(2021) 3:38
Chan et al. Arthroplasty
https://doi.org/10.1186/s42836-021-00094-4

Arthroplasty
Open Access

RESEARCH

The application of close incisional negative
pressure wound therapy in revision arthroplasty
among asian patients: a comparative study
Ping Keung Chan1* , Wing Chiu Fung2, Kar Hei Lam2, Winnie Chan3, Vincent Wai Kwan Chan1, Henry Fu1,
Amy Cheung1, Man Hong Cheung2, Chun Hoi Yan2 and Kwong Yuen Chiu2

Abstract
Introduction: Peri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order toreduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT)
has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of
ciNPWT in revision arthroplasty.
Methods: This was a single-centre retrospective comparative study approved by the Institutional Review Board.
Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author’s institution
from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients,
who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort
included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts.
Results: There was a statistically significant difference in the rate of superficial surgical site infection (SSI) between
control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statisticallysignificance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504).
Conclusions: The application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties.
Trial registration: UW19-706
Keywords: Closed-incisional negative pressure wound therapy, Surgical site infection, Periprosthetic joint infection,
Arthroplasty
Introduction
Complications to wound healing can be detrimental tothe clinical outcomes after arthroplasty. It can lead tomajor complications including infection and need for
subsequent surgery. Among patients having primary*Correspondence: cpk464@yahoo.com.hk
1
Department of Orthopaedics and Traumatology, Queen Mary Hospital,
Hong Kong SAR, China
Full list of author information is available at the end of the article

total knee arthroplasties, 0.33% had early wound complications, which subsequently resulted in further surgical management within 30 days [1]. Those patientsrequiring surgery for wound complications from thefirst 30 days had 7–13 times higher risk of deep infection
when compared to those without wound problems [1,2]. Measures to prevent wound complications were evenmore important to revision arthroplasty as revision total
knee arthroplasty was associated with a 15 fold increase© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.

Chan et al. Arthroplasty(2021) 3:38

in postoperative complications rates relative to primaryknee arthroplasty [3].
Various measures were advocated to optimize woundhealing after arthroplasty. These included preoperative
optimization of modifiable risk factors such as nutritional
status, smoking status, and diabetic control. Intraoperatively, surgeon should have meticulous handling of theskin and soft tissue. Advanced dressing management
is another important area, which has recently got more
attention as more scientific evidence proven it clinicaleffectiveness in arthroplasty.
Traditionally, cotton gauze fabric was widely used inwound care because of its excellent absorption power
and low cost. However, other advanced dressing materials were recently showed to have more meaningful
clinical benefits. The application of a commercial silverimpregnated occlusive dressing, which is a hydrofiber
dressing with antibi-microbial ionic silver, was showed toresult in a fourfold reduction in acute periprosthetic joint
infection when compared with conventional sterile gauze
dressing [4]. Closed-incisional negative pressure woundtherapy (ciNPWT) is another evidence-based option,
which was put in the place of field of arthroplasty for over
10 years [5]. A recent randomized controlled trial comparing the effectiveness of ciNPWT versus silver-impregnated dressing showed that ciNPWT was statisticallysignificant more effective in reducing the 90-day postoperative surgical site complication (ciNPWT: 3.4% vs silver-dressing: 14.3%; odds ratio (OR): 0.22; p = 0.0013) [6].
The proposed primary mechanisms of ciNPWT in promoting wound healing include: (i) macrodeformation by
drawing wound edges together, (ii) microdeformation byfacilitating cell proliferation, and (iii) fluid removal fromextra-cellar matrix and environmental control to keep thewound insulated, warm and hydrated [7]. It has been propose that ciNPWT could better protect incisions against
external contamination compared to conventional dressing [8]. Studies were also proposed that ciNPWT facilitates healing by improving perfusion, reducing oedema
and preventing the formation of haematoma [9, 10].
Long-term benefits include improving the incision quality in terms of mechanical strength and histological properties [11–14].
The cost of the application of these advanced dressing
materials is still a concern. The cost of single-use, disposable reported in the literature was between $500 and$600
USD [15]. In Asia, limited literatures were expected to bereleased to discuss the application of ciNPWT in arthroplasty. One of the reasons of low utilization for ciNPWTin Asia might be due to the cost consideration.
Revision arthroplasty was deemed to be a major risk
factor of wound related complications. According to thenational registries from England and Finland, revision

