
==== Front
J Orthop Surg Res
J Orthop Surg Res
Journal of Orthopaedic Surgery and Research
1749-799X
BioMed Central London

39252068
5038
10.1186/s13018-024-05038-7
Systematic Review
Effect of negative pressure wound therapy on the incidence of deep surgical site infections after orthopedic surgery: a meta-analysis and systematic review
Liu Huan 12
Zhang Ge 13
Wei An 13
Xing Hao 12
Han Changsheng 13
Chang Zhengqi 26766771@qq.com

1
1 https://ror.org/01ye08k77 grid.470927.f 0000 0004 6005 6970 Department of Orthopedics, The 960th Hospital of PLA, Jinan, 250031 Shandong China
2 School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053 Shandong China
3 https://ror.org/0523y5c19 grid.464402.0 0000 0000 9459 9325 Shandong University of Traditional Chinese Medicine, Jinan, 250355 China
9 9 2024
9 9 2024
2024
19 5551 7 2024
27 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objective

This meta-analysis aimed to explore the impact of prophylactic negative pressure wound therapy (NPWT) on the occurrence of deep surgical site infections (SSIs) following orthopedic surgery.

Methods

A systematic search was conducted across Medline, Embase, Cochrane Library, and Web of Science databases for articles concerning NPWT in patients who underwent orthopedic surgery up to May 20, 2024. Using Stata 15.0, the combined odds ratios (ORs) were calculated with either a random-effects model or a fixed-effects model, depending on the heterogeneity values.

Results

From a total of 440 publications, studies that utilized NPWT as the experimental group and conventional dressings as the control group were selected to analyze their impact on SSIs. Ultimately, 32 studies met the inclusion criteria. These included 12 randomized controlled trials and 20 cohort studies, involving 7454 patients, with 3533 of whom received NPWT and 3921 of whom were treated with conventional dressings. The results of the meta-analysis demonstrated that the NPWT group had a lower incidence of deep SSIs in orthopedic surgeries than did the control group [OR 0.64, 95% CI (0.52, 0.80), P = 0.0001]. Subgroup analysis indicated a notable difference for trauma surgeries [OR 0.65, 95% CI (0.50, 0.83), P = 0.001], whereas joint surgeries [OR 0.65, 95% CI (0.38, 1.12), P = 0.122] and spine surgeries [OR 0.61, 95% CI (0.27, 1.35), P = 0.221] did not show significant differences. Additionally, when examined separately according to heterogeneity, trauma surgeries exhibited a significant difference [OR 0.50, 95% CI (0.31, 0.80), P = 0.004].

Conclusion

The results of our study indicate that the prophylactic use of NPWT reduces the incidence of deep SSIs following orthopedic trauma surgery when compared to the use of conventional dressings. We postulate that the prophylactic application of NPWT in patients at high risk of developing complications from bone trauma may result in improved clinical outcomes and an enhanced patient prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-024-05038-7.

Keywords

Surgical site infections
Negative pressure wound therapy
Orthopedic procedures
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

The field of orthopedic surgery encompasses the full range of activities related to the prevention, diagnosis, and treatment of musculoskeletal system diseases and injuries, across the entire lifespan [1]. However, postsurgical complications, especially deep SSIs, remain a significant challenge [1]. Deep SSIs, such as deep wound infections, periprosthetic joint infections (PJI), and osteomyelitis, are common and serious issues [2–4]. For instance, a meta-analysis on spinal surgery reported a 1.5% incidence of deep SSIs and a 12–25% recurrence rate [5]. In another study, the incidence of deep SSIs after repairing periprosthetic knee fractures was alarmingly high at 88% [6]. Despite timely and appropriate management, deep SSIs can lead to severe outcomes, including multiple surgeries, permanent joint dysfunction, removal of the internal fixator, and even death in extreme cases [7, 8]. Additionally, these infections often result in longer hospital stays and higher healthcare costs, placing a substantial financial burden on patients and healthcare systems [1, 9]. Therefore, the most cost-effective strategy for preventing deep SSIs is to identify risk factors early and intervene promptly.

