Closed Incision Negative Pressure Wound Therapy vs Conventional Dry Dressings After Primary Knee Arthroplasty: A Randomized Controlled Study

doi:10.1016/j.arth.2016.04.016

The Journal of Arthroplasty

Volume 31, Issue 11, November 2016, Pages 2487-2494

https://doi.org/10.1016/j.arth.2016.04.016 Get rights and content

Abstract

Background

The purpose of this study was to assess the effect of negative pressure wound therapy (NPWT) on quality of life (QoL), wound complications, and cost after primary knee arthroplasty.

Methods

A prospective analysis of 33 patients undergoing primary knee arthroplasty performed by 3 surgeons in one institution. The first 12 patients (3 bilateral and 9 unilateral) had conventional dry dressings (CDD) applied and cost of dressings was assessed. The other 21 patients all underwent bilateral knee arthroplasty and had either side randomized to receiving NPWT or CDD. Cost of dressings, wound complications, and QoL were compared.

Results

One patient had a reaction to the NPWT requiring readmission. Another had persistent wound drainage that required NPWT application. There were no wound issues in the remaining 31 patients. The average cost in the first 12 patients was Australian dollar $48.70 with an average of 1.5 changes on ward. In the 21 patients receiving both dressings, the average cost for CDD was less (Australian dollar $43.51 vs $396.02, P ≤ .011, effect size [ES] = 1.06). When comparing QoL factors, wound leakage (0.14 vs 0.39 P = .019, ES = 1.02), and wound protection (0.16 vs 0.33, P = .001, ES = 0.021) were better in the NPWT group. There was no other significant difference in QoL factors. The average number of changes on the ward was less for the NPWT group (1.19 vs 1.38, P = .317, ES = 1.02).

Conclusion

We found no benefit in wound healing or cost with NPWT post knee arthroplasty. There was some benefit in NPWT QoL factors less wound leakage and better protection.

Section snippets

Materials and Methods

Fifty-seven primary knee arthroplasty surgeries in 33 patients performed by 3 surgeons occurring between February and December 2014 in our institution were included in this study. Twenty-three patients underwent bilateral total knee arthroplasty, 9 patients underwent unilateral total knee arthroplasty, and 1 patient underwent bilateral unicompartmental knee arthroplasty. All total knee arthroplasty procedures were using a subvastus approach under computer-assisted navigation specifically using

Results

Thirty-three patients (19 males and 14 females) underwent 57 primary knee arthroplasties. The breakdown of all patient demographics is shown in Table 1. Mean age was 66 (45-80), body mass index 29.79 (23-44), ASA 2 (1-3), and CCI 2.33 (0-5). One patient had a diagnosis of rheumatoid arthritis (n = 1), the rest had osteoarthritis (n = 32). None of the patients included in this study were considered high risk with a mean ASA of 2 (1-3) and CCI of 2.33 (0-5). The average length of stay was 4.1

Discussion

Our study has indicated that routine application of NPWT post knee arthroplasty has no economic benefit. There were benefits in regard to wound leakage and wound protection, but other QoL factors were similar between the groups. We found no clear benefit of wound healing or cost in the utilization of the NPWT for routine knee arthroplasty incision sites.

Surgical site infections post arthroplasty surgery increases the risk of deep wound and prosthesis infections dramatically. Current

Acknowledgments

The authors sincerely thank the rest of the staff at Orthopaedic Research Institute of Queensland for their assistance throughout this study with paperwork and organization. The authors also show their appreciations and thanks to the nursing staff in theater and the orthopedic ward at the Mater Health Services North Queensland Ltd who assisted them with the dressing application and changes. The authors also thank Dr Geoffrey Dobson and Dr Hayley Letson at the James Cook University for their

