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Effect of negative pressure wound therapy on the incidence of deep surgical site infections after orthopedic surgery: a meta-analysis and systematic review

Journal of Orthopaedic Surgery and Research volume 19, Article number: 555 (2024) Cite this article

Abstract

Objective

This meta-analysis aimed to explore the impact of prophylactic negative pressure wound therapy (NPWT) on the occurrence of deep surgical site infections (SSIs) following orthopedic surgery.

Methods

A systematic search was conducted across Medline, Embase, Cochrane Library, and Web of Science databases for articles concerning NPWT in patients who underwent orthopedic surgery up to May 20, 2024. Using Stata 15.0, the combined odds ratios (ORs) were calculated with either a random-effects model or a fixed-effects model, depending on the heterogeneity values.

Results

From a total of 440 publications, studies that utilized NPWT as the experimental group and conventional dressings as the control group were selected to analyze their impact on SSIs. Ultimately, 32 studies met the inclusion criteria. These included 12 randomized controlled trials and 20 cohort studies, involving 7454 patients, with 3533 of whom received NPWT and 3921 of whom were treated with conventional dressings. The results of the meta-analysis demonstrated that the NPWT group had a lower incidence of deep SSIs in orthopedic surgeries than did the control group [OR 0.64, 95% CI (0.52, 0.80), P = 0.0001]. Subgroup analysis indicated a notable difference for trauma surgeries [OR 0.65, 95% CI (0.50, 0.83), P = 0.001], whereas joint surgeries [OR 0.65, 95% CI (0.38, 1.12), P = 0.122] and spine surgeries [OR 0.61, 95% CI (0.27, 1.35), P = 0.221] did not show significant differences. Additionally, when examined separately according to heterogeneity, trauma surgeries exhibited a significant difference [OR 0.50, 95% CI (0.31, 0.80), P = 0.004].

Conclusion

The results of our study indicate that the prophylactic use of NPWT reduces the incidence of deep SSIs following orthopedic trauma surgery when compared to the use of conventional dressings. We postulate that the prophylactic application of NPWT in patients at high risk of developing complications from bone trauma may result in improved clinical outcomes and an enhanced patient prognosis.

Introduction

The field of orthopedic surgery encompasses the full range of activities related to the prevention, diagnosis, and treatment of musculoskeletal system diseases and injuries, across the entire lifespan [1]. However, postsurgical complications, especially deep SSIs, remain a significant challenge [1]. Deep SSIs, such as deep wound infections, periprosthetic joint infections (PJI), and osteomyelitis, are common and serious issues [2,3,4]. For instance, a meta-analysis on spinal surgery reported a 1.5% incidence of deep SSIs and a 12–25% recurrence rate [5]. In another study, the incidence of deep SSIs after repairing periprosthetic knee fractures was alarmingly high at 88% [6]. Despite timely and appropriate management, deep SSIs can lead to severe outcomes, including multiple surgeries, permanent joint dysfunction, removal of the internal fixator, and even death in extreme cases [7, 8]. Additionally, these infections often result in longer hospital stays and higher healthcare costs, placing a substantial financial burden on patients and healthcare systems [1, 9]. Therefore, the most cost-effective strategy for preventing deep SSIs is to identify risk factors early and intervene promptly.

NPWT is widely used for various wound types and has shown significant efficacy in promoting wound healing and preventing infections. Mechanistically, NPWT works by stabilizing wounds, reducing bacterial loads, decreasing edema, modulating the immune response, stimulating granulation tissue formation, inducing angiogenesis, and enhancing blood circulation [10,11,12]. There is substantial evidence that NPWT significantly reduces surgical wound complications and prevents postoperative infections, both in clean and contaminated wounds, compared to traditional dressings [13, 14].

Many studies have explored the impact of NPWT on reducing the incidence of deep postoperative orthopedic infections, but the findings regarding its effectiveness vary across different studies. While some research shows that NPWT significantly lowers deep infection rates [15, 16], other studies have not found notable benefits [17, 18]. These conflicting findings underscore the urgent need for more thorough and detailed analyses to uncover the true effectiveness of prophylactic NPWT. To better understand NPWT's role in preventing SSIs in orthopedics, this study conducted a meta-analysis and systematic review, providing clinicians with insights into the effects of prophylactic NPWT on the incidence of deep SSIs after orthopedic surgery.

Information and methods

The program has been designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviews will strictly follow these guidelines [19].

Literature search

A search was conducted on Medline, Embase, Cochrane Library, and Web of Science for cohort studies and case–control studies analyzing multifactorial risk factors for orthopedic SSIs up to May 20, 2024. The search employed subject terms and free-text keywords including orthopedics, surgical site infections, and negative pressure wound therapy. Specific search strategies are detailed in the supplementary material.

