Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery.
AdogwaOFatemiPPerezE, et al. Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience. Spine J. 2014;14(12):2911-2917.
2.
AkbariAMoodiHGhiasiFSaghebHMRashidiH. Effects of vacuum-compression therapy on healing of diabetic foot ulcers: randomized controlled trial. J Rehabil Res Dev. 2007;44(5):631-636.
3.
AndresTvon LubkenFFriemertBAchatzG. Vacuum-assisted closure in the management of degloving soft tissue injury: a case report. J Foot Ankle Surg. 2016;55(4):852-856.
4.
ArgentaLCMorykwasMJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563-576; discussion 577.
5.
BegkasDMichelarakisJMirtsiosHDeimedesPBougiouklisD. The role of negative pressure wound therapy in salvaging a six-year-old child’s crushed foot—a case report. Foot Ankle Surg. 2018;24(1):e1-e6.
6.
BlumePAWaltersJPayneWAyalaJLantisJ. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care2008;31(4):631-636.
7.
BondsAMNovickTKDietertJBAraghizadehFYOlsonCH. Incisional negative pressure wound therapy significantly reduces surgical site infection in open colorectal surgery. Dis Colon Rectum. 2013;56(12):1403-148.
8.
BourguistOGustafssonLIngemanssonRMalmsjöM. Micro- and macromechanical effects on the wound bed of negative pressure wound therapy using gauze and foam. Ann Plast Surg. 2010;64(6):789-93.
9.
ClareMPFitzgibbonsTCMcMullenSTSticeRCHayesDFHenkelL. Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int. 2002;23(10):896-901.
10.
DickensJFKilcoyneKGKlukMWGordonWTShawenSBPotterBK. Risk factors for infection and amputation following open, combat-related calcaneal fractures. J Bone Joint Surg Am. 2013;95(5):e24.
11.
EdwardsRHardingKG. Bacteria and wound healing. Curr Opin Infect Dis. 2004;17(2):91-96.
12.
FierhellerMSibbaldRG. A clinical investigation into the relationship between increased periwound skin temperature and local wound infection in patients with chronic leg ulcers. Adv Skin Wound Care2010;23(8):369-379; quiz 380-381.
13.
GoldsteinJAIorioMLBrownBAttingerCE. The use of negative pressure wound therapy for random local flaps at the ankle region. J Foot Ankle Surg. 2010;49(6):513-516.
14.
GossSGSchwartzJAFacchinFAvdagicEGendicsCLantisJC2nd. Negative pressure wound therapy with instillation (NPWTi) better reduces post-debridement bioburden in chronically infected lower extremity wounds than NPWT alone. J Am Coll Clin Wound Spec. 2012;4(4):74-80.
15.
GoudieEBGendicsCLantisJC2nd. Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers. Int Wound J2012;9(2):132-138.
16.
GrauhanONavasardyanAHofmannMMullerPSteinJHetzerR. Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. J Thorac Cardiovasc Surg. 2013;145(5):1387-1392.
17.
HermansMHCuttingK. NPWT or HRT-dressing? Results of an expert panel and a Delphi panel analysis. J Wound Care. 2013;22(11):573-574, 576-581.
18.
JentzschTOsterhoffGZwolakP, et al. Bacterial reduction and shift with NPWT after surgical debridements: a retrospective cohort study. Arch Orthop Trauma Surg. 2017;137(1):55-62.
19.
JungiusKPChillaBKLablerLTeodorovicNMarincekB. Non-invasive assessment of the perfusion of wounds using power Doppler imaging: vacuum assisted closure versus direct wound closure [in German]. Ultraschall Med. 2006;27(5):473-477.
20.
KairinosNSolomonsMHudsonDA. Negative-pressure wound therapy, I: the paradox of negative-pressure wound therapy. Plast Reconstr Surg. 2009;123(2):589-598; discussion 599-600.
KarlakkiSLHamadAKWhittallCGrahamNMBanerjeeRDKuiperJH. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: a randomised controlled trial. Bone Joint Res. 2016;5(8):328-337.
23.
KimBSChoiWJBaekMKKimYSLeeJW. Limb salvage in severe diabetic foot infection. Foot Ankle Int. 2011;32(1):31-37.
24.
LablerLRancanMMicaLHarterLMihic-ProbstDKeelM. Vacuum-assisted closure therapy increases local interleukin-8 and vascular endothelial growth factor levels in traumatic wounds. J Trauma. 2009;66(3):749-757.
25.
LaveryLABoultonAJNiezgodaJASheehanP. A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care. Int Wound J. 2007;4(2):103-113.
26.
LeeHJKimJWOhCW, et al. Negative pressure wound therapy for soft tissue injuries around the foot and ankle. J Orthop Surg Res. 2009;4:14.
27.
LiXLiuJLiuY, et al. Negative pressure wound therapy accelerates rats diabetic wound by promoting agenesis. Int J Clin Exp Med. 2015;8(3):3506-3513.
28.
LudolphIFriedFWKneppeKArkudasASchmitzMHorchRE. Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure. Int Wound J. 2018;15(6):978-984.
29.
MaZShouKLiZJianCQiBYuA. Negative pressure wound therapy promotes vessel destabilization and maturation at various stages of wound healing and thus influences wound prognosis. Exp Ther Med. 2016;11(4):1307-1317.
