Sternal wounds

• Wound infection occurred in 3/75 (4%) NPWT patients versus 12/75 (16%) controls (P=.0266; OR 4.57; 95% CI 1.23-16.94) (p.1387).
• Infection by Gram-positive skin flora occurred in only 1 NPWT patient versus 10 controls (P=.0090; OR 11.39; 95% CI 1.42-91.36) (p.1387).
• When the foam dressing was removed at day 6-7, the incision was primarily closed in 71/75 (95%); no infection occurred thereafter, supporting closure as a barrier to skin flora (p.1390).
• 9/12 control infections occurred beyond the first postoperative week (up to day 35), indicating the sterile dressing established an adequate barrier considerably later (p.1391).
• All 3 control sternal osteomyelitis cases were skin-flora deep infections potentially preventable by prophylactic NPWT (p.1392).

CAT: OCEBM 3 · This is not a randomised trial and it should never be described as one in a motivation. Patients were allocated by ALTERNATION according to the time of operation, with diabetics deliberately split half and half between the arms 'with priority'. Alternation is fully predictable — the surgeon knows before the case which dressing the next patient will get — and the diabetic quota is an admission that the sequence could be steered. The effect is nevertheless large and the arithmetic is clean. Wound infection 3 of 75 (4.0%) with NPWT against 12 of 75 (16.0%) with conventional dressing. Recomputed here: relative risk 0.25, absolute risk reduction 12.0% (95% CI 2.6% to 21.4%), number needed to treat 8.3 (4.7 to 38.6). Every printed statistic reproduces exactly. Fisher exact on 3 of 75 against 12 of 75 returns p = 0.0266, matching the printed P = .0266 to four places; the odds ratio 4.57 (1.23 to 16.94) reproduces exactly on a Woolf interval. Gram-positive skin flora 1 of 75 against 10 of 75, Fisher p = 0.0090 against a printed .0090, odds ratio 11.39 (1.42 to 91.36) reproducing exactly. Sternal dehiscence 1 against 3, Fisher p = 0.6199 against a printed .6199. The mechanism is coherent: the effect sits almost entirely in skin flora, 9 of the 12 control infections arose after the first postoperative week, and once the foam came off on day 6 or 7 with the incision primarily closed in 71 of 75 (95%), no further infection occurred in that arm. GRADE therefore starts low, loses a step for risk of bias and regains one for a large effect, landing at low. It is not upgraded further for a dose-response gradient, because none was tested, and it is not downgraded for imprecision, because the interval for the absolute benefit excludes zero. What holds it at Low rather than Moderate is that a predictable allocation sequence plus an unadjusted analysis in a single centre can generate a 12-point difference on its own, and nothing in the paper rules that out.

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CAT: OCEBM 3 · START LOW (predominantly observational). Prophylactic foam ciNPT: all 7 studies favoured NPWT (study RRs 0.25-0.94) — LOW, and at risk of being overstated because the review's search closed before the two largest randomised nulls in this wiki (Scheier 2025, Pérez-Granda 2025). Canister-free ciNPT: one comparative study, RR 0.30 for wound failure — VERY LOW. Open sternal infection: hospital stay 32.3 vs 57.3 days in observational comparisons with obvious severity confounding — VERY LOW. Bridge to closure: recurrent SSI 2.9% vs 10.6% after secondary closure (P = .049) — VERY LOW. The authors' own conclusion is appropriately cautious: prophylactic ciNPT 'may be reasonable to consider in selected high-risk patients pending randomized trial confirmation'.

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Read this table with the adherence figure and the words "not powered" in view. Neither is a footnote.

The odds ratios reconcile with the raw counts. Re-derived by hand from 16/1,022 and 17/1,208, the crude odds ratio is 1.11 (0.56 to 2.22) against the model's 1.11 (0.56 to 2.20); for all sternal SSI, 1.13 (0.72 to 1.76) against 1.12 (0.71 to 1.75). The hierarchical model returned essentially the crude estimate, which is what a well-balanced two-period cross-over should do.