NPWT is widely used for various wound types and has shown significant efficacy in promoting wound healing and preventing infections. Mechanistically, NPWT works by stabilizing wounds, reducing bacterial loads, decreasing edema, modulating the immune response, stimulating granulation tissue formation, inducing angiogenesis, and enhancing blood circulation [10–12]. There is substantial evidence that NPWT significantly reduces surgical wound complications and prevents postoperative infections, both in clean and contaminated wounds, compared to traditional dressings [13, 14].

Many studies have explored the impact of NPWT on reducing the incidence of deep postoperative orthopedic infections, but the findings regarding its effectiveness vary across different studies. While some research shows that NPWT significantly lowers deep infection rates [15, 16], other studies have not found notable benefits [17, 18]. These conflicting findings underscore the urgent need for more thorough and detailed analyses to uncover the true effectiveness of prophylactic NPWT. To better understand NPWT's role in preventing SSIs in orthopedics, this study conducted a meta-analysis and systematic review, providing clinicians with insights into the effects of prophylactic NPWT on the incidence of deep SSIs after orthopedic surgery.

Information and methods

The program has been designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Reviews will strictly follow these guidelines [19].

Literature search

A search was conducted on Medline, Embase, Cochrane Library, and Web of Science for cohort studies and case–control studies analyzing multifactorial risk factors for orthopedic SSIs up to May 20, 2024. The search employed subject terms and free-text keywords including orthopedics, surgical site infections, and negative pressure wound therapy. Specific search strategies are detailed in the supplementary material.

Inclusion and exclusion criteria

Inclusion criteria: 1. Research articles on the effectiveness of NPWT versus conventional dressings for treating orthopedic SSIs, particularly those involving deep SSIs. 2. Conformance with the diagnostic standards for deep SSIs [20].

Excluded studies consisted of conference abstracts, meta-analyses, protocols, letters, duplicate publications, systematic reviews, and animal experiments. Figure 1 depicts the entire study process.Fig. 1 Demonstrates the entire retrieval process

Studies were included without restrictions on size or type, and no language limitations were applied.

Data extraction

H.L and G.Z conducted a thorough screening of the literature for data extraction. This involved reviewing titles, abstracts, and full-text articles. Any discrepancies regarding inclusion were resolved through ZQ.C. Strict adherence to inclusion and exclusion criteria was maintained during the screening process. Extracted data included the first author's name, year of publication, country, study design, sample size, gender distribution, and age demographics. Cross-checking of extracted data was performed to ensure consistency.

Quality evaluation

The quality of the randomized controlled trials included in the study was assessed using the RoB 2 (Risk of Bias 2) tool, an updated iteration of the Cochrane Risk of Bias Tool for Randomized Trials [21]. Each study was evaluated against specific criteria and categorized into one of three levels of bias risk:Low: Assigned when all quality criteria were fully met. Unclear: Assigned when one or more criteria were partially met or unclear. High: Assigned when one or more criteria were not met or included. Three aspects of case–control and cohort studies were evaluated using the Newcastle–Ottawa Scale (NOS) [22]: selection of study population (4 points), comparability between groups (2 points), and assessment of exposure factors or outcome measures (3 points). Scores on the scale ranged from 0 to 9, with ≤ 4 indicating low quality, 5–6 moderate quality, and ≥ 7 high quality. Weighted Cohen's kappa coefficients were used to measure the consistency of the evaluations, the results of which can be found in Table 1. Any disagreements that arise between the two assessors during the assessment process are resolved through discussion or consultation with a third party to reach a final decision.Table 1 Cohen's Kappa for studies

