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Int Wound J
Int Wound J
10.1111/(ISSN)1742-481X
IWJ
International Wound Journal
1742-4801
1742-481X
Blackwell Publishing Ltd Oxford, UK

10.1111/iwj.70034
IWJ70034
Original Article
Original Article
Incisional negative pressure wound therapy for the prevention of surgical site complications in Paediatric patients with non‐idiopathic scoliosis: A randomized clinical trial
Pérez‐Acevedo et al.
Pérez‐Acevedo Gemma 1 gemma.perez@sjd.es

Torra‐Bou Joan Enric https://orcid.org/0000-0001-9410-4668
2 3 jetorrabou@hotmail.com

Peiró‐García Alejandro 4
Vilalta‐Vidal Inmaculada 4
Urrea‐Ayala Mireia 5
Bosch‐Alcaraz Alejandro https://orcid.org/0000-0001-6369-9697
6
Blanco‐Blanco Joan 7 8 9
1 Doctoral candidate in health and advance practice nurse in pediatric complex wounds Sant Joan de Déu Hospital Barcelona Spain
2 Doctoral Program Faculty of Nursing and Physiotherapy‐GESEC, University of Lleida Barcelona Spain
3 Researcher and GRECS‐IRBLleida, Tr2Lab (Tissue Repair and Regeneration Laboratory) Research Group Institute for Research and Innovation in Life and Health Sciences in Central Catalonia (IRIS‐CC) Barcelona Spain
4 Unidad de Columna Hospital Sant Joan de Déu Barcelona Spain
5 Head, Clinical Safety Program Sant Joan de Déu Hospital Barcelona Spain
6 Department of Public Health, Mental Health and Maternal and Child Health Nursing, Faculty of Nursing University of Barcelona Barcelona Spain
7 Faculty of Nursing and Physiotherapy‐GESEC University of Lleida Lleida Spain
8 GRECS‐IRBLleida Research Group University of Lleida Lleida Spain
9 CIBERFES Biomedical Research Center en Red Institute for Research and Innovation Madrid Spain
* Correspondence
Gemma Pérez‐Acevedo, Doctoral candidate in health and advance practice nurse in pediatric complex wounds, 16‐20 Roseta Canalias St, Barcelona 08750, Spain.
Email: gemma.perez@sjd.es
Joan Enric Torra‐Bou, Doctoral Program, Faculty of Nursing and Physiotherapy‐GESEC, University of Lleida, 5 Bis Galla St, Barcelona 08031, Spain.
Email: jetorrabou@hotmail.com

03 9 2024
9 2024
21 9 10.1111/iwj.v21.9 e7003409 8 2024
26 6 2024
11 8 2024
© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Abstract

Surgical wound complications are adverse events with important repercussions for the health of patients and health system. Surgical site infections and wound dehiscences are among the most important surgical wound complications, with a high incidence in paediatric patients undergoing surgery for non‐idiopathic scoliosis. Incisional negative pressure wound therapy for surgical incisions is used as a preventive measure against surgical wound complications in adults; however, there has been scant evidence for using it in children. The purpose of this study is to evaluate the cost‐effectiveness of incisional negative pressure wound therapy in preventing surgical wound complications in paediatric patients undergoing surgery to treat non‐idiopathic scoliosis. Randomized clinical trial. Children younger than 18 years of age undergoing surgery for non‐idiopathic scoliosis were randomly assigned into two groups to receive one of two different types of dressings for the first 7 days after surgery. One group were treated with a postoperative hydrofibre and hydrocolloid dressing with silver for wounds (control group), and the other group received a single‐use incisional negative pressure wound therapy system (intervention group). The wounds were assessed after removal of the dressings at 7 days after surgery and again at 30, 90, and 180 days after surgery. Surgical wound complications, sociodemographic variables, variables related to the procedure and postoperative period, economic costs of treatment of surgical wound complications, and time to healing of the surgical wound were recorded. Per protocol and per intention to treat analysis was made. The per protocol incidence of surgical wound complications was 7.7% in the intervention group versus 38.5% in the control group (p = 0.009; Fisher exact test. RR = 0.20 IC95%: 0.05–0.83). Surgical wound dehiscence, surgical site infections, seroma, and fibrin were the most common surgical wound complications. The type of surgery, duration of surgery, and patients' age were associated with a higher risk for surgical wound complications. Postoperative hydrofibre and hydrocolloid dressing with silver for wounds were found to be associated with a longer time to healing. Initial costs for dressings in the group receiving incisional negative pressure wound therapy were higher, but the total postoperative costs were higher for those receiving postoperative hydrofibre and hydrocolloid dressing with silver for wounds. It was found that for each US$1.00 of extra costs for using incisional negative pressure wound therapy, there was a benefit of US$12.93 in relation to the cost of complications prevented. Incisional negative pressure wound therapy is cost‐effective in the prevention of surgical wound complications in children undergoing surgery for non‐idiopathic scoliosis.

negative pressure wound therapy
paediatrics
prevention
spine surgery
surgical wound complications
Support was provided by a Catalonian Health Department research grantPERIS 2017‐2021‐ SLT017/20/000194 unrestricted Smith & Nephew grantCCG00159 source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:03.09.2024
Pérez‐Acevedo G , Torra‐Bou JE , Peiró‐García A , et al. Incisional negative pressure wound therapy for the prevention of surgical site complications in Paediatric patients with non‐idiopathic scoliosis: A randomized clinical trial. Int Wound J. 2024;21 (9 ):e70034. doi:10.1111/iwj.70034
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pmc1 INTRODUCTION

The wound‐healing process is the essential mechanism by which the body repairs damage. This process consists of several essential stages, including haemostasis, inflammation, proliferation, re‐epithelialization, and tissue remodelling. Several factors may disrupt or slow down the wound healing process. This may prolong the time required for complete healing of the surgical wound and increase the risk of complications such as infection, dehiscence, seroma, and site necrosis. 1 , 2

These complications are considered adverse events that impact the health and quality of life of patients and their families. In addition, costs increase because of additional treatments and tests, extended hospital stays, and reoperations. 3 , 4

