Negative pressure wound therapy: Where are we in 2022?

Abstract

The use of negative pressure wound therapy (NPWT) continues to be an important tool for surgeons. As the use and general acceptance of NPWT have grown, so have the indications for its use. These indications have expanded to include soft tissue defects in trauma, infection, surgical wound management, and soft tissue grafting procedures. Many adjuvants have been engineered into newer generations of NPWT devices such as wound instillation of fluid or antibiotics allowing surgeons to further optimize the wound healing environment or aid in the eradication of infection. This review discusses the recent relevant literature on the proposed mechanisms of action, available adjuvants, and the required components needed to safely apply NPWT. The supporting evidence for the use of NPWT in traumatic extremity injuries, infection control, and wound care is also reviewed. Although NPWT has a low rate of complication, the surgeon should be aware of the potential risks associated with its use. Furthermore, the expanding indications for the use of NPWT are explored, and areas for future innovation and research are discussed.

Keywords: infection; negative pressure wound therapy; orthopaedic trauma; soft tissue injury; wound vac.

FIGURE 1.

A, Wound vac application can be challenging in soft tissue injuries encompassing a large surface area, across flexion and extension surfaces, or when external fixation is needed and pins encroach the wound edges. B, The use of an antimicrobial adhesive drape can be used primarily or as an adjunct to the traditional semiocclusive dressing to achieve a seal around challenging anatomical structures and external fixation pins.

FIGURE 2

. Use of elastic vessel loops can be used to achieve tension free closure of challenging skin incisions. A, When a fasciotomy incision is unable to be closed primarily, B, the use of an interlacing elastic vessel loop and a NPWT system can assist in the approximation of the skin edges. C, Primary closure may be possible after using this method and is assisted with the use of clamps. (D) Closure can be achieved using a tension relieving suture in an interrupted pattern. If primary closure is unachievable, this method still allows for the formation of a healthy granulation tissue bed and reduces the surface area that might require split-thickness skin grafting.

FIGURE 3

. Application of a single-use incisional wound vac system. A, Using the supplied nonocclusive adhesive tape provided in the kit (tan) a 2–3-mm margin of the peri-incisional skin (red) along the periphery of the incision is left exposed. The tape provides a barrier to the vacuum sponge to prevent maceration and injury to the healthy surrounding skin. B, A single-use motorized vacuum pump and absorbent occlusive sponge are then applied. The pump is activated, and suction is verified. The patient can be sent home with the manufacturer insert and counseled on the operation of the device, signs of malfunction, and when to remove it.

FIGURE 4.

In this example, a 15 French, flat, fenestrated drain was used (A). The drain is placed in a similar manner to when used without incorporating into a NPWT dressing, but the exit point should be in close proximity to the incision to allow incorporation into the dressing. The authors prefer to have the drain come out through a stab incision in-line with surgical incision at either end of the incision (B). A small rongeur is used to “bite” out a series of holes within the tubing, so the suction applied to the dressing is applied to the drain (C). The incisional NPWT dressing is then applied, in this case, directly to the skin with the drain draped over the foam sponge (D), which is then covered by an additional piece of the foam sponge (E). Suction is applied allowing for a deep drain incorporated into the incisional NPWT dressing (F). The incisional NPWT dressing with the drain incorporated into it should be removed at no more than 72 hours postoperative when the black open-pore foam sponge is placed directly on the skin to minimize ingrowth.