity. Surg Clin North Am 2024; 104:385-404. [PMID: 38453309 DOI: 10.1016/j.suc.2023.10.006] [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: 03/09/2024]
Abstract
Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.
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Affiliation(s)
- Erin Farrelly
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA.
| | - Rae Tarapore
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Sierra Lindsey
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
| | - Mark D Wieland
- Department of Orthopaedic Surgery, MedStar Orthopaedic Institute, Union Memorial Hospital, Baltimore, MD, USA
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Gottipati S, Gowtham B, Chalimeda S, Ravipati S, P V, Khullar K. Functional Outcomes in Orthopaedic Open Wounds Treated With Vacuum-Assisted Closure Therapy: A Prospective Case Series. Cureus 2024; 16:e54468. [PMID: 38510913 PMCID: PMC10953839 DOI: 10.7759/cureus.54468] [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] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Open fractures with extensive soft-tissue damage, significant periosteal stripping, and exposed bone ends pose a significant challenge in orthopaedics. So, we conducted a prospective study that investigated the efficacy of vacuum-assisted closure (VAC) therapy in improving functional outcomes for orthopaedic open wounds. METHODS A prospective case series was conducted for a period of 18 months at the department of orthopaedics. Seventeen patients with open wounds were included in the study after fulfilling specific criteria. The study involved 17 patients with open wounds, where VAC therapy was applied within 24 hours of admission for 14 patients, and for three patients with superficial infection, thorough wound debridement preceded VAC dressing. Follow-up with patients continued until definitive skin cover procedures were performed. RESULTS The majority of cases were attributed to open compound fractures caused by road traffic accidents (82.35%), followed by train traffic accidents (11.76%) and accidental falls (5.88%). The leg (47%) was the most common location of injury, followed by the forearm (23.52%). The average treatment duration was 10.5 days, with an average of 3.3 dressing changes, indicating the efficacy and feasibility of VAC therapy in clinical practice. The average wound size reduction at completion was 15mm, and 15 out of 17 patients achieved successful wound healing. The average time required for forming a uniform granulation bed was 10.5 days, highlighting the efficiency of VAC therapy in promoting tissue regeneration. CONCLUSION Our study findings revealed that there is a significant reduction in the rate of wound infection with the application of VAC therapy, along with a shorter duration for the formation of healthy granulation tissue, rendering the wound suitable for definitive skin cover procedures such as split skin graft and flap cover at an accelerated rate. Additionally, technical challenges associated with applying VAC dressing in the presence of an external fixator were successfully managed through realignment strategies, further underscoring the adaptability and efficacy of VAC therapy in addressing complex wound scenarios.
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Affiliation(s)
- Sunil Gottipati
- Orthopaedics, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Bandi Gowtham
- Orthopaedics, Great Eastern Medical School and Hospital, Srikakulam, IND
| | - Sindhu Chalimeda
- Orthopaedics and Traumatology, Singareni Institute of Medical Sciences, Ramagundam, IND
| | - Shivani Ravipati
- Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | - Vishaal P
- Orthopaedics, Stanley Medical College, Chennai, IND
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Kumaar A, Shanthappa AH, Hongaiah D, Sanjay N, Sharma A. Evaluation of Clinical Outcomes of Negative-Pressure Wound Therapy in Gustilo-Anderson Type IIIA/IIIB Open Fractures of Extremities. Cureus 2024; 16:e53801. [PMID: 38465189 PMCID: PMC10924076 DOI: 10.7759/cureus.53801] [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] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Background Open fractures are common and serious injuries that primarily affect young males. Fracture management has improved in the last decade. However, infections with their complications are still a concern, especially in open fractures for primary closure of the injured area. A newer technique called vacuum-assisted therapy has become a therapy of choice for many orthopedic surgeons. This study aimed to determine whether vacuum-assisted closure reduces the duration of wound healing and the frequency of infections after fixation of Gustilo-Anderson Type IIIA/IIIB fractures of the extremities. Methodology An observational analytical study was conducted among 34 patients with Gustilo-Anderson Type IIIA/IIIB fractures of the limbs who presented to the Department of Orthopaedics, R. L. Jalappa Hospital, Kolar, from December 2019 to July 2021. Negative-pressure wound therapy was employed for wound closure after fixation of fractures. Patients were followed up for one month. Results The mean age of the patients was 37.06 ± 10.340 years. The prevalence of infection before vacuum-assisted closure dressing was 80.6%, and the prevalence of infection after vacuum-assisted closure dressing was 19.4%. The difference in proportion before versus after the intervention was statistically significant (p < 0.001) according to the McNemar Test. Hence, vacuum-assisted closure dressing decreased the rate of infection. The mean dimension of the wound before vacuum-assisted closure therapy was 66.05 cm2 and the mean dimension of the wound after vacuum-assisted closure therapy was 27.97 cm2. The difference in the mean before and after the intervention was statistically significant according to the paired t-test (p < 0.001). Hence, vacuum-assisted closure dressing helped decrease the wound size which was proven statistically. Conclusions Vacuum-assisted closure is a viable and beneficial treatment option for complicated fractures with large soft-tissue abnormalities.
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Affiliation(s)
- Arun Kumaar
- Orthopaedics, Sri Devaraj Urs Medical College and Research Institute, Kolar, IND
| | - Arun H Shanthappa
- Orthopaedics, Sri Devaraj Urs Medical College and Research Institute, Kolar, IND
| | - Deepak Hongaiah
- Plastic Surgery, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Nandini Sanjay
- Orthopaedics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Abhi Sharma
- Orthopaedics, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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13
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Johnson TR, Oquendo YA, Seltzer R, Van Rysselberghe NL, Bishop JA, Gardner MJ. Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1173-1181. [PMID: 37989870 DOI: 10.1007/s00590-023-03782-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To determine if incisional negative pressure wound therapy is protective against post-operative surgical site complications following definitive fixation of bicondylar tibial plateau fractures. METHODS A retrospective analysis of patients diagnosed with an acute bicondylar tibial plateau fracture (AO/OTA 41-C) undergoing ORIF from 2010 to 2020 was performed. Patients received either a standard sterile dressing (SD) or incisional negative pressure wound therapy (iNPWT). Primary outcomes included surgical site infection, osteomyelitis, and wound dehiscence. Secondary outcomes included non-union and return to the operating room. Multivariate logistic regression analyses were performed. RESULTS 180 patients were included and 22% received iNPWT (n = 40) and 78% received standard dressings (n = 140). iNPWT was more common in active smokers (24.7% vs. 19.3%, p = 0.002) and the SD group was more likely to be lost to follow up (3.6% vs. 0%, p = 0.025). iNPWT was not protective against infection or surgical site complications, and in fact, was associated with higher odds of post-operative infection (OR: 8.96, p = 0.005) and surgical site complications (OR:4.874, p = 0.009) overall. Alcohol abuse (OR: 19, p = 0.005), tobacco use (OR: 4.67, p = 0.009), and time to definitive surgery (OR = 1.21, p = 0.033) were all independent risk factors for post-operative infection. CONCLUSION In this series of operatively treated bicondylar tibial plateau fractures, iNPWT did not protect against post-operative surgical site complications compared to conventional dressings. Tobacco use, alcohol abuse, and time to definitive surgery, were independent risk factors for post-operative infection. Further studies are needed to determine if iNPWT offers a protective benefit in exclusively high-risk patients with relevant medical and social history.