Page 2 of 10

arthroplasty showed an increased risk of postoperative
infection-related complications when compared to primary arthroplasty [16, 17]. A recent review studying theclinical effectiveness of ciNPWT in arthroplasty showedthat ciNPWT was indicated to be used in revisionarthroplasty instead of primary arthroplasty because of
the relatively higher risk of wound complication in revision arthroplasty [18]. Moreover, the use of ciNPWT for
infection prevention following revision total knee arthroplasty was demostrated to be cost-effective [19]. Basedupon the cost-effectiveness consideration, ciNPWT was
mainly utilized in patients having the high-risk of woundcomplications (revision THA and revision TKA) since
January 2018 in our institution.
This study aimed to review the efficacy of the application of ciNPWT in revision arthroplasty when comparedwith conventional dressing in the authors’ institution,
which is one of the major joint replacement centres in
Asia.

Methods
Study design

This was a single-centre, retrospective comparative study
approved by the Institutional Review Board (HKU/HAHKW IRB) (Reference no. UW19-706) in a tertiary referral university hospital.
Patients, who underwent revision TKA or THA at our
institution from January 2016 to October 2019, were
included in this study. The conventional dressing used
traditionally was Cosmopor® E (Hartmann), which is asterile, adhesive wound dressing made of soft, non-woven
polyester. Since January 2018, the surgical team changed
the dressing to ciNPWT, which were either Prevena Incision Management System (Acelity, San Antonio, TX) or
PICO (Single use ciNPWT system, Smith & Nephew,
Hull, UK) (Fig. 1). The change of practice in wound dressing provided us with 2 naturally formed cohort groups:
those patients who underwent surgery between January
2016 to December 2017 received a conventional dressing,whereas those patients who underwent surgery between
Jan 2018 to October 2019 received ciNPWT. All patientswere treated by the same surgical team consisting of four
fellowship-trained surgeons, who performed revision
surgery with similar surgical techniques.
The patients in both cohorts were managed according to the same perioperative protocols with the difference mainly in the dressing material used at the end of
the surgical procedures. Prophylactic antibiotics, single
dose of 1 g cefazolin, were given 30-min before the surgical incision. For revision surgery due to aseptic causes
e.g. aseptic loosening or periprosthetic fracture, cefazolin would only be used for 24-h after the operation. For
revision surgery because of infection, 2-stage revision

Chan et al. Arthroplasty(2021) 3:38

Fig. 1 ciNPWT devices used in revision arthroplasties. a PICO systemb Prevena system

surgery would be performed. The perioperative antibiotic used was according to the recommendation byclinical microbiologist based on the antibiotic sensitivity
profile of the bacteria. To decrease perioperative blood
loss, Intravenous tranexamic acid was given at a dosageof 15 mg/kg before induction of anaesthesia, and anotherintravenous injection of the same dosage would be given
4-h afterwards. For revision TKA, tourniquet was usedthroughout the surgical invasive procedures. Antibioticloaded cement (PALACOS® + G, Heraeus), was used for
all cemented prosthesis. Allogenic blood transfusion wasprescribed if postoperative haemoglobin drop to ≤ 7 g/dL
in hemodynamically stable adults, or ≤ 8 g/dL in patients
who had underly cardiovascular or respiratory comorbidities. No surgical drainage was used. All wounds wereclosed in layers with barbed sutures (Stratafix, Depuy
Synthes).
For the postoperative wound surveillance, the dressingin the ciNPWT cohort would be kept intact for 7 days,
and then changed to conventional dressing, whereas thewound condition in the conventional dressing cohort wasreviewed at postoperative day 3, and then a new piece of
conventional dressing would be re-applied to the surgicalwound. The conventional dressing used in both cohorts
would be kept intact and removed on postoperative day
14.
All the patient’s medical records and perioperative
parameters were reviewed. Patient demographics, thetype of revision arthroplasty, indications for surgery,