Inclusion and exclusion criteria

Inclusion criteria: 1. Research articles on the effectiveness of NPWT versus conventional dressings for treating orthopedic SSIs, particularly those involving deep SSIs. 2. Conformance with the diagnostic standards for deep SSIs [20].

Excluded studies consisted of conference abstracts, meta-analyses, protocols, letters, duplicate publications, systematic reviews, and animal experiments. Figure 1 depicts the entire study process.

Fig. 1
figure 1

Demonstrates the entire retrieval process

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Studies were included without restrictions on size or type, and no language limitations were applied.

Data extraction

H.L and G.Z conducted a thorough screening of the literature for data extraction. This involved reviewing titles, abstracts, and full-text articles. Any discrepancies regarding inclusion were resolved through ZQ.C. Strict adherence to inclusion and exclusion criteria was maintained during the screening process. Extracted data included the first author's name, year of publication, country, study design, sample size, gender distribution, and age demographics. Cross-checking of extracted data was performed to ensure consistency.

Quality evaluation

The quality of the randomized controlled trials included in the study was assessed using the RoB 2 (Risk of Bias 2) tool, an updated iteration of the Cochrane Risk of Bias Tool for Randomized Trials [21]. Each study was evaluated against specific criteria and categorized into one of three levels of bias risk:Low: Assigned when all quality criteria were fully met. Unclear: Assigned when one or more criteria were partially met or unclear. High: Assigned when one or more criteria were not met or included. Three aspects of case–control and cohort studies were evaluated using the Newcastle–Ottawa Scale (NOS) [22]: selection of study population (4 points), comparability between groups (2 points), and assessment of exposure factors or outcome measures (3 points). Scores on the scale ranged from 0 to 9, with ≤ 4 indicating low quality, 5–6 moderate quality, and ≥ 7 high quality. Weighted Cohen's kappa coefficients were used to measure the consistency of the evaluations, the results of which can be found in Table 1. Any disagreements that arise between the two assessors during the assessment process are resolved through discussion or consultation with a third party to reach a final decision.

Table 1 Cohen's Kappa for studies
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Statistical analyses

The data were analyzed using Stata version 15.0 to compute combined odds ratios (OR) and their respective 95% confidence intervals (CI). The suitable model for calculating combined OR values was chosen following the assessment of heterogeneity using the Q-test and the I2 statistic. When I2 was greater than 50%, a random-effects model was applied, whereas for I2 values of 50% or lower, a fixed-effects model was utilized. Sensitivity analyses involved conducting a one-by-one exclusion test for studies with I2 exceeding 50%. Publication bias across the literature was evaluated using Egger's test, with statistical significance set at α = 0.05. Results were deemed statistically significant if P was less than 0.05.

Results

Literature search and selection process

Medline, Embase, the Cochrane Library, and Web of Science were systematically searched for studies investigating the impact of NPWT on orthopedic SSIs. Literature management was conducted using EndNote 21. Initially, 440 documents were retrieved, and after 139 duplicates were removed, 301 unique documents remained. Following the exclusion criteria and screening of titles and abstracts, 48 documents were selected for full-text review. Ultimately, 32 papers met the inclusion criteria and were included in the analysis.

Basic characteristics of included literature

The analysis included a total of 32 studies [17, 18, 23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52], consisting of 12 randomized controlled trials and 20 cohort studies. These studies encompassed 17 articles on trauma surgery, 11 on joint surgeries, and 4 on spinal surgeries. Overall, the research involved 7545 patients, with 3582 undergoing NPWT and 3963 receiving conventional dressings. Detailed descriptions of the included studies are provided in Table 2.

Table 2 Characteristics of literature table
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Among 32 included articles, randomized controlled trials were assessed using the Cochrane Risk of Bias Tool for Randomized Trials, and the specific risk of bias evaluations are shown in Fig. 2. Cohort studies were appraised using the Newcastle–Ottawa Scale (NOS), revealing one study scoring 6, while the remaining articles scored between 7 and 9, indicating overall high quality among the included studies. The detailed results of the quality assessment are outlined in Table 3.

Fig. 2
figure 2

Evaluation of bias across 11 randomized controlled studies

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Table 3 Newcastle–Ottawa Scale (NOS) for studies
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Meta-analysis

Orthopedic area

A total of 32 studies were included in the meta-analysis. The heterogeneity test (I2 = 37.8%, P = 0.016) indicated that a fixed-effects model was suitable for the analysis. NPWT significantly decreased the occurrence of deep SSIs in postoperative orthopedic patients [OR 0.64, 95% CI (0.52, 0.80), P = 0.0001]. The detailed results can be found in Fig. 3 and Table 4.

