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. 2019 Apr 4;16(4):960–967. doi: 10.1111/iwj.13128

Negative pressure wound therapy as a definitive treatment for upper extremity wound defects: A systematic review

Julien Shine 1, Johnny I Efanov 1,✉, Laurence Paek 1, Édouard Coeugniet 1, Michel A Danino 1, Ali Izadpanah 1
PMCID: PMC7948791  PMID: 30950218

Abstract

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: “upper extremity,” “arm,” “forearm,” “wrist,” “hand,” “finger” AND “negative‐pressure wound therapy,” “VAC therapy,” “vacuum assisted closure.” A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Keywords: hand, NPWT, upper extremity, VAC

1. INTRODUCTION

Wound defects of the hand and upper extremity represent a sizeable reconstructive challenge because of the anatomical and mechanical complexity of this region. Hand stiffness and disability can occur as a result of the treatment option that was chosen. Soft tissue composition also differs significantly depending on the specific area of the upper extremity, with thicker palmar surface of the hand providing protection and precise sensitive feedback versus the thin and supple dorsal counterpart, which affords unimpeded glide to underlying tendons and musculature. In addition, underlying avascular structures of the volar portion make for a poor recipient site to any newly grafted skin, and the limited area of adjacent tissue and relative lack of superfluous musculature make for a paucity of available local or regional flaps, especially in cases of extensive upper extremity injury.1, 2, 3

The necessity of rapidly covering the tendinous, osseous, and ligamentous structures of the hand has thus compelled hand surgeons to resort to more complex echelons of the reconstructive ladder, including free flap and staged groin flap reconstructions. However, patient comorbidities, polytrauma, and technical complexity may limit the success of such complex procedures.4 The search for simpler definitive or temporary alternatives of coverage is ongoing.

Negative pressure wound therapy (NPWT) has become ubiquitous in many surgical specialties as it has been shown to accelerate tissue growth and reduce length of hospital stay.5, 6, 7 Attributes such as its relative accessibility, low cost, rapid wound healing, and early mobilisation have made NPWT a popular method for the coverage of soft‐tissue defects of the upper extremity, either as an adjunct to more complex surgical interventions or as an ultimate procedure.8, 9, 10

However, indications are not universal, and the need for revision surgery after NPWT is unavoidable in certain cases. Therefore, the goal of this study was to perform a systematic review of the literature in order to investigate the most common indications of NPWT in the upper extremity and to determine the success rate when this therapy is used as a definitive treatment option.

2. METHODS

A systematic review of the literature was performed according to the PRISMA standards. Embase, Medline, and PubMed were searched from 1 January 1997 to 1 August 2018. The following keywords and their combinations were used: “upper extremity,” “arm,” “forearm,” “wrist,” “hand,” “finger” AND “negative‐pressure wound therapy,” “VAC therapy,” “vacuum assisted closure” to extract all articles pertaining to reconstruction of the upper extremity with NPWT. Reference lists from the articles resulting from in the keyword search were analysed for relevance. Articles written in languages other than English were excluded, as well as publications reporting on animal experimentation.

As the objective of this study was to garner an appreciation of the breadth of applications of NPWT in upper extremity reconstruction, studies of all levels of evidence were included in the review. Year and journal of publication, the type of methodology and the number of patients included, the presence or absence of a comparison group, the indication and anatomical location of the intervention, the type and number of complications, and the overall outcome of the interventions were extracted from the selected manuscripts.

Cases with NPWT used as definitive treatment were classified either as a success, a partial failure, or a total failure. Definitions of each category are as follows: complete coverage of soft‐tissue defect requiring no revision intervention is considered a success; a partial loss of coverage requiring either conservative or minor surgical intervention is considered a partial failure; and a complete loss of coverage requiring additional major surgical intervention is considered a complete failure. Functional and aesthetic outcomes were not included in this systematic review. Statistical analysis was performed and presented as measures of central tendency, with mean values and percentile ranges.