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Affiliation(s)
- Taylor R Johnson
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA.
| | - Yousi A Oquendo
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Ryan Seltzer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | | | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
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Johnson WB, Young A, Goldman S, Wilson J, Alderete JF, Childers WL. Exoskeletal solutions to enable mobility with a lower leg fracture in austere environments. WEARABLE TECHNOLOGIES 2023; 4:e5. [PMID: 38487779 PMCID: PMC10936379 DOI: 10.1017/wtc.2022.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/12/2022] [Accepted: 10/12/2022] [Indexed: 03/17/2024]
Abstract
The treatment and evacuation of people with lower limb fractures in austere environments presents unique challenges that assistive exoskeletal devices could address. In these dangerous situations, independent mobility for the injured can preserve their vital capabilities so that they can safely evacuate and minimize the need for additional personnel to help. This expert view article discusses how different exoskeleton archetypes could provide independent mobility while satisfying the requisite needs for portability, maintainability, durability, and adaptability to be available and useful within austere environments. The authors also discuss areas of development that would enable exoskeletons to operate more effectively in these scenarios as well as preserve the health of the injured limb so that definitive treatment after evacuation will produce better outcomes.
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Affiliation(s)
- W. Brett Johnson
- Research and Surveillance Division, Extremity Trauma and Amputation Center for Excellence, San Antonia, TX78234, USA
- Center for the Intrepid, Brooke Army Medical Center, San Antonia, TX78219, USA
| | - Aaron Young
- School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA30332, USA
| | - Stephen Goldman
- Research and Surveillance Division, Extremity Trauma and Amputation Center for Excellence, San Antonia, TX78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD20814, USA
| | - Jon Wilson
- Alabama College of Osteopathic Medicine, Dothan, AL36303, USA
| | | | - W. Lee Childers
- Research and Surveillance Division, Extremity Trauma and Amputation Center for Excellence, San Antonia, TX78234, USA
- Center for the Intrepid, Brooke Army Medical Center, San Antonia, TX78219, USA
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15
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Patterson JT, Becerra JA, Brown M, Roohani I, Zalavras C, Carey JN. Antibiotic bead pouch versus negative pressure wound therapy at initial management of AO/OTA 42 type IIIB open tibia fracture may reduce fracture related infection: A retrospective analysis of 113 patients. Injury 2023; 54:744-750. [PMID: 36588031 DOI: 10.1016/j.injury.2022.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Fracture related infection (FRI) may be a devastating complication of open tibial shaft fractures. We sought to determine if antibiotic bead pouch, negative pressure wound therapy, or negative pressure wound therapy over antibiotic beads as the initial coverage method for type IIIB open tibial shaft fractures is associated with risk of FRI. PATIENTS AND METHODS Retrospective cohort study with radiograph and chart review of patients aged ≥16 years with isolated, displaced, extra-articular, Gustilo-Anderson type IIIB open diaphyseal AO/OTA 42 tibial fractures requiring rotational or free tissue transfer for soft tissue coverage at one Level 1 trauma center between 2007 and 2020. An association of dressing applied at the first surgical debridement (application of antibiotic bead pouch, negative pressure wound therapy, or combined therapy) with a primary outcome of FRI requiring debridement or amputation was analyzed by multivariable logistic regression considering demographic, injury, and treatment characteristics. RESULTS 113 patients met eligibility criteria. Median follow-up was 33 months (interquartile range 5-88). 41 patients were initially treated with NPWT, 59 with ABP, and 13 with ABP+NPWT at the initial surgical debridement. 39 (35%) underwent subsequent debridement or amputation for FRI. One amputation occurred in the ABP group for refractory deep surgical site infection (p = 0.630). Initial wound management with an antibiotic bead pouch versus either negative pressure wound therapy alone or negative pressure wound therapy combined with an antibiotic bead pouch was associated with lower odds of debridement or amputation for FRI (β = -1.08, 95% CI -2.00 to -0.17, p = 0.02). CONCLUSIONS In our retrospective analysis, antibiotic bead pouch for initial coverage of type IIIB open tibial shaft fractures requiring flap coverage was associated with a lower risk of FRI requiring debridement or amputation than negative pressure wound therapy applied with or without antibiotic beads. A prospective clinical trial is warranted.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Jacob A Becerra
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Michael Brown
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Idean Roohani
- Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Charalampos Zalavras
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Joseph N Carey
- Department of Surgery, Division of Plastic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Sweere V, Sliepen J, Haidari S, Depypere M, Mertens M, IJpma F, Metsemakers WJ, Govaert G. Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence. Injury 2022; 53:3938-3944. [PMID: 36424686 DOI: 10.1016/j.injury.2022.10.014] [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: 02/14/2022] [Revised: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients. PATIENTS AND METHODS This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. RESULTS A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]). CONCLUSION Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.
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Affiliation(s)
- Vera Sweere
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Susan Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Mertens
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
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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; 28:1120-1128. [PMID: 35450789 DOI: 10.1016/j.fas.2022.03.012] [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: 10/13/2021] [Revised: 01/11/2022] [Accepted: 03/26/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The superiority of negative pressure wound therapy (NPWT) to standard gauze dressings for managing open fractures of the lower limbs remains controversial. This study aimed to comprehensively compare their clinical efficacy through a meta-analysis using randomized controlled trials (RCTs) alone. We hypothesized that NPWT would be more superior against infections. METHODS A literature search was implemented in various databases, including PubMed, Web of Science, Medline, Clinicaltrial.gov, and Cochrane Library, etc, to screen eligible RCTs. All included RCTs were evaluated for risk of bias using the Cochrane Collaboration tool. In accordance with the heterogeneity assessment, a fixed-effect or random-effect model was chosen for the data analysis. RESULTS Ten RCTs, including 2780 patients, were eligible for the meta-analysis. We found that patients in the NPWT group showed a lower overall infection rate (MD=0.70, 95% CI: 0.54-0.90, P = 0.005), acute wound infection rate (MD = 0.35, 95% CI: 0.16-0.77, P = 0.009), and shorter hospital stay (MD = 24.00, 95% CI: 6.82-84.46, P < 0.00001) compared with the control group. The NPWT group showed a higher proportion of patients with wound coverage than the control group. No significant difference was found between the two groups in terms of function score and other complications, including deep infection rate, amputation, and bone nonunion. CONCLUSIONS From the pooled results, we suggest that NPWT may be superior than traditional gauze dressings for managing open fractures of the lower limbs.
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Affiliation(s)
- Hu Qian
- Department of Orthopeadic Surgery, Xiangya Hospital Central South University, China
| | - Ting Lei
- Department of Orthopeadic Surgery, Xiangya Hospital Central South University, China.
| | - Yihe Hu
- Department of Orthopeadic Surgery, Xiangya Hospital Central South University, China; Department of Orthopedic Surgery, The First Affliated Hospital, College of Medicine, Zhejiang University, China; Hunan Engineering Research Center of Biomedical Metal and Ceramic Implants, China.