Fig. 3
figure 3

Forest plot depicting the impact of prophylactic NPWT versus conventional dressing on infection rates at deep orthopedic surgical sites

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Table 4 Meta-analysis
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Subgroup analyses

The 32 studies were further analyzed in subgroups based on different types of surgeries: 17 studies focused on orthopedic trauma, 11 on joint surgeries, and 4 on spinal surgeries. The results indicated a significant reduction in the incidence of deep SSIs in trauma surgeries [OR 0.65, 95% CI (0.50, 0.83), P = 0.001]. However, the differences were not statistically significant for joint surgeries [OR 0.65, 95% CI (0.38, 1.12), P = 0.122] or spinal surgeries [OR 0.61, 95% CI (0.27, 1.35), P = 0.221]. The detailed results are shown in Fig. 4 and Table 4.

Fig. 4
figure 4

Forest plots depicting subgroup analyses categorized by various types of surgical procedures

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Orthopedic trauma area

In the subgroup analysis of patients who underwent orthopedic trauma surgery, where heterogeneity was observed at 58.2%, a random-effects model was applied to analyze 17 relevant studies. The analysis demonstrated a significant reduction in the occurrence of deep SSIs with NPWT in patients who underwent orthopedic trauma surgery [OR 0.50, 95% CI (0.31, 0.80), P = 0.004]. The detailed findings are presented in Fig. 5 and Table 4.

Fig. 5
figure 5

Forest plot analyzed separately for the orthopedic trauma field

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Reanalysis: results after excluding costa 2020

Because the Costa 2020 study constituted 27.56% of the weighting in the overall analysis and that publication bias for orthopedic trauma surgery (P = 0.051) was tantamount to the level of statistical significance, a reanalysis was conducted to exclude the Costa 2020 study to ascertain its impact on the results of the analysis. The results of the reanalysis are presented below:

Orthopedic area

The incidence of deep SSIs in postoperative orthopedic patients remained significantly lower after the exclusion of the Costa 2020 study, with a statistically significant difference [OR 0.57, 95% CI (0.44, 0.73), P = 0.000]. The discrepancy was marginal in comparison to the outcomes of the analyses that incorporated the Costa 2020 study. Please refer to Fig. 6 and Table 4 for further details.

Fig. 6
figure 6

Forest plot depicting the impact of prophylactic NPWT versus conventional dressing on infection rates at deep orthopedic surgical sites, after the exclusion of the Costa 2020 study

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Orthopedic trauma area

Following the exclusion of the Costa 2020 study, the incidence of deep SSIs in postoperative patients undergoing orthopedic trauma surgery remained significantly lower, with a statistically significant difference (OR 0.45, 95% CI (0.26, 0.77), P = 0.004). This difference was relatively minor in comparison to the results of the analyses that included the Costa 2020 study. Please refer to Fig. 7 and Table 4 for further details.

Fig. 7
figure 7

Forest plot analyzed separately for the orthopedic trauma field, after the exclusion of the Costa 2020 study

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Publication bias

The Egger test was applied to the entire field of orthopedic surgery and orthopedic trauma surgery to assess publication bias. The results indicated that there was no publication bias in either orthopedic surgery (P = 0.109) or orthopedic trauma surgery (P = 0.051) as the P-values were greater than 0.05. After removing Costa 2020, the results remained unchanged with both orthopedic surgery (P = 0.340) and orthopedic trauma surgery (P = 0.143) having P-values greater than 0.05, suggesting that there was no significant publication bias.

Discussion

This meta-analysis examined the effect of NPWT on the incidence of deep SSIs. Across the included studies, the incidence of deep SSIs in the NPWT group ranged from 0 to 23%. NPWT was found to be effective in reducing the incidence of deep SSIs following orthopedic surgery compared to conventional dressing therapy. However, this result requires further interpretation. Subgroup analyses revealed that prophylactic NPWT significantly reduced deep SSIs only in the orthopedic trauma area, with no significant differences observed in the spine and joint areas. Furthermore, as the Costa 2020 study constituted 27.56% of the overall analysis and the publication bias for orthopedic trauma surgery (P = 0.051) was nearly at the level of statistical significance, we conducted a new meta-analysis and test for publication bias, excluding the Costa 2020 study, and compared the results with those of the previous analysis. The results of the comparison demonstrated no significant alteration in the outcomes of the two analyses, indicating that the analyses remain robust even with the inclusion of the Costa 2020 study.

