JOURNAL ARTICLE
RANDOMIZED CONTROLLED TRIAL

Negative pressure wound therapy after severe open fractures: a prospective randomized study

James P Stannard, David A Volgas, Rena Stewart, Gerald McGwin, Jorge E Alonso
Journal of Orthopaedic Trauma 2009, 23 (8): 552-7
19704269

OBJECTIVES: To evaluate the impact of negative pressure wound therapy (NPWT) after severe open fractures on deep infection.

DESIGN: Prospective randomized study.

SETTING: Academic level I trauma center.

PATIENTS/PARTICIPANTS: Fifty-nine patients with 63 severe high-energy open fractures were enrolled in this study, with data available on 58 patients with 62 open fractures.

INTERVENTION: Twenty-three patients with 25 fractures randomized to the control group and underwent initial irrigation and debridement followed by standard fine mesh gauze dressing, with repeat irrigation and debridement every 48-72 hours until wound closure. Thirty-five patients randomized to the NPWT group and had identical treatment except that NPWT was applied to the wounds between irrigation and debridement procedures until closure.

MAIN OUTCOME MEASUREMENTS: The presence or absence of deep wound infection or osteomyelitis, wound dehiscence, and fracture union were primary outcome measures.

RESULTS AND CONCLUSIONS: Control patients developed 2 acute infections (8%) and 5 delayed infections (20%), for a total of 7 deep infections (28%), whereas NPWT patients developed 0 acute infections, 2 delayed infections (5.4%), for a total of 2 deep infections (5.4%). There is a significant difference between the groups for total infections (P = 0.024). The relative risk ratio is 0.199 (95% confidence interval: 0.045-0.874), suggesting that patients treated with NPWT were only one-fifth as likely to have an infection compared with patients randomized to the control group. NPWT represents a promising new therapy for severe open fractures after high-energy trauma.

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Rune Jakobsen

Bogdans comments: This randomized study evaluated gauze dressing (control) versus wound vac placement between washouts for severe (mostly grade 3) open fractures. 23 patients were randomized to the control group, and 35 to the vac group. Exclusion criteria were open fractures that could be closed after one debridement (vast majority of the open fractures seen by the authors during that time period), or those that were already infected. All procedures were performed by fellowship trained trauma surgeons, which is important because you know that they were well-trained and experienced in severe traumatic injuries and how to do proper debridements etc. Cultures were sent at the second debridement, and all subsequent ones. Mean followup was 28 months.

A few things stand out to me in this study:

1. There were no significant differences in wound dimensions, number of debridements, diabetics or smokers, and the fracture types (about half in each group were tibias) were evenly distributed. Illuminating these potential confounders speaks to great thoughtfulness on the part of the authors, and including these factors in the very beginning makes the study more believable.

2. Infection rates were 28% in the control, and 5.4% in the vac. Outcomes on the short form 36 favored the wound vac patients, but I do not hold much stock in that, because outcomes after severe open fractures are notoriously poor and are affected by many different things, not the least of which is psychological factors.

3. Coverage was achieved in approximately three days in both groups, which also helps their outcomes.

4. It is interesting that the wound vac did not shorten the time necessary to achieve closure, nor had a significant impact on closure method. At least in residency, I often heard people say that the wound vac would “shrink” the wound, but the literature suggests that this is not true. This helps us understand why vascular and general surgeons have such a different approach on fasciotomy closures than we do. I used to cringe when I would see the “shoelace” technique or other methods on the fasciotomies that vascular performed. But actually, several randomized trials support this. Zannis et al show that when put up against wet saline dressings, the wound vac does better. But when the wound vac is compared to shoelace technique, two randomized trials show that it is the shoelace that triumphs, achieving faster rates to closure and better results. But there is a difference between fasciotomy wounds done by vascular and those done by ortho – in the latter, there is an underlying fracture. The combination of these trials shows that where the wound vac really shines is in infection prevention as a result of the open fracture, not in the “shrinkage” of the wound. This is why it’s important to branch out your search if you don’t understand something, and read the literature of other subspecialties. For more on this, see below.

Wound vac vs saline dressings:
Zannis et al, annals of Plastic Surg 2009: https://www.ncbi.nlm.nih.gov/m/pubmed/19325346/

Wound vac vs. shoelace:
Johnson et al, Am J Surg 2018: https://www.ncbi.nlm.nih.gov/m/pubmed/30064725/
Kakagia et al, Injury 2014: https://www.ncbi.nlm.nih.gov/m/pubmed/22377275/

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