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Agarwal A. Evolution of Negative Pressure Wound Therapy in Orthopaedic Trauma. J Orthop Trauma 2022; 36:S1-S5. [PMID: 35994301 DOI: 10.1097/bot.0000000000002431] [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
Negative Pressure Wound Therapy (NPWT) has evolved from open wound management to now include closed incision management. It has been a major advance in the management of open wounds and closed incisional wounds especially in orthopaedic trauma surgery. Because of the success of NPWT in the late 1990s and early 2000s, surgeons began using NPWT with adjuncts on closed incisions as a way to help prevent surgical wound dehiscence especially in at-risk patients for wound problems. It has been well established that obesity, diabetes, and smoking in addition to other comorbidities increase the risk of wound dehiscence and surgical site infections in orthopaedic patients. It is widely used for open wound management, often associated with open fractures, and in the mitigation of risk of surgical site infections over closed incisions (incisional negative pressure wound therapy). Newer systems allow the use of various topical wound solutions to be instilled in conjunction with NPWT, termed NPWTi-d. This has shown promising results in difficult wounds that may be resistant to standard NPWT. This article reviews the evolution and use of NPWT in orthopaedic trauma.
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Affiliation(s)
- Animesh Agarwal
- Division of Orthopaedic Trauma, University of Texas Health Science Center at San Antonio, Department of Orthopaedics, San Antonio, TX
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Gálvez-Sirvent E, Ibarzábal-Gil A, Rodríguez-Merchán EC. Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management. EFORT Open Rev 2022; 7:554-568. [PMID: 35924649 PMCID: PMC9458943 DOI: 10.1530/eor-22-0004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis. The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA. Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection. In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage). Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.
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Affiliation(s)
- Elena Gálvez-Sirvent
- Department of Orthopaedic Surgery, “Infanta Elena” University Hospital, Valdemoro, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Aitor Ibarzábal-Gil
- Department of Orthopaedic Surgery, “La Paz” University Hospital, Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, “La Paz” University Hospital, Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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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. [PMID: 35509767 PMCID: PMC9060726 DOI: 10.7759/cureus.23727] [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] [Accepted: 03/31/2022] [Indexed: 01/13/2023] Open
Abstract
Background: Orthopedic surgeons face a difficult task in treating serious open fractures, which usually result in complications, morbidity, and even amputation. Compound fracture wounds were traditionally treated with a standard saline dressing. To avoid infection and problems during therapy, several studies found that open fractures require early skeletal stability as well as soft tissue repair. In favoring the above fact vacuum-assisted closure (VAC) is now undergoing a paradigm shift. With this background, this study aimed to compare the effects of VAC dressing versus standard wound dressing on compound fracture wounds. Methodology: This study has been conducted as a single-blind randomized control trial among 128 patients who got admitted to the Department of Orthopedics, R L Jalappa Hospital attached to Sri Devaraj Urs Medical College, Karnataka, India from August 2019 to November 2021. The study participants were randomly allotted into two groups negative pressure wound therapy (NPWT) and standard wound therapy (SWT) consisting of 64 participants in each group. VAC dressing was used on group NPWT, while normal saline wound dressing was used on group SWT. Both groups were followed up for a month after their discharge from the hospital. Frequency in dressing changes wound healing time, infection presence, and hospitalization days were all recorded and compared over one month. The data collection was done using questionnaires and the statistical analysis was done with SPSS version 21 (Chicago, IL: IBM Corp.). Results: There was a statically significant difference favoring group NPWT compared to group SWT with a hospital stay, number of dressings required, wound size reduction, wound healing time, and deep infection rate (p<0.05). Conclusions: The use of NPWT speeds up the healing of compound fracture wounds significantly. It is affordable and can be used as a substitute in resource-constrained areas to reduce infection and manage open fracture wounds quickly.
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Wu J, Qin Y, Li Z, Li J, Li L, Tao S, Liu D. Comprehensive analysis of lncRNA and miRNA expression profiles and ceRNA network construction in negative pressure wound therapy. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1383. [PMID: 34733935 PMCID: PMC8506533 DOI: 10.21037/atm-21-3626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022]
Abstract
Background This study aims to explore the molecular mechanism of negative pressure wound therapy (NPWT) at the transcriptome level through whole transcriptome sequencing and biometric analysis. Methods A rat skin defect model was constructed and randomly divided into a NPWT group and a gauze group. The tissue in the center of the wound was used for whole transcriptome sequencing, and differentially expressed messenger RNAs (DEmRNAs), long noncoding RNAs (DElncRNAs), and microRNAs (DEmiRNAs) were identified between the two groups. Quantitative real time-polymerase chain reaction (qRT-PCR) analysis was used to verify the sequencing results. Functional enrichment analysis, pathway analysis, and protein-protein interaction (PPI) network analysis of DEmRNAs were conducted. Through bioinformatics analysis, a lncRNA-associated competing endogenous RNA (ceRNA) network was identified and constructed. Results We detected 896 DEmRNAs, 1,471 DElncRNAs, and 20 DEmiRNAs between the two groups. qRT-PCR verified the sequencing results. Functional analysis showed that DEmRNAs were mainly enriched in immune system processes and the Notch signaling pathway. Protein tyrosine phosphatase receptor type C (PTPRC) and signal transducer and activator of transcription 1 (STAT1) were the central hub nodes in the PPI analysis. The ceRNA network contained 11 mRNAs, 15 lncRNAs, and 4 miRNAs. Conclusions We identified several DEmRNAs, DElncRNAs, and DEmiRNAs between the NPWT treatment group and the control group. These findings may provide new insights into the pathophysiological mechanism of NPWT and wound healing.
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Affiliation(s)
- Jie Wu
- Department of Orthopedics, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Yong Qin
- Department of Orthopedics, Second Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Zhirui Li
- Department of Orthopedics, Hainan Hospital of PLA General Hospital, Sanya, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Jiantao Li
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Litao Li
- Department of Orthopedics, The Eighth Medical Center of PLA General Hospital, Beijing, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Sheng Tao
- Department of Orthopedics, The Eighth Medical Center of PLA General Hospital, Beijing, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Daohong Liu
- Department of Orthopedics, The Eighth Medical Center of PLA General Hospital, Beijing, China.,Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
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Haidari S, IJpma FFA, Metsemakers WJ, Maarse W, Vogely HC, Ramsden AJ, McNally MA, Govaert GAM. The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7742227. [PMID: 34722772 PMCID: PMC8548908 DOI: 10.1155/2021/7742227] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. METHODS A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. RESULTS After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. CONCLUSION This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.
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Affiliation(s)
- Susan Haidari
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank F. A. IJpma
- Department of Trauma Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | - Wies Maarse
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - H. Charles Vogely
- Department of Orthopedic Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Alex J. Ramsden
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Bone Infection Unit, Nuffield Orthopedic Centre, Oxford, UK
| | | | - Geertje A. M. Govaert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Mener A, Staley C, Boissonneault A, Reisman W, Schenker M, Hernandez-Irizarry R. Infection after Open Long Bone Fractures: Can we Improve on Prophylaxis? J Surg Res 2021; 268:33-39. [PMID: 34280663 DOI: 10.1016/j.jss.2021.05.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 03/14/2021] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. METHODS We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). RESULTS GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. CONCLUSION For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2's broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.
