Use of negative pressure wound therapy on conflict-related wounds
Authors: Rex E Atwood, Matthew J Bradley, Eric A Elster
Journal: The Lancet Global Health (2020)

For the past 20 years of armed conflict in Afghanistan, Iraq, and neighbouring states, negative pressure wound therapy (NPWT) has played a crucial role in the management of extremity soft tissue injuries for US forces.1Cubano M Butler F Emergency war surgery.5th edn. The Borden Institute, Fort Sam Houston2018: 97-108Google Scholar, 2Connolly M Ibrahim Z Johnson O Changing paradigms in lower extremity reconstruction in war-related injuries.Mil Med Res. 2016; 3: 9Crossref PubMed Google Scholar After aggressive and prompt surgical debridement, NPWT was commonly used before evacuation from combat-theatre hospitals. Almost all US military casualties with extremity wounds, especially those needing delayed or complex reconstruction, arrive with NPWT in place on arrival to the USA for tertiary care. NPWT aids extremity-injured casualties in several ways. First, NPWT allows containment of contaminated wounds from clean wounds obtained in course of care, such as trauma laparotomies or vascular cut downs. Second, NPWT can increase the interval between trips to the operating room, increasing recovery time between each anaesthetic and debridement. Last, NPWT can be used on conformationally challenging wounds that can be difficult to access during standard nursing care or difficult to tolerate for a non-anaesthetised patient, such as wounds located on the groin and perineum, and amputations.3Milcheski D Zampieri F Nakamoto H Tuma Júnior, P Ferreira M Negative pressure wound therapy in complex trauma of perineum.Rev Col Bras Cir. 2013; 40: 312-317Crossref PubMed Scopus (11) Google Scholar The randomised trial by Andreas Älgå and colleagues4Älgå A Haweizy R Bashaireh K et al.Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial.Lancet Glob Health. 2020; 8: e423-e429Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar provides data procured in a combat zone (Syria) from civilians with injuries similar to those seen in US service members. Älgå and colleagues randomly assigned patients receiving traumatic extremity soft tissue injury to treatment with NPWT or standard wound care in a resource-constrained setting. The primary endpoint was closure by day 5 with coprimary endpoints of bleeding, amputation, wound infection, and sepsis. The trial provides a review of relevant randomised controlled trials and meta-analyses. It adds to the growing body of literature showing that NPWT might not be superior to standard wound care, especially in resource-constrained settings. As cited in the Article,4Älgå A Haweizy R Bashaireh K et al.Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial.Lancet Glob Health. 2020; 8: e423-e429Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar multiple examples from literature show use of NPWT in traumatic wounds to be contradictory. The key conclusion of this study is that NPWT does not improve wound closure at day 5 day or local complications in patients with small to moderately sized wounds and with minimal additional trauma burden. However, as with many studies regarding use of NPWT, the endpoints of the trial used to determine success or failure of therapy matter substantially. This trial used wound closure at day 5 as its primary outcome, which might be appropriate for isolated extremity injury. However, with casualties severely injured in combat and large, contaminated wounds, 5 days becomes an unrealistic endpoint. Closing extremity wounds in patients with severe polytrauma weeks after initial injury is not uncommon, especially if the wounds have fungal contamination or the surgical team is attempting limb salvage. Additionally, the finding that the proportion of patients with wound infection in the conventional treatment group was higher than in the NPWT group, although not reaching statistical significance, is noteworthy as these patients had a smaller wound area and generally more favourable wound characteristics (less underlying fracture, vascular, or neurological injury). Finally, NPWT is often cited as being more expensive than conventional therapy, yet large cost savings can be achieved with fewer trips to the operating room and fewer dressing changes by surgical, nursing, or wound care personnel. Although not thoroughly tested like commercially available products, improvised NPWT devices have been described and can be a useful adjunct in resource-constrained settings.5Tiwari N Ganguly G Garg A Use of improvised vacuum assisted suction drainage for cases of deep sternal wound infection.Heart Lung Circ. 2013; 22: 542-544Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar One of the most important questions to be answered regarding NPWT in traumatic wounds is how to identify which patients will benefit from NPWT on the basis of their initial debridement. Additionally, it needs to be further established when wounds undergoing NPWT are ready for closure. The surgeon needs to balance the patient's overall trauma burden with the anticipated closure method for each wound and determine whether NPWT can increase closure speed or decrease risk of wound or systemic complications. For surgeons debating time to closure, a study6Lisboa F Dente C Schobel S et al.Utilizing precision medicine to estimate timing for surgical closure of traumatic extremity wounds.Ann Surg. 2019; 270: 535-543Crossref PubMed Scopus (3) Google Scholar by the senior author established a clinical decision support tool, using cytokines from effluent of the NPWT device on traumatic wounds, to help determine optimal time to closure. Although such tools are not yet available in low-resource settings, technology will evolve to allow broad application and augment such decision making. We agree with Älgå and colleagues4Älgå A Haweizy R Bashaireh K et al.Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial.Lancet Glob Health. 2020; 8: e423-e429Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar that further investigation into this topic is warranted, specifically looking at NPWT use with different closure methods in mind. We declare no competing interests. Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trialNPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. Full-Text PDF Open Access