3. RESULTS

A total of 45 articles published between 1999 and 2018 were included in this systematic review (Table 1). They represent 404 cases of upper extremity reconstruction requiring NPWT as a definitive treatment. Of these articles, 42% (n = 19) were case reports, 29% (n = 13) were case series, 20% (n = 9) were retrospective analyses, and 9% (n = 4) were prospective randomised studies. They accounted for, respectively, 5% (n = 19), 24% (n = 98), 55% (n = 224), and 16% (n = 63) of the total number of cases (Figure 1).

Table 1.

Characteristics of 45 included studies on applications and success of VAC therapy on upper extremity

Author Year Journal Methodology Comparison # cases
Zhou M et al 2013 Microsurgery Retrospective Dressing changes 25
Andrews BT et al 2006 Laryngoscope Retrospective No 34
Avery C et al 2000 Int J Oral Maxillofac Surg Case series No 15
Chipp E et al 2014 J Wound Care Case series No 5
Dadaci M et al 2016 J Wound Care Retrospective No 11
Foo A et al 2009 J Plast Reconstr Aesthet Surg Case report No 1
Fujitani T et al 2015 J UOEH Case series No 2
Fujiwara M et al 2011 Hand Surg Case report No 1
Greer SE et al 1999 Ann Plast Surg Case series No 2
Hasegawa K et al 2013 Acta Med Okayama Case series No 4
Hynes PJ et al 2002 Br J Plast Surg Case series No 5
Kamolz L et al 2013 Burns Case series No 12
Kang GC et al 2008 Int Wound J Case report No 1
Kasukurthi R et al 2010 Hand (N Y) Case series No 7
Kilian M 2016 Chin J Traumatol Case report No 1
Kneser U et al 2006 Zentralbl Chir Retrospective No 7
Koehler C et al 2008 J Trauma Case report No 1
Kopp J et al 2006 Zentralbl Chir Case report No 1
Lesiak AC et al 2013 J Hand Surg Am Case report No 1
Narayan N et al 2014 BMJ Case Rep Case report No 1
Ng R et al 2006 J Plast Reconstr Aesthet Surg Case report No 1
DeFranzo AJ et al 1999 Plast Reconstr Surg Case report No 1
Patel R et al 2012 J Hand Surg Am Case report No 1
Polykandriotis E et al 2006 Zentralbl Chir Case series No 9
Pyle JW et al 2010 Hand (N Y) Case report No 1
Sommier B et al 2014 J Hand Surg Eur Vol Case report No 1
Seyhan H et al 2006 Zentralbl Chir Case report No 1
Stannard JP et al 2009 J Orthop Trauma RCT Serial debridements with dressing changes 3
Steiert AE et al 2009 J Plast Reconstr Aesthet Surg Case series No 10
Taylor CJ et al 2011 J Hand Surg Am Case report No 1
Ullmann Y et al 2006 Ann Plast Surg Case series No 8
Uygur F et al 2008 Int Wound J Case report No 1
Vidrine DM et al 2005 Otolaryngol Head Neck Surg Retrospective Bolster + splint 20
Weinand C 2009 J Burn Care Res Case report No 1
Zannis J et al 2009 Ann Plast Surg Retrospective Wet‐to‐dry dressing 68
Chio EG et al 2010 Otolaryngol Head Neck Surg RCT Static pressure dressing 23
Ehrl D et al 2018 J Burn Care Res Retrospective no 47
Niu XF et al 2017 Orthopaedics & Traumatology: Surg & Res Case series no 17
Petkar KS et al 2011 Burns RCT yes 7
Shim HS et al 2018 Biomed Research International RCT yes 30
Poulakidas SJ et al 2016 J Burn Care Res Retrospective no 3
Matsushita Y et al 2012 Hand Surg Case series no 2
Takeuchi N et al 2011 Fukuoka Igaku Zasshi Case report no 1
Aydin U et al 2010 J Plast Reconstr Aesthet Surg Case report no 1
Wang F et al 2015 Ann Plast Surg Retrospective no 9
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Figure 1.