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Affiliation(s)
- Amanda Mener
- Emory University School of Medicine, Atlanta, GA
| | | | - Adam Boissonneault
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - William Reisman
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mara Schenker
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
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Matsumine H. NPWTi allows safe delayed free flap repair of Gustilo IIIb injuries: A prospective case series. Regen Ther 2021; 18:82-87. [PMID: 33997186 PMCID: PMC8094577 DOI: 10.1016/j.reth.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Free flap lower extremity repair is associated with a high complication rate (>31%); higher rates are observed in more severe patients. In cases requiring prior systemic/local stabilization, delayed repair increases complication rate (+10% at 7 days): Negative-pressure Wound Therapy (NPWT) decreases complications but only when applied for less than 7 days. Recent limited evidence suggests that augmentation of NPWT with instillation for wound irrigation (NPWTi) might safely extend such window. This study hypothesizes that, through the combined cleansing effect of NPWT and instillation, NPWTi allows safe (low complication rate) delayed free flap repair in severe patients with Gustilo IIIb injuries (GIIIb). Methods A prospective case series was designed (inclusion criteria: GIIIb requiring microsurgical repair, severe patient/injury condition preventing immediate/early repair; exclusion criteria: allergy to NPWTi dressing). Patients received NPWTi (suction: 125 mmHg continuous; irrigation: NaCl 0.9%) until considered clinically ready for repair. Preoperative/postoperative complications (dehiscence, wound infection, bone non-union, osteomyelitis, flap failure) were monitored with clinical signs, imaging, and serum markers (CRP, WBC). Results Four patients (male: N = 4, female N = 1; Age: 59 [44-75] years-old) were treated. NPWTi was applied for 15.2 [9-28] days. No complication (0%) was observed preoperatively or postoperatively. Delayed repair occurred by latissimus dorsi musculocutaneous flap (N = 3), and anterolateral thigh flap (N = 2). All patients walked weight-bearing 12 [6-20] weeks after injury. Conclusions NPWTi seems to allow safe delayed free flap repair in patients with severe lower extremity injuries unable to undergo immediate/early repair.
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Affiliation(s)
- Hajime Matsumine
- Corresponding author. Department of Plastic and Reconstructive Surgery, Yachiyo Medical Center, Tokyo Women's Medical University, 477-96 Owada-shinden, Yachiyo-shi, Chiba, 276-8524, Japan.
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25
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Shiels SM, Sgromolo NM, Wenke JC. Negative pressure wound therapy does not diminish efficacy of topical antibiotic powder in a preclinical contaminated wound model. Bone Joint Res 2021; 10:149-155. [PMID: 33595334 PMCID: PMC7937412 DOI: 10.1302/2046-3758.102.bjr-2020-0171.r1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AIMS High-energy injuries can result in multiple complications, the most prevalent being infection. Vancomycin powder has been used with increasing frequency in orthopaedic trauma given its success in reducing infection following spine surgery. Additionally, large, traumatic injuries require wound coverage and management by dressings such as negative pressure wound therapy (NPWT). NPWT has been shown to decrease the ability of antibiotic cement beads to reduce infection, but its effect on antibiotic powder is not known. The goal of this study was to determine if NPWT reduces the efficacy of topically applied antibiotic powder. METHODS Complex musculoskeletal wounds were created in goats and inoculated with a strain of Staphylococcus aureus modified to emit light. Six hours after contaminating the wounds, imaging, irrigation, and debridement and treatment application were performed. Animals received either vancomycin powder with a wound pouch dressing or vancomycin powder with NPWT. RESULTS There were no differences in eradication of bacteria when vancomycin powder was used in combination with NPWT (4.5% of baseline) compared to vancomycin powder with a wound pouch dressing (1.7% of baseline) (p = 0.986), even though approximately 50% of the vancomycin was recovered in the NPWT exudate canister. CONCLUSION The antimicrobial efficacy of the vancomycin powder was not diminished by the application of NPWT. These topical and locally applied therapies are potentially effective tools that can provide quick, simple treatments to prevent infection while providing coverage. By reducing the occurrence of infection, the recovery is shortened, leading to an overall improvement in quality of life. Cite this article: Bone Joint Res 2021;10(2):149-155.
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Affiliation(s)
- Stefanie M Shiels
- Orthopaedic Trauma Research Department, U.S. Army Institute of Surgical Research, San Antonio, Texas, USA
| | - Nicole M Sgromolo
- Orthopaedic Trauma Research Department, U.S. Army Institute of Surgical Research, San Antonio, Texas, USA.,Department of Orthopaedic Surgery, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Joseph C Wenke
- Orthopaedic Trauma Research Department, U.S. Army Institute of Surgical Research, San Antonio, Texas, USA
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Fujioka M, Fukui K, Noguchi M. How long can secondary resurfacing surgery be delayed with continuous irrigation therapy for gustilo-anderson type iii fracture? A retrospective clinical study. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2021. [DOI: 10.4103/jodp.jodp_4_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Roddy E, Patterson JT, Kandemir U. Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures. Injury 2020; 51:1999-2003. [PMID: 32482427 DOI: 10.1016/j.injury.2020.04.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 04/03/2020] [Accepted: 04/18/2020] [Indexed: 02/02/2023]
Abstract
AIMS Antibiotic administration, severity of injury, and debridement are associated with surgical site infection (SSI) after internal fixation of open fractures. We sought to validate a time-dependent treatment effect of antibiotic administration. PATIENTS Consecutive open fracture patients at a level 1 trauma center with minimum 30-day follow-up were identified from an orthopaedic registry from 2013-2017. METHODS The primary endpoint was SSI within 90 days. A threshold time to antibiotic administration associated with SSI was ascertained by receiver-operator analysis. A Cox proportional hazards model adjusted for age, smoking, and drug use determined the treatment effect of antibiotic administration within the threshold period. RESULTS Ten percent of 230 patients developed a SSI. There was a trend for patients who did not develop an SSI to receive antibiotics earlier than those who did develop an SSI (61 minutes, IQR 33-107 vs 83 minutes, IQR 40-186), p=0.053). Intravenous antibiotic administration after 120 minutes of presentation of an open fracture to emergency department was significantly associated with a 2.4 increased hazard of surgical site infection (p=0.036) within 90 days. CONCLUSION Antibiotic administration greater than 120 minutes after ED presentation of an open fracture was associated with an increased risk of SSI.