Page 3 of 10

mode of anaesthesia, American Society of Anaesthesiologist (ASA) grade and operative duration were recorded.
Patients’ preoperative status were also documented,
including haemoglobin and albumin level, comorbidities and risk factors for wound complications. Clinicalphotos were taken at the surgical sites with a high-resolution digital camera, and the wound conditions were
documented in the wound surveillance chart by a nursing
specialist, who specialized in managing surgical wounds
in the orthopaedic department. The nurse was in chargeof the documentation in the wound surveillance chart,
documentation of the postoperative surgical wound conditions, including both septic and aseptic wound complications, during the course of recovery in the in-patientand out-patient periods. Septic complications, such as
surgical site infections (SSI) and prosthetic joint infection(PJI) were recorded. SSI, including both superficial incisional SSI and deep incisional SSI, were defined according to the criteria by Centers for Disease Control (CDC)[20], while prosthetic joint infection (PJI) was definedaccording to the criteria provided by Musculoskeletal
Infection Society (MSIS) [21]. Aseptic wound complications, such as persistent drainage, haematoma formation,wound dehiscence, suture granuloma, blister formation,and maceration of the wound, were also documented.
The patient would be arranged to have wound surveillance in the out-patient follow-up at 2-week, 6-week,
3-month, 6-month and yearly after discharge from hospital. Data, including wound complications, re-operations
due to wound complications of other causes, readmission
within 30 days of surgery, periprosthetic joint infection,
90-day perioperative and mortality, were retrieved fromthe medical record system at our institution.
The primary outcomes were (1) the overall incidence of
septic and aseptic wound complications, and (2) the incidence of septic and (3) the incidence of aseptic woundcomplications. The secondary outcomes include thelength of hospital stay, re-operations due to wound complications, 90-day postoperative mortality, and readmission within 30 days of surgery. All the outcome measures
were reviewed by two orthopaedic specialists individually, and the cases would be reviewed together so as tomake a consensus in case a discrepancy in the individual
assessments.
Statistical analysis

The statistical analysis was performed using IBM SPSS
26.0 software (IBM, Armonk, NY, USA), and the statistically significance took place at the 5% significancelevel. The primary and secondary outcome measures
was compared. To control for confounding factors, thebaseline data between the two cohorts, including patient
demographics, existing comorbidities, types of revision

Chan et al. Arthroplasty(2021) 3:38

Page 4 of 10

arthroplasty performed, indications for revision arthroplasty, ASA grade, mode of anaesthesia, operation duration, as well as preoperative and postoperative levels ofalbumin and haemoglobin, were also compared.
The choice of statistical tests based on the data distribution, and the nature of the data (nominal, ordinal orinterval/ratio). The independent samples t test was used
for parametric data, while the chi-square or Fisher exact
test was used only non-parametric data and categorical
data depending on the observed frequency. All available data were incorporated in data listings and tabulations. No imputation of values for missing data were
performed.

Results
A total of 84 patients were reflected in the present study.
They underwent either revision hip arthroplasty (n = 38)
or revision knee arthroplasty (n = 46). The majority of cases were revised because of infection (n = 43,
51.2%), whereas the others were revised because of different aseptic causes (n = 41, 48.8%), including loosening, polythene wear, instability, fracture, and dislocation.