Figure 1

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Type of methodology

The forearm was the anatomical location involved in 53% (n = 213) of cases, the hand in 36% (n = 147), the fingers in 10% (n = 39), and proximal to elbow in 1% (n = 5) (Figure 2). Seventeen different indications were cited across the 45 manuscripts. Figure 3 shows a detailed breakdown of the most commonly described indications and their respective success rates. Included in the “others” category are cases of degloving injuries (n = 4), frostbite (n = 3), splinting (n = 3), flap salvage (n = 2), paediatric gangrene (n = 1), hand reconstruction with a flap (n = 1), and postoperative care following Dupuytren's fasciectomy (n = 1).

Figure 2.

Figure 2

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Anatomical region of negative pressure wound therapy (NPWT)

Figure 3.

Figure 3

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Most common indications of negative pressure wound therapy (NPWT) and their revision rates

Figure 4 shows the number of NPWT cases that were successful (no revision intervention required), a partial failure (conservative or minor surgical intervention), and a total failure (major revision surgery). Cases of compartment syndrome, replantation, debridement of soft‐tissue defect, contracture release, wound infection, and all cases in the aforementioned “other” category had a success rate of 100%. Closure of the radial forearm flap donor site was the least successful, with only 69% (n = 65) of cases not requiring revision intervention. In total, 90% (n = 365) of cases reviewed were described as a success, whereas only 6% (n = 24) and 4% (n = 15) were considered partial and total failures, respectively.

Figure 4.

Figure 4

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Overall success, partial failure, and total failure rates

4. DISCUSSION

NPWT, first introduced in 1997,11 is now a common therapeutic adjunct that applies subatmospheric pressure to a wound by means of an adhesive dressing connected to a vacuum. Although the exact mechanism of its regenerative properties remains to be elucidated, most believe the cellular deformation induced by NPWT favours angiogenesis and mitosis.5, 6, 7 In addition, NPWT's capacity to remove excessive fluid and bacterial load, promote local perfusion,11 and approximate wound edges12 are thought to contribute to the accelerated tissue regeneration.

In comparison with the numerous potential advantages of NPWT, few contraindications exist. Direct application over exposed vessels, nerves, fresh anastomoses, and organs is strongly discouraged as shearing forces induced by the subatmospheric pressure may damage these fragile adjacent structures. The consequences of continuously suctioning the contents of a ruptured vessel may be fatal. Malignant wounds, untreated osteomyelitis, non‐enteric or unexplored fistulas, and eschar‐covered necrotic wounds are other relative contraindications of NPWT.13

NPWT is particularly appealing to cover upper extremity defects, which can prove to be challenging reconstructions. It serves to close and protect the wound, favours granulation,7 and affords surgeons additional time to consider and plan more complex reconstructive options when needed. NPWT has also been shown to improve skin graft take ‐ notoriously difficult to achieve on the dorsum of the hand as underlying tendons and bones make for poor recipient sites ‐ because it reduces the occurrence of haematoma and protects the graft from shearing forces.5 Conventional upper extremity wound dressings also pose their own challenge and may be tedious to replace daily. NPWT may thus serve to alleviate dressing changes by the nursing staff. On the other hand, some might argue that a poorly vascularised wound bed leading to scarring and loss of tendon glide is a disadvantage of NPWT.14

Other authors have explored the combined use of dermal matrices, such as Integra Matrix Wound Dressing (Integra LifeSciences, Plainsboro, New Jersey), with NPWT in complex soft‐tissue reconstructions. Several studies have demonstrated beneficial effects of combining both reconstructive techniques. An in vitro model by Baldwin et al showed that negative pressure managed to switch endothelial cells, which normally fail to fully penetrate Integra, to a migratory and proliferative phenotype and demonstrated that intermittent negative pressure allowed greatest ingress.15 Other groups showed significantly increased take rate and integration, reduced hospital stay, improved clinical outcomes, and reduced complication rates when NPWT was applied to Integra.16, 17, 18, 19, 20 Although cases of hand and upper extremity reconstructions are included in these studies, very few authors have limited their analysis to that anatomical region. Reynolds et al, who retrospectively analysed the use of Integra in 14 cases of complex oncological and non‐burn trauma hand wounds, found a non‐statistically significant reduction of mean time from Integra to skin graft placement when NPWT was used.21 A large randomised controlled trial (RCT) examining the effect of combining NPWT and Integra, or any other dermal matrix, in the specific context of complex hand injuries would be greatly beneficial to the literature.

