Negative pressure wound therapy and orthopaedic trauma

The Bone & Joint JournalVol. 98-B, No. 8 EditorialFree AccessNegative pressure wound therapy and orthopaedic trauma where are we now?CrossMarkJ. P. M. Masters, J. Nanchahal, M. L. CostaJ. P. M. MastersClinical Research FellowCorrespondence should be sent to Mr J. P. M. Masters; e-mail: E-mail Address: [email protected]The Kadoorie Centre, Orthopaedic Trauma, John Radcliffe Hospital Oxford OX3 9DU, UK., J. NanchahalProfessor of Hand, Plastic and Reconstructive Surgery, NDORMsUniversity of Oxford, Kennedy Institute of Rheumatology, Roosevelt Drive, Headington, Oxford, UK., M. L. CostaProfessor, Orthopaedic TraumaThe Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK.Published Online:1 Aug 2016https://doi.org/10.1302/0301-620X.98B8.BJJ-2016-0373AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Negative pressure wound therapy (NPWT) has become a common form of treatment for both open and closed wounds. The use of this sophisticated dressing has increased dramatically over the last decade in many fields of surgical practice.It was originally used in complex open wounds such as pressure ulcers and diabetic feet. However, there has been an expansion of the indications and it is now also used for incisional wounds, where there is concern about wound discharge and healing potential. This article considers NPWT in orthopaedic trauma. The evidence from trauma is also informing elective practice, particularly in high-risk wounds such as those used in arthroplasty1 and spinal surgery.2 What these areas of practice have in common is a surgical wound, where wound breakdown and subsequent infection would have catastrophic consequences for the patient.Open woundsThe initial use of NPWT in orthopaedic trauma was in wounds associated with open fractures. Stannard et al3 performed a randomised controlled trial (RCT) involving 59 patients with 63 fractures and showed a significantly lower rate of infection in those treated with NPWT. This important finding has not yet been replicated in further randomised trials. However, other authors have reported corroborating clinical metrics, such as the rate of wound healing.4 Téot et al5 studied 257 trauma patients as part of a large multicentre non-randomised study examining outcome measures including definitive closure, complete re-epithelialisation or improvement in the wound. They found that NPWT resulted in an improved healing time in different types of wound. They did not assess the rate of infection in those treated with 'standard' non-NPWT dressings.A systematic review of the literature on the use of NPWT in open fractures identified 13 studies.6 The report was of a reduced rate of infection in patients treated with NPWT compared with gauze dressings. However, the study by Stannard et al,3 described above, was the only randomised trial. Stannard et al3 also suggested that NPWT may allow definitive soft-tissue coverage to be deferred beyond 72 hours without an increase in infection. However, this is in contradiction to the current National Institute for Health and Care Excellence guidelines.7Incisional woundsThe application of NPWT to closed incisions is a recent occurence. There are fewer studies in this area but there is growing use of NPWT for this indication. In orthopaedics, the scope for this is huge, with 'high-risk' closed incisions making up much of the work done in trauma as well as in areas of elective surgery. High-risk wounds in young patients are usually associated with high-energy injuries, such as road traffic accidents and falls from a height where there is significant damage to the soft tissues, as well as to bone. In older patients, even wounds associated with low-energy fractures may be considered a high risk as the soft tissues are more fragile and the patients have more comorbidities.8-10The largest study in closed wounds in orthopaedic trauma was also conducted by Stannard et al.11 They randomised 249 patients with fractures of the tibial plateau, pilon or os calcis to receive either NPWT or standard wound dressings. They found a significant reduction in the rate of infection and wound dehiscence in the NPWT group. This is the most recent work from these authors pointing towards a beneficial effect in the 'high-risk' trauma group.3,12Hyldig et al13 attempted to synthesise those RCTs which looked at NPWT in closed incisional wounds, not only in orthopaedics but in thoracic, abdominal and plastic surgery. They concluded that whilst NPWT appeared to reduce the rate of wound infection and complications, the heterogeneity of the patients limited the strength of recommendations that could be made.NPWT has particular relevance in orthopaedic trauma surgery when the management of the soft tissues may be the key to the successful management of any associated fracture.Application of subatmospheric pressure to the dressing results in positive pressure to the wound. For wounds with closed incisions, NPWT distributes the tension at the wound margins and helps obliterate the dead