Study	Selection bias	Selection bias	Performance bias	Detection bias	Attrition bias	Reporting bias	Other bias	
Randomized controlled study	
Arti [23]	Low	Unclear	Low	Low	Low	Unclear	Unclear	
Cai [24]	Low	Unclear	Low	Unclear	High	Low	Unclear	
Costa [25]	Low	Low	Low	Low	Low	Low	Low	
Costa [18]	Low	Low	Low	Low	Low	Low	Low	
Crist [26]	Unclear	Unclear	Low	Unclear	Low	Unclear	Unclear	
Gillespie [27]	Low	Unclear	Low	Low	Low	Low	Unclear	
Cooper [28]	Unclear	Low	Low	Unclear	Low	Low	Unclear	
Higuera-Rueda [29]	Unclear	Low	Low	Low	Low	Low	Unclear	
Keeney [30]	Unclear	Unclear	Low	Low	Low	Unclear	Unclear	
Masters [31]	Low	Low	Low	Low	Low	Low	Unclear	
Stannard [32]	Unclear	Unclear	Low	Unclear	Low	Unclear	Unclear	
Virani [33]	Low	Unclear	Low	Unclear	Low	Unclear	Unclear	
Kappa value	0.467	0.581	NA	0.7	1	0.7	0.6	
Study	Selection of study population	Comparability between groups	Assessment of exposure factors or outcome measures	
Cohort study	
Adogwa [34]	4	2	3	
Blum [35]	4	2	2	
Cooper [36]	4	1	3	
Cooper [37]	4	1	3	
Crist [26]	4	1	2	
Dingemans [38]	3	2	2	
Doman [39]	4	1	3	
Dyck [40]	4	2	3	
Gantz [41]	4	1	3	
Joethy [42]	3	1	2	
Johnson [43]	4	2	3	
Matsumoto [44]	4	1	2	
Newman [45]	4	2	3	
Redfern [46]	3	1	3	
Takahashi [47]	4	2	3	
Tyagi [48]	4	1	3	
Vidalis [49]	4	1	3	
Zhou [50]	4	2	3	
Reddix Jr [51]	4	1	2	
Mascarenhas [17]	4	2	3	
Qi-Chun Song [52]	4	2	3	
Kappa value	0.696	1	0.557	
Because of the significant differences in appearance between NPWT and conventional dressings, the included studies could not be blinded to clinicians and patients. Therefore performance bias was uniformly considered low and kappa tests were not performed

Statistical analyses

The data were analyzed using Stata version 15.0 to compute combined odds ratios (OR) and their respective 95% confidence intervals (CI). The suitable model for calculating combined OR values was chosen following the assessment of heterogeneity using the Q-test and the I2 statistic. When I2 was greater than 50%, a random-effects model was applied, whereas for I2 values of 50% or lower, a fixed-effects model was utilized. Sensitivity analyses involved conducting a one-by-one exclusion test for studies with I2 exceeding 50%. Publication bias across the literature was evaluated using Egger's test, with statistical significance set at α = 0.05. Results were deemed statistically significant if P was less than 0.05.

Results

Literature search and selection process

Medline, Embase, the Cochrane Library, and Web of Science were systematically searched for studies investigating the impact of NPWT on orthopedic SSIs. Literature management was conducted using EndNote 21. Initially, 440 documents were retrieved, and after 139 duplicates were removed, 301 unique documents remained. Following the exclusion criteria and screening of titles and abstracts, 48 documents were selected for full-text review. Ultimately, 32 papers met the inclusion criteria and were included in the analysis.