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Affiliation(s)
- Erika Roddy
- Dept. of Orthopedic Surgery, University of California San Francisco, San Francisco General Hospital, San Francisco, CA.
| | - Joseph T Patterson
- Dept. of Orthopedic Surgery, University of California San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Utku Kandemir
- Dept. of Orthopedic Surgery, University of California San Francisco, San Francisco General Hospital, San Francisco, CA
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Tahir M, Chaudhry EA, Zimri FK, Ahmed N, Shaikh SA, Khan S, Choudry UK, Aziz A, Jamali AR. [RETRACTED] Negative pressure wound therapy versus conventional dressing for open fractures in lower extremity trauma. Bone Joint J 2020; 102-B:912-917. [PMID: 32600140 DOI: 10.1302/0301-620x.102b7.bjj-2019-1462.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. METHODS This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples t-test were applied for secondary outcomes. Analyses of primary and secondary outcomes were performed using SPSS v. 22.0.1 and p-values of < 0.05 were considered significant. RESULTS A total of 486 patients were randomized between January 2016 and December 2018. Overall 206 (49.04%) patients underwent NPWT, while 214 (50.95%) patients were allocated to the standard dressing group. There was no statistically significant difference in DRI at 12 months between NPWT and standard dressing groups (mean difference 0.5; 95% confidence interval (CI) -0.08 to 1.1; p = 0.581). Regarding SF-12 scores at 12 months follow-up, there was no significant difference at any point from injury until 12 months (mean difference 1.4; 95% CI 0.7 to 1.9; p = 0.781). The 30-day deep infection rate was slightly higher in the standard gauze dressing group. The non-union odds were also comparable (odds ratio (OR) 0.90, 95% CI 0.56 to 1.45; p = 0.685). CONCLUSION Our study concludes that NPWT therapy does not confer benefit over standard dressing technique for open fractures. The DRI, SF-12 scores, wound infection, and nonunion rates were analogous in both study groups. We suggest surgeons continue to use cheaper and more readily available standard dressings. Cite this article: Bone Joint J 2020;102-B(7):912-917.
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Affiliation(s)
- Muhammad Tahir
- Department of Orthopaedics, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Ejaz A Chaudhry
- Department of Orthopaedics, Ghurkhi Trust Hospital, Lahore, Pakistan
| | - Faridullah K Zimri
- Department of Orthopaedics, National Institute of Rehabilitation Medicine, Islamabad, Pakistan
| | - Nadeem Ahmed
- Department of Orthopaedics, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Saeed A Shaikh
- Department of Orthopaedics, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Shoaib Khan
- Department of Orthopaedics, Whiston Hospital, Prescot, United Kingdom
| | | | - Amer Aziz
- Department of Orthopaedics, Ghurkhi Trust Hospital, Lahore, Pakistan
| | - Allah R Jamali
- Department of Orthopaedics, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
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Loh ML, Goh BKL, Kong Y, Varughese G, Ng JL, Lo ZJ, Pek CH. Combination therapy of oxidised regenerated cellulose/collagen/silver dressings with negative pressure wound therapy for coverage of exposed critical structures in complex lower-extremity wounds. Int Wound J 2020; 17:1356-1365. [PMID: 32447838 DOI: 10.1111/iwj.13406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/05/2020] [Indexed: 01/17/2023] Open
Abstract
Complex wounds with exposed critical structures such as tendon and bone are a conundrum in wound management, especially in the setting where the patient is not a suitable candidate for flap surgery. While the individual use of negative pressure wound therapy (NPWT) and oxidised regenerated cellulose (ORC)/collagen/silver (PROMOGRAN PRISMA) dressing has been described in the literature, there are little data on the efficacy of their combined use. In this study, we describe a novel technique of combining the use of NPWT and ORC/collagen/silver dressings to manage complex wound beds as an alternative management option for patients not suitable for reconstructive flap surgery. This technique was performed in a series of 37 patients with complex lower-extremity wounds that were not healing with conventional NPWT alone. All patients had open wounds with exposed critical structures that were difficult to manage, such as exposed tendon, bone, deep crevices, and joint. Successful coverage of exposed critical structures was achieved in 89% of patients, and coverage was achieved within 28 days of combination therapy in 82% of these patients, without any complications. The novel technique of combining ORC/collagen/silver dressing and NPWT provides a useful option in the armamentarium of a reconstructive surgeon dealing with difficult complex lower-extremity wounds.
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Affiliation(s)
- Mei Ling Loh
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Benjamin K L Goh
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Yuan Kong
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - George Varughese
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Jia Lin Ng
- Department of Podiatry, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Zhiwen J Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chong Han Pek
- Department of General Surgery, Plastic, Reconstructive and Aesthetic Surgery Service, Khoo Teck Puat Hospital, Singapore, Singapore
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Kim JH, Lee DH. Are high-risk patient and revision arthroplasty effective indications for closed-incisional negative-pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta-analysis. Int Wound J 2020; 17:1310-1322. [PMID: 32406175 DOI: 10.1111/iwj.13393] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/02/2020] [Indexed: 12/21/2022] Open
Abstract
To determine the effective indications of closed-incisional negative-pressure wound therapy (ciNPWT) following total hip or knee arthroplasty, this systematic review and meta-analysis was conducted. The systematic search was performed on MEDLINE, Embase, and Cochrane Library, and 11 studies were included. The studies comparing between ciNPWT and conventional dressings were categorised into following subgroups based on patient risk and revision procedures: routine vs high-risk patient; primary vs revision arthroplasty. Pooled estimates were calculated for wound complication and surgical site infection (SSI) rates in the subgroup analyses using Review Manager. In high-risk patients, the overall rates of wound complication (odds ratio [OR] = 0.38; 95% confidence interval [CI] 0.15-0.93; P = .030) and SSI (OR = 0.24; 95% CI = 0.09-0.64; P = .005) were significantly lower in the ciNPWT; however, there were no differences in routine patients. In cases involving revision arthroplasties, the overall rates of wound complication (OR = 0.33; 95% CI = 0.18-0.62; P < .001) and SSI (OR = 0.26; 95% CI = 0.11-0.66; P = .004) were significantly lower in the ciNPWT; however, there were no differences in cases involving primary arthroplasties. In summary, ciNPWT showed a positive effect in decreasing the rates of wound complication and SSI in high-risk patients and in revision arthroplasties.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury 2020; 51 Suppl 2:S57-S63. [PMID: 31679836 DOI: 10.1016/j.injury.2019.10.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/07/2019] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Daniel Popp
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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The Effectiveness of Negative Pressure Wound Therapy Versus Conventional Dressing in the Treatment of Open Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma 2020; 34:223-230. [PMID: 32079890 DOI: 10.1097/bot.0000000000001750] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the efficacy of negative pressure wound therapy (NPWT) versus conventional dressings (CD) in the management of open fractures. DATA SOURCES A systematic search of English articles in the PubMed/MEDLINE, Embase, and the Cochrane Library through April 2019 comparing NPWT versus CD in the management of open fractures. STUDY SELECTION Inclusion criteria were articles in English language, comparing NPWT with CD in skeletally mature individuals who had sustained an open fracture at any anatomical site, reporting on rates of deep infection, flap frequency, flap failure, nonunion, amputation, length of hospital, or intensive care unit stay. DATA EXTRACTION Two authors independently extracted data from selected studies, and the data collected were compared with verify agreement. DATA SYNTHESIS Pooled odds ratios were calculated for dichotomous outcomes, whereas continuous data were analyzed using the standard weighted mean difference. A random or fixed effect model was used depending on the level of heterogeneity between the studies. CONCLUSIONS NPWT results in decreased likelihood of deep infection and flap failure compared with CD in the management of open fractures not directly amenable to early closure. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Open fractures with soft-tissue loss: Coverage options and timing of surgery. OTA Int 2020; 3:e053. [PMID: 33937679 PMCID: PMC8081466 DOI: 10.1097/oi9.0000000000000053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022]
Abstract
Open fractures with soft-tissue loss remain challenging injuries to treat. These often high-energy fractures are at a higher risk of delayed healing and at much higher risk of infection than open fractures with less significant soft-tissue injury. The initial management of the open wound, flap coverage options, and the timing of definitive coverage all remain areas of controversy, which will be discussed in this article.