NPWT is widely recognized as being able to prevent and treat infections and may be associated with several potential mechanisms for preventing deep infections [53]. Firstly, the vacuum-enclosed membrane provided by NPWT provides a physical barrier on the surface of the wound, which prevents the invasion of external bacteria [54]. Secondly, NPWT can promote wound healing through its negative pressure effect. Mechanistically, NPWT enhances local blood perfusion and promotes granulation tissue production, while stabilizing the wound environment through protein regulation and inflammatory cytokine clearance, all of which provide an optimal environment for wound healing [55,56,57,58]. Recently, some researchers have found that NPWT also promotes wound healing by upregulating IL-17 expression [59]. Finally, NPWT can disrupt bacterial biofilms. The use of implants in orthopedic surgery creates conditions for the formation of bacterial biofilms, and some studies have reported that bacterial biofilms contain up to 97% water, and NPWT can expel the water in the biofilm through the effect of sustained negative pressure to necrose the bacteria in the biofilm, which may reduce the chance of bacterial aggregation on the surface of the implant and the reconstruction of the biofilm [60].

It is noteworthy that NPWT also plays a regulatory role in local immunity, a function that may be linked to the mechanistic action of the ion channel protein Piezo1. NPWT provides mechanical forces, particularly traction forces, which may be detected by Piezo1 and transformed into electronic and chemical signals, ultimately regulating cellular functions [61]. Studies have shown that NPWT enhances neutrophil recruitment and modulates neutrophil immune function, possibly through a mechanism involving Piezo1 [62]. Nevertheless, the precise way NPWT impacts immunoregulation remains unclear and warrants further research.

Our findings reveal that NPWT significantly reduces the incidence of deep infections in bone trauma surgeries. The study included various complex procedures, such as pelvic fracture surgery, acetabular fracture repair, and open fracture surgeries. These surgeries often involve challenging conditions that require advanced surgical skills, longer operative times, and cause more severe damage to the surrounding soft tissues and blood supply [16]. Unlike joint and spine surgeries, trauma surgeries frequently involve open wounds, which not only increase the risk of infection but also add to the complexity of the procedure [63]. Larger surgical wounds lead to longer healing times and increased exudate at the surgical site, allowing NPWT to fully promote wound healing and utilize negative pressure suction to reduce deep SSIs.

Our results are consistent with findings from previous meta-analyses. For instance, studies by Zhang et al. [16], Marc et al. [64], and Xie et al. [15] have all demonstrated that NPWT effectively reduces the occurrence of deep SSIs. However, not all research aligns with our findings. Studies by Li et al. [65] and Qian et al. [66] reported no significant difference between the NPWT group and the conventional dressing group in preventing deep SSIs. This disparity may be attributed to variations in sample size and types of surgeries conducted in the studies. Specifically, Li et al. included only four studies with a total of 744 patients to analyze the effect of prophylactic NPWT on the incidence of deep SSIs after orthopedic trauma surgery. The smaller number of studies and small sample size may have resulted in a decrease in the robustness of the results, which, in turn, led to findings that were inconsistent with those of our study. Qian et al. included six studies with a total of 2344 patients to analyze the effect of prophylactic NPWT on the incidence of deep SSIs after open lower extremity fracture surgery. Limiting the study to open lower extremity fracture surgery may have limited the generalisability of the results, which in turn may have led to inconsistencies with our findings. Zhang et al., Xie et al., and our study, in contrast to previous studies, did not limit the type of surgery, and the patients included in the analyses numbered over 3000. By employing a larger sample size and an unrestricted approach to surgery, our study enhances the reliability and generalizability of the results. This allows us to validate the effectiveness of NPWT in large sample sizes and diverse patient populations.

The findings from our study regarding joint did not demonstrate a significant difference between the two treatment modalities, which aligns with the results reported by Kim et al. [67]. In their meta-analysis, Kim and colleagues analyzed nine studies focusing on total hip and knee arthroplasty to evaluate the impact of NPWT on deep SSIs, and they also observed no significant differences. Unlike bone trauma surgery, joint surgeries typically involve cleaner surgical environments, shorter operative times, lower complexity, and less tissue trauma. These factors may limit the ability of NPWT to provide its full range of benefits in joint surgeries.

In the context of spinal surgery, our findings showed no significant difference between the two treatment groups. There is limited literature on deep SSIs in spinal procedures, and no meta-analysis has specifically explored the impact of prophylactic NPWT on these infections. Although a meta-analyze has reported that prophylactic NPWT effectively reduces SSIs after spinal surgery, our research suggests that prophylactic NPWT does not offer any significant advantage over conventional dressings in preventing deep SSIs [68]. This might be due to the deep and complex nature of spinal wounds, as well as the thicker soft tissue coverage involved. The presence of substantial subcutaneous tissue and intricate incisions may reduce the effectiveness of the negative pressure applied by NPWT. Additionally, in cases where there is surgical contamination or inadequate wound irrigation, bacterial biofilm formation on internal fixation devices can occur. Given the deeper location of these biofilms, NPWT may be less effective at disrupting them. As a result, NPWT's effectiveness in such cases may be limited. Future high-quality randomized controlled trials are needed to confirm these findings.

