Webster J, Scuffham P, Stankiewicz M, Chaboyer WP, et al.
The Cochrane database of systematic reviews. Date of publication 2014 Oct 7;volume (10):CD009261.
1. Cochrane Database Syst Rev. 2014 Oct 7;(10):CD009261. doi:
10.1002/14651858.CD009261.pub3.
Negative pressure wound therapy for skin grafts and surgical wounds healing by
primary intention.
Webster J(1), Scuffham P, Stankiewicz M, Chaboyer WP.
Author information:
(1)Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Level 2,
Building 34, Butterfield Street, Brisbane, Queensland, Australia, 4029.
Update of
Cochrane Database Syst Rev. 2012;(4):CD009261.
BACKGROUND: Indications for the use of negative pressure wound therapy (NPWT) are
broadening with a range of systems now available on the market, including those
designed for use on clean, closed incisions and skin grafts. Reviews have
concluded that the evidence for the effectiveness of NPWT remains uncertain,
however, it is a rapidly evolving therapy. Consequently, an updated systematic
review of the evidence for the effects of NPWT on postoperative wounds expected
to heal by primary intention is required.
OBJECTIVES: To assess the effects of NPWT on surgical wounds (primary closure,
skin grafting or flap closure) that are expected to heal by primary intention.
SEARCH METHODS: We searched the following electronic databases to identify
reports of relevant randomised clinical trials: the Cochrane Wounds Group
Specialised Register (searched 28 January 2014); the Cochrane Central Register of
Controlled Trials (CENTRAL; 2013, issue 12); Database of Abstracts of Reviews of
Effects (2013, issue 12); Ovid MEDLINE (2011 to January 2014); Ovid MEDLINE
(In-Process & Other Non-Indexed Citations 24 January 2014); Ovid EMBASE (2011 to
January 2014 Week 44); and EBSCO CINAHL (2011 to January 2014). We conducted a
separate search to identify economic evaluations.
SELECTION CRITERIA: We included trials if they allocated patients to treatment
randomly and compared NPWT with any other type of wound dressing, or compared one
type of NPWT with a different type of NPWT.
DATA COLLECTION AND ANALYSIS: We assessed trials for their appropriateness for
inclusion and for their quality. This was done by three review authors working
independently, using pre-determined inclusion and quality criteria.
MAIN RESULTS: In this first update, we included an additional four trials, taking
the total number of trials included to nine (785 participants). Three trials
involved skin grafts, four included orthopaedic patients and two included general
surgery and trauma surgery patients; all the included trials had unclear or high
risk of bias for one or more of the quality indicators we assessed. Seven trials
compared NPWT with a standard dressing (two of these were 'home-made' NPWT
devices), one trial compared one 'home-made' NPWT with a commercially available
device. In trials where the individual was the unit of randomisation, there were
no differences in the incidence of surgical site infections (SSI); wound
dehiscence, re-operation (in incisional wounds); seroma/haematoma; or failed skin
grafts. Lower re-operation rates were observed among skin graft patients in the
'home-made' NPWT group (7/65; 10.8%) compared to the standard dressing group
(17/66; 25.8%) (risk ratio (RR) 0.42; 95% CI 0.19 to 0.92). The mean cost to
supply equipment for VAC® therapy was USD 96.51/day compared to USD 4.22/day for
one of the 'home-made' devices (P value 0.01); labour costs for dressing changes
were similar for both treatments. Pain intensity score was also reported to be
lower in the 'home-made' group when compared with the VAC® group (P value 0.02).
One of the trials in orthopaedic patients was stopped early because of a high
incidence of fracture blisters in the NPWT group (15/24; 62.5%) compared with the
standard dressing group (3/36; 8.3%) (RR 7.50; 95% CI 2.43 to 23.14).
AUTHORS' CONCLUSIONS: Evidence for the effects of negative pressure wound therapy
(NPWT) for reducing SSI and wound dehiscence remains unclear, as does the effect
of NPWT on time to complete healing. Rates of graft loss may be lower when NPWT
is used, but hospital-designed and built products are as effective in this area
as commercial applications. There are clear cost benefits when non-commercial
systems are used to create the negative pressure required for wound therapy, with
no evidence of a negative effect on clinical outcome. In one study, pain levels
were also rated lower when a 'home-made' system was compared with a commercial
counterpart. The high incidence of blisters occurring when NPWT is used following
orthopaedic surgery suggests that the therapy should be limited until safety in
this population is established. Given the cost and widespread use of NPWT, there
is an urgent need for suitably powered, high-quality trials to evaluate the
effects of the newer NPWT products that are designed for use on clean, closed
surgical incisions. Such trials should focus initially on wounds that may be
difficult to heal, such as sternal wounds or incisions on obese patients.
DOI: 10.1002/14651858.CD009261.pub3
PMID: 25287701 [Indexed for MEDLINE]