Basic characteristics of included literature

The analysis included a total of 32 studies [17, 18, 23–52], consisting of 12 randomized controlled trials and 20 cohort studies. These studies encompassed 17 articles on trauma surgery, 11 on joint surgeries, and 4 on spinal surgeries. Overall, the research involved 7545 patients, with 3582 undergoing NPWT and 3963 receiving conventional dressings. Detailed descriptions of the included studies are provided in Table 2.Table 2 Characteristics of literature table

Study	Country	Design	Sample size	Gender (M/F)	Age (years)	The type of surgery	
NPWT	CD	
S	NS	S	NS	NPWT	CD	NPWT	CD	
Costa [25]	Britain	RCT	16	210	19	215	178/48	164/70	42	43	Open lower limb fracture	
Costa [18]	Britain	RCT	45	725	50	729	482/302	482/281	NA	NA	Major trauma to the lower limb	
Crist [26]	Britain	RCT	5	28	2	31	27/6	20/13	44.2	43.2	Acetabular fracture ORIF	
Cai [24]	China	RCT	0	55	1	52	38/17	32/21	43.1	40.4	Closed calcaneal fracture	
Masters [31]	Britain	RCT	4	210	14	204	72/160	62/168	85.2	84.9	Hip fractures	
Stannard [32]	USA	RCT	14	127	23	99	161/88		43		High-Risk Lower Extremity Fractures	
Arti [23]	Iran	RCT	3	42	4	41	68/22		31.86		Open fracture wounds	
Virani [33]	India	RCT	2	41	11	39	28/15	32/18	34.8	37.4	open diaphyseal tibial fractures	
Gillespie [27]	Australia	RCT	0	35	0	35	20/15	17/18	63.8	62.5	Primary Hip Arthroplasty	
Keeney [30]	Columbia	RCT	6	179	4	209	NA		NA		Primary or revision hip or knee arthroplasties	
Higuera-Rueda [29]	USA	RCT	1	146	3	144	64/83	55/92	64.7	65.1	Revision Knee Arthroplasty	
H.John Cooper [28]	USA	RCT	1	59	0	60	21/39	23/37	63.6	64.4	Anterior Total Hip Arthroplasty	
Dingemans [38]	Netherlands	CS	2	45	3	44	39/14	36/11	43.9	42.2	Lower extremity fracture surgery	
Johnson [43]	USA	CS	9	31	11	129	25/15	80/60	51	53	Bicondylar tibial plateau fractures	
Takahashi [47]	Japanese	CS	0	16	4	12	11/5	13/3	73	65	Major Lower Extremity Amputation	
Crist [26]	USA	CS	5	44	2	40	101/36		42		Hip, Pelvis, and Acetabular Fracture Surgery	
Gantz [41]	Italy	CS	0	133	7	126	100/31	96/37	54.92	59.65	Lower extremity amputations	
Zhou [50]	China	CS	0	22	4	50	10/12	20/34	59.1	57.2	Ankle Surgery	
Reddix Jr [51]	USA	CS	3	232	4	62	NA		NA		Acetabular fracture surgery	
Blum [35]	Australia	CS	14	152	13	50	126/40	50/13	40.3	36.8	Open Tibial Fractures	
Cooper [36]	USA	CS	0	27	10	30	NA	76.3	73.2		Periprosthetic fracture surgery around the hip and knee	
Joethy [42]	Singapore	CS	5	46	6	12	NA	40	38		Open fractures of the lower limb	
Adogwa [34]	USA	CS	5	41	17	97	16/30	32/82	65.31	63.28	Long-segment thoracolumbar spinal fusion	
Vidalis [49]	USA	CS	0	28	3	11	9/19	7/7	65.2	61.2	Surgical Decompression for Metastatic Spine Disease	
Dyck [40]	Canada	CS	2	19	5	38	13/8	28/15	59.5	58.9	Spine surgery	
Mascarenhas [17]	USA	CS	2	38	2	28	NA		NA		Neuromuscular Scoliosis Surgery	
Cooper [36]	USA	CS	0	30	10	98	NA	71.7	70.9		Revision Hip and Knee Surgery	
Redfern [46]	USA	CS	2	194	5	395	67/129	184/216	66.9	66.8	Total Hip and Knee Arthroplasty	
Matsumoto [44]	USA	CS	1	36	1	36	20/17	16/21	58.6	58	Total Ankle Arthroplasty	
Qi-Chun Song [52]	China	CS	6	144	21	189	49/101	66/144	62.83	63.52	Total knee arthroplasty in patients with obesity	
Newman [45]	USA	CS	2	75	7	73	40/39	45/35	65	65	Revision Total Hip and Knee Arthroplasty	
Tyagi [48]	USA	CS	1	85	1	188	36/50	94/95	61.9	60.5	Direct Anterior Approach Primary Total Hip Arthroplasty	
Doman [39]	USA	CS	2	128	1	129	32/98	45/85	64.2	64	Total Knee Arthroplasty	
NPWT Negative Pressure Wound Therapy; CS Cohort Study;S:People with deep SSI; NS People without deep SSI; NA Not applicable