Several independent risk factors have been identified as contributing to the development of deep SSIs following bone trauma surgery. These include older age, diabetes, smoking, extended surgical duration, and open injuries [7, 69,70,71,72,73,74]. We recommend the prophylactic application of NPWT for patients presenting with these risk factors to lower the likelihood of deep infections. For patients experiencing superficial SSIs, utilizing NPWT as a treatment method could potentially prevent the progression of these infections into deeper SSIs. This is because NPWT can remove superficial bacteria along with exudate through its suction mechanism, thereby reducing the possibility of bacterial penetration into deeper tissues. However, there is a lack of conclusive evidence linking superficial site infections to an increased risk of deeper infections. For instance, research by Patterson et al. [75] indicates that deep infections rarely follow superficial infections after surgical fixation of the tibial plateau and distal tibial fractures. Given the economic considerations surrounding NPWT, its use has been somewhat restricted. Further research is required to elucidate the connection between superficial and deep SSIs, thereby providing a stronger theoretical foundation for the clinical use of NPWT.

Conclusion

In conclusion, our study revealed that NPWT effectively reduced the incidence of deep SSIs following orthopedic surgery compared with conventional dressings. However, subgroup analyses revealed a significant difference only in patients who underwent orthopedic trauma surgery. We suggest that prophylactic NPWT in high-risk orthopedic trauma patients may yield significant clinical benefits and improve patient outcomes. To validate the effect of NPWT on deep SSIs after spine surgery, rigorous randomized controlled trials are necessary. Furthermore, further research is needed to elucidate the specific mechanisms by which NPWT influences immune modulation in these contexts. The connection between superficial and deep SSIs warrants additional investigation.

Limitations

There are several limitations to this meta-analysis. First, an overrepresentation of studies focused on orthopedic trauma surgery may bias the overall results in favor of NPWT's effect on reducing deep SSIs in this specific field. Second, the limited number of studies pertaining to spine surgery may compromise the accuracy of our findings in that context. Third, the literature reviewed in this study did not specifically categorize PJI, making it impossible to distinguish between acute and chronic PJI. This limitation hindered our ability to analyze variations in the effectiveness of prophylactic NPWT across different types of PJI. Future research should aim to clearly define and differentiate between PJI types to more precisely evaluate the impact of NPWT. Finally, the inclusion of retrospective studies with varying follow-up durations introduces potential biases related to interviewer bias.

Availability of data and materials

Data is provided within the manuscript or supplementary information files.

References

  1. Parker B, et al. Economic outcomes associated with deep surgical site infection in patients with an open fracture of the lower limb. Bone Joint J. 2018;100-b(11):1506–10.

    Article  CAS  PubMed  Google Scholar 

  2. Xing W, et al. A comparison of negative pressure and conventional therapy in spine infections: a single-center retrospective study. J Pers Med. 2023;13(2):162.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nelson SB, et al. Periprosthetic joint infection: current clinical challenges. Clin Infect Dis. 2023;77(7):e34–45.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Dietz N, et al. Health care utilization and associated economic burden of postoperative surgical site infection after spinal surgery with follow-up of 24 months. J Neurol Surg A Cent Eur Neurosurg. 2023;84(1):21–9.

    Article  PubMed  Google Scholar 

  5. Freire-Archer M, et al. Incidence and recurrence of deep spine surgical site infections: a systematic review and meta-analysis. Spine Phila Pa 1976. 2023;48(16):E269-e285.

    PubMed  Google Scholar 

  6. Norris GR, et al. Prevalence of deep surgical site infection after repair of periarticular knee fractures: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(8): e199951.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Zhao H, et al. Risk factors for deep surgical site infection following surgically treated peri-ankle fractures: a case-control study based on propensity score matching. J Orthop Surg Res. 2022;17(1):542.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Yin D, et al. Management of late-onset deep surgical site infection after instrumented spinal surgery. BMC Surg. 2018;18(1):121.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Brodke D, et al. Predictors of deep infection after distal femur fracture: a multicenter study. J Orthop Trauma. 2023;37(4):161–7.

    Article  PubMed  Google Scholar 

  10. Acosta S, Björck M, Wanhainen A. Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery. Br J Surg. 2017;104(2):e75–84.

    Article  CAS  PubMed  Google Scholar 

  11. Agarwal A. Evolution of negative pressure wound therapy in orthopaedic trauma. J Orthop Trauma. 2022;36(Suppl 4):S1-s5.

    Article  PubMed  Google Scholar 

  12. Zhang YG, et al. Negative pressure technology enhances bone regeneration in rabbit skull defects. BMC Musculoskelet Disord. 2013;14:76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Yuan S, et al. Impact of negative pressure wound treatment on incidence of surgical site infection in varied orthopedic surgeries: a systematic review and meta-analysis. Int Wound J. 2023;20(6):2334–45.