36 patients were enrolled in the ciNPWT cohort and48 patients in the control cohort. Among the ciNPWT
cohort, the PICO and Prevena systems were utilized or
22 and 14 patients respectively.
There were no significant differences in terms of age,sex, types of revision procedure performed, indications
for revision arthroplasty, ASA grade, mode of anaesthesia, operation duration, as well as preoperative and postoperative levels of albumin and haemoglobin, between
the two cohorts (Table 1). While revision arthroplasty
itself being a major risk factor for wound complications,some patients had additional risk factors, most commonly history of prior joint infection (ciNPWT 63.9%
Vs Control 41.7%), ASA grade ≥ 3 (ciNPWT 61.2% Vs
Control 60.4%), and diabetes mellitus (ciNPWT 33.3%Vs
Control 20.8%) (Table 2). Apart from the risk factor ofprior joint infection reaching statistically significant(ciNPWT 63.9% Vs Control 41.7%, p = 0.05), other risk
factors in both cohorts did not show a statistically significant difference.
The bacteriology in PJI cases in both cohorts werereviewed in details (Table 3). There were no statistically

Table 1 Patients demographics and surgical details
ciNPWT
Number of patients
Total Number of patientsControl%

36

Number of patients

P-value%48

Age at operations

Mean age

69.4

Sex

Male

20

55.6

17

35.4

Female

16

44.4

31

64.6

Hip

12

33.3

26

54.2

Knee

24

66.7

22

45.8

Infected

23

63.9

20

41.7

Loosening

5

13.9

17

35.4

PE wear/ failure

1

2.8

4

8.3

Instability

1

2.8

2

4.2

Wound drainage

0

0

2

4.2

Fracture

1

2.8

2

4.2

Dislocation

4

11

1

2.1

Flexion contracture

1

2.8

0

0

≤2

15

41.7

19

39.6

≥3

21

58.3

29

60.4

General / General & regional

27

75

39

81.3

Spinal / Combined spinal epidural

9

25

9

18.8

Operation Duration (min)

Mean

207.2

225.5

0.376

Haemoglobin

Per-operative mean

11.5

11.9

0.322

Post-operative mean

9.4

9.8

Transfusion

11

Pre-operative mean

38.31

39.83

0.243

Post-operative mean

28.56

27.77

0.530

Types of revision surgery
Indications

ASA Grade
Anesthesia

Albumin

ASA American Society of anesthesiologis

70.9

30.6

11

0.557
0.066
0.058
0.083

0.847
0.490

0.306
22.9

0.431

Chan et al. Arthroplasty(2021) 3:38

Page 5 of 10

Table 2 Patient risk factors / Comorbidities
ciNPWT

Control

Number of patients
Total Number%

36

Number of patients

P-value%48

Risk Factors
  Prior Joint Infection

23

63.9

20

41.7

0.050

  ASA ≥ 3

21

58.3

29

60.4

0.847

  Diabetes Mellitus

12

33.3

10

20.8

0.197

  Smoker

12

33.3

11

22.9

0.289

  Cardiovascular Disease: IHD / Heart Failure / CABG / PCI before

10

27.8

12

25.0

0.774

  Obesity (BMI ≥ 30)

9

25.0

10

20.8

0.651

  Active Cancer / Previous Cancer with RT to surgical site

4

11.1

8

16.7

0.471

  Pre-operative Albumin ≤ 30

4

11.1

2

4.2

0.395

  Liver Disease

2

5.7

1

2.1

0.570

  Renal Failure

2

5.6

2

4.2

1.000

  Active Infection / Sepsis

2

5.6

3

6.3

1.000

  Depression / Schizophrenia

2

5.6

1

2.1

0.574

  Deep Vein Thrombosis

1

2.8

1

2.1

1.000

  B12 Deficiency Anaemia

1

2.8

1

2.1

0.676

  Current use of corticosteroid / Immunosuppressant

0

0

2

4.2

0.504

BMI Body Mass index, RT Radiotherapy, IHD Ischaemic Heart Disease, CABG Coronary artery bypass graft, PCI Percutaneous coronary intervention, ASA American
Society of anesthesiologists