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The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads in Lower Extremity Salvage. J Surg Res 2020; 247:499-507. [DOI: 10.1016/j.jss.2019.09.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 07/03/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023]
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35
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Sagy M, Singh J, kalia A, Dahuja A, Garg S, Garg R. Wound healing of open fractures: comparison of vaccum assisted dressing versus traditonal dressing. Int J Orthop Trauma Nurs 2020; 36:100722. [DOI: 10.1016/j.ijotn.2019.100722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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36
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Lim K, Lim X, Hong Q, Yong E, Chandrasekar S, Tan GWL, Lo ZJ. Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage. Int Wound J 2020; 17:531-539. [PMID: 31972901 DOI: 10.1111/iwj.13307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/23/2019] [Accepted: 01/10/2020] [Indexed: 11/29/2022] Open
Abstract
Use of negative pressure wound therapy (NPWT) in peripheral artery disease (PAD) and diabetic limb salvage (DLS) improves wound healing by providing moist wound conditions, reducing exudate, controlling wound-bed infection, and stimulating granulation. NPWT duration may take several weeks, and home-based NPWT allows patient to recover in the community while minimising risks of prolonged hospitalisation. The aim of this study is to review the use and outcomes of home NPWT in PAD and DLS. The methodology is the retrospective review of patients who were discharged with home NPWT after in-patient PAD revascularisation and DLS debridement or minor amputations. The results included a total of 118 patients who received home NPWT between January 2017 and December 2017. The mean age was 62.8 years with 66% male and 34% female patients. The study population comprised 25% smokers, 98% patients with diabetics, 35% with ischemic heart disease, and 21% with end-stage renal failure (ESRF). Of which, 56% of patients required revascularisation while 31% of patients underwent foot debridement, 48% underwent toe amputations, and 20% underwent forefoot amputations. All patients received in-patient NPWT for a week before being discharged on home NPWT for 4 weeks. Then, 62% received targeted antibiotics regime while 36% received empirical antibiotics on discharge; 60% of patients achieved wound healing on home NPWT, with 9% requiring split-thickness skin graft; 4% required further surgical debridement, 16% required further minor amputation while 20% required major amputation. 9% required further home NPWT extension, with a mean length of 7.1 ± 4.7 weeks' extension. Overall survival of 1 year was 89%. Risk factors that predict the failure of home NPWT includes subjects with a background of ESRF and wet gangrene on presentation. Home NPWT is a useful adjunct in the management of PAD and DLS foot wounds.
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Affiliation(s)
- Kai Lim
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Xuxin Lim
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Glenn W L Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Zhiwen J Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Horch RE, Ludolph I, Müller-Seubert W, Zetzmann K, Hauck T, Arkudas A, Geierlehner A. Topical negative-pressure wound therapy: emerging devices and techniques. Expert Rev Med Devices 2020; 17:139-148. [PMID: 31920139 DOI: 10.1080/17434440.2020.1714434] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.
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Affiliation(s)
- Raymund E Horch
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Wibke Müller-Seubert
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Katharina Zetzmann
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Theresa Hauck
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Alexander Geierlehner
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
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Hatashita S, Kawakami R, Ejiri S, Sasaki N, Toshiki N, Ito M, Konno SI, Hakozaki M. ‘Acute Masquelet technique’ for reconstructing bone defects of an open lower limb fracture. Eur J Trauma Emerg Surg 2020; 47:1153-1162. [DOI: 10.1007/s00068-019-01291-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/17/2019] [Indexed: 11/28/2022]
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Green T, Kavros S, Springer S, Drez D, McCabe M, Gremillion J. Team Approach: Complex Dermal Wound-Healing Utilizing Negative-Pressure Wound Therapy (NPWT) in Orthopaedic Trauma. JBJS Rev 2019; 6:e1. [PMID: 29509555 DOI: 10.2106/jbjs.rvw.17.00042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Tyson Green
- Imperial Health Center for Orthopaedics, Lake Charles, Louisiana
| | | | - Steve Springer
- Imperial Health Center for Orthopaedics, Lake Charles, Louisiana
| | - David Drez
- Imperial Health Center for Orthopaedics, Lake Charles, Louisiana
| | - Matthew McCabe
- Imperial Health Center for Orthopaedics, Lake Charles, Louisiana
| | - Jared Gremillion
- Imperial Health Center for Orthopaedics, Lake Charles, Louisiana
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Kim JH, Kim HJ, Lee DH. Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:2804-2814. [PMID: 31288945 DOI: 10.1016/j.arth.2019.06.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 05/20/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH). METHODS Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data. RESULTS Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001). CONCLUSION Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Kim JH, Lee DH. Negative pressure wound therapy vs. conventional management in open tibia fractures: Systematic review and meta-analysis. Injury 2019; 50:1764-1772. [PMID: 31047682 DOI: 10.1016/j.injury.2019.04.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/20/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Severe open tibia fractures are disastrous injuries associated with a high incidence of complications. Negative pressure wound therapy (NPWT) is a novel treatment for open tibia fractures; however, its efficacy remains unclear. This is a systematic review and meta-analysis performed to evaluate the effect of NPWT on decreasing the infection rate, amputation rate, nonunion rate, and flap-related complications in open tibia fractures. METHODS The MEDLINE, EMBASE, and Cochrane Library databases were systematically searched. Complications were evaluated in terms of the rates of infection, amputation, nonunion, and flap-related complications. RESULTS Twelve studies were included. In the meta-analysis, NPWT showed significantly lower soft-tissue infection rate (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.34-0.68, P < 0.0001), nonunion rate (OR 0.61, 95% CI 0.39-0.95, P = 0.03), flap necrosis rate (OR 0.37, 95% CI 0.21-0.63, P = 0.0003), and flap revision rate (OR 0.44, 95% CI 0.22-0.89, P = 0.02) than conventional wound management. However, no significant difference was found in osteomyelitis rate (OR 0.54, 95% CI 0.09-3.28, P = 0.50) and amputation rate (OR 0.89, 95% CI 0.36-2.22, P = 0.80) between the 2 groups. CONCLUSION Lower rates of soft-tissue infection, nonunion, flap necrosis, and flap revision were observed in the NPWT group than in the conventional dressing group. However, additional high-quality studies are warranted to verify the efficacy of NPWT in the treatment of severe open tibia fractures. We could not make a definitive conclusion about the comparative efficacy of the 2 methods in terms of complications because of insufficient data.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Li Z, Yu Q, Wang S, Wang G, Li T, Tang PF, Liu D. Impact of negative-pressure wound therapy on bacterial behaviour and bioburden in a contaminated full-thickness wound. Int Wound J 2019; 16:1214-1221. [PMID: 31483575 DOI: 10.1111/iwj.13197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 12/25/2022] Open
Abstract
The use of negative-pressure wound therapy (NPWT) has displayed significant clinical benefits in the healing of infected wounds. However, the effects of NPWT on bacterial colonisation and infection of traumatic wounds has been controversial. The aim of this study is to evaluate the impact of NPWT treatment in rabbits with a contaminated full-thickness wound on bacterial behaviour, including colony morphology, spatial distribution, fissional proliferation, and bacterial bioburden. Full-thickness wounds were created on the back of rabbits, and were inoculated with bioluminescent Staphylococcus aureus. The wounds were treated with sterile gauze dressings and NPWT with continuous negative pressure (-125 mm Hg). Wound samples were harvested on days 0 (6 hours after bacterial inoculation), 2, 4, 6, and 8 at the centre of wound beds before irrigation. Scanning electron microscopy and transmission electron microscopy (TEM) analyses were performed to determine the characteristic bacteriology. Laser scanning confocal microscopy was performed to obtain bioluminescent images, which were used to observe spatial distribution of the GFP-labelled S. aureus within the tissue and quantify the bacterial bioburden. NPWT resulted in sparse amounts of scattered bacteria on the wound surface or as sparsely spaced single colonies within the tissue. Wound bioburden on day 8 in the NPWT and gauze groups was 34.6 ± 5.5% and 141.9 ± 15.4% of the baseline values (N = 6), respectively (P < .0001). TEM showed a lack of S. aureus active fission within NPWT-treated tissue. NPWT can impact S. aureus colony morphology and spatial distribution both on the surface and within wound tissue, and reduce S. aureus as early as 48 hours after therapy initiation. Additionally, NPWT inhibits bacterial fissional proliferation in microcolonies.