Surgical wound dehiscence is one of the possible surgical wound complications. It usually occurs within 4–14 days after surgery. 5 Surgical wound dehiscence can occur in both the superficial and deep layers of an surgical wound, which is why they are associated with the possible development of other complications such as surgical site infection. The US centres for disease control and prevention define surgical site infection as any infection that occurs within 30–90 days after surgery, with purulent drainage from the incision, dehiscence of the incision with positive findings on bacterial culture, and the presence of any of the following symptoms: fever, localized pain or pain on palpation, or an abscess or imaging test results that identify an internal tissue infection. 6 , 7 According to the centres for disease control and prevention, surgical site infections can be classified as superficial, deep, or organ/space incisional. 6

Patients with an surgical site infection have a fivefold increased risk of reoperation and a twofold increased risk of death. 6 Some authors, such as Berríos‐Torres et al 8 and Stewart, 9 have reported the overall incidence of surgical site infection to be between 1.9% and 2.8%. These numbers can increase to by 30%–40% in some at‐risk populations. 10

All patients, whether adults or children, who are undergoing surgery, can develop surgical wound complications. The correction of spinal deformities or scoliosis is one type of surgery performed when patients are children. There may not be a clear cause or comorbidity for abnormal curvature of the spine known as idiopathic scoliosis (IS). In contrast, when the abnormal curvature results from problems associated with congenital defects that cause the malformation, with neuromuscular disease, or with a syndrome, it is called non‐idiopathic scoliosis (NIS). 11 The clinical relevance of determining the type of scoliosis and postoperative treatment to be applied resides in the fact that according to the literature, 12 , 13 , 14 the likelihood of developing surgical site infections increases to between 6.1% and 15.2% in patients who undergo surgery for neuromuscular congenital scoliosis, and to between 8% and 41.7% in patients with congenital or syndromic scoliosis. 15 Moreover, it has been reported that 50% of these infections require multiple instances of debridement, antibiotic therapy, and local wound care treatments to promote complete healing, and that in 28% of cases, even after procedures such as those described have been performed, it becomes necessary to remove the materials implanted in the initial procedure. 15

Considering the impact of possible surgical wound complications on paediatric patients undergoing surgery to treat NIS, it is essential to establish preventive strategies to help reduce the incidence of these complications and avoid reoperation and removal of the materials implanted in the initial procedure. By doing so, we will improve the quality of life for patients and their families and reduce the healthcare costs related to these complications.

Negative pressure wound therapy has been known as a treatment since the late 1990s. 16 It was later observed that negative pressure wound therapy could also be indicated for primary wound closure in patients at risk for developing surgical wound complications; this technique is called incisional negative pressure therapy (iNPWT). 17 Negative pressure wound therapy is currently one of the most widely used therapies for the treatment of complex wounds. 18 It involves the application of subatmospheric pressure to a porous foam or gauze dressing placed in direct contact with the wound bed, which causes local mechanical deformation that helps the wound edges to draw together, increases local blood flow, accelerates the process of granulation tissue formation, reduces oedema, and helps reduce the bacterial load of the wound by inhibiting the enzymatic activity of pathogens, reducing the wound's exposure to the environment, protecting it from external aggressions and thereby accelerating the healing process. 19 , 20

The benefits of iNPWT for the prevention of surgical wound complications have been shown, which has led to its use as a preventive tool in adult patients with risk factors. 21 , 22 , 23 , 24 Despite the benefits for the adult population, iNPWT is not commonly used as a preventive measure in paediatric patients, reducing its usual indication for use in the management of complex wounds or extremely complicated situations. There is little published scientific literature on the subject, although what does exist reports lower incidences of surgical wound complications, surgical wound dehiscence, and surgical site infections, as well as shorter hospital stays for paediatric patients treated with iNPWT. 25

This investigation is justified considering the objective of improving prevention of surgical wound complications and generating evidence regarding cost‐effectiveness of iNPWT in preventive postoperative management of surgical wound complications in paediatric patients with NIS.

The overall objective of our research was to evaluate the effectiveness and cost of using a single‐use iNPWT system for the prevention of surgical wound complications in paediatric patients undergoing surgery for NIS (intervention group [IG]), versus using postoperative hydrofibre and hydrocolloid dressing with silver for wounds (PHHDSWs) as per the hospital's current protocol (control group [CG]).The following specific objectives stemmed from the overall goals of effectiveness and controlled cost: (1) to determine and compare the incidence of surgical wound complications in paediatric patients operated on for NIS in the CG and in the IG; (2) to analyse and compare the cost variables associated with surgical wound complication treatment in paediatric patients undergoing surgery for NIS; and (3) to assess the time to healing for paediatric patients undergoing surgery for NIS in the CG and the IG.

2 MATERIALS AND METHODS

To this end, an open randomized clinical trial was conducted from November 1, 2021, to November 1, 2022. The trial was registered with the Spanish Agency for Medicines and Medical Devices as clinical research using medical devices with European Conformity marking for approved indications with variation from the Notifications of Observational Studies of Medical Devices database, under registration number 22–0075.

This research project was conducted in accordance with Spain's national and regional regulations regarding clinical studies. Before conducting the study, we requested authorization and permits from the clinical research ethics committee of the hospital where it was conducted (authorization PS‐06‐21), which supervised the study and ensured compliance with ethical principles and standards of good practice. Confidentiality of study participants' records was protected at all times, respecting their privacy and following the ethical principles promulgated by the Declaration of Helsinki regarding respect for persons, beneficence, autonomy, and justice.

In its capacity as data controller, the hospital ethics committee ensured that the processing, communication, and transfer of the personal data of all the participants were in compliance with regulation 2016/679 of the European Parliament, of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and of organic law 3/2018 of 5 December 2018 on the protection of personal data and the guarantee of digital rights. A code was used for the data collected in this study, so it is not possible to identify the participants, thereby preserving their anonymity.

The study was conducted at a tertiary women's and children's hospital, renowned nationally and internationally for its specialist services in neurology, congenital cardiopathies, and orthopaedic surgery, among others. An average of 120 scoliosis surgeries are performed at the hospital every year, 41% of which are to treat NIS.