Among 32 included articles, randomized controlled trials were assessed using the Cochrane Risk of Bias Tool for Randomized Trials, and the specific risk of bias evaluations are shown in Fig. 2. Cohort studies were appraised using the Newcastle–Ottawa Scale (NOS), revealing one study scoring 6, while the remaining articles scored between 7 and 9, indicating overall high quality among the included studies. The detailed results of the quality assessment are outlined in Table 3.Fig. 2 Evaluation of bias across 11 randomized controlled studies

Table 3 Newcastle–Ottawa Scale (NOS) for studies

Study	Selection	Comparability	Outcome	Total score	
Cohort study	
Adogwa [34]	****	**	***	9	
Blum [35]	****	**	**	8	
Cooper [36]	****	*	***	8	
Cooper [37]	****	*	***	8	
Crist [26]	****	*	**	7	
Dingemans [38]	***	**	**	7	
Doman [39]	****	*	***	8	
Dyck [40]	****	**	***	9	
Gantz [41]	****	*	***	8	
Joethy [42]	***	*	**	6	
Johnson [43]	****	**	***	9	
Matsumoto [44]	****	*	**	7	
Newman [45]	****	**	***	9	
Redfern [46]	***	*	***	7	
Takahashi [47]	****	**	***	9	
Tyagi [48]	****	*	***	8	
Vidalis [49]	****	*	***	8	
Zhou [50]	****	**	***	9	
Reddix Jr [51]	****	*	**	7	
Mascarenhas [17]	****	**	***	9	
Qi-Chun Song [52]	****	**	***	9	

Meta-analysis

Orthopedic area

A total of 32 studies were included in the meta-analysis. The heterogeneity test (I2 = 37.8%, P = 0.016) indicated that a fixed-effects model was suitable for the analysis. NPWT significantly decreased the occurrence of deep SSIs in postoperative orthopedic patients [OR 0.64, 95% CI (0.52, 0.80), P = 0.0001]. The detailed results can be found in Fig. 3 and Table 4.Fig. 3 Forest plot depicting the impact of prophylactic NPWT versus conventional dressing on infection rates at deep orthopedic surgical sites

Table 4 Meta-analysis

Surgery	No.of study	Heterogeneity	ES (95%CI)	P	Egger	
I2 (%)	P	
Orthopaedic surgery	32	37.4	0.019	0.64 (0.52, 0.80)	0.0001	0.109	
Orthopaedic surgery (Delete Costa2020)	31	34.8	0.031	0.57 (0.44, 0.73)	0.0001	0.340	
Trauma Surgery	17	58.2	0.004	0.50 (0.31, 0.80)	0.004	0.051	
Trauma Surgery (Delete Costa2020)	16	56.3	0.003	0.45 (0.26, 0.77)	0.004	0.143	

Subgroup analyses

The 32 studies were further analyzed in subgroups based on different types of surgeries: 17 studies focused on orthopedic trauma, 11 on joint surgeries, and 4 on spinal surgeries. The results indicated a significant reduction in the incidence of deep SSIs in trauma surgeries [OR 0.65, 95% CI (0.50, 0.83), P = 0.001]. However, the differences were not statistically significant for joint surgeries [OR 0.65, 95% CI (0.38, 1.12), P = 0.122] or spinal surgeries [OR 0.61, 95% CI (0.27, 1.35), P = 0.221]. The detailed results are shown in Fig. 4 and Table 4.Fig. 4 Forest plots depicting subgroup analyses categorized by various types of surgical procedures