    Article  PubMed  Google Scholar 

  14. Liu ZS, Tian SB. Influence of closed-incision negative-pressure wound therapy on the incidence of surgical site wound infection in patients undergoing spine surgery: a meta-analysis. Int Wound J. 2023;20(10):4193–9.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Xie W, et al. Negative pressure wound therapy compared with conventional wound dressings for closed incisions in orthopaedic trauma surgery: a meta-analysis. Int Wound J. 2022;19(6):1319–28.

    Article  PubMed  Google Scholar 

  16. Zhang D, He L. A systemic review and a meta-analysis on the influences of closed incisions in orthopaedic trauma surgery by negative pressure wound treatment compared with conventional dressings. Int Wound J. 2023;20(1):46–54.

    Article  CAS  PubMed  Google Scholar 

  17. Mascarenhas DC, et al. Incisional negative pressure wound therapy does not affect deep surgical site infection rates in neuromuscular scoliosis surgery. Orthopedics. 2023;46(6):373–8.

    Article  PubMed  Google Scholar 

  18. Costa ML, et al. Negative-pressure wound therapy compared with standard dressings following surgical treatment of major trauma to the lower limb: the WHiST RCT. Health Technol Assessm (Winchester, England). 2020;24(38):1–86.

    Article  Google Scholar 

  19. Liberati A, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7): e1000100.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Horan TC, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control. 1992;20(5):271–4.

    Article  CAS  PubMed  Google Scholar 

  21. Sterne JAC, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366: l4898.

    Article  PubMed  Google Scholar 

  22. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.

    Article  PubMed  Google Scholar 

  23. Arti H, Khorami M, Ebrahimi-Nejad V. Comparison of negative pressure wound therapy (NPWT) & conventional wound dressings in the open fracture wounds. Pak J Med Sci. 2016;32(1):65–9.

    PubMed  PubMed Central  Google Scholar 

  24. Cai L, et al. Comparison of vacuum sealing drainage and conventional drainage for postoperative drainage in closed calcaneal fracture: A randomized controlled trial. Injury. 2022;53(2):777–83.

    Article  PubMed  Google Scholar 

  25. Costa ML, et al. Negative-pressure wound therapy versus standard dressings for adults with an open lower limb fracture: the WOLLF RCT. Health Technol Assessm (Winchester, England). 2018;22(73):1–162.

    Article  Google Scholar 

  26. Crist BD, et al. Role of acute negative pressure wound therapy over primarily closed surgical incisions in acetabular fracture ORIF: a prospective randomized trial. Injury. 2017;48(7):1518–21.

    Article  PubMed  Google Scholar 

  27. Gillespie BM, et al. Use of negative-pressure wound dressings to prevent surgical site complications after primary hip arthroplasty: a pilot RCT. Surg Innov. 2015;22(5):488–95.

    Article  PubMed  Google Scholar 

  28. Cooper HJ, et al. Randomized controlled trial of incisional negative pressure following high-risk direct anterior total hip arthroplasty. J Arthroplasty. 2022;37(8S):S931–6.

    Article  PubMed  Google Scholar 

  29. Higuera-Rueda CA, et al. The effectiveness of closed-incision negative-pressure therapy versus silver-impregnated dressings in mitigating surgical site complications in high-risk patients after revision knee arthroplasty: the PROMISES randomized controlled trial. J Arthroplasty. 2021;36(7s):S295-S302.e14.

    PubMed  Google Scholar 

  30. Keeney JA, et al. Incisional negative pressure wound therapy devices improve short-term wound complications, but not long-term infection rate following hip and knee arthroplasty. J Arthroplasty. 2019;34(4):723–8.

    Article  PubMed  Google Scholar 

  31. Masters J, et al. A feasibility study of standard dressings versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for hip fractures: the WHISH randomized controlled trial. Bone Joint J. 2021;103-B(4):755–61.

    Article  PubMed  Google Scholar 

  32. Stannard JP, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. 2012;26(1):37–42.

    Article  PubMed  Google Scholar 

  33. Virani SR, et al. Impact of negative pressure wound therapy on open diaphyseal tibial fractures: a prospective randomized trial. J Clin Orthopaed Trauma. 2016;7(4):256–9.

    Article  Google Scholar 

  34. Adogwa O, et al. Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience. Spine J. 2014;14(12):2911–7.

    Article  PubMed  Google Scholar 

  35. Blum ML, et al. Negative pressure wound therapy reduces deep infection rate in open tibial fractures. J Orthop Trauma. 2012;26(9):499–505.

    Article  PubMed  Google Scholar 

  36. Cooper HJ, Bas MA. Closed-incision negative-pressure therapy versus antimicrobial dressings after revision hip and knee surgery: a comparative study. J Arthroplasty. 2016;31(5):1047–52.