One printed denominator does not reconcile. The Results state the primary composite "occurred in 33/2107 (1.5%) diabetic or obese patients" and all sternal SSI in "80/2107 (3.6%)", but the trial's own arm totals are 1,022 + 1,208 = 2,230, the figure used everywhere else in the paper including Table 2. Against 2,230 the rates are 1.48% and 3.59%. This is a typographical defect in a denominator, not an analytical one — no effect estimate depends on it — but it should be quoted as 33/2,230.

Ten serious adverse device effects were reported and none was adjudicated as device-related.

CAT: OCEBM 2 · START HIGH — a randomised trial, prospective, blinded outcome adjudication, 90-day follow-up, 2,230 high-risk patients in the wound-management comparison, which makes it the largest prospective randomised sternal ciNPT dataset this wiki holds. −1 imprecision, and this is the downgrade that matters: the trial was explicitly not powered for a clinical outcome. It is a vanguard phase that was stopped 'due to lack of additional funding' before the main trial began, and the authors say so in their own conclusion — 'No firm conclusions should be drawn regarding the effectiveness of Prevena'. The primary composite produced 33 events in total. The confidence interval, OR 1.11 (0.56 to 2.20), is compatible with a 44% REDUCTION and with a 120% INCREASE in deep sternal infection. To detect the risk ratio of roughly 0.47 that the general cardiac syntheses report, from a 1.4% control rate at 80% power, requires about 2,900 patients per arm before any inflation for cluster randomisation; this trial had 1,022 and 1,208. −1 risk of bias from non-adherence: only 68.1% (696/1,022) of patients allocated to PREVENA actually received it, and the intention-to-treat estimate is therefore diluted toward the null by construction. Adherence was 93.0% at one site and 42.8% at the other, so more than half the intervention arm at one hospital received the control treatment. NOT DOWNGRADED for indirectness — obese and diabetic sternotomy patients are exactly the population a ciNPT motivation concerns — and NOT downgraded for inconsistency, since the treatment-by-centre interaction was flat (p = 0.905). Net low. The inference this page exists to block: a null result from an underpowered trial in which a third of the intervention arm never received the intervention is not evidence that ciNPT does not work. It is evidence that this design could not answer the question, which is what a vanguard trial is built to find out. The as-treated analysis, which removes the dilution, gives OR 1.17 (0.54 to 2.53) — no closer to benefit, and no better powered. What this trial does legitimately establish is that the large treatment effects reported by retrospective sternal series are not visible in the one prospective randomised dataset of this size, and that any motivation quoting a 50% reduction should expect a reviewer to raise it.

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Effect estimates, computed here because the paper reports none. Mediastinitis, NPWT versus gauze: RR 0.333 (0.068 to 1.638), risk difference −1.33% (−3.17 to +0.50), NNT 75, Fisher p = 0.286. NPWT versus the two other arms pooled: RR 0.333 (0.075 to 1.480), RD −1.33% (−2.78 to +0.12), Fisher p = 0.160. Superficial SSI, NPWT versus gauze: RR 1.286 (0.485 to 3.408). Mortality, NPWT versus foam: RR 0.529 (0.240 to 1.169).