Orthopedic trauma area

In the subgroup analysis of patients who underwent orthopedic trauma surgery, where heterogeneity was observed at 58.2%, a random-effects model was applied to analyze 17 relevant studies. The analysis demonstrated a significant reduction in the occurrence of deep SSIs with NPWT in patients who underwent orthopedic trauma surgery [OR 0.50, 95% CI (0.31, 0.80), P = 0.004]. The detailed findings are presented in Fig. 5 and Table 4.Fig. 5 Forest plot analyzed separately for the orthopedic trauma field

Reanalysis: results after excluding costa 2020

Because the Costa 2020 study constituted 27.56% of the weighting in the overall analysis and that publication bias for orthopedic trauma surgery (P = 0.051) was tantamount to the level of statistical significance, a reanalysis was conducted to exclude the Costa 2020 study to ascertain its impact on the results of the analysis. The results of the reanalysis are presented below:

Orthopedic area

The incidence of deep SSIs in postoperative orthopedic patients remained significantly lower after the exclusion of the Costa 2020 study, with a statistically significant difference [OR 0.57, 95% CI (0.44, 0.73), P = 0.000]. The discrepancy was marginal in comparison to the outcomes of the analyses that incorporated the Costa 2020 study. Please refer to Fig. 6 and Table 4 for further details.Fig. 6 Forest plot depicting the impact of prophylactic NPWT versus conventional dressing on infection rates at deep orthopedic surgical sites, after the exclusion of the Costa 2020 study

Orthopedic trauma area

Following the exclusion of the Costa 2020 study, the incidence of deep SSIs in postoperative patients undergoing orthopedic trauma surgery remained significantly lower, with a statistically significant difference (OR 0.45, 95% CI (0.26, 0.77), P = 0.004). This difference was relatively minor in comparison to the results of the analyses that included the Costa 2020 study. Please refer to Fig. 7 and Table 4 for further details.Fig. 7 Forest plot analyzed separately for the orthopedic trauma field, after the exclusion of the Costa 2020 study

Publication bias

The Egger test was applied to the entire field of orthopedic surgery and orthopedic trauma surgery to assess publication bias. The results indicated that there was no publication bias in either orthopedic surgery (P = 0.109) or orthopedic trauma surgery (P = 0.051) as the P-values were greater than 0.05. After removing Costa 2020, the results remained unchanged with both orthopedic surgery (P = 0.340) and orthopedic trauma surgery (P = 0.143) having P-values greater than 0.05, suggesting that there was no significant publication bias.

Discussion

This meta-analysis examined the effect of NPWT on the incidence of deep SSIs. Across the included studies, the incidence of deep SSIs in the NPWT group ranged from 0 to 23%. NPWT was found to be effective in reducing the incidence of deep SSIs following orthopedic surgery compared to conventional dressing therapy. However, this result requires further interpretation. Subgroup analyses revealed that prophylactic NPWT significantly reduced deep SSIs only in the orthopedic trauma area, with no significant differences observed in the spine and joint areas. Furthermore, as the Costa 2020 study constituted 27.56% of the overall analysis and the publication bias for orthopedic trauma surgery (P = 0.051) was nearly at the level of statistical significance, we conducted a new meta-analysis and test for publication bias, excluding the Costa 2020 study, and compared the results with those of the previous analysis. The results of the comparison demonstrated no significant alteration in the outcomes of the two analyses, indicating that the analyses remain robust even with the inclusion of the Costa 2020 study.