space in the underlying tissues.14,15The mechanisms of action of negative pressure therapy has been explored using human samples and cells and animal models in a wide range of types of wound.16 NPWT on open wounds leads to local hypoxia, which in turn leads to increased expression of vascular endothelial growth factor, platelet derived growth factor and fibroblast growth factor 2; important mediators of neovascularisation. NPWT also leads to reduced local inflammation, including reduced macrophage infiltration, down regulation of tumour necrosis factor, interleukin-1β and upregulation of interleukin-10. Additionally, there is reduced expression of the matrix metalloproteinases, whilst the levels of tissue inhibitors of metalloproteinases remain unchanged.16 An important mode of action is through microdeformation of mechanically sensitive cells, leading to enhanced cellular proliferation, migration and differentiation.17The current situationNPWT shows great promise in reducing the complications associated with high-risk wounds, both for the management of open and closed wounds. However, as in many areas of orthopaedic practice, our ability to interpret the evidence is limited by low numbers of underpowered trials and the use of heterogenous outcome measures.18As with any new technology, the issue of cost effectiveness inevitably rears its head. Even if using NPWT dressings can reduce the rate of wound complications, can the significant difference in price justify its widespread adoption? A study comparing NPWT with standard dressings found that whilst the inpatient costs of NPWT were approximately four times higher, this was offset by a shorter inpatient stay and 'time to outcome'.5 However, a Cochrane review of NPWT on closed incisions failed to identify studies evaluating the economics of NPWT that would be suitable for inclusion.18We need to develop a stronger evidence base of the use of NPWT. There are four key outstanding issues:- The development of a core set of outcomes for wound healing to be used in all clinical research in this area;- Larger trials to confirm the clinical effectiveness of NPWT in both open and incisional wounds;- Robust health economic evaluations to assess the cost effectiveness of NPWT;- Detailed understanding of the mechanisms of action of NPWT both in open and closed incisions, which may lead to improved use of the technique.There is some progress in each of these areas. At this year's inaugural Wound Research Network Meeting, delegates promoted the concept of a generic core set of outcomes to be used in research in the area of wound healing. This may take some time. However, some advances have been made in developing sets of outcomes which might be used for specific wounds, for example a United Kingdom-wide consensus for a set of outcomes for open fractures.Two large-scale National Institute for Health Research Health Technology Assessment (HTA) trials to investigate both clinical and cost effectiveness are currently underway. The Wound in Open Lower Limb Fractures (WOLLF) trial19 has finished recruitment in 22 trauma centres throughout the United Kingdom, and is due to report early in 2017. This RCT involving 460 patients compares the use of NPWT with routine dressings in open fractures where the wound has not been primarily closed after initial debridement. In order to reflect the expanding use of NPWT in the management of closed incisional wounds, HTA have also funded the Wound Healing in Surgical Trauma (WHiST) trial. This has recently started to recruit patients in the United Kingdom in order to assess the effect of NPWT on wound infection at 30 days compared with standard dressings on closed incisions in major trauma patients with limb fractures. This trial will recruit 1540 patients from the United Kingdom's major trauma research network.20 WHiST will also facilitate further laboratory studies to elucidate the mechanism of action of NPWT in trauma surgery.The use of large-scale trials gives an unparalleled insight into the effectiveness of an intervention in a health service. This in turn can inform clinical practice at a national and international level. However, the timing of such trials in the lifecycle of the development and implementation of a technology is critical. The Normalisation Process Theory attempts to describe how new technologies and behaviours are implemented in health care.21 However, it is not clear at which stage of the process it is best to undertake large pragmatic trials. The IDEAL framework, seeks to provide guidance on the matter, but this is still a controversial area;22 too early, and the multimillion pound trial is an expensive way to test unproven technologies; too late, and behaviour relating to new technologies is entrenched. This, in turn, may make equipoise difficult and interfere with recruitment,23 although there is evidence that even where behaviour is well established, trials can influence practice.24We hope that WHiST and WOLLF will offer answers about the optimal application of NPWT in orthopaedic trauma, before indiscriminate usage becomes normal practice. References 1 Pachowsky M, Gusinde J, Klein A, et al. Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. Int Orthop 2012;36:719–722. Crossref, Medline, ISI, Google Scholar2 Nordmeyer M, Pauser J, Biber R, et al. Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. Int Wound J 2015. (Epub ahead of print). ISI, Google Scholar3 Stannard JP, Volgas DA, Stewart R, McGwin G Jr, Alonso JE. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma 2009;23:552–557. Crossref, Medline, ISI, Google Scholar4 Arti H, Khorami M, Ebrahimi-Nejad V. Comparison of negative pressure wound therapy (NPWT) & conventional wound dressings in the open fracture wounds. Pak J Med Sci 2016;32:65–69. Medline, ISI, Google Scholar5 Téot L, Guillot-Masanovic M, Miquel P, et al. Clinical impact of negative-pressure wound therapy: a 1,126-patient observational prospective study. Wound Repair Regen 2014;22:341–350. Crossref, Medline, ISI, Google Scholar6 Schlatterer DR, Hirschfeld AG, Webb LX. Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures? Clin Orthop Relat Res 2015;473:1802–1811. Crossref, Medline, ISI, Google Scholar7 No authors listed. NICE. Fractures (Complex): Assessment and Management.: https://http://www.nice.org.uk/guidance/ng37/chapter/Recommendations (date last accessed 16 May 2016). Google Scholar8 Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 2005;20(Suppl 3):46–50. Crossref, ISI, Google Scholar9 Dowsey MM, Choong PF. Early outcomes and complications following joint arthroplasty in obese patients: a review of the published reports. ANZ J Surg 2008;78:439–444. Crossref, Medline, ISI, Google Scholar10 Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999;22:1408–1414. Crossref, Medline, ISI, Google Scholar11 Stannard JP, Volgas DA, McGwin G III, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma 2012;26:37–42. Crossref, Medline, ISI, Google Scholar12 Stannard J. Complex orthopaedic wounds: prevention and treatment with negative pressure wound therapy. Orthop Nurs 2004;23(Suppl 1):3–10. Medline, Google Scholar13 Hyldig N, Birke-Sorensen H, Kruse M, et al. Meta-analysis of negative-pressure wound therapy for closed surgical incisions. Br J Surg 2016;103:477–486. Crossref, Medline, ISI, Google Scholar14 Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg 2014;51:301–331. Crossref, Medline, ISI, Google Scholar15 Suh H, Lee AY, Park EJ, Hong JP. Negative Pressure Wound Therapy on Closed Surgical Wounds With Dead Space: Animal Study Using a Swine Model. Ann Plast Surg 2016;76:717–722. Crossref, Medline, ISI, Google Scholar16 Glass GE, Murphy GF, Esmaeili A, Lai LM, Nanchahal J. Systematic review of molecular mechanism of action of negative-pressure wound therapy. Br J Surg 2014;101:1627–1636. Crossref, Medline, ISI, Google Scholar17 Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg 2014;51:301–331. Crossref, Medline, ISI, Google Scholar18 Webster J, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev 2014;10:CD009261. Google Scholar19 Achten J, Parsons NR, Bruce J, et al. Protocol for a randomised controlled trial of standard wound management versus negative pressure wound therapy in the treatment of adult patients with an open fracture of the lower limb: UK Wound management of Open Lower Limb Fractures (UK WOLFF). BMJ Open 2015;5:009087. Crossref, ISI, Google Scholar20 No authors listed. WHist. http://www.ndorms.ox.ac.uk/clinical-trials/current-trials-and-studies/whist (date last accessed 16 May 2016). Google Scholar21 May CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:29. Crossref, Medline, ISI, Google Scholar22 Ergina PL, Barkun JS, McCulloch P, et al. IDEAL framework for surgical innovation 2: observational studies in the exploration and assessment stages. BMJ 2013;346:3011. Crossref, Google Scholar23 Potter S, Mills N, Cawthorn SJ, Donovan J, Blazeby JM. Time to be BRAVE: is educating surgeons the key to unlocking the potential of randomised clinical trials in surgery? A qualitative study. Trials 2014;15:80. Crossref, Medline, ISI, Google Scholar24 Costa ML, Jameson SS, Reed MR. Do large pragmatic randomised trials change clinical practice?: assessing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT). Bone Joint J 2016;98-B:410–413. Link, ISI, Google ScholarFiguresReferencesRelatedDetailsCited ByEffect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower LimbJAMA, Vol. 319, No. 22Prophylactic negative pressure wound therapy after lower extremity fracture surgery: a pilot study29 January 2018 | International Orthopaedics, Vol. 42, No. 4Team Approach: Complex Dermal Wound-Healing Utilizing Negative-Pressure Wound Therapy (NPWT) in Orthopaedic Trauma6 March 2018 | JBJS Reviews, Vol. 6, No. 3Negative pressure wound therapy in modern orthopaedic practiceCurrent Orthopaedic Practice, Vol. 29, No. 1 Vol. 98-B, No. 8 Metrics Downloaded 216 times History Published online 1 August 2016 Published in print 1 August 2016 InformationCopyright © 2016, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download