Can Closed Incisional NPWT Reduce the Risk of Wound Complications after Revision TKA?
Silver-impregnated occlusive dressings have become the standard of care for covering the surgical wound after revision total knee arthroplasty (TKA), and in most cases, they’re the right choice for prevention of surgical site complications.
Some revision TKA patients, though, have comorbidities that put them at a higher risk for postoperative surgical site complications. What options are available to prevent these complications in high-risk patients?
A pilot study from Cleveland Clinic suggested that 1 option may be closed incisional negative pressure wound therapy (ciNPWT), which was shown in that study to decrease the risk of surgical site complications, surgical site infections, and reoperations. 
The study had some limitations related to the randomization process and the size of the analyzed cohorts, however, and “for that reason, we decided to do a multicenter, prospective, randomized study with a larger cohort,” said senior author Carlos Higuera Rueda, MD, Center Director of Cleveland Clinic Florida’s Orthopaedic & Rheumatologic Center and Chairman of the Levitetz Department of Orthopaedic Surgery.
The results of this multicenter study – presented recently at the annual meeting of the Musculoskeletal Infection Society (MSIS) – confirmed the positive results of the pilot study, showing that ciNPWT mitigates 90-day surgical site complications and readmission rates in high-risk revision TKA patients. It also requires fewer dressing changes than the standard of care product (silver-impregnated occlusive dressings).
“Given the prior results and anecdotal experience, we were not surprised by the findings,” said Dr. Higuera Rueda, who is MSIS president and who was program chair for the 2020 annual meeting. “This intervention works well to prevent surgical site complications.”
For the multicenter study, the researchers randomized 294 revision TKA patients who were considered to be at high risk for surgical site complications to receive either ciNPWT or the standard of care (147 patients in each group). The groups were further stratified by the reason for revision, either aseptic or septic. Dr. Higuera Rueda said “high risk” was defined as patients having 1 or more of the following:
- BMI greater than 35
- Use of anticoagulants other than aspirin after surgery
- Peripheral vascular disease
- Diabetes mellitus
- Current tobacco use
- History of prior infection
- Current use of immunomodulators or steroids
- Current history of cancer or hematologic malignancy
- Rheumatoid arthritis
- Renal failure or dialysis
- Liver disease
- Transplant status
- Positive for human immunodeficiency virus
The duration of treatment for patients in the ciNPWT group was a minimum of 5 days, with the suction system adjusted at 125mmHg. The researchers assessed outcomes through 90 days after surgery and calculated surgical site complication rates using intention to treat (ITT) and modified ITT analyses. They also used ITT to evaluate healthcare utilization and patient-reported outcomes.
Of the original cohort, 242 patients completed the follow-up, 124 in the ciNPWT group (84.4%) and 118 in the standard of care group (80.3%). The ITT analysis showed that the rate of surgical site complications was significantly lower with ciNPWT than with the standard of care (P=0.001). The modified ITT analysis had a similar result, with a surgical site complication rate of 4% for ciNPWT compared with 16.4% for standard of care (OR:0.22, 95%CI [0.08, 0.59]; P=0.001). A lower readmission rate and fewer dressing changes were also seen in the ciNPWT group compared with the standard of care group.
Dr. Higuera Rueda said that ciNPWT is reserved for high-risk patients who would gain the most from this technology. Cost may be an issue, but the “cost-benefit makes sense, as a readmission or reoperation is way more expensive than the device,” he said.
Emara A, Cooper H, Cross M, Guild G, Nam D, Scuderi G, Cushner F, Silverman R, Higuera Rueda C. Decreased 90-Day Surgical Site Complication Rates with Closed Incision Negative Pressure Therapy after Revision Knee Arthroplasty: A Randomized Trial. Abstract 69. Presented at the 30th Annual Open Scientific Meeting of the Musculoskeletal Infection Society, August 7-8. The program and abstracts can be found here.
- Newman JM, Siqueira MBP, Klika AK, Molloy RM, Barsoum WK, Higuera CA. Use of closed incisional negative pressure wound therapy after revision total hip and knee arthroplasty in patients at high risk for infection: a prospective, randomized clinical trial. J Arthroplasty. 2019 Mar;34(3):554-559.e1. Epub 2018 Nov 17.