Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures?

BACKGROUND: Grade IIIB open tibia fractures are devastating injuries. Some clinicians advocate wound closure or stable muscle flap coverage within 72 hours to limit complications such as infection. Negative pressure wound therapy was approved by the FDA in 1997 and has become an adjunct for many surgeons in treating these fractures. Opinions vary regarding the extent to which negative pressure wound therapy contributes to limb salvage. Evidence-based practice guidelines are limited for use of negative pressure wound therapy in Grade IIIB tibia fractures. This systematic literature review of negative pressure wound therapy in Grade IIIB tibia fractures may substantiate current use and guide future studies. QUESTIONS/PURPOSES: We sought to answer the following: (1) Does the use of negative pressure would therapy compared with gauze dressings lead to fewer infections? (2) Does it allow flap procedures to be performed safely beyond 72 hours without increased infection rates? (3) Is it associated with fewer local or free flap procedures?
METHODS: We conducted a systematic review of six large databases (through September 1, 2013) for studies reporting use of negative pressure wound therapy in Grade IIIB open tibia fractures, including information regarding infection rates and soft tissue reconstruction. The systematic review identified one randomized controlled trial and 12 retrospective studies: four studies compared infection rates between negative pressure wound therapy and gauze dressings, 10 addressed infection rates with extended use, and six reported on flap coverage rates in relation to negative pressure wound therapy use beyond 72 hours. None of the 13 studies was eliminated owing to lack of study quality.
RESULTS: Negative pressure wound therapy showed a decrease in infection rates over rates for gauze dressings in two of four studies (5.4% [two of 35] versus 28% [seven of 25], and 8.4% [14 of 166] versus 20.6% [13 of 63]), an equivalent infection rate in one study (15% [eight of 53] versus 14% [five of 16]), and an increased infection rate in the fourth study (29.5% [23 of 78] versus 8% [two of 25]). In terms of the second question regarding infection rates with negative pressure wound therapy beyond 72 hours, eight of 10 studies concluded there was no increase in infection rates, whereas two of 10 reported an increase in infection rates associated with negative pressure wound therapy use beyond 72 hours. Infection rates varied from 0% to 57% in these 10 studies. Five studies reported low infection rates of 0% to 7% and five reported rates of 27% to 57%. The third question (addressed by six studies) regarded the potential decreased use of a soft tissue flap in patients treated with extended negative pressure wound therapy. Flap rates were reduced by 13% to 60% respectively compared with those of historical controls. Grade IIIB tibia fractures by definition required soft tissue procedures. The patients in these six studies had Grade IIIB tibia fractures after the first débridement. However, after extended negative pressure wound therapy, fewer patients required flaps than grading at the first débridement would have predicted.
CONCLUSIONS: There is an increasing body of data supporting negative pressure wound therapy as an adjunctive modality at all stages of treatment for Grade IIIB tibia fractures. There is an association between decreased infection rates with negative pressure wound therapy compared with gauze dressings. There is evidence to support negative pressure wound therapy beyond 72 hours without increased infection rates and to support a reduction in flap rates with negative pressure wound therapy. However, negative pressure wound therapy use for Grade IIIB tibia fractures requires extensive additional study. LEVEL OF EVIDENCE: Level III, therapeutic study.