CAT: OCEBM 2 · Start HIGH (randomised, 900 patients). -1 risk of bias: NO BLINDING of any clinical party is described; The analysis population is never declared - intention-to-treat, per-protocol and modified intention-to-treat appear nowhere and every denominator is fixed at 300; Losses to follow-up are reported nowhere while Figure 2's at-risk table implies 46 patients (16/19/11) left the risk set by day 90; Figure 1 contains no post-randomisation flow boxes at all; and six OR seven baseline variables are imbalanced at p < 0.05 - including DIABETES (21.0% / 32.0% / 26.7%, p = 0.010), which is the paper's OWN dominant risk factor for mediastinitis at IRR 5.420 (1.745-16.85) - while the text asserts 'no significant differences between the three groups in underlying conditions'. -1 imprecision: The sample size cannot be reproduced under any plausible baseline rate (an absolute 10-point reduction needs 195/arm from 20% to 10%, 146 from 16% to 6%, 132 from 15% to 5%; a relative 10% reduction from the observed 2.8% would need about 51,800/arm), and recomputed achieved power is 0.08 for superficial SSI and 0.31 to 0.40 for mediastinitis - the paper itself concedes 'barely more than 20% power'. Net LOW for the null results, which is what this trial can support. For the subgroup claim, -2 further for indirectness and selective reporting: the CABG-with-mammary-graft finding is never labelled post hoc, the number of subgroups examined is never stated, it rests on 10 events in 301 patients with 2 in the NPWT arm, the paper's own two zero-inflated negative binomial models give the vacuum coefficient p = 0.923 and p = 0.378 in opposite directions, and the printed 13-FOLD estimate with CI 1.394 to 123.08 cannot be reproduced from any 2x2 table constructible from the paper's own published counts - its implied log-scale standard error is 1.143 against an actual 0.800 for the reconstructed 2/107 versus 8/184 table. Net VERY LOW.

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• Four core mechanisms of action underpin every indication: (1) reduces tissue oedema; (2) increases granulation tissue formation; (3) increased perfusion as a secondary/later effect; (4) with instillation and dwell time can reduce wound contamination.
• Vascular surgery: high-level evidence supports NPWT for infected vessels and prosthetic vascular grafts — strong recommendation for high-risk surgical patients with a fully exposed, infected prosthetic vascular graft, together with debridement and appropriate antibiotics; continuous suction at lower levels (-50 to -100 mmHg) recommended to avoid bleeding.
• Traumatic/surgical wounds: NPWT is first-line for preoperative wound-bed preparation post-debridement, typically 7-10 days before definitive surgery; strong for open fractures that cannot be closed primarily (used between debridement and reconstruction); caution when tendon/bone exposed; do not use if underlying arterial impairment is not addressed (red).
• Diabetic foot ulcers: first-line post-surgical treatment for DFU once ischaemia is excluded (University of Texas Grade A2/A3); consider for chronic DFU not progressing after 4 weeks; contraindicated where ischaemia is due to concomitant peripheral arterial disease (red).
• Sternal dehiscence: NPWT is the method of choice for post-sternotomy mediastinitis (strong); caution in the haemodynamically unstable patient; the open sternum with exposed vulnerable structures is not an indication (red).
• Abdominal / dehisced abdominal wounds: strong for the open abdomen and for dehisced wounds with intact abdominal wall; NPWT with instillation (NPWTi-d) is effective in reducing infection in the infected open/dehisced abdomen (moderate); do not use if size/severity does not merit it.
• Skin grafts, burns, venous ulcers, pressure injuries, enterocutaneous fistulae: NPWT endorsed for wound-bed optimisation before grafting and intra-operative graft stabilisation; acute burn indications supported but not a substitute for grafting; venous ulcers only if <30% area reduction in 4 weeks and ABPI 0.8-1.2 (contraindicated if ABPI <0.6); NPIAP stage 3/4 pressure injuries until surgical closure (moderate); ECF in selected collapsible/low-output cases only, never in unexplored fistulae.
• Closed incisional NPWT (ciNPT): recommended to decrease wound complications, dehiscence, haematoma/seroma and surgical site infection (strong).
• Contraindications listed: clotting disorders, active non-capillary bleeding post-debridement, exposed organs/vasculature/anastomoses, eschar or dry necrosis, neoplastic tissue, untreated osteomyelitis, non-enteric and unexplored fistulae.

AGREE II: Recommended with modifications — Scope 67% · Stakeholders 56% · Rigour 23% · Clarity 67% · Applicability 46% · Independence 25%

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