30.
MorykwasMJArgentaLCShelton-BrownEIMcGuirtW. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553-562.
31.
MorykwasMJSimpsonJPungerKArgentaAKremersLArgentaJ. Vacuum-assisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg. 2006;117(7)(suppl):121S-126S.
32.
MosserPKelmJAnagnostakosK. Negative pressure wound therapy in the management of late deep infections after open reconstruction of achilles tendon rupture. J Foot Ankle Surg. 2015;54(1):2-6.
33.
MouesCMvan ToorenenbergenAWHeuleFHopWCHoviusSE. The role of topical negative pressure in wound repair: expression of biochemical markers in wound fluid during wound healing. Wound Repair Regen. 2008;16(4):488-494.
34.
MouesCMVosMCvan den BemdGJStijnenTHoviusSE. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen2004;12(1):11-17.
35.
NatherAChionhSBHanAYChanPPNambiarA. Effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers. Ann Acad Med Singapore. 2010;39(5):353-358.
36.
PatmoASKrijnenPTuinebreijerWEBreederveldRS. The effect of vacuum-assisted closure on the bacterial load and type of bacteria: a systematic review. Adv Wound Care (New Rochelle). 2014;3(5):383-389.
37.
PenhallowK. A review of studies that examine the impact of infection on the normal wound-healing process. J Wound Care. 2005;14(3):123-126.
38.
PontellMESaadNWintersBSDanielJNSaadA. Reverse sural adipofascial flaps with acellular dermal matrix and negative-pressure wound therapy. Adv Skin Wound Care. 2018;31(1):612-617.
RaoAJKemptonSJEricksonBJLevineBRRaoVK. Soft tissue reconstruction and flap coverage for revision total knee arthroplasty. J Arthroplasty. 2016;31(7):1529-1538.
41.
SalcidoR. Healing by Intention. Adv Skin Wound Care. 2017;30(6):246-247.
42.
SangerPCvan RamshorstGHMercanE, et al. A Prognostic model of surgical site infection using daily clinical wound assessment. J Am Coll Surg. 2016;223(2):259-270.e2.
43.
SaxenaVHwangCWHuangSEichbaumQIngberDOrgillDP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg. 2004;114(5):1086-1096; discussion 1097-1098.
44.
SchererSSPietramaggioriGMathewsJCPrsaMJHuangSOrgillDP. The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg. 2008;122(3):786-797.
45.
SchintlerMV. Negative pressure therapy: theory and practice. Diabetes Metab Res Rev. 2012;28(suppl 1):72-77.
46.
SeoSGYeoJHKimJHKimJBChoTJLeeDY. Negative-pressure wound therapy induces endothelial progenitor cell mobilization in diabetic patients with foot infection or skin defects. Exp Mol Med. 2013;45:e62.
47.
ShenPBlackhamAULewisS, et al. Phase II randomized trial of negative-pressure wound therapy to decrease surgical site infection in patients undergoing laparotomy for gastrointestinal, pancreatic, and peritoneal surface malignancies. J Am Coll Surg. 2017;224(4):726-737.
48.
StannardJPRobinsonJTAndersonERMcGwinGJrVolgasDAAlonsoJE. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006;60(6):1301-1306.
49.
StoneCSmithN. Resection arthroplasty, external fixation, and negative pressure dressing for first metatarsophalangeal joint ulcers. Foot Ankle Int. 2011;32(3):272-277.
50.
SundbyOHHoisethLOMathiesenIJorgensenJJSundhagenJOHisdalJ. The effects of intermittent negative pressure on the lower extremities’ peripheral circulation and wound healing in four patients with lower limb ischemia and hard-to-heal leg ulcers: a case report. Physiol Rep. 2016;4(20).
51.
TangSYChenSZHuZHSongMCaoDYLuXX. Influence of vacuum-assisted closure technique on expression of Bcl-2 and NGF/NGFmRNA during wound healing [in Chinese]. Zhonghua Zheng Xing Wai Ke Za Zhi. 2004;20(2):139-142.
52.
VaseenonTSomsukW. Negative pressure wound therapy for traumatic foot and ankle wound: two case reports and review of the literature. J Med Assoc Thai. 2015;98(1):111-116.
53.
WangZQuWLiuT, et al. A two-stage protocol with vacuum sealing drainage for the treatment of type C pilon fractures. J Foot Ankle Surg. 2016;55(5):1117-1120.
54.
XiaCYYuAXQiBZhouMLiZHWangWY. Analysis of blood flow and local expression of angiogenesis associated growth factors in infected wounds treated with negative pressure wound therapy. Mol Med Rep. 2014;9(5):1749-1754.
55.
YangSLZhuLYHanRSunLLDouJT. Effect of negative pressure wound therapy on cellular fibronectin and transforming growth factor-beta1 expression in diabetic foot wounds. Foot Ankle Int. 2017;38(8):893-900.
56.
ZagrockiLRossAHicksA. Management of degloving injuries of the lower extremity: a case report of a forklift injury. Foot Ankle Spec. 2013;6(2):150-153.
57.
ZhangJHuZCChenDGuoDZhuJYTangB. Effectiveness and safety of negative-pressure wound therapy for diabetic foot ulcers: a meta-analysis. Plast Reconstr Surg. 2014;134(1):141-151.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