The study population consisted of patients from birth to 18 years of age who underwent surgery for NIS at the hospital during the study period and met the following criteria: Inclusion criteria: Patients undergoing surgery for NIS whose legal guardians agreed to voluntarily participate in the study and provide documented informed consent

Exclusion criteria: Patients who had allergic skin reactions to the dressing materials and patients who were not residents of Spain during the study period, because of the impossibility of monitoring them after surgery

Withdrawal criteria: Patients who retained the iNPWT dressing without vacuum for more than 1 day and those who did not meet the protocol requirements during postoperative management

According to the hospital's own unpublished data collected by the authors, surgical wound complications can occur in up to 40% of wounds treated with the standard treatment, and based on the hypothesis that this could be reduced to 6% with the investigational therapy, it was estimated that 26 patients were needed in each group to detect this difference, with an 80% statistical power and a level of significance of 5%, using a chi‐square test.

Patients were randomly assigned to one of the groups using a random number table entered into a database created using REDCap (Research Electronic Data Capture, software created by Vanderbilt University), to ensure that both groups were homogeneous.

The obvious differences between the two therapies prevented blinding of both the patients and the clinicians who collected the information. Therefore, only the statistical analysis was blinded.

Sociodemographic and clinical variables for the patients were recorded for the study, including the following:Sex and age, comorbidities, allergies, weight (kilograms), height (centimetres), and body mass index.

Variables related to the procedure, such as type of surgery (primary or reoperation over 6–12 months), number and size (centimetres) of the incisions, score on the American Society of Anesthesiologists Physical Status Classification System, duration of the procedure (minutes), administration of vasoactive drugs during surgery, corticosteroids during surgery, antibiotic prophylaxis and timing of preoperative administration, implant materials (titanium/chrome), pelvic fixation, fusion, administration of intrawound vancomycin powder, use of a Redon‐like drain, and type of postoperative dressing (PHHDSWs /iNPWT).

In addition, postoperative variables were recorded, including the following:Use of postoperative antibiotic therapy, postoperative vasoactive drugs, or postoperative corticosteroids.

Presence of oedema.

Admission to the paediatric intensive care unit (PICU) and duration of stay in the PICU.

Length of hospital stay (days).

Number of postoperative dressing changes.

Day when complications occurred.

When a complication occurred, data for the following items were recorded:Pharmacologic treatment and/or surgical procedures to resolve the surgical wound complication.

Whether the patient was readmitted because of the complication and length of stay.

Whether the complication caused the patient to be admitted to PICU and duration of stay.

Additional examinations for the surgical wound complication (ultrasonography, cultures, computed tomography, radiography, and/or seroma puncture).

Surgical debridement.

Cost of the dressing materials (Negative pressure wound therapy, dressings, bacteriostatic agents, and/or cleansing solutions).

Nursing time spent in treating the wound and the administration of antibiotic therapy (specifying type).

The cost of any prosthetic materials removed because of the complication.

The unit costs were provided by the hospital's financial department after analysis of each case. Nursing costs were calculated on the basis of the time spent by nurses on wound therapy, which data found takes an average of 30 min per wound.

The study protocol was designed to be accessible to all study participants. The study variables were taken from the hospital's electronic medical records. All of the patient information taken from the medical records was recorded in the REDCap database and classified into four sections: sociodemographic data, surgical procedure variables, postoperative variables, and surgical wound complication variables.

All patients were operated on by the same orthopaedic surgery team. When patients in the CG underwent their procedures, the team performed the spinal surgery as scheduled and, after closing the surgical incision and while in the same operating room, applied a PHHDSWs, which is the one that is routinely applied after this type of procedure at the hospital, adjusted to the length of the incision. Dressing size varies according to the length of the incision (Figure 1).

FIGURE 1 Postoperative hydrofibre and hydrocolloid dressing with silver for wounds (PHHDSWs).

The patients in the CG were treated with the PHHDSWs routinely used, which was left in place without being touched for the first 7 days, except when the dressing appeared to be saturated or detaching, at which point it was changed using an aseptic technique, and the date and reason for the change was recorded, following the hospital's protocol.

The same orthopaedic surgery team performed spinal surgery on the patients in the IG as scheduled and, after closing the surgical incision and while in the same operating room, applied a single‐use iNPWT dressing, adjusted to the length of the incision. This is a single‐use negative pressure wound therapy system that consists of a pump that generates continuous pressure at −80 mmHg and a dressing that applies the negative pressure to the wound surface or closed incision and manages exudate. The pump has an alarm that warns when there is a loss of negative pressure or if the dressing is saturated. The dressings come in different sizes (Figure 2).

FIGURE 2 A single‐use incisional negative pressure therapy (iNPWT).

The patients in the IG were treated with the iNPWT dressing, which was left in place without being touched for the first 7 days, except in cases in which the dressing appeared to be fully saturated and/or losing negative pressure. If the device indicator showed there was loss of seal (an air leak) before it was time to change the dressing, the edges of the dressing were reinforced and, if necessary, the device was restarted. If a dressing change was required, it was performed using an aseptic technique, and the date and reason for the change were recorded.

After 1 week, the dimensions of the incisions of each study group were measured with a metric ruler (in centimetres). The team, consisting of the orthopaedic specialist and the nurse, evaluated the presence of any signs of surgical wound complications, including wound edge separation, erythema, secretions, active exudate drainage, devitalized tissue between the wound edges, or fluctuation beneath the sutured tissues. All evaluations were performed by the same specialists and nurses, who recorded in the patient's medical record whether the surgical wound was considered healed and if it was left uncovered, applying wound tape strips (steri‐strips) that were kept in place until they fell off.

Reviews of the condition of the patients who underwent surgery and the incisions were scheduled at 30, 90, and 180 days after the procedure, in the hospital ward when the patient was hospitalized, in outpatient clinics if the patient had been discharged, or by telephone, and with an image of the wound in cases where the patient was discharged to another region and was not required to return to the study site for identification of any late surgical wound complications. In cases where a surgical wound complication had been identified earlier, it was reviewed at the time of identification, either during the patient's hospital stay, through an appointment with the nurse/specialist, or in the hospital's emergency department.

