Paper of the week: Effect of Incisional Negative Pressure Wound Therapy vs. Standard Wound Dressing on Deep Surgical Site Infection After Surgery for Lower Limb Fractures Associated with Major Trauma

The WHIST Randomized Clinical Trial Matthew L. Costa, Ph.D.; Juul Achten, Ph.D.; Ruth Knight, Ph.D.; Julie Bruce, Ph.D.; Susan J. Dutton, MSc; Jason Madan, Ph.D.; Melina Dritsaki, Ph.D.; Nick Parsons, Ph.D.; Miguel Fernandez, Ph.D.; Richard Grant; Jagdeep Nanchahal, Ph.D.; for the WHIST Trial Collaborators

JAMA. 2020;323(6):519-526. DOI:10.1001/jama.2020.0059

Summary by Emanuele Chisari MD

Major trauma is one of the most common causes of death in the western world [1], [2]. The metabolic and inflammatory states associated with trauma put patients at high risk of surgical site infection. This risk is particularly high following major trauma to the lower extremities due to the high degree of soft tissue disruption [3], [4]. Despite many recent clinical and surgical advancements, surgical site infection remains a significant burden for both patients and health systems. Incisional negative pressure wound therapy, however, is one of many new techniques to demonstrate promising results following certain surgical procedures. To date, there is limited evidence for the effectiveness of incisional negative pressure wound therapy in mitigating orthopaedic-related surgical site infection [5], [6].
In this article, The WHIST trial collaborators presented the results of the first large multicentre study comparing traditional wound dressing with the negative pressure wound therapy for lower extremity trauma. The primary outcome was the rate of surgical site and deep infection after surgery. Although the rate of infection in the incisional negative pressure wound therapy group was slightly reduced compared to the traditional wound dressing group at both 30 days (5.8% vs. 6.7%) and 90 days (11.4% vs. 13.2%) post-operatively, there was no statistically significant difference. THE WHIST trial is the first study reporting level 1 evidence with sufficient statistical power (n=1,548) to adequately compare post-operative infection rates between traditional wound dressings and negative pressure wound therapy.

Several limitations were acknowledged by the authors. In particular, the study did not include patients whose wound could not be closed primarily. In addition, the study did not compare different types of impregnated wound dressing, which may be beneficial for preventing wound infection [7]. Finally, although the original study design only included the 30-day endpoint, the authors were able to follow-up with most patients to the 90-day endpoint with minimal (2%) drop out.


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  5. J. P. Stannard et al., “Incisional negative pressure wound therapy after high-risk lower extremity fractures,” J. Orthop. Trauma, vol. 26, no. 1, pp. 37–42, Jan. 2012.
  6. G. E. Glass, G. F. Murphy, A. Esmaeili, L. M. Lai, and J. Nanchahal, “Systematic review of molecular mechanism of action of negative-pressure wound therapy,” British Journal of Surgery, vol. 101, no. 13. John Wiley and Sons Ltd, pp. 1627–1636, 01-Dec-2014.
  7. K. Goswami, K. L. Stevenson, and J. Parvizi, “Intraoperative and Postoperative Infection Prevention,” J. Arthroplasty, vol. 35, no. 3, pp. S2–S8, Mar. 2020.

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