Negative Pressure Wound Therapy - Open and Closed Fractures
After closed fracture fixation, negative pressure wound therapy may mitigate the risk of revision surgery or SSIs; however, after open fracture fixation, negative pressure wound therapy does not appear to offer an advantage when compared to sealed dressings as it does not decrease wound complications or amputations.
Prevention of Surgical Site Infection After Major Extremity Trauma (2022)
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: ASES, POSNA, AOFAS, IDSA, OTA


Four high quality (Costa 2018, Virani 2016, Arti 2006, Stannard 2006) and five low quality (Rinker 2008, Labler 2004, Burtt 2020, Blum 2012, Joethy 2013) studies have evaluated the role of negative pressure wound therapy for wound management after high-energy trauma. This includes both open fracture care as well as for the management of post-operative incisions following stabilization of at-risk fractures. The higher quality studies included 2 large multicenter RCTs, as well as 3 small single center RCTs. The large multicenter studies concluded NPWT did not provide any benefit compared to standard wound care with sterile gauze dressings. The use of NPWT did not improve patient self-rated disability at 12 months, and rates of deep infection were not reduced with NPWT compared to standard dressings. Although the three smaller single center RCTs demonstrated better outcomes with NPWT, these findings were not confirmed. Although several low-quality studies demonstrated more favorable outcomes with NPWT, this more likely reflects elements of selection bias and other confounding variables often associated with uncontrolled retrospective studies.

Benefits & Harms
The large high-level study demonstrated that NPWT does not appear to have any significant influence on the risk of deep infection, the length of hospitalization, or the risk of later developing either skeletal or soft-tissue specific complications. At least one recent low-quality study (Burtt 2020) suggests NPWT may be associated with a dramatically increased risk of one or more complications, and its continued use for this clinical situation should be considered recognizing the decision is difficult to justify with respect to the increased costs associated.

Outcome Importance
Routine wound care with sterile gauze dressing changed regularly appears to be equally efficacious in comparison to NPWT, as demonstrated in the highest quality study to evaluate these two treatment alternatives. While this suggests that either treatment could be employed with complete confidence at the discretion of treating clinicians, the financial implications and burden on the healthcare system cannot support the continued use of NPWT for this particular application.

Cost Effectiveness/Resource Utilization
The lack of any genuine benefit resulting from NPWT does not at this time justify the increased costs associated. Despite the outcomes reported in earlier uncontrolled retrospective studies, as epitomized by Blum (2012), high quality studies reveal the convenience and potential theoretical advantages of NPWT do not warrant the increased costs that inevitably accrue. This likely reflects inherent biases and confounding factors characteristic of many retrospective clinical studies.

Standard wound care with sterile gauze dressings changed regularly has proven to be equally effective when compared to NPWT. The current literature fully supports this conclusion, and this recommendation should be considered highly acceptable.

Despite the attraction of convenience with respect to nursing staff and dressings used, the potential benefits of NPWT for wound care related to major extremity trauma have not yet been realized. While highly feasible in many clinical situations, the inability to demonstrate any tangible benefits has failed to justify the increased costs associated.

Future Research
Although large multicenter randomized trials have failed to demonstrate any advantage of NPWT for the early management of open fractures, the potential benefit of this type of treatment for post-operative wounds following stabilization of complex high-energy at-risk fractures has not been evaluated with as much rigor. Similarly, the role of intermittent irrigation with antibiotics or other wound cleansing agents as  an adjunct to standard NPWT has also not been adequately explored with any high-level studies.