    Article  PubMed  Google Scholar 

  37. Cooper HJ, et al. Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee. Injury. 2018;49(2):386–91.

    Article  PubMed  Google Scholar 

  38. Dingemans SA, et al. Prophylactic negative pressure wound therapy after lower extremity fracture surgery: a pilot study. Int Orthop. 2018;42(4):747–53.

    Article  PubMed  Google Scholar 

  39. Doman DM, et al. Comparison of surgical site complications with negative pressure wound therapy vs silver impregnated dressing in high-risk total knee arthroplasty patients: a matched cohort study. J Arthroplasty. 2021;36(10):3437–42.

    Article  PubMed  Google Scholar 

  40. Dyck BA, et al. Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study. J Neurosurg Spine. 2019;31(3):430–9.

    Article  PubMed  Google Scholar 

  41. Gantz OB, et al. Postoperative negative pressure wound therapy is associated with decreased surgical site infections in all lower extremity amputations. J Orthop. 2020;21:507–11.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Joethy J, et al. Effect of negative-pressure wound therapy on open fractures of the lower limb. Singapore Med J. 2013;54(11):620–3.

    Article  PubMed  Google Scholar 

  43. Johnson TR, et al. Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures. Eur J Orthop Surg Traumatol. 2024;34(2):1173–81.

    Article  PubMed  Google Scholar 

  44. Matsumoto T, Parekh SG. Use of negative pressure wound therapy on closed surgical incision after total ankle arthroplasty. Foot Ankle Int. 2015;36(7):787–94.

    Article  PubMed  Google Scholar 

  45. Newman JM, et al. Use of closed incisional negative pressure wound therapy after revision total hip and knee arthroplasty in patients at high risk for infection: a prospective. Random Clin Trial J Arthroplasty. 2019;34(3):554-559.e1.

    Google Scholar 

  46. Redfern RE, et al. Closed incision negative pressure therapy effects on postoperative infection and surgical site complication after total hip and knee arthroplasty. J Arthroplasty. 2017;32(11):3333–9.

    Article  PubMed  Google Scholar 

  47. Takahashi H, et al. Effectiveness of specific single-use incisional negative pressure wound therapy (PICO System) after major lower extremity amputation. Int J Low Extrem Wounds 2023;15347346231221116.

  48. Tyagi V, et al. Negative pressure incisional therapy and infection after direct anterior approach primary total hip arthroplasty. Orthopedics. 2019;42(6):e539–44.

    Article  PubMed  Google Scholar 

  49. Vidalis BM, et al. Negative pressure wound therapy in facilitating wound healing after surgical decompression for metastatic spine disease. World Neurosurg. 2022;159:e407–15.

    Article  PubMed  Google Scholar 

  50. Zhou ZY, et al. Prevention of surgical site infection after ankle surgery using vacuum-assisted closure therapy in high-risk patients with diabetes. J Foot Ankle Surg. 2016;55(1):129–31.

    Article  PubMed  Google Scholar 

  51. Reddix RN Jr, et al. The effect of incisional negative pressure therapy on wound complications after acetabular fracture surgery. J Surg Orthop Adv. 2010;19(2):91–7.

    PubMed  Google Scholar 

  52. Song QC, et al. Negative pressure wound therapy reduces the incidence of postoperative wound dehiscence and surgical site infections after total knee arthroplasty in patients with obesity. Medicine (Baltimore). 2022;101(27): e29641.

    Article  PubMed  Google Scholar 

  53. Normandin S, et al. Negative pressure wound therapy: mechanism of action and clinical applications. Semin Plast Surg. 2021;35(3):164–70.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Canavese F, et al. Deep postoperative spine infection treated by negative pressure therapy in patients with progressive spinal deformities. Arch Orthop Trauma Surg. 2018;138(4):463–9.

    Article  PubMed  Google Scholar 

  55. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma. 2019;10(5):845–8.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Banwell P, Téot L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Tissue Viability. 2006;16(1):16–24.

    Article  PubMed  Google Scholar 

  57. Wu YK, Cheng NC, Cheng CM. Biofilms in chronic wounds: pathogenesis and diagnosis. Trends Biotechnol. 2019;37(5):505–17.

    Article  CAS  PubMed  Google Scholar 

  58. Kilarski WW, et al. Biomechanical regulation of blood vessel growth during tissue vascularization. Nat Med. 2009;15(6):657–64.

    Article  CAS  PubMed  Google Scholar 

  59. Xiao S, et al. A new mechanism in negative pressure wound therapy: interleukin-17 alters chromatin accessibility profiling. Am J Physiol Cell Physiol. 2024;327(1):C193-c204.