Table 3 Comparison of bacteriology of PJI cases in the cohorts
ciNPWT(%)

Control(%)

P-value

Culture negative PJI

44%

30%

0.362

Culture positive PJI

56%

70%

0.362

Among Culture positive PJI
  • Methicillin sensitive Staphylococcus aureus

69.2%

78.6%

0.454

  • Streptococcus

15.4%

0%

0.222

  • Diphtheroids

7.7%

7.1%

0.741

  • Other organism

7.7%

14.3%

0.529

  • Antibiotic resistant organism eg MRSA, ESBL E-coli, VRSA

0%

0%

1.000

  • With gram positive Bacteria a

92.3%

100%

0.481

  • With gram negative Bacteria a

15.4%

7.1%

0.471

  • MSSA

69.2%

78.6%

0.454

  • Non-MSSA

30.8%

21.4%

0.454

  • PJI with positive culture of 1 bacteria

92.3%

92.9%

0.741

  • PJI with positive culture >  = 2 bacteria

7.7%

7.1%

0.741

MRSA Methicillin-resistant Staphylococcus aureus, ESBL E-coli Extended Spectrum Beta-Lactamase Escherichia coli, VRSA Vancomycin-resistant Staphylococcus aureus,
MSSA Methicillin sensitive Staphylococcus aureusa

Not add up to 100% because the culture results could have 2 bacteria, one gram positive and one gram negative

significant differences in the septic and aseptic revisioncase distribution in both cohorts (septic revision: ciNPWT 63.9% Vs Control 41.7%, p = 0.082). For the septic revision cases, the diagnosis of PJI was based on the
MSIS criteria [21]. There was also no statistically significant difference in culture negative PJI in both cohorts(ciNPWT 44% Vs Control30%, p = 0.362). Among PJI
cases having a positive bacterial culture, there was no
statistically significant difference in the bacteriological profile. Methicillin sensitive staphylococcus aureus(MSSA) was the most commonly found organism inboth cohorts, and there were no statistically significant

Chan et al. Arthroplasty(2021) 3:38

Page 6 of 10

differences in case distribution in both cohorts (MSSA:ciNPWT 69.2% Vs Control: 78.6%, p = 0.454). And
there were no antibiotic resistant organisms, eg methicillin resistant staphylococcus aureus, in both cohorts.
Across both cohorts, 10 patients (11.9%) developed
wound complications, including superficial SSI (n = 6),
persistent drainage (n = 3), blister formation (n = 1) andhaematoma formation requiring drainage (n = 1). There
was one case of reoperation due to superficial SSI,
other cases of superficial SSI were treated with antibiotic only.

The overall wound complication rate of the ciNPWT
cohort was 8.3% (n = 3, 2 persistent drainage, 1 blister
formation) compared to 14.6% for the control cohort(n = 7, 6 superficial SSIs, 1 persistent drainage). Hence,
the overall wound complication rates of the two cohorts
did not differ statistical significantly (p = 0.504) (Table 4,
Fig. 2). Septic wound complications (SSI and PJI) andaseptic wound complications (persistent drainage, haematoma formation, wound dehiscence, suture granuloma, blister formation, and maceration of the wound)
were compared separately. The rate of septic wound

Table 4 Summary of primary and secondary outcomes
ciNPWT
Number of patients
Total Number

Control%

36

Number of patients

P-value%48

Primary outcomes  Overall wound complications

3

8.3

7

14.6

0.504

  Septic wound complications

0

0

6

12.5

0.035*

  Aseptic wound complications

3

8.3

1

2.5

0.309

0

1

2.1

1.000

Secondary outcomes  Length of hospital stay (Mean)

31.5

  Re-operations due to wound complications

0

22.9

0.125

  90-day perioperative mortality

0

0

1

2.1

1.000

  Readmission within 30 days of surgery

0

0

0

0

1.000

*

= statistical significance at p < 0.05

Fig. 2 Comparison of wound complication rate. *= statistical significance at p<0.05