Per protocol and per intention to treat analysis was performed, in order to assess the impact who can introduce the cases who not fulfil the right protocol. We first performed a descriptive statistical analysis for each of the variables. For quantitative variables, we used descriptive measures of central tendency (mean, median, and mode) and dispersion/variability (standard deviation and variance). Qualitative variables were described using frequencies (absolute, relative/proportions, and their respective cumulative frequencies) and bar charts. The Wilcoxon rank sum test for 2 samples was used to compare the values of a numeric variable between paired samples, and the Friedman test was used to compare more than 2 samples. For 2 independent samples, the Student's t test was used, and the analysis of variance method (ANOVA) was used for more than 2. The chi‐square or Fisher's test was used to determine whether there was an association between 2 categorical variables, and the Spearman rank correlation was used to determine the relationship between 2 numeric variables. In addition, the incidence of effects in each group was calculated and reported as relative or absolute measures of risk. To estimate the effect of the treatment on the rest of the population, the 95% confidence interval was calculated, which helped us estimate the limits within which the true value of the treatment was likely to be found. A p value <0.05 was considered statistically significant. Statistical analysis was performed with the assistance of the hospital research foundation, using SPSS 24.0 software (IBM).

3 RESULTS

A total of 66 patients were included, 35 in the IG and 31 in the CG. During sample collection there were a number of drop outs in both groups, due to protocol deviations by the clinicians involved in the study. Ten patients were withdrawn from the IG. Of those, 7 were because of premature removal of the device, because they were switched to another dressing because of a lack of knowledge about how to correctly resolve problems such as leaks or dressing saturation. One patient also excluded because of manipulation of the wound that removed the dressing, another after it was determined that the patient had IS, and another who, finally, did not undergo surgery after having been included in the database and not was included on the analysis.

A total of 5 patients were withdrawn from the CG. One was because of death, a second because he did not follow the study protocol because he was switched to negative pressure wound therapy on the second day, a third because of IS, and 2 more because of wound manipulation that involved lifting the dressing.

In the end, according to the protocol, only 52 patients completed the study, 26 in the IG and 26 in the CG. The 52 patients studied were a mean age of 11.9 ± 4 years. Table 1 shows the anthropometric data for the entire study population, and Table 2 summarizes the patient characteristics for each group. Of all participants, 28.85% (n = 15) underwent surgery for the first time, whereas 71.15% (n = 37) underwent reoperation. All patients in the sample were sutured in layers with resorbable monofilament, which does not require suture removal. Table 3 shows data for the surgeries, which are detailed per study group in Table 4. Table 5 summarizes the data for the postoperative phase for each group.

TABLE 1 Sociodemographic and clinical data of the sample (n = 52).

Characteristics	Values	
Sex: n (%)	
Male	35 (67.30%)	
Female	17 (32.70%)	
Age (years): mean ± SD	11.90 ± 4.00	
Weight (kg): mean ± SD	39.33 ± 15.58	
Height (cm): mean ± SD	143.06 ± 22.03	
Body mass index: mean ± SD	19.47 ± 5.26	
Surgery type: n (%)	
Primary	15 (28.85%)	
Reoperation	37 (71.15%)	
Type of surgery n (%)	
Growing rods	14 (26.95%)	
Fusion	10 (19.23%)	
Rod lengthening/reanchoring/replacement	23 (44.23%)	
Rib distractor (vertical expandable prosthetic titanium rib implant)	5 (5.61%)	
Abbreviation: SD, standard deviation.

TABLE 2 Patients' sociodemographic and clinical data by group.

Characteristics	Control group	Intervention group	p value	
Sex: n (%)			0.03 a	
Male	21 (80.80%)	14 (53.80%)		
Female	5 (19.20%)	12 (46.20%)		
Age (years): mean ± SD	12.00 ± 4.79	11.88 ± 3.21	0.92 b	
Weight (kg): mean ± SD	42.15 ± 18.13	36.85 ± 18.13	0.40 c	
Height (cm): mean ± SD	142.81 ± 20.53	139.88 ± 15.12	0.56 b	
Body mass index: mean ± SD	20.08 ± 5.63	18.60 ± 5.06	0.42 c	
a Chi‐square test.

b Student t test.

c Mann–Whitney U test.

TABLE 3 Data for surgery features.

Feature	Values	
Surgery time, min: mean and interquartile range	103.50 (37.25–150.85)	
In patients with SWCs: mean and interquartile range	172.33 (112.50–209.25)	
In patients without SWCS: mean and interquartile range	86.25 (29.50–128)	
Surgical prophylaxis: n (%)	51 (98.1%)	
Intrawound vancomycin powder, n (%)	15 (28.84%)	
Corticosteroids during surgery: n (%)	43 (82.69%)	
Number of incisions/incision dimensions (cm)	
1 Incision: median and interquartile range	11.50 (7.00–15.25)	
2 Incisions: median and interquartile range	10.00 (6.00–14.00)	
3 Incisions: mean ± SD	5.00 ± 1.52	
Median time to healing (days)	7.0	
Control group	7 (7–199)	
Intervention group	7 (7–23)	
ASA II classification: n (%)	18 (34.60%)	
SWCs with ASA II status: n (%)	3 (25%)	
ASA III classification: n (%)	34 (65.45%)	
SWCs with ASA III status: n (%)	9 (75%)	
Administration of vasoactive drugs: n (%)	7 (13.4%)	
Antibiotic prophylaxis: n (%)	50 (96.15%)	
<30 min: n (%)	15 (30.00%)	
30 min: n (%)	16 (32.00%)	
60 min, n (%)	8 (16.00%)	
>60 min: n (%)	11 (22.00%)	
Not recorded: n (%)	2 (3.84%)	
Implant materials	
Titanium: n (%)	38 (73.1%)	
Cobalt‐chrome: n (%)	3 (5.76%)	
Pelvic fixation: n (%)	4 (11.5%)	
Fusion: n (%)	10 (19.23%)	
Fusion SWCs: n (%)	2 (3.84%)	
Redon drain: n (%)	0 (0%)	
Abbreviations: ASA, American Society of Anesthesiologists; SWCs, surgical wound complications.

TABLE 4 Characteristics of surgery by group.