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Affiliation(s)
- Zhirui Li
- Department of Orthopedics, The General Hospital of People's Liberation Army, Beijing, China.,Department of Orthopedics, Chinese PLA General Hospital and Hainan Branch, Sanya, China
| | - Qingwen Yu
- Department of Orthopedics, Beijing, China
| | - Song Wang
- Medical College, Nankai University, Tianjin, China
| | - Guoqi Wang
- Department of Orthopedics, The General Hospital of People's Liberation Army, Beijing, China
| | - Tongtong Li
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Pei-Fu Tang
- Department of Orthopedics, The General Hospital of People's Liberation Army, Beijing, China
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Zhang Z, Wang G. Letter to the editor regarding "Negative pressure wound therapy vs. conventional management in open tibia fractures: Systematic review and meta-analysis". Injury 2019; 50:1495. [PMID: 31204026 DOI: 10.1016/j.injury.2019.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 05/18/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Zhen Zhang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Guanglin Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China.
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Sirisena R, Bellot GL, Puhaindran ME. The Role of Negative-Pressure Wound Therapy in Lower-Limb Reconstruction. Indian J Plast Surg 2019; 52:73-80. [PMID: 31456615 PMCID: PMC6664838 DOI: 10.1055/s-0039-1687922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Negative-pressure wound therapy (NPWT) has gained increasing popularity among clinicians since its introduction in 1997 as a potential aid to wound healing. Multiple benefits of NPWT have since been proven in studies, including increase in granulation tissue formation, decrease in bacterial load, and the improved survival of flaps. With our increasing use and greater understanding of the tissue and cellular changes that occur in a wound treated with NPWT, our lower-limb reconstructive practice has also evolved. Although controversial, the definite timing for lower-limb reconstruction has stretched from 72 hours to longer than 2 weeks as NPWT contains the wound within a sterile, closed system. It has also shown to decrease the rate of infection in open tibia fractures. Previously, a large number of critical defects of the lower limb would require free tissue transfer for definitive reconstruction. NPWT has reduced this rate by more than 50% and has allowed for less complicated resurfacing procedures to be performed instead.
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Affiliation(s)
- Renita Sirisena
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Gregory Lucien Bellot
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Mark Edward Puhaindran
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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Frear CC, Griffin B, Cuttle L, McPhail SM, Kimble R. Study of negative pressure wound therapy as an adjunct treatment for acute burns in children (SONATA in C): protocol for a randomised controlled trial. Trials 2019; 20:130. [PMID: 30760332 PMCID: PMC6374905 DOI: 10.1186/s13063-019-3223-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although negative pressure wound therapy (NPWT) is widely used in the management of several wound types, its efficacy as a primary therapy for acute burns has not yet been adequately investigated, with research in the paediatric population particularly lacking. There is limited evidence, however, that NPWT might benefit children with burns, amongst whom scar formation, wound progression and pain continue to present major management challenges. The purpose of this trial is to determine whether NPWT in conjunction with standard therapy accelerates healing, reduces wound progression and decreases pain more effectively than standard treatment alone. METHODS/DESIGN A total of 104 children will be recruited for this trial. To be eligible, candidates must be under 17 years of age and present to the participating children's hospital within 7 days of their injury with a thermal burn covering <5% of their total body surface area. Facial and trivial burns will be excluded. Following a randomised controlled parallel design, participants will be allocated to either an active control or intervention group. The former will receive standard therapy consisting of Acticoat™ and Mepitel™. The intervention arm will be treated with silver-impregnated dressings in addition to NPWT via the RENASYS TOUCH™ vacuum pump. Participants' dressings will be changed every 3 to 5 days until their wounds are fully re-epithelialised. Time to re-epithelialisation will be studied as the primary outcome. Secondary outcomes will include pain, pruritus, wound progression, health-care-resource use (and costs), ease of management, treatment satisfaction and adverse events. Wound fluid collected during NPWT will also be analysed to generate a proteomic profile of the burn microenvironment. DISCUSSION The study will be the first randomised controlled trial to explore the clinical effects of NPWT on paediatric burns, with the aim of determining whether the therapy warrants implementation as an adjunct to standard burns management. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12618000256279 . Registered on 16 February 2018.