There is an increasing body of literature on NPWT therapy for the upper extremity. As illustrated in Figure 1, prospective randomised studies represent only 9% of all articles cited in this systematic review, accounting for 16% of the 404 included cases. This may be partially explained by the very nature of negative pressure wound therapy, which does not readily lend itself to the design of RCTs. Adequate blinding of subjects and researchers is indeed difficult to achieve. VAC therapy also tends to be a long‐term solution, which increases the costs and complexity level of any prospective study. Finally, the uniqueness of upper extremity reconstructive cases impedes proper case‐by‐case comparison of outcomes. Although unable to perform a meta‐analysis because of the inclusion of a lower level of evidence studies, the 404 cases described in this systematic review nonetheless make it the largest study on the topic.

Only six studies included in this review contained a comparative group. Zhou et al compared 12 cases of upper extremity replantation requiring postoperative NPWT with eight cases subjected to conventional dressings. Although the authors found no difference in replant survival between groups, they claimed that NPWT allowed for a significant reduction in the number of days between primary and secondary surgical interventions.22

In 2009, Stannard et al examined outcomes of open wounds after open fracture fixation. Patients were brought bi‐weekly to the operating room for irrigation and debridement and treated with either NPWT (n = 35) or conventional fine‐mesh gauze dressings (n = 25). They found that, when compared with the control group, NPWT cases were only 20% as likely to develop a wound infection. It must be noted, however, that only five of these cases dealt with upper extremity injuries, three of which were assigned to the NPWT group in this systematic review.23

A RCT published by Vidrine et al in 2004 compared the effects of NPWT and conventional bolster and splint dressings in radial forearm flap donor sites. They report a significant improvement in split‐thickness skin graft 4‐week survival in 20 NPWT cases compared with the 25 control group patients.24 Chio and Agrawal found no significant improvement of radial forearm free flap (RFFF) healing in an RCT comparing 27 cases of NPWT with 27 cases using standard bolster dressings.25

Petkar et al reported a higher percentage of graft take and reduced duration of dressings in an RCT comparing NPWT with conventional dressings in 40 cases of split thickness skin graft (STSG) reconstruction in burn patients. Only 12 cases, however, implicated the upper extremity.26

Shim et al published an RCT comparing NPWT with conventional foam and splint dressings in 51 cases of acute hand trauma. They found a statistically significant reduction in time to recovery and in the Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 month in the NPWT group.27 The authors concluded that NPWT to the hand facilitated wound healing and provided immobilisation in a functional position, which decreased complications and enabled early rehabilitation.

The five most commonly encountered indications for NPWT in this systematic review are radial forearm donor site, burn care, compartment syndrome, complex hand injuries, and replantation. Together, these account for just over 80% of included cases. Less frequently cited indications include wound care related to infection or necrosis, frostbite, flap salvage, splinting, Dupuytren's fasciectomy, and hidradenitis suppurativa.

Of the 404 reviewed cases of NPWT, 365 were considered successful, meaning that no further surgical procedure was necessary for wound coverage. In comparison, only 24 and 15 were deemed partial (minor surgical revision) and total (major surgical revision) failures, respectively. This yields a 90% success rate. Eighteen partial failures and 10 total failures originate from only three studies referring to 77 cases of NPWT on RFFF donor sites. A fourth RFFF NPWT study reports no failures in 15 cases.