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Potential additional benefits to a regular dressing include apposition of wound edges together and keeping the wound dry.29 There is now a body of evidence to support this type of wound therapy in colorectal, orthopedic, and cardiothoracic surgery.11,12,30 NIRS uses wavelength analysis to measure the relative amounts of oxygenated and deoxygenated hemoglobin in a volume of tissue.
Patients with diabetes undergoing CABG are at risk of wound infection. Incisional negative pressure wound therapy has been shown to be effective in decreasing incidence of infection in high-risk wounds. Near infrared spectroscopy (NIRS) can be used to assess wound oxygenation and low values can predict infection.
To evaluate utility of NIRS to assess wound oxygenation, to assess effect of sternotomy, left internal thoracic artery harvest, and wound dressing type on wound edge oxygenation.
In this blinded randomized control trial, patients with diabetes undergoing isolated coronary artery bypass grafting with a left internal thoracic artery were randomized to receive either incisional negative pressure wound therapy dressing or a standard dressing. NIRS measurements were made on the left upper arm (control), and left and right parasternal regions on day –1 (preoperative), day 5, and week 6 after surgery. Results were analyzed using repeated measures parametric methods.
Eighty patients with diabetes were recruited, 40 to the incisional negative pressure wound therapy group and 40 to the standard dressing group. Adjusted NIRS readings dropped significantly in all patients by day 5 and partially recovered by week 6. In both groups, there was no difference between readings on the left and right. At all time points and on both sides, there was no difference in readings between patients in the 2 groups.
NIRS can be used to assess oxygenation adjacent to a sternotomy wound. Adjusted tissue oxygen levels change with time after sternotomy and left internal thoracic artery harvest in patients with diabetes. Wound dressing type does not influence day 5 wound edge oxygenation.
Closed Incision Negative Pressure Therapy vs Standard of Care Over Closed Knee and Hip Arthroplasty Surgical Incisions in the Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis of Comparative Studies
2023, Arthroplasty Today
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common surgical procedures but carry a risk of harmful and costly surgical site complications (SSCs). This systematic review and meta-analysis examined the impact of closed incision negative pressure therapy (ciNPT) on the risk of SSCs following THA and TKA.
A systematic literature review identified studies published between January 2005 and July 2021 comparing ciNPT (Prevena Incision Management System) to traditional standard-of-care dressings for patients undergoing THA and TKA. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national database.
Twelve studies met the inclusion criteria. Eight studies evaluated SSCs, where a significant difference was seen in favor of ciNPT (relative risk [RR]: 0.332, P < .001). Significant benefits in favor of ciNPT were also observed for surgical site infection (RR: 0.401, P = .016), seroma (RR: 0.473, P = .008), dehiscence (RR: 0.380, P = .014), prolonged incisional drainage (RR: 0.399, P = .003), and rate of return to the operating room (RR: 0.418, P = .001). The estimated cost savings attributed to ciNPT use was $932 per patient.
The use of ciNPT after TKA and THA was associated with a significant reduction in the risk of SSCs, including surgical site infections, seroma, dehiscence, and prolonged incisional drainage. The risk of reoperation was reduced as were the costs of care in the modeled cost analysis, suggesting a potential for both economic and clinical advantages for ciNPT over standard-of-care dressings, particularly in high-risk patients.
Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study
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Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study’s purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing.
One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m², autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation.
Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications.
Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.
Orthopaedic surgical dressings
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The choice of which surgical dressing to use is an important step in the postoperative care of orthopaedic patients. This decision is influenced in part by the patient's level of activity prior to surgery, medical history, wound classification, and cost. As orthopaedic wounds are inherently complex, often overlying bony prominences, it is imperative that orthopaedic providers are aware of the dressings available and how best to deploy them.
Classified into three categories (passive, active, and interactive), orthopaedic surgical dressings can vary based upon their mechanism of action, absorptive capacity, and ability to provide wound protection. Through the activation or promotion of one of the four stages of wound healing, orthopaedic surgical dressings act to optimize postoperative wound care, leading to improved patient outcomes and a decrease in associated complications.
The combined use of multiple dressings, with varying attributes, provides the ultimate method for obtaining the ideal orthopaedic surgical dressing. Choosing the appropriate dressing and subsequent care regimen can prevent unnecessary hospitalizations and additional costs associated with complex wound care. Future prospective trials aimed at evaluating specific dressings and their utility in orthopaedics is warranted.
Effectiveness of Different Wound Dressings in the Reduction of Blisters and Periprosthetic Joint Infection After Total Joint Arthroplasty: A Systematic Review and Network Meta-Analysis
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Citation Excerpt :
In terms of blind assessment, 3 studies [25,32,41] had blinding of participants and personnel, and 6 studies [22,27,32–34,41] had blinding of all assessors. The bias of incomplete outcome data was found in 4 studies [27,32,33,41], and possible selective reporting existed in 3 studies [34,39,41]. Finally, 8 studies showed some concerns [22,23,25,30,31,33,34,39], and 2 studies had high risk for overall bias [26,29].
The optimal type of dressing in the setting of total joint arthroplasty (TJA) remains uncertain. The aim of this network meta-analysis was to compare various wound dressings and identify the optimal type of dressings for blister reduction and prevention of periprosthetic joint infection (PJI) in patients after TJA.
Studies comparing 2 or more dressing groups after TJA (hip or knee) were systematically searched on PubMed, Embase, and Scopus. Two authors performed the study selection, risk of bias assessment, and data extraction. Both outcomes were assessed using odds ratios (OR) with 95% confidence intervals (CI) and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to determine a hierarchy of dressings. A sensitivity analysis was performed to reduce the effect of intransitivity between studies.
A total of 21 studies, consisting of 12 dressing types in 7293 TJAs, were included in the final analysis. The highest incidence of blisters occurred when using negative-pressure wound therapy (OR 9.33, 95% CI 3.51-24.83, vs gauze). All dressings ranked better than gauze in infection rate except for hydrofiber (OR 1.46, 95% CI 0.02-112.53) and fabric dressings (OR 1.46, 95% CI 0.24-9.02). For blister reduction, alginate (SUCRA = 87.7%) and hydrofiber with hydrocolloid (SUCRA = 92.3%) were ranked as the optimal dressings before and after a sensitivity analysis, respectively. Antimicrobial dressing (SUCRA = 83.7%) demonstrated the most efficacy for preventing PJI.
Based on the evidence from our analysis, an antimicrobial dressing is the optimal dressing to prevent PJI. If negative-pressure wound therapy is used, surgeons should be aware of an increased incidence of blister formation. Further studies should focus on the alginate versus hydrofiber and hydrocolloid dressing to determine the optimal dressing to reduce blisters.
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Only 2 studies reported cost data for ciNPWT and standard dry dressings, but the data were not comparable [19,23]. Gillespie et al [19] reported average cost per day in the hospital, whereas Manoharan et al [23] reported average total cost during the entire hospital length of stay. The use of ciNPWT has shown promise in minimizing wound infections across many surgical fields, especially in the field of orthopedic trauma.
Persistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.
MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.
SSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).
ciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.

