Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties

Author(s): S. L. Karlakki , FRCS(Orth), MSc, LLM ¹ ^, , A. K. Hamad , FRCS (Orth) ¹ , C. Whittall , BSc Hons, PhD ¹ , N. M. Graham , FRCS (Orth) ¹ , R. D. Banerjee , FRCS (Orth), Cert Med Ed ¹ , J. H. Kuiper , MSc, PhD ¹

Publication date (Electronic): 31 August 2016

Journal: Bone & Joint Research

Keywords: NPWT, iNPWTd, Incisional wound, TKA, THA, Wound complications

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Abstract

Objectives

Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties.

Methods

A total of 220 patients undergoing elective primary total hip and knee arthroplasties were recruited into in a non-blinded RCT. For the final analysis there were 102 patients in the study group and 107 in the control group.

Results

An improvement was seen in the study (iNPWTd) group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced (p = 0.007). Overall LOS reduction (0.9 days, 95% confidence interval (CI) -0.2 to 2.5) was not significant (p = 0.07) but there was a significant reduction in patients with extreme values of LOS in the iNPWTd group (Moses test, p = 0.003). There was a significantly reduced number of dressing changes (mean difference 1.7, 95% CI 0.8 to 2.5, p = 0.002), and a trend to a significant four-fold reduction in reported post-operative surgical wound complications (8.4% control; 2.0% iNPWTd, p = 0.06).

Conclusions

Based on the results of this RCT incisional negative pressure wound therapy dressings have a beneficial role in patients undergoing primary hip and knee arthroplasty to achieve predictable length of stay, especially to eliminate excessive hospital stay, and minimise wound complications.

Cite this article: S. L. Karlakki, A. K. Hamad, C. Whittall, N. M. Graham, R. D. Banerjee, J. H. Kuiper. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res 2016;5:328–337. DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

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Most cited references 37

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Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.

L Argenta, M Morykwas (1997)

Despite numerous advances, chronic and other difficult-to-manage wounds continue to be a treatment challenge. Presented is a new subatmospheric pressure technique: vacuum-assisted closure (The V.A.C.). The V.A.C. technique entails placing an open-cell foam dressing into the wound cavity and applying a controlled subatmospheric pressure (125 mmHg below ambient pressure). Three hundred wounds were treated: 175 chronic wounds, 94 subacute wounds, and 31 acute wounds. Two hundred ninety-six wounds responded favorably to subatmospheric pressure treatment, with an increased rate of granulation tissue formation. Wounds were treated until completely closed, were covered with a split-thickness skin graft, or a flap was rotated into the health, granulating would bed. The technique removes chronic edema, leading to increased localized blood flow, and the applied forces result in the enhanced formation of granulation tissue. Vacuum-assisted closure is an extremely efficacious modality for treating chronic and difficult wounds.

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Enhanced recovery program for hip and knee replacement reduces death rate

Ajay Malviya, Kate Martin, Ian Harper … (2011)

Background and purpose Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications. Patients and methods We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications. Results There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8). Interpretation This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.

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Incisional negative pressure wound therapy after high-risk lower extremity fractures.

Thomas Moore, Gerald McGwin, James Stannard … (2011)

To investigate negative pressure wound therapy (NPWT) to prevent wound dehiscence and infection after high-risk lower extremity trauma. Prospective randomized multicenter clinical trial. Four Level I trauma centers. Blunt trauma patients with one of three high-risk fracture types (tibial plateau, pilon, calcaneus) requiring surgical stabilization. Incisional NPWT (Group B) was applied to the closed surgical incisions of patients randomized to the study arm of this trial, whereas standard postoperative dressings (Group A) were applied to the control patients. Acute and chronic wound dehiscence and infection. Two hundred forty-nine patients with 263 fractures have enrolled in this study with 122 randomized to Group A (controls) and 141 to Group B (NPWT). There was no difference between the groups in the distribution of calcaneus (39%), pilon (17%), or tibial plateau (44%) fractures. There were a total of 23 infections in Group A and 14 in Group B, which represented a significant difference in favor of NPWT (P = 0.049). The relative risk of developing an infection was 1.9 times higher in control patients than in patients treated with NPWT (95% confidence interval, 1.03-3.55). There have been no studies evaluating incisional NPWT as a prophylactic treatment to prevent infection and wound dehiscence of high-risk surgical incisions. Our data demonstrate that there is a decreased incidence of wound dehiscence and total infections after high-risk fractures when patients have NPWT applied to their surgical incisions after closure. There is also a strong trend for decreases in acute infections after NPWT. Based on our data in this multicenter prospective randomized clinical trial, NPWT should be considered for high-risk wounds after severe skeletal trauma.

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Author and article information

Contributors

S. L. Karlakki: Role: Consultant Orthopaedic Surgeon

A. K. Hamad: Role: Orthopaedic Registrar

C. Whittall: Role: Research Trial Manager

N. M. Graham: Role: Consultant Orthopaedic Surgeon

R. D. Banerjee: Role: Consultant Orthopaedic Surgeon

J. H. Kuiper: Role: Statistician

Journal

Journal ID (nlm-ta): Bone Joint Res

Title: Bone & Joint Research

ISSN (Electronic): 2046-3758

Publication date Collection: August 2016

Publication date (Electronic): 31 August 2016

Volume: 5

Issue: 8

Pages: 328-337

Affiliations

[1 ]Arthroplasty Department, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS FT, Oswestry, SY10 7AG, UK

Author notes

[*]Mr S. L. Karlakki; email: sudheer.karlakki@ 123456rjah.nhs.uk

Article

Publisher ID: 10.1302_2046-3758.58.BJR-2016-0022.R1

DOI: 10.1302/2046-3758.58.BJR-2016-0022.R1

PMC ID: 5013893

PubMed ID: 27496913

SO-VID: 3ab29e98-7c99-4d55-800c-3c882cd6de7d

License:

This is an open-access article distributed under the terms of the Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties : A randomised controlled trial

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Abstract

Objectives

Methods

Results

Conclusions

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Negative Pressure Wound Therapy

Most cited references 37

Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.

Enhanced recovery program for hip and knee replacement reduces death rate

Incisional negative pressure wound therapy after high-risk lower extremity fractures.

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