The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal

Abstract

Introduction. Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. Methods. A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. Results. After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. Conclusion. This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.

Evaluating the efficacy of combined flap coverage, antibiotic‐loaded bone cement and negative pressure irrigation in traumatic osteomyelitis management

“…Recent studies have provided valuable insights and support for our research direction. For instance, Haidari et al's 36 study on the role of NPWT in fracture‐related infections underscores the challenges in managing soft tissue defects, similar to our study. However, our research provides more concrete evidence on the efficacy of combining NPWT with antibiotic‐loaded bone cement and flap coverage, highlighting a comprehensive approach towards traumatic osteomyelitis management.…”

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

“…Regarding negative pressure therapy, a number of studies have shown a decreased infection rate in open tibial fractures, the possibility of extending the time to definitive coverage, and a lower failure rate of definitive flaps (63,64). However, other studies have shown no clear evidence for the advantage of this type of system over classic coverage (65,66,67,68). There are authors who value its use only temporarily until definitive coverage and no longer than 1 week due to the risk of colonisation with resistant microorganisms (69).…”

Current Concepts of Fracture-Related Infection

“…The studies uncover the possible limitations of NPWT technology, but its advantages should not be fully denied. Regarding the role of NPWT in FRI therapy, a 2021 systematic review [ 104 ] indicated that there was still lack of strong evidence to support the use of NPWT as a definitive treatment for FRI. Similarly, in a recently published retrospective cohort study, Sweere et al [ 105 ] found that delayed wound closure with NPWT increased the risk of infection recurrence among patients with soft tissue defects following FRI treatment.…”