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: Human research ethics approval and trial registration: Ethics committee approval for this trial was obtained through Internal Regulatory Governance Body at the Mater Health Services North Queensland Human Research Ethics Committee, Approval number–MHS20131216-02. The trial was also registered with the Australia New Zealand Clinical Trials Registry, Registration code–ACTRN12615001350516. No changes to methods were made during the trial period.

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.04.016

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Primary ArthroplastyClosed Incision Negative Pressure Wound Therapy vs Conventional Dry Dressings After Primary Knee Arthroplasty: A Randomized Controlled Study

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

J Arthroplasty

Clin Microbiol Infect

J Orthop Res

Curr Probl Surg

J Arthroplasty

Ann Thorac Surg

The management of peri-prosthetic infection in total joint arthroplasty

J Bone Jt Surg Br

How-to guide: prevent surgical site infection for hip and knee arthroplasty 2012

Wound infection in hip and knee arthroplasty

J Bone Joint Surg Br

Factors associated with prolonged wound

J Bone Jt Surg

Infection after total hip replacement

J Bone Jt Surg

First experience with a new negative pressure incision management system on surgical incisions after cardiac surgery in high risk patients

J Cardiothorac Surg

Use of negative pressure wound therapy over clean, closed surgical incisions

Int Wound J

“Homemade” negative pressure wound therapy: treatment of comples wounds under challenging conditions

Wounds

A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting

Plast Reconstr Surg

Negative-pressure wound therapy over surgically closed wounds in open fractures

J Orthop Surg (Hong Kong)

Simplified negative pressure wound therapy: clinical evaluation of an ultraportable, no-canister system

Int Wound J

Primary Arthroplasty
Closed Incision Negative Pressure Wound Therapy vs Conventional Dry Dressings After Primary Knee Arthroplasty: A Randomized Controlled Study