Variables	Control group	Intervention group	p values	
Type of surgery, n (%)			1.00 a	
Primary	8 (30.80%)	7 (26.90%)		
Reoperation	18 (69.20%)	19 (73.00%)		
Duration of surgery, min: median and interquartile range	126.69 (45.75–185.75)	85.54 (27.75–129.25)	0.09 b	
Intrawound vancomycin powder, n (%)	9 (34.61%)	6 (23.07%)	0.54 a	
Corticosteroids during surgery, n (%)	21 (80.80%)	22 (84.60%)	1.00 c	
No. of incisions/incision size (cm)			0.23 b	
1 Incision: n (%)/median and interquartile range	13 (50.00%)/18.12 (8.00–30.50)	17 (65.40%)/12.36 (7.00–15.00)	0.29 b	
2 Incisions: n (%)/median and interquartile range	12 (48.00%)/8.62 (5.00–12.00)	8 (30.80%)/11.1 (8.00–14.00)	0.34 b	
3 Incisions: n (%)/mean ± standard deviation	1 (4.00%)/7.00 (7.00–7.00)	1 (3.80%)/4.00 (4.00–4.00)		
ASA classification			0.24 a	
ASA II: n (%)	7 (26.90%)	11 (42.30%)		
ASA III: n (%)	19 (73.10%)	15 (57.70%)		
Antibiotic prophylaxis: n (%)	25 (96.15%)	25 (96.15%)	1.00 c	
<30 min: n (%)	6 (24.00%)	9 (36.00%)		
30 min: n (%)	6 (24.00%)	10 (40.00%)		
60 min: n (%)	6 (24.00%)	2 (8.00%)		
>60 min: n (%)	7 (28.00%)	4 (16.00%)		
Not recorded: n (%)	1 (4.00%)	1 (4.00%)		
Materials implanted			0.23 c	
Titanium: n (%)	18 (85.70%)	20 (95.20%)		
Cobalt‐chrome: n (%)	3 (14.30%)	0 (0.00%)		
Pelvic fixation: n (%)	2 (7.69%)	2 (7.69%)	1.00 c	
Fusion, n (%)	7 (26.90%)	3 (11.50%)	0.29 c	
Fusion with SWC: n (%)	2 (7.69%)	0.00 (0.00%)	1.00 c	
Fusion without SWC: n (%)	5 (19.20%)	0.00 (0.00%)		
Redon drain: n (%)	0 (0.00%)	0 (0.00%)		
Abbreviations: ASA, American Society of Anesthesiologists; SWC, surgical wound complication.

a Chi‐square test.

b Mann–Whitney U test.

c Fisher's exact test.

TABLE 5 Data for postoperative features.

Feature	IG value	CG value	
Antibiotic therapy: n (%)	0 (0%)	4.00 (15.38%)	
Corticosteroid therapy: n (%)	0 (0%)	0 (0%)	
Oedema: n (%)	0 (0%)	2.00 (7.69%)	
Administration of vasoactive drugs: n (%)	0 (0%)	0 (0%)	
Admission to PICU: (%)	10 (38.46%)	15 (56.69%)	
Length of stay in PICU: days (mean ± SD)	1.40 ± 0.69	1.07 ± 0.25	
Hospital stay: days (mean ± SD)	8.19 ± 10.13	4.96 ± 8.51	
Number of dressing changes (median)	5	58	
Allergic reactions to the dressing: n (%)	0 (0%)	0 (0%)	
Time to occurrence of surgical wound complications: days (mean ± SD)	12.00 ± 11.31	10.20 ± 4.28	
Abbreviations: CG, control group; IG, intervention group; PICU, paediatric intensive care unit; SD, standard deviation.

In the intention‐to‐treat analysis the incidence of surgical wound complications was 22.9% (IC95% = 8.9%–36.8%) in the IG and 45.2% (IC95% = 27.6%–62.7%) in the CG, (Chi‐square: 3.680, p = 0.055, Fisher's exact test: 0.049), indicating a RR of 0.51 (IC95% = 0.25–1.04). The relative risk reduction was 49.39% (IC95% = 0.15%–98.92%). These data indicate that, although descriptively and despite not performing the study treatment, the IG has half the risk of complications of the CG. Nevertheless, the data are not statistically significant but approaching it.

In the per‐protocol analysis the incidence of surgical wound complications was 7.7% (IC95% = 0.0%–17.9%) in the IG versus 38.5% (IC95% = 19.8%–57.2%) in the CG (Chi‐square: 6.933, p = 0.008, Fisher exact test: 0.009). The RR was 0.2 (IC95% = 0.05–0.83). The Relative Risk Reduction was 80.0% (IC95% = 24.6%–135.4%). Demonstrating that when the protocol was followed, a statistical significance was achieved. In both cases, per protocol and per intention to treat the treatment favours IG, despite the cases who were dropped out.

Analysing the patients who followed the study protocol, in both groups, the mean time of occurrence of surgical wound complications was 10.77 ± 5.08 days after surgery. As for the types of complications, in the IG 3.8% (n = 1) presented with surgical wound dehiscence and 3.8% (n = 1) with fibrin. In the CG, 26.9% (n = 7) presented with surgical wound dehiscence, 15.4% (n = 4) with seroma, and 7.7% (n = 2) with deep surgical site infection; in both cases of deep surgical site infection, removal of the implant materials was required. The differences between both groups resulted in p values of 0.05 for surgical wound dehiscence, 0.11 for seromas, and 0.49 for surgical site infection.

Of the total sample, 17 patients required dressing changes, with statistical significance found for the relationship between these changes and the occurrence of surgical wound complications (Table 6).

TABLE 6 Relationship between dressing changes and development of SWCs.

Dressing changes	SWCs	No SWCs	p value	
Control group			0.22 a	
13 Patients, dressing change	7	6		
13 Patients, no dressing change	3	10		
Intervention group			0.28 a	
4 Patients with dressing change	1	3		
22 Patients with no dressing	1	21		
Total			0.01 a	
17 Patients with dressing change	8	9		
35 Patients with no dressing change	4	31		
a Fisher's exact test.

Abbreviation: SWCs, surgical wound complications.

Table 7 shows information regarding the relationship between sociodemographic and clinical variables in the groups of patients with and without surgical wound complications. Although it is true that there is an imbalance in the number of fusions in the two groups, we did not find any significant relationship between fusions and the development of surgical wound complications. The duration of surgery, patients' ages, dimensions of the incision, and type of surgery (primary) have a statistically significant relationship with the increased risk of developing surgical wound complications.

TABLE 7 Relationship between sociodemographic and clinical variables, and the groups of patients with and without surgical wound complications.