Chan et al. Arthroplasty(2021) 3:38

complication was statistically significantly higher in thecontrol cohort than the ciNPWT cohort (ciNPWT 0%
Vs Control 12.5%, p = 0.035). One patient with superficial
SSI subsequently developed PJI, which required 3 reoperations, and eventually succumbed due to persistentbacteremia. The rate of aseptic wound complications did
not differ significantly in both cohorts (ciNPWT 8.3% Vs
Control 2.5% Vs, p = 0.309).
There were no statistically significant differences in thesecondary outcomes which included the length of hospital stay (ciNPWT 31.5 ± 28.6 Vs Control 22.9 ± 19.2,,
p = 0.125), re-operations due to wound complications(ciNPWT 0% Vs Control: 2.1%,, p = 1.000), 90-day perioperative mortality (ciNPWT 0% Vs Control: 2.1%,,
p = 1.000) and readmission within 30 days of surgery(ciNPWT 0% Vs Control: 0%,, p = 1.000).

Discussion
The basic scientific mechanism, and the advantages of
ciNPWT were well-reported [22–24]. Immediate effectsof ciNPWT include protecting the incision from external contamination, decreasing the lateral tension appliedon the incision, increasing the appositional strength,normalizing stress distribution and increasing skin perfusion. Long-term benefits include improving incisionquality, in terms of the mechanical strength, histologicaland gene expression profile.
A recent meta-analysis of 11 studies on ciNPWT in
knee or hip arthroplasty (including 8 randomized trials and 3 comparative cohort studies) found that ciNPWT could significantly reduce the incidence of woundcomplication and SSI in high-risk patients, and patients
undergoing revision arthroplasties when compared withconventional dressing [25]. Among the high-risk patients,
the ciNPWT cohort had significantly lower rates ofwound complication (OR = 0.38, p = 0.030) and SSI(OR = 0.24, p = 0.005). Likewise, among patients undergoing revision arthroplasty, the ciNPWT cohort had
lower rates of wound complication (OR = 0.33, p < 0.001)
and SSI (OR = 0.26, p = 0.004). However, there were no
significant differences in wound complication and SSI
between ciNPWT versus conventional dressing among
non-high-risk patients and patients undergoing primaryarthroplasty. Another meta-analysis involving 8 randomized trials reported a significantly lower overall SSI
risk for primary and revision arthroplasty in patients having ciNPWT compared to conventional dressings, andspecifically lower in revision THA and TKA [26]. However, ciNPWT may increase the risk of noninfectious
complications after primary TKA, such as blisters, seroma, hematoma, persistent drainage and wound dehiscence [26].