Split‐thickness skin graft loss of the RFFF donor site is common.8, 24, 25, 28 The most commonly cited complication is tendon exposure, reported in up to 30% or 50% of cases.29, 30 This is likely because of the proximity and mobility of underlying tendon and poor vascularity. In addition, the RFFF is most commonly used in a patient population with comorbidities that impede wound healing, such as tobacco and alcohol use, malignancy, and diabetes.8

All four studies reported good graft take at initial VAC removal, which varied from 5 to 7 days postoperatively. In their retrospective review, Andrews et al found no failure in 14 patients who kept their initial VAC in place for 6 or 7 days after several months of follow up. However, 11 of 20 patients with an initial 5‐day VAC therapy had some amount of tendon exposure at least 1 month postoperatively, which was treated with conventional wound care and eventually healed in all cases.8 In another previously described retrospective review, Vidrine et al compared 20 cases of NPWT with 25 cases of splinting and found that the latter yielded almost three times as many major graft losses ‐ defined as greater than 20% of STSG area ‐ as the former at the 4‐week follow‐up visit.24 Although both groups ultimately recommend the use of NPWT in cases of RFFF donor site reconstruction with STSG, Vidrine et al cites its high costs as a reason for reserving it for patients with predictors for poor healing, need for early hand mobilisation, or close monitoring of hand perfusion.8, 24

Chio et al, who conducted a prospective randomised study involving 54 cases of RFFF reconstruction with STSG, were the only group to find that NPWT offered no statistically significant improvement in healing of the donor site. They suggest that inadequate sample size and lack of power may have contributed to the lack of statistical significance of the observed lower number of complications in their NPWT subgroup 2 weeks postoperatively.25

Avery et al reported no failures in 15 cases of RFFF donor site STSG reconstruction. Comparatively lower defect surface area (36 cm2 versus up to 70 cm2) and shorter follow‐up period (2 weeks versus up to several months) may help explain this impressive result.28

In summary, although cases of RFFF donor site reconstruction with STSG represent a disproportionate number of failures found in this systematic review, NPWT was still generally found to be superior to conventional dressings in these patients with high complication rates. By neglecting to account for this indication, this review would show a success rate of more than 97% (n = 301 cases) in 310 total cases, with only five partial and five total failures.

Some limitations need to be addressed. First, this review only reports whether NPWT is sufficient as a definitive treatment. This study does not include cases where NPWT is used as a temporising measure or as a salvage after a failed flap reconstruction. Functional and aesthetic outcomes are not reported in the studies included in this systematic review. The application of NPWT was considered successful based on the necessity to do another surgical procedure or not. Furthermore, the inherent heterogeneity of defects, reconstructive methods, and NPWT application techniques constitute another limitation of this study. In addition, although this is the largest systematic review of upper extremity NPWT, it includes low evidence level literature and few proper comparative studies. Finally, the impact of publication bias is not negligible and should be considered when analysing the literature.

Unfortunately, this review is unable to provide the number of cases of upper extremity reconstructions that occurred during the reviewed period and that did not use NPWT. This element was not part of our search criteria, and as a consequence, most cited manuscripts do not involve such cases. The inclusion of this comparative element would be an excellent opportunity for future research and would show how frequently NPWT is used in upper extremity reconstructions and whether or not its use has increased over time. However, the aim of this study was to gain a better understanding of the various indications of NPWT and the reported success rates of these indications.

In our institution (Centre Hospitalier de l'Université de Montréal), NPWT is used frequently in cases of upper extremity reconstruction. As a referral centre for burn patients, NPWT is systematically applied to split‐thickness skin grafts or Integra applied to the upper extremity, except in the case of the relative contraindications mentioned above. Complex wounds after compartment syndrome release and necrotising infections are facilitated to heal with negative pressure entirely or as an adjunct to delayed flap reconstruction. Finally, NPWT is often utilised in the context of complex traumas of the upper extremity referred to our regional replantation programme.

5. CONCLUSION

Hand and upper extremity reconstruction can be challenging when soft‐tissue defects result in the exposure of tendons, ligaments, and muscles. This systematic review shows that NPWT can be used as a definitive treatment for wound healing in the upper extremity for a variety of indications. Large‐cohort RCTs would be beneficial in quantifying the functional and aesthetic outcomes of NPWT over conventional dressings.

Shine J, Efanov JI, Paek L, Coeugniet É, Danino MA, Izadpanah A. Negative pressure wound therapy as a definitive treatment for upper extremity wound defects: A systematic review. Int Wound J. 2019;16:960–967. 10.1111/iwj.13128

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