Variable	Surgical wound complications	No surgical wound complications	p value	
Age (years)	14.25 ± 3.05	11.2 ± 4.05	0.02 a	
Body mass index	21.56 ± 5.30	18.67 ± 5.20	0.08 a	
Surgery type			0.01 b	
Primary: 28.84% (n = 15)	46.70% (n = 7)	53.30% (n = 8)		
Growing rods	33.33% (n = 5)	26.66% (n = 4)	
Fusion	13.33% (n = 2)	26.66% (n = 4)	
Rod lengthening/reanchoring/replacement	0.00% (n = 0)	0.00% (n = 0)	
Rib distractor (VEPTR)	0.00% (n = 0)	0.00% (n = 0)	
Reoperation: 71.15% (n = 37)	14.70% (n = 5)	86.50% (n = 32)	
Growing rods	5.40% (n = 2)	8.10% (n = 3)	
Fusion	0.00% (n = 0)	10.81% (n = 4)	
Rod lengthening/reanchoring/replacement	8.10% (n = 3)	54.05% (n = 20)	
Rib distractor (VEPTR)	0.00% (n = 0)	13.51% (n = 5)	
Procedure duration (min)	172.3 (112.–209.25)	86.25 (29.50–128)	<0.00 a	
Physical status classification			0.50 b	
ASA II	25% (n = 3)	37.50% (n = 15)		
ASA III	75% (n = 9)	62.50% (n = 25)	
Preoperative antibiotic prophylaxis	21.60% (n = 11)	78.4% (40)	1.00 b	
Intrawound vancomycin	16.70% (n = 2)	36.10% (n = 13)	0.29 c	
Corticosteroids	83.30% (n = 10)	82.50% (n = 33)	1.00 c	
Incision dimensions				
Dimension 1	23.23 ± 14.79	12.65 ± 7.37	0.01 d	
Dimension 2	9.17 ± 3.54	9.76 ± 4.25	0.72 d	
Dimension 3	5.00	4.5 ± 0.7	0.04 d	
Time to healing	22.81 ± 38.87	7.76 ± 3.231	0.00 c	
Spinal fusion	20.00% (n = 2)	80.00% (n = 8)	1.00 c	
a Student t test.

b Chi‐square test.

c Fisher's exact test.

d Mann–Whitney's U test.

Abbreviations: ASA, American Society of Anesthesiologists; VEPTR, vertical expandable prosthetic titanium rib implant.

With regard to costs, the postoperative dressings used in the IG and in the CG were counted and an assessment was made of whether it was necessary to change them during the first week after the surgery and the cost that doing so entailed. The IG initially required 35 dressings at a cost of US$4411.30. The cost did not increase despite the necessity of changing a total of 8 dressings in 4 patients, because iNPWT sets come with two dressings and not all were used initially. The CG initially required 44 dressings at a cost of US$789.91, which was increased by US$1043.71 because 55 of the dressings had to be replaced during the first 7 days because of saturation, loss of adherence, or poor condition of the dressing. (Appendices A and B include detailed patient information in Tables A1 and A2).

Table 8 details the costs associated with the different surgical wound complications in both study groups. The costs generated by the treatment of surgical wound complications include necessary diagnostic tests (laboratory and imaging), wound treatment (topical dressings, surgical interventions such as surgical debridement, removal of materials, and insertion of new materials), and systemic treatments such as antibiotic therapy, fluid therapy, and analgesics. When the costs of treatment of surgical wound complications are included, we see that the economic cost in the CG increased by US$30175.96 versus increasing by US$713.82 in the IG. However, the cost for the implant materials removed in the 2 patients with surgical site infection SSI in the CG amounted to US$16322.72, compared with US$0.00 for the IG. This means that when we consider the total economic costs associated with the use of both surgical dressings and add the costs for dressing replacements plus those for the treatment of surgical wound complications and those for the removal of implant materials to the cost of the initial surgical dressings, the total costs amounted to US$48329.52 in the CG versus US$5125.05 in the IG. Accordingly, management of CG patients resulted in a total increase in expenditures of US$43204.47 (Table 9).

TABLE 8 Comparison of estimated cost differences between study groups for treating surgical wound complications.

Imputed cost source	Number	Individual Costs	Total costs	
CG	IG	CG	IG	CG	IG	
Admissions	4	0	US$2640.15 + US$3168.18 + US$6327.85 + US$4422.38	US$0.00	US$16558.56	US$0.00	
Diagnostic tests							
Ultrasonography	2	0	US$31.28 + US$31.28	US$0.00	US$62.56	US$0.00	
Cultures	12	1	US$29.22 × 12	US$29.22	US$350.65	US$29.22	
Computed TomographyScans	1	0	US$95.41	US$0.00	US$95.41	US$0.00	
Radiographs	3	0	US$13.64 × 3	US$0.00	US$40.92	US$0.00	
Puncture	3	0	US$29.22 × 3	US$0.00	US$87.66	US$0.00	
Debridement	2	0	US$2983.30 + US$5524.64	US$0.00	US$8507.95	US$0.00	
Dressing materials	8	2	US$477.07 + US$43.37 + US$50.96 + US$381.66 + US$26.02 + US$408.76 + US$555.14 + US$242.87	US$332.86 + US$197.33	US$2185.85	US$530.20	
Time spent changing dressings					US$1670.87	US$154.40	
Ward nurse	1024 min × US$0.17	0	US$177.64	US$0.00	
Traumatology nurse	60 min × US$1.08	0	US$65.05	US$0.00	
Wounds nurse	37 visits × US$38.60	0	US$1428.17	US$154.40	
Antibiotic therapy					US$615.53	US$0.00	
IV ceftazidime	12 doses × US$3.79	0	US$45.54	US$0.00			
IV vancomycin	27 doses × US$4.34	0	US$117.10	US$0.00			
Oral amoxicillin	30 doses × US$0.33	0	US$9.76	US$0.00			
IV cefazolin	66 doses × US$3.25	0	US$214.68	US$0.00			
Oral cefadroxil	168 doses × US$0.33	0	US$54.26	US$0.00			
IV tazobactam	15 doses × US$3.79	0	US$56.92	US$0.00			
Oral levofloxacin	154 doses × US$0.38	0	US$58.44	US$0.00			
Oral rifampin	154 doses × US$0.38	0	US$58.44	US$0.00			
Total					US$30175.96	US$713.82	
Abbreviations: CG, control group; IG, intervention group; IV, intravenous; SWC, surgical wound complication.