NPWT is widely recognized as being able to prevent and treat infections and may be associated with several potential mechanisms for preventing deep infections [53]. Firstly, the vacuum-enclosed membrane provided by NPWT provides a physical barrier on the surface of the wound, which prevents the invasion of external bacteria [54]. Secondly, NPWT can promote wound healing through its negative pressure effect. Mechanistically, NPWT enhances local blood perfusion and promotes granulation tissue production, while stabilizing the wound environment through protein regulation and inflammatory cytokine clearance, all of which provide an optimal environment for wound healing [55–58]. Recently, some researchers have found that NPWT also promotes wound healing by upregulating IL-17 expression [59]. Finally, NPWT can disrupt bacterial biofilms. The use of implants in orthopedic surgery creates conditions for the formation of bacterial biofilms, and some studies have reported that bacterial biofilms contain up to 97% water, and NPWT can expel the water in the biofilm through the effect of sustained negative pressure to necrose the bacteria in the biofilm, which may reduce the chance of bacterial aggregation on the surface of the implant and the reconstruction of the biofilm [60].

It is noteworthy that NPWT also plays a regulatory role in local immunity, a function that may be linked to the mechanistic action of the ion channel protein Piezo1. NPWT provides mechanical forces, particularly traction forces, which may be detected by Piezo1 and transformed into electronic and chemical signals, ultimately regulating cellular functions [61]. Studies have shown that NPWT enhances neutrophil recruitment and modulates neutrophil immune function, possibly through a mechanism involving Piezo1 [62]. Nevertheless, the precise way NPWT impacts immunoregulation remains unclear and warrants further research.

Our findings reveal that NPWT significantly reduces the incidence of deep infections in bone trauma surgeries. The study included various complex procedures, such as pelvic fracture surgery, acetabular fracture repair, and open fracture surgeries. These surgeries often involve challenging conditions that require advanced surgical skills, longer operative times, and cause more severe damage to the surrounding soft tissues and blood supply [16]. Unlike joint and spine surgeries, trauma surgeries frequently involve open wounds, which not only increase the risk of infection but also add to the complexity of the procedure [63]. Larger surgical wounds lead to longer healing times and increased exudate at the surgical site, allowing NPWT to fully promote wound healing and utilize negative pressure suction to reduce deep SSIs.

Our results are consistent with findings from previous meta-analyses. For instance, studies by Zhang et al. [16], Marc et al. [64], and Xie et al. [15] have all demonstrated that NPWT effectively reduces the occurrence of deep SSIs. However, not all research aligns with our findings. Studies by Li et al. [65] and Qian et al. [66] reported no significant difference between the NPWT group and the conventional dressing group in preventing deep SSIs. This disparity may be attributed to variations in sample size and types of surgeries conducted in the studies. Specifically, Li et al. included only four studies with a total of 744 patients to analyze the effect of prophylactic NPWT on the incidence of deep SSIs after orthopedic trauma surgery. The smaller number of studies and small sample size may have resulted in a decrease in the robustness of the results, which, in turn, led to findings that were inconsistent with those of our study. Qian et al. included six studies with a total of 2344 patients to analyze the effect of prophylactic NPWT on the incidence of deep SSIs after open lower extremity fracture surgery. Limiting the study to open lower extremity fracture surgery may have limited the generalisability of the results, which in turn may have led to inconsistencies with our findings. Zhang et al., Xie et al., and our study, in contrast to previous studies, did not limit the type of surgery, and the patients included in the analyses numbered over 3000. By employing a larger sample size and an unrestricted approach to surgery, our study enhances the reliability and generalizability of the results. This allows us to validate the effectiveness of NPWT in large sample sizes and diverse patient populations.

The findings from our study regarding joint did not demonstrate a significant difference between the two treatment modalities, which aligns with the results reported by Kim et al. [67]. In their meta-analysis, Kim and colleagues analyzed nine studies focusing on total hip and knee arthroplasty to evaluate the impact of NPWT on deep SSIs, and they also observed no significant differences. Unlike bone trauma surgery, joint surgeries typically involve cleaner surgical environments, shorter operative times, lower complexity, and less tissue trauma. These factors may limit the ability of NPWT to provide its full range of benefits in joint surgeries.

