Current Indications for Negative Pressure Therapy in Wound Healing in Orthopedic and Traumatological Patients

Introduction

The principle of negative pressure therapy is the application of subatmospheric pressure to a wound using a porous sponge covered with an airtight film, which is connected to a drainage system device. The method has several variations differing in devices and drainage systems, as well as the structure and technology of the sponges and other additional aids.

Negative pressure therapy quickly gained popularity due to the possibility of less frequent dressing changes and patient treatment at the bedside, with a general belief that it shortens wound care time. In practice, it is most commonly used for temporary wound coverage, stimulation of granulations in the wound bed, reduction of defects, and subsequent transition to conventional moist wound healing or preparation of the wound for plastic surgery. However, negative pressure therapy is not almighty, and its indications need to be carefully considered.

The correct and incorrect indications for negative pressure therapy in orthopedic and traumatological patients are addressed by the cited French study with reference to the recommendations of local specialist authorities.

Correct Indications for Negative Pressure Therapy

The correct indications for negative pressure therapy for acute wounds include:

• Clean or infected traumatic wounds with deep and/or extensive skin defects that prevent primary suture.
• Clean or infected surgical excisions with deep and/or extensive skin defects.
• Clean or infected dehiscence of surgical wounds that are extensive and/or associated with healing risk factors (such as diabetes mellitus, obesity, glucocorticoid or immunosuppressive therapy, fragile skin cover) where debridement has been performed as needed.

Specific situations where negative pressure therapy may be considered include:

• Venous ulcers requiring skin graft coverage if the ulcer persists despite optimal topical therapy over a long period (e.g., 3–6 months for venous ulcers).
• Stage III and IV pressure ulcers as preparation before plastic defect coverage, with this indication showing the highest level of evidence.
• Diabetic foot defects with deep and/or extensive skin defects.
• Soft tissue traumas and open fractures where the wound cannot be closed or delayed suture is planned, treatment of defects caused by fasciotomy, temporary defect coverage (considered sterile coverage if applied in the operating room), and in cases of tissue necrosis at risk of exposing osteosynthetic material after careful debridement.

Incorrect Indications for Negative Pressure Therapy

Negative pressure therapy is not recommended and should not be applied in the following cases:

• Small wounds not requiring negative pressure therapy.
• No improvement between subsequent dressing changes or after 1 week of therapy.
• Actively bleeding wounds (in the case of difficult-to-achieve hemostasis in wounds with a risk of bleeding, the suction pressure can be reduced to 75 mmHg).
• Tissues destroyed by a tumor (due to stimulation of angiogenesis and increased risk of tumor growth).
• Uncontrolled wound infections (negative pressure therapy generally represents an adjunct method in infected wounds).
• Presence of necrotic tissue requiring debridement.
• Presence of peripheral arterial disease of the lower limbs.

Conclusion

The cited overview article offers a view of French healthcare authorities on the correct and incorrect indications of negative pressure therapy, which can generally be interpreted for indications in our conditions. The source text also brings many other interesting practical insights regarding negative pressure therapy in orthopedic and traumatological patients, whose complete list is beyond the scope of this message.

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Source: Robert N. Negative pressure wound therapy in orthopedic surgery. Orthop Traumatol Surg Res 2017; 103 (1S): S99–S103, doi: 10.1016/j.otsr.2016.04.018.