ABSTRACT
OBJECTIVE: To compare treatment outcomes of open foot wounds with significant soft tissue defects using either negative pressure wound therapy (NPWT) or standard wet-to-moist saline-soaked gauze dressings.
SUBJECTS: Forty-seven subjects with open wounds with significant soft tissue defects.
DESJGN: A retrospective analysis of sequentially selected records of patients treated with NPWT or standard wetto-moist dressings.
RESULTS: Risk of complications, subsequent foot surgeries, and hospital readmissions (secondary outcomes) were all reduced by 70% or more for the patients treated with NPWT. Length of stay during readmissions tended to be shorter; rates of wound cavity filling and wound healing (primary outcomes) tended to be greater with NPWT, although the differences were not statistically significant.
CONCLUSION: Patients included in the study treated with NPWT had fewer foot-related complications, less additional foot surgery, and fewer readmissions for the study foot than did patients treated with standard therapy. Further research using randomized clinical trials is needed to confirm the findings of the current study's data.
CLINICAL RELEVANCE: Wound cavity filling time and time to complete closure were similar in both study groups, despite the fact that patients receiving NPWT were older, had larger wounds, and had poorer nutrition. NPWT may be an effective modality for the healing of open wounds with significant defects and for reducing subsequent care.
ADV SKIN WOUND CARE 2004;17:354,356,358-60,362-64.
More than 2.8 million patients in the United States suffer from chronic wounds, costing billions of dollars annually. ' Prevalence of chronic ulcers has been estimated to be 120 per 100,000 patients between the ages of 45 and 64 years; prevalence increases to more than 800 per 100,000 patients over age 75.2 Patients with diabetes have a 15% lifetime risk of developing a foot ulcer and up to a 40-fold greater risk of lower-extremity amputation than do their counterparts without diabetes.3 Approximately 82,000 hospital discharges for diabetes-related nontraumatic amputations occurred in the United States in 2001, the last year for which published statistics are available.4 The 5-year survival rate following amputation of a diabetic limb is less than 50%.s/h
The causes of chronic wounds include nonhcaling diabetic, pressure, or vascular ulcers; cellulitis or osteomyelitis; wound dehiscencc; and trauma. Complicated ulcers often require aggressive debridcmcnt and/or open amputation, which can result in large soft tissue defects. These defects, in turn, may produce large, deep wounds with exposed bone, tendon, capsule, and muscle that are difficult and costly to heal. Often, these wounds are associated with further complications and the need for other surgical procedures.
As a consequence of the extreme morbidity, mortality, and cost of managing lower-extremity ulcérations and their complications, many modalities have been developed to improve wound closure. Among the newer technologies recently used to promote closure of such wounds is negative pressure wound therapy (NPWT; Vacuum Assisted Closure [V.A.C.] Advanced Therapy System; KCI, San Antonio, TX). Developed in the 1990s by researchers at Wake Forest University, NPWT has been used successfully to treat a variety of wounds, including surgical wounds,7-14 grafts15-19 diabetic foot ulccrs,20-23 and pressure ulcers,24-26 with the aim of increasing the rate of wound closure, increasing patient comfort, decreasing length of hospitalization, and reducing the cost of care.27-36 The persistence of senescent, chronic cells and protease-containing wound fluid at the wound interface is deleterious to wound healing.37-38 Therefore, it is theorized that NPWT aids in wound healing by removing excess interstitial fluids, increasing vascularity, decreasing bacterial colonization, and mechanically stimulating the surrounding tissues.39-41
NPWT has been used regularly since early 2000 by the Podiatry section at the CarlT. HaydenVA Medical Center (VA), Phoenix, AZ, for the management of open foot wounds with significant soft tissue defects. Initial impressions of its efficacy were favorable. The podiatry team desired to confirm or refute these impressions through a retrospective analysis of selected outcomes in patients treated with either NPWT or standard wet to moist dressings.
OBJECTIVES
The purpose of this study was to compare specific outcomes in groups of patients treated either with NPWT or with standard wet-to-moist, saline-soaked dressings for open foot wounds with significant soft tissue defects. The primary outcomes to be assessed were wound cavity filling time and total time to complete closure of the wound (Table 1). secondary outcomes considered were other surgical procedures performed on the study foot, complications of the study foot, and number and length of readmissions for subsequent problems in the study foot. All secondary outcomes were assessed during the year following the definitive surgical procedure, which was performed just prior to initiation of NPWT or wet-to-moist gauze dressings.