TABLE 9 Differential costs of total treatment for study groups.

Study group	Initial costs of dressing	Cost of replacement	Cost of surgical wound complications	Cost of removal of materials due to surgical site infection	Total cost	
CG	US$789.91	US$1043.71	US$30173.17	US$16322.72	US$48329.52	
IG	US$4411.30	US$0.00	US$713.75	US$9.00	US$5125.05	
Difference between CG and IG	−US$3621.39	+US$1043.71	+US$29459.42	+US$16322.72	+US$43204.47	
Abbreviations: CG, control group; IG, intervention group.

4 DISCUSSION

The literature published on the prevention of surgical wound complications after primary closure provides results that indicate that there are several indications for negative pressure wound therapy, including prophylaxis for surgical site infections. 22 , 23 , 24 , 25 Although in our study there were no statistically significant results in surgical site infections, surgical site infections were observed in 7.7% of the patients who did not receive iNPWT and in no patients in the iNPWT group, which would corroborate the conclusions reached in the study by White et al, 26 which shows that overall, iNPWT is effective in reducing the risk of infection by reducing the effect of local factors that may affect wound healing, as well in as reducing wound manipulation and thereby preventing bacterial colonization and infection.

At present, iNPWT is associated with a reduction in surgical wound complications such as surgical site infection, surgical wound dehiscence, and seroma, 27 , 28 , 29 which is why its use after primary closure is endorsed in some high‐risk specialties such as cardiac and abdominal surgery in adult patients, 26 spine surgery, 30 or surgery for tibia fractures or ankle fractures, surgery in those who are obese, and surgery in those who are at risk for wound contamination or who are immunocompromised. 17 , 31

Even so, use of this treatment for paediatric patients is not widespread, and its use is mainly intended for the treatment of surgical wound complications, not for their prevention. 15 , 32 , 33 Few studies on the use of negative pressure wound therapy have been conducted in paediatric patients; in 2017 Visser R et al. reported data similar to those obtained by us, showing a reduction in surgical wound complications and a shortening of hospital stay 25 with reduced wound infections in laparoscopic paediatric surgery. Currently, even with doubts, its application is beginning to be suggested in the clinical practice guidelines for paediatric spine surgery. 34 , 35

Despite these recommendations, a 2019 Cochrane review on iNPWT concluded that the evidence for its effect on reducing surgical site infections is of low quality and suggested the need for further studies, 22 conclusions that are currently contradicted by Groenen et all. in their meta‐analysis with high evidence between the effectiveness of iNPWT and surgical site infection reduction. 36 In our study, no surgical site infections SSIs occurred in the IG, although they did occur in 2 CG patients and required the removal of the prosthetic materials.

The results of our study provide evidence that applying iNPWT as a preventive measure for surgical wound complications in paediatric patients undergoing surgery for NIS is significantly more cost‐effective than using an PHHDSWs. This agrees with the benefits proposed by White et al in a 2022 literature review about adult patients. 26

Surgical time is a variable that may influence the risk of surgical wound complications, as confirmed by our study with a significant p‐value. Table 3 shows the operative times for patients with and without surgical wound complications, and it is evident that those without complications had surgeries that were nearly half as long. Therefore, surgical time, along with other factors such as wound size, could suggest the potential benefit of iNPWT as a preventive tool. Peart J et al., in their 2019 article ‘A Tool to Assess the Risk of Surgical Site Infections and the Suitability of Negative Pressure Wound Therapy’, identify prolonged surgical times as a Level 1 risk factor for complications in adult patients and recommend iNPWT for patients at risk level 1 or 2. 37

We observed shorter healing times in patients who received iNPWT, a fact that is consistent with what has been described by White et al, 26 saying that this therapy affects the global management of surgical wounds favouring continuous contraction, promoting approximation of incision edges, and reducing the traction and tension forces that are sometimes generated when the patient moves.

From an economic viewpoint, the use of iNPWT to prevent surgical wound complications in paediatric patients undergoing surgery for NIS has proven to be cost‐effective. Although initially the use of iNPWT represents an extra cost of US$3621.39 compared with the cost for use of an PHHDSWs, when the costs associated with dressing changes, complications, and removal of prosthetic materials were factored in, the extra costs in the PHHDSWs group amounted to US$43204.47, so we can establish that for each US$1.00 of extra cost for the iNPWT, there is a benefit of US$12.93 in relation to the use of the silver dressings.

This trial did not study the impact of this preventive measure on the quality of life of patients and their families. Even so, we can state that the reduction in surgical wound complications and removals of prosthetic materials should have an impact on their quality of life, and therefore there will be further research on the topic.

The main limitation of this study was related to the management and care of patients treated with iNPWT and the possible lack of knowledge on the use of this treatment by the hospital ward staff. To avoid this bias, it was proposed that the staff be trained in the application of iNPWT and the control of possible leaks, and that care procedures using this treatment be protocolized.

In view of the obtained results, we think that our sample size has also been a limitation in obtaining more conclusive results regarding surgical site infection prevention, given that there were only 2 surgical site infections in the total study population.

5 CONCLUSION

iNPWT is a cost‐effective measure for the prevention of surgical wound complications in paediatric patients undergoing surgery for NIS. The results we obtained allow us to state that patients treated with iNPWT are less likely to present with surgical wound complications, mainly surgical wound dehiscence. The duration of surgery, patients' ages, dimensions of the incision, and type of surgery have a statistically significant relationship with the increased risk of developing surgical wound complications. iNPWT significantly reduces the time to healing of surgical wounds and thus has a direct impact on patients and their families.

Therefore, the findings of this study justify the need to implement protocolized intraoperative use of iNPWT for the prevention of surgical wound complications in patients undergoing surgery for NIS.

FUNDING INFORMATION

Support was provided by a Catalonian Health Department research grant (PERIS 2017–2021‐ SLT017/20/000194) and an unrestricted Smith & Nephew grant (CCG00159).

CONFLICT OF INTEREST STATEMENT

All authors declare that they have no conflicts of interest.