    Article  PubMed  Google Scholar 

  60. Wang J, et al. Safety and efficacy of negative pressure wound therapy in treating deep surgical site infection after lumbar surgery. Int Orthop. 2022;46(11):2629–35.

    Article  PubMed  Google Scholar 

  61. Syeda R, et al. Piezo1 channels are inherently mechanosensitive. Cell Rep. 2016;17(7):1739–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Li J, Chang Z. Case Report: a spinal infection with bilateral psoas abscesses was treated with NPWT to enhance the local infection by increasing the infiltration of neutrophil cells and draining the pus. Front Cell Infect Microbiol. 2023;13:1228376.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Lu K, et al. Incidence and risk factors for surgical site infection after open reduction and internal fixation of intra-articular fractures of distal femur: a multicentre study. Int Wound J. 2019;16(2):473–8.

    Article  PubMed  Google Scholar 

  64. Grant-Freemantle MC, et al. The effectiveness of negative pressure wound therapy versus conventional dressing in the treatment of open fractures: a systematic review and meta-analysis. J Orthop Trauma. 2020;34(5):223–30.

    Article  PubMed  Google Scholar 

  65. Li P, Li J. Effect of incisional negative pressure therapy and conventional treatment on wound complications after orthopaedic trauma surgery: a meta-analysis of randomized controlled studies. Int Wound J. 2023;20(10):4291–9.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Qian H, Lei T, Hu Y. Negative pressure wound therapy versus gauze dressings in managing open fracture wound of lower limbs: a meta-analysis of randomized controlled trials. Foot Ankle Surg. 2022;28(7):1120–8.

    Article  PubMed  Google Scholar 

  67. Kim JH, Lee DH. Are high-risk patient and revision arthroplasty effective indications for closed-incisional negative-pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta-analysis. Int Wound J. 2020;17(5):1310–22.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Lu S, et al. The impact of negative pressure wound therapy on surgical wound infection, hospital stay and postoperative complications after spinal surgery: a meta-analysis. Int Wound J. 2024;21(1): e14378.

    Article  PubMed  Google Scholar 

  69. Wilkinson BG, et al. A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail. Injury. 2023;54(10): 110965.

    Article  PubMed  Google Scholar 

  70. Anderson BM, et al. Admission hyperglycemia is a risk factor for deep surgical-site infection in orthopaedic trauma patients. J Orthop Trauma. 2021;35(12):e451–7.

    Article  PubMed  Google Scholar 

  71. Meng J, et al. Deep surgical site infection after ankle fractures treated by open reduction and internal fixation in adults: a retrospective case-control study. Int Wound J. 2018;15(6):971–7.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Ma Q, et al. Incidence and risk factors for deep surgical site infection after open reduction and internal fixation of closed tibial plateau fractures in adults. Int Wound J. 2018;15(2):237–42.

    Article  PubMed  Google Scholar 

  73. Parkkinen M, et al. Risk factors for deep infection following plate fixation of proximal tibial fractures. J Bone Joint Surg Am. 2016;98(15):1292–7.

    Article  PubMed  Google Scholar 

  74. Ovaska MT, et al. Risk factors for deep surgical site infection following operative treatment of ankle fractures. J Bone Joint Surg Am. 2013;95(4):348–53.

    Article  PubMed  Google Scholar 

  75. Patterson JT, et al. Do superficial infections increase the risk of deep infections in tibial plateau and plafond fractures? Eur J Orthop Surg Traumatol. 2023;33(7):2805–11.

    Article  PubMed  Google Scholar 

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Acknowledgements

We extend our sincere gratitude to the reviewers and editors for their valuable feedback and suggestions on this manuscript.

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Authors and Affiliations

  1. Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031, Shandong, China

    Huan Liu, Ge Zhang, An Wei, Hao Xing, Changsheng Han & Zhengqi Chang

  2. School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053, Shandong, China

    Huan Liu & Hao Xing

  3. Shandong University of Traditional Chinese Medicine, Jinan, 250355, China

    Ge Zhang, An Wei & Changsheng Han

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  1. Huan Liu
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  6. Zhengqi Chang
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Contributions

Huan Liu was involved in study design, selection, analysis, report writing and manuscript review. Ge Zhang was involved in in study design, selection and report writing Hao Xing, An Wei and Changsheng Han participated in information retrieval and manuscript review. Zhengqi Chang contributed to the design, selection, analysis, report writing and manuscript review. All authors read and approved the final manuscript.

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Correspondence to Zhengqi Chang.

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Liu, H., Zhang, G., Wei, A. et al. Effect of negative pressure wound therapy on the incidence of deep surgical site infections after orthopedic surgery: a meta-analysis and systematic review. J Orthop Surg Res 19, 555 (2024). https://doi.org/10.1186/s13018-024-05038-7

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Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X