In the context of spinal surgery, our findings showed no significant difference between the two treatment groups. There is limited literature on deep SSIs in spinal procedures, and no meta-analysis has specifically explored the impact of prophylactic NPWT on these infections. Although a meta-analyze has reported that prophylactic NPWT effectively reduces SSIs after spinal surgery, our research suggests that prophylactic NPWT does not offer any significant advantage over conventional dressings in preventing deep SSIs [68]. This might be due to the deep and complex nature of spinal wounds, as well as the thicker soft tissue coverage involved. The presence of substantial subcutaneous tissue and intricate incisions may reduce the effectiveness of the negative pressure applied by NPWT. Additionally, in cases where there is surgical contamination or inadequate wound irrigation, bacterial biofilm formation on internal fixation devices can occur. Given the deeper location of these biofilms, NPWT may be less effective at disrupting them. As a result, NPWT's effectiveness in such cases may be limited. Future high-quality randomized controlled trials are needed to confirm these findings.

Several independent risk factors have been identified as contributing to the development of deep SSIs following bone trauma surgery. These include older age, diabetes, smoking, extended surgical duration, and open injuries [7, 69–74]. We recommend the prophylactic application of NPWT for patients presenting with these risk factors to lower the likelihood of deep infections. For patients experiencing superficial SSIs, utilizing NPWT as a treatment method could potentially prevent the progression of these infections into deeper SSIs. This is because NPWT can remove superficial bacteria along with exudate through its suction mechanism, thereby reducing the possibility of bacterial penetration into deeper tissues. However, there is a lack of conclusive evidence linking superficial site infections to an increased risk of deeper infections. For instance, research by Patterson et al. [75] indicates that deep infections rarely follow superficial infections after surgical fixation of the tibial plateau and distal tibial fractures. Given the economic considerations surrounding NPWT, its use has been somewhat restricted. Further research is required to elucidate the connection between superficial and deep SSIs, thereby providing a stronger theoretical foundation for the clinical use of NPWT.

Conclusion

In conclusion, our study revealed that NPWT effectively reduced the incidence of deep SSIs following orthopedic surgery compared with conventional dressings. However, subgroup analyses revealed a significant difference only in patients who underwent orthopedic trauma surgery. We suggest that prophylactic NPWT in high-risk orthopedic trauma patients may yield significant clinical benefits and improve patient outcomes. To validate the effect of NPWT on deep SSIs after spine surgery, rigorous randomized controlled trials are necessary. Furthermore, further research is needed to elucidate the specific mechanisms by which NPWT influences immune modulation in these contexts. The connection between superficial and deep SSIs warrants additional investigation.

Limitations

There are several limitations to this meta-analysis. First, an overrepresentation of studies focused on orthopedic trauma surgery may bias the overall results in favor of NPWT's effect on reducing deep SSIs in this specific field. Second, the limited number of studies pertaining to spine surgery may compromise the accuracy of our findings in that context. Third, the literature reviewed in this study did not specifically categorize PJI, making it impossible to distinguish between acute and chronic PJI. This limitation hindered our ability to analyze variations in the effectiveness of prophylactic NPWT across different types of PJI. Future research should aim to clearly define and differentiate between PJI types to more precisely evaluate the impact of NPWT. Finally, the inclusion of retrospective studies with varying follow-up durations introduces potential biases related to interviewer bias.

Supplementary Information

Supplementary file 1.

Acknowledgements

We extend our sincere gratitude to the reviewers and editors for their valuable feedback and suggestions on this manuscript.

Author contributions

Huan Liu was involved in study design, selection, analysis, report writing and manuscript review. Ge Zhang was involved in in study design, selection and report writing Hao Xing, An Wei and Changsheng Han participated in information retrieval and manuscript review. Zhengqi Chang contributed to the design, selection, analysis, report writing and manuscript review. All authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Availability of data and materials

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

PROSPERO

CRD42024553860

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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