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Affiliation(s)
- Cody C. Frear
- Centre for Children’s Burns and Trauma Research, Level 7, Children’s Health Research Center, The University of Queensland, 62 Graham St., South Brisbane, QLD 4101 Australia
- The Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Lvl. 5, 501 Stanley St., South Brisbane, QLD 4101 Australia
- The University of Queensland Faculty of Medicine, 288 Herston Rd., Brisbane, QLD 4006 Australia
| | - Bronwyn Griffin
- Centre for Children’s Burns and Trauma Research, Level 7, Children’s Health Research Center, The University of Queensland, 62 Graham St., South Brisbane, QLD 4101 Australia
- The Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Lvl. 5, 501 Stanley St., South Brisbane, QLD 4101 Australia
- The University of Queensland Faculty of Medicine, 288 Herston Rd., Brisbane, QLD 4006 Australia
| | - Leila Cuttle
- Institute of Health and Biomedical Innovation, Centre for Children’s Burns and Trauma Research, Lvl 8, Children’s Health Research Centre, Queensland University of Technology, South Brisbane, QLD 4101 Australia
| | - Steven M. McPhail
- Centre for Functioning and Health Research, Metro South Health, Queensland Health, Brisbane, QLD 4102 Australia
- School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4059 Australia
| | - Roy Kimble
- Centre for Children’s Burns and Trauma Research, Level 7, Children’s Health Research Center, The University of Queensland, 62 Graham St., South Brisbane, QLD 4101 Australia
- The Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Lvl. 5, 501 Stanley St., South Brisbane, QLD 4101 Australia
- The University of Queensland Faculty of Medicine, 288 Herston Rd., Brisbane, QLD 4006 Australia
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Peswani A, Chalwade C, Patil D, Baliarsing A. Suction-assisted device: A substitute to postoperative packing of abscess cavity in patients with ear burns. INDIAN JOURNAL OF OTOLOGY 2019. [DOI: 10.4103/indianjotol.indianjotol_81_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Demitri S, Vicenti G, Carrozzo M, Bizzoca D, De Franceschi D, Moretti B. The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: A case report. Injury 2018; 49 Suppl 4:S58-S62. [PMID: 30526950 DOI: 10.1016/j.injury.2018.11.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/19/2018] [Accepted: 11/23/2018] [Indexed: 02/02/2023]
Abstract
The treatment of open distal tibia fractures remains challenging, particularly when the fracture involves severe soft tissue damage and segmental bone loss. We present the case of a 33-year-old woman who sustained an open distal tibia fracture type 43-A3.3, with segmental bone loss, and a closed bifocal fibular fracture. The fractures were initially fixed with a temporary external fixator. The open distal tibial fracture underwent an intramedullary nailing on day six post-trauma, while the segmental bone loss was refilled with a temporary cement spacer, in order to create a biologic chamber, according to the technique by Masquelet et al. At three months post-trauma, the temporary cement spacer was removed and the bone loss was filled with an autologous bone graft obtained with the Reaming Irrigation Aspiration (RIA) system. The fracture successfully healed at 13 months post-trauma. Masquelet technique, in association with the RIA system, represents a valid strategy in the treatment of non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss.
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Affiliation(s)
- Silvio Demitri
- Clinic of Orthopaedics, Academic Hospital of Udine, Italy
| | - Giovanni Vicenti
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy.
| | - Massimiliano Carrozzo
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy
| | - Davide Bizzoca
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy
| | | | - Biagio Moretti
- School of Medicine, University of Bari "Aldo Moro"- AOU Consorziale "Policlinico", Department of Basic Medical Sciences, Neuroscience and Sense Organs, Orthopaedic and Unit, Bari, Italy
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Abstract
Wound management is a notable healthcare and financial burden, accounting for >$10 billion in annual healthcare spending in the United States. A multidisciplinary approach involving orthopaedic and plastic surgeons, wound care nursing, and medical and support staff is often necessary to improve outcomes. Orthopaedic surgeons must be familiar with the fundamental principles and evidenced-based concepts for the management of acute and chronic wounds. Knowledge of surgical dressings, negative pressure wound therapy, tissue expanders, dermal apposition, biologics, and extracellular matrices can aide practitioners in optimizing wound care.
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Laporte J, Herlin C, Delicque J, Saunière D, Perrot P, Duteille F. [Free flaps use in chronic wounds: Retrospective study about 91 cases]. ANN CHIR PLAST ESTH 2018; 64:251-258. [PMID: 30327209 DOI: 10.1016/j.anplas.2018.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Chronic wounds represent a major health challenge with no current standardized surgical treatment. The use of free flaps is little discussed in the literature, with a supposed propensity to failure given unfavorable local conditions and land often debility. We present here the analysis of our monocentric experience of the use of free flaps in the curative treatment of chronic wounds. PATIENTS ET METHODS We performed a retrospective monocentric study over 18 years of all free flaps used for the treatment of a chronic wound between January 2001 and September 2016. Several criteria were evaluated on patients, wounds, free flaps used and immediate to late outcomes. RESULTS Ninety-one patients were included (sex ratio M/F: 3.55) with an average age of 41.6±16 years. Wounds were localized to the leg in 92.3% of cases and 58% of patients had initial osteomyelitis. The flaps used were predominantly muscle flaps (61.6%). The flaps survival rate was 92.3%. With a mean follow-up of 50 months, the reconstructive failure rate was 20.9%. The presence of a chronic osteomyelitis is the only statistically significant factor of reconstruction failure (P=0.0169) with a risk of failure multiplied by 5. CONCLUSION Our study demonstrates that the reliability of free flaps in the treatment of chronic wounds is comparable, regardless of the time since the initial cutaneous lesion, to that existing in the treatment of acute wounds or in the reconstruction after oncological excision. The presence of a chronic osteomyelitis, however, represents a major risk of reconstruction failure by increasing 5 times the risk of failure. Recent changes in the integumentary reconstruction paradigm of the lower limb will undoubtedly allow in the next few years to establish more rationally the place of muscle free flaps in the therapeutic armamentarium of chronic wounds.
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Affiliation(s)
- J Laporte
- Plastic and reconstructive surgery department, university hospital Caremeau of Nîmes, place du Pr-Robert-Debré, 30029 Nîmes, France.
| | - C Herlin
- Plastic and reconstructive surgery department, university hospital Lapeyronie of Montpellier, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - J Delicque
- Medical imaging department, university hospital Saint-Éloi of Montpellier, 80, avenue Augustin-Fliche, 34090 Montpellier, France
| | - D Saunière
- Plastic and reconstructive surgery department, university hospital Caremeau of Nîmes, place du Pr-Robert-Debré, 30029 Nîmes, France
| | - P Perrot
- Plastic and reconstructive surgery department, university hospital Hôtel-Dieu of Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - F Duteille
- Plastic and reconstructive surgery department, university hospital Hôtel-Dieu of Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
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Mattox EA. Reducing Risks Associated With Negative-Pressure Wound Therapy: Strategies for Clinical Practice. Crit Care Nurse 2018; 37:67-77. [PMID: 28966197 DOI: 10.4037/ccn2017308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Negative-pressure wound therapy represents a relatively new strategy for wound management. Significant, life-threatening complications (bleeding, infection, and retained dressing material) have been associated with negative-pressure wound therapy. As a result, the Food and Drug Administration published several warnings to negative-pressure wound therapy users and recommended that clinicians ordering, managing, and/or monitoring negative-pressure wound therapy be aware of the potential complications and be prepared to take prompt action to reduce patients' risk for harm. This article reviews and organizes published consensus, expert opinion, research, and manufacturer guidelines about patient safety during negative-pressure wound therapy relevant to nurses practicing in acute and critical care settings, including in advanced practice roles.
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Affiliation(s)
- Elizabeth Andersson Mattox
- Elizabeth Andersson Mattox is a nurse practitioner at the VA Puget Sound Health Care System in the pulmonary and critical care medicine section. She previously worked as the director of patient safety for a large, high-complexity health care system.
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