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Existing studies demonstrated the effectiveness of ciNPWT in decreasing wound complications, specificallyin revision arthroplasty. In a 2016 comparative study
involving high-risk patients with multiple risk factors for
SSIs, the ciNPWT group had significantly fewer woundcomplications (6.7% vs 26.9%, p = 0.024) and SSIs (3.3%
vs 18.5%, p = 0.045) compared to patients treated with
antimicrobial dressings [27]. In a 2019 randomised controlled cohort study involving revision arthroplasty inpatients with risk factors for wound complications [28],the ciNPWT group had a significantly lower woundcomplication rate (10.1% vs 23.8%, p = 0.022) and rate of
re-operation (2.5% vs 12.5%, p = 0.017) than the control
group (who received conventional dressing). However,
ciNPWT was not found to have any significant effect on
reducing the number of superficial or deep surgical site
infections.
The majority of the literatures studying the use of ciNPWT in arthroplasty were from North America. Thismight be explained by the current marketing strategies
by the industrial companies in targeting the users of
ciNPWT devices in the North America. At present, theciNPWT market was primarily located in North America, with a revenue of USD 738.1 million in 2018 [29].
Nevertheless, the demand for ciNPWT was projected toincrease in the Asia–Pacific region, especially In China.
The ciNPWT market was expected to grow at a tremendous high rate between 2020 and 2027 in China as
the growing economy expediate the market demand fora better dressing material for the postoperative surgicalwound management [30].
There is a paucity of clinical data from local and Asian
regions. In a recent comparative study in China involving patients undergoing total ankle replacement, the ciNPWT group had lower rates of wound complication 7.7%
vs 19.0%, p = 0.34) and infection (0% vs 4.8%, p = 0.62,[31], although these differences were not statistically significant. Hence, our study aimed to further investigate
the role of ciNPWT in Asian patients undergoing arthroplasty. Our study showed that ciNPWT could reduce therate of superficial surgical site infections (0% vs 12.5%,
p = 0.035) when compared to conventional dressing.
Because of the convincing data showed in our study, ciNPWT is currently used for all patients who undergo revision arthroplasty in our institution.
In our study, it was interesting to note that the overall wound complication rate of the ciNPWT cohort andcontrol cohort did not differ significantly (8.3% vs 14.6%,
p = 0.504). It was caused by the higher number of noninfectious wound complications in ciNPWT cohort,in particular blister formation. The increase in the blister complication in the surgical wound among ciNPWT
cohort might result from inadequate experience in theChan et al. Arthroplasty(2021) 3:38

application of ciNPWT during the initial use. Although
the difference was not statistically significant, the precautions in the application of ciNPWT to avoid blister formation should be taken. An earlier study using ciNPWTin total knee arthroplasty was prematurely terminated
due to blister formation and maceration of the surrounding skin [32]. Vaez-zadeh proposed blisters could form at
the interface of the foam edge and the transparent film
under the effect of negative pressure, if the skin is notwell protected by transparent film in accordance withthe manufacturer’s recommendations [33]. In our study,
a patient was complicated by the blister formation in the
ciNPWT cohort on postoperative day 4 (Fig. 3). ciNPWT was stopped, and the conventional dressing wasapplied. Blisters resolved eventfully without any further
complications. To avoid blister formation, the following
procedures were recommended during the applicationof ciNPWT. First, the skin around the surgical woundshould be cleaned up and dried thoroughly to ensure no
foreign products interfering the negative suction. Second, the foam dressing should be accurately positioned
to avoid the foam edge placing directly over edges of thesurgical wound because the negative suction force may
cause secondary injury to the wound edges. Third, it isimportant to ensure that the transparent film applied
over the foam does not create excessive air spaces or
bubbles around the foam dressing, which may affect thepressure distribution on the intact skin around the foam
dressing. When the transparent film was applied to theknee, the knee should be flexed around 60 degrees so as
to minimize the maceration of the skin upon knee flexion. Fourth, daily checking and documentation of theperi-wound skin condition should be undertaken by the
medical and nursing team.
One of the concerns of using ciNPWT was the cost of
the device, but it was showed to be cost-effective paradoxically in further studies. The main reasons for hospital
readmission after hospital discharge among patients having arthroplasty were infection and wound complication,
which contributed 35.9% and 14.4% of the unplanned
readmissions respectively [34]. By reducing woundcomplications, ciNPWT could potentially result in costsavings by reducing hospital readmission, and the subsequent surgical management such as reoperation anddebridement. In a UK cost-effectiveness analysis on primary hip and knee arthroplasty, an estimated USD1607
per patient could be saved by using a single-use ciNPWT
device instead of conventional dressings, with greatersavings demonstrated in high-risk subgroups such as
patients with obesity and ASA grade ≥ 3 [35].
There are limitations to this study. First, two models of ciNPWT device, including PICO and Prevena,
were applied in the current study, and this may cause