ACKNOWLEDGMENTS

We thank the nursing and medical staff as well as the management of the hospital where the study was conducted for their support. We also thank the hospital's research foundation for assistance and for providing grants for the research and Sol Balsells Mejilla, MD (Barcelona, Spain) provided professional statistical analysis of the study. Our sincere thanks to the patients and families who have collaborated with us. Ana Salvador Amela, MD (Barcelona, Spain) provided professional Spanish‐to‐English translation of this article, and medical editor Katharine O'Moore‐Klopf, ELS (East Setauket, NY, USA) provided professional English‐language editing.

DATA AVAILABILITY STATEMENT

Data available on request from the authors.The data that support the findings of this study are available from the corresponding author upon reasonable request.

APPENDIX A  

TABLE A1 Cost of initial postoperative dressings plus replacements in control group.

Patient	No. of incisions	Postoperative dressing sizes	No. of replacement dressings	Price of dressings a	Cost of initial dressings	Cost of replacement dressings	Total cost of dressings	
1	2	Size 15 for each incision	0	US$14.63 × 2	US$29.26	US$0.00	US$29.26	
2	1	Size 15	0	US$14.63	US$14.63	US$0.00	US$14.63	
3	2	Size 20 for each incision	2	US$18.42 × 2	US$36.84	US$73.69	US$110.53	
4	1	Size 20	0	US$18.42	US$18.42	US$0.00	US$18.42	
5	1	Size 20	0	US$18.42	US$18.42	US$0.00	US$18.42	
6	2	Size 20 for each incision	0	US$18.42 × 2	US$36.84	US$0.00	US$36.84	
7	1	Sizes 35 and 15 (both for 1 incision)	2	US$19.61 + US$14.63	US$34.24	US$68.49	US$102.73	
8	2	Size 20 for each incision	2	US$18.42 × 2	US$36.84	US$73.69)	US$110.53	
9	1	Size 15	1	US$14.63	US$14.63	US$14.63	US$29.26	
10	2	Size 25 for each incision	0	US$18.42 × 2	US$36.84	US$0.00	US$36.84	
11	1	Sizes 35 and 25 (both for 1 incision)	2	US$19.61 + US$18.42	US$38.04	US$82.43	US$114.11	
12	3	Size 25 for each incision	3	US$18.42 × 3	US$55.27	US$165.80	US$221.06	
13	2	Size 35 for each incision	3	US$19.61 × 2	US$39.23	US$117.68	US$156.91	
14	1	Size 35	0	US$19.61	US$19.61	US$0.00	US$19.61	
15	1	Sizes 35 and 25 (both for 1 incision)

	0	US$19.61 + US$18.42	US$38.04	US$0.00	US$38.04	
16	2	Size 25 for each incision	0	US$18.42 × 2	US$36.84	US$0.00	US$36.84	
17	2	Size 15 for each incision	1 + 3	US$14.63 × 2	US$29.26	US$102.40	US$131.66	
18	2	Size 25 for each incision	0	US$18.42 × 2	US$36.84	US$0.00	US$36.84	
19	1	Size 35	0	US$19.61	US$19.61	US$0.00	US$19.61	
20	1	Size 25	0	US$18.42	US$18.42	US$0.00	US$18.42	
21	2	Size 35 for each incision	1	US$19.61 × 2	US$39.23	US$39.23	US$78.46	
22	2	Sizes 35 and 25 (both for 1 incision)	2	US$19.61 + US$18.42	US$38.04	US$76.07	US$114.11	
23	2	Size 25 for each incision	4	US$18.42 × 2	US$36.84	US$147.38	US$184.22	
24	2	Size 15 for each incision	1	US$14.63 × 2	US$29.26	US$29.26	US$55.27	
25	1	Size 35	3	US$19.61	US$19.61	US$58.84	US$78.46	
26	1	Size 25	0	US$18.42	US$18.42	US$0.00	US$18.42	
Total no. of dressing used		44	55					
Total costs of all dressings					US$789.54	US$1043.22	US$1832.76	
a Depending on dressing size.

APPENDIX B TABLE A2 Cost of initial postoperative dressings plus replacements in intervention group.

Patient	No. of incisions	Postoperative dressing sizes	No. of replacement dressings	Price for 2 dressings a	Cost of initial dressings	Cost of replacement dressings	Total cost of dressings	
1	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
2	1	Size 20	0	US$166.09	US$166.09	US$0.00	US$166.09	
3	2	Size 20 for each incision	2	US$166.09	US$166.09	US$0.00	US$166.09	
4	2	Sizes 40 and 20	0	US$181.54	US$181.54	US$0.00	US$181.54	
5	1	Size 20	1	US$166.09	US$166.09	US$0.00	US$166.09	
6	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
7	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
8	1	Size 15	0	US$166.19	US$166.1	US$0.00	US$166.19	
9	1	Size 20	0	US$166.09	US$166.09	US$0.00	US$166.09	
10	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
11	1	Size 20	1	US$166.09	US$166.09	US$0.00	US$166.09	
12	2	Size 20 × 25 for each incision	0	US$181.54	US$181.54	US$0.00	US$181.54	
13	2	Size 20 × 25 for each incision	0	US$181.54	US$181.54	US$0.00	US$181.54	
14	1	Size 15	0	US$166.19	US$166.1	US$0.00	US$166.19	
15	2	Size 20 × 25 for each incision	0	US$181.54	US$181.54	US$0.00	US$181.54	
16	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
17	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
18	1	Size 20	0	US$166.09	US$166.09	US$0.00	US$166.09	
19	1	Size 20	0	US$166.09	US$166.09	US$0.00	US$166.09	
20	1	Size 20	0	US$166.09	US$166.09	US$0.0	US$166.09	
21	2	Size 20 × 25 for each incision	0	US$181.54	US$181.54	US$0.00	US$181.54	
22	2	Size 20 for each incision	0	US$166.09	US$166.09	US$0.00	US$166.09	
23	1	Size 15	2	US$166.19	US$166.19	US$0.00	US$166.19	
24	1	Size 15	0	US$166.19	US$166.19	US$0.00	US$166.19	
25	2	Size 15 for each incision	0	US$166.19	US$166.19	US$0.00	US$166.19	
26	2	Size 15 for each incision	0	US$166.19	US$166.19	US$0.00	US$166.19	
Total no. of dressings used		35	8					
Total costs of all dressings					US$4402.65	US$0.00	US$4402.65	
a Depending on dressing size.
==== Refs
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