Page 8 of 10

Fig. 3 Blisters were observed medial to surgical incision, which
subsequently resolved with conventional dressing

heterogeneity in our results. The prinicipal difference between two devices is the design in foam layers:
Prevena having a single layer of foam dressing, while
PICO having 4 layers of dressing. Since there was no
study demonstrating any significant clinical difference
between the two products, they were not analyzed
separately in our study. Second, although baseline characteristics of the two cohorts were compared, it is possible that some confounders may be missed due to theretrospective nature of our study. Third, the antibiotic
used postoperatively among the septic revision cases
were not compared because of the heterogenicity of theChan et al. Arthroplasty(2021) 3:38

antibiotic used. This might contribute to the confounding factor. Finally, hip and knee revision arthroplasties,
and septic and aseptic revision was not analysed separately in both cohorts because of the insufficient number of revision cases. Additionally, sub-group analysis
could be performed in future study involving higher
caseloads. Nevertheless, our study was among the firststudy to investigate the clinical outcome of ciNPWT in
Asian patients after revision arthroplasties. Together
with existing literature, this work opens to the way
towards the use of ciNPWT for wound managementin patients undergoing revision arthroplasty or at highrisk of surgical site infection.

Conclusion
The application of ciNPWT could result in a lower rateof superficial surgical site infection when compared withconventional dressing among the patients undergoing
revision total knee and total hip arthroplasties.
These results supported the use of ciNPWT in patients
undergoing revision arthroplasty. Proper training andprecautions should be made during the application of
ciNPWT to avoid blister formation.
Abbreviations
ASA: American Society of Anaesthesiologists; CDC: Centers for Disease
Control; ciNPWT: Close Incisional Negative Pressure Wound Therapy; ESBL
E-coli: Extended Spectrum Beta-Lactamase Escherichia coli; HKU/HA HKW
IRB: Institutional Review Board of University of Hong Kong/Hospital Authority
Hong Kong West Cluster; MRSA: Methicillin-resistant Staphylococcus aureus;
MSSA: Methicillin sensitive Staphylococcus aureus; MSIS: Musculoskeletal
Infection Society; NICE: National Institute for Health and Care Excellence; OR:
Odds Ratio; PJI: Prosthetic joint infection; RR: Risk Ratio; SSI: Superficial SurgicalSite Infection; THA: Total Hip Arthroplasty; TKA: Total Knee Arthroplasty; VRSA:
Vancomycin-resistant Staphylococcus aureus.
Acknowledgements
We also acknowledge and express our gratitude to Ms LS Lee for English editing advices.
Authors’ contributions(1) Concept or design: Ping Keung Chan, (2) Acquisition of data: Wing Chiu
Fung, Kar Hei Lam, Winnie Chan, Vincent Wai Kwan Chan. (3) Analysis orinterpretation of data: Ping Keung Chan, Wing Chiu Fung, Kar Hei Lam, Henry
Fu, Amy Cheung, MH Cheung. (4) Drafting of the article: Ping Keung Chan,
Wing Chiu Fung. (5) Critical revision for important intellectual content: Chun
Hoi Yan, Kwong Yuen Chiu. All authors had full access to the data, contributed
to the study, approved the final version for publication, and take responsibility
for its accuracy and integrity.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Availability of data and materials
The datasets used and/or analysed during the current study are available fromthe corresponding author on reasonable request.

Page 9 of 10

Declarations
Ethics approval and consent to participate
Approval from Institutional Review Board of the University of Hong Kong/
Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) was obtained
for this study (Reference no. UW 21–034). Patient consents were waived by theInstitutional Review Board.
Consent for publication
Not applicable.
Competing interests
Chun Hoi Yan and Kwong Yuen Chiu are the members of the Editorial Board of
Arthroplasty and other authors declare that they have no competing interests.
All authors were not involved in the journal’s review of or decisions related
to this manuscript.
Author details
1
Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong
Kong SAR, China. 2 Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China. 3 Department of Nursing, Queen
Mary Hospital, Operation Theatre Services, Hong Kong SAR, China.
Received: 17 March 2021 Accepted: 16 August 2021

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