Diskusi

Secara keseluruhan kualitas dari studi sebelumnya untuk analisis relatif

buruk, termasuk RCT’s dan studi kohort retrospektif. Bukti RCT yang
disertakan adalah, secara umum, risiko bias yang tidak jelas dan hasil
perhitungan harus diperlakukan dengan hati-hati.
The overall quality of the previous studies for analysis was relatively poor,
including both RCTs and the retrospective cohort studies. The included
RCT evidence was, in general, of unclear risk of bias and the results of
these tials should be treated with caution. NPWT was tended to be chosen
in treatment of more seriously injured patients in most of the retrospective
cohort studies, which would affect the preoperative intergroup
comparability in favor of the conventional wound dressings. Therefore, any
advantage of NPWT needed to be significant enough to be observed while
any advantage of the conventional wound dressings should be treated
with caution. Moreover, some of the outcomes reported by the cohort
studies were not mentioned by the RCTs studies, which might be a sign of
the selective reporting. According to the results of the current study,
evidence from both the RCTs and the cohort studies has indicated that the
proper application of NPWT, based on radical debridement and copious
irrigation before wound closure for open fractures, can remarkably reduce
the risk of infection, which is consistent with the result from the previous
studies [9]. Clearance of wound bacterial counts and resultant
inflammatory cells, as a frequently cited benefit of NPWT [26], may have
contributed to this result [18]. Some evidence also indicates that NPWT
can significantly accelerate the wound healing process, which is also in
accordance with the result from the previous studies [27]. For associated
flap surgeries, findings from the previous studies showed a reduction in
the incidence of flap procedures in severe open fractures because of the
NPWT application [28, 29]. Nevertheless, evidence retrieved from the
current systematic review failed to find out any significant intergroup
difference in the flap surgery rate and the proportion of the free flaps
needed to treat open fractures.
These findings are inconsistent with the previous belief [9, 30]. This
inconsistency may result from the disguise of insufficient inspection
efficiency due to the small sample size or the intergroup incomparability in
injury severity among the retrospective cohort studies in the current
review. However, inclusion of the case series lacking the comparable
control groups and adoption of the historical control by the previous
studies [28, 29] may also contribute to this inconsistency. Another factor
that may affect the conclusion is the concomitant amputation rate. As is
known, a decrease in the use of flaps with simultaneous increase in the
amputation rate is not a good sign. It means that there are more limbs
beyond salvation even with flaps. However, the previous studies
discussed the flap rates without mentioning the concomitant amputation
rate [28, 29]. Most of the studies in this systematic review excluded the
patients who underwent amputation. Only two retrospective cohort studies
reported the concomitant amputation rate, and the pooled result showed a
higher amputation rate in the conventional wound dressings group despite
the lower degree of the average injury severity in this group. Although with
a wide 95% CI, OR was only 0.15, which indicated that a 6 fold of
amputation risk would occur in the control group. This may be the result of
a sharp contrast with the relatively inadequate sample size. This result
indicated that use of NPWT might lower the wound complexity and turn
some of the unsalvageable limbs into salvageable ones with flaps. This is
consistent with the previous knowledge that NPWT can promote the
growth of granulation tissues and reduce the wound size [13, 18, 31].
However, no definitive conclusion could be obtained because of the small
relevant sample size. Thus, we believe that the current evidence is not
strong enough to support the conclusion that NPWT can reduce the
expectation for flap surgery and the proportion of free flaps. Concrete
conclusion should wait till more evidence has developed. On the other
hand, there has been a debate on the effect of NPWT on flap survival.
Some previous studies showed that use of NPWT could significantly
increase the flap survival rate [32]. A high-level negative pressure over
-100 mmHg could also be thought of as a possible risk factor for flap
necrosis [33]. Based on the findings of the current systematic review, a
slightly significant difference was observed in favor of NPWT in the flap
survival despite the continuous use of a relatively high negative pressure
of -125 mmHg [21, 24]. Such a subtle difference had limited clinical
significance, but it was based on the fact that the patients in the control
group were less seriously injured. The definitive proof for the reduced flap
survival rate after the use of NPWT with a continuous high negative
pressure over -100 mmHg was not obtained. This indicates that the use of
NPWT with flaps is probably safe. However, considering the fragile blood
supply of flaps and the absence of relevant high-quality RCT evidence
with an adequate sample size in the current systematic review, NPWT with
flaps should be applied with caution before the details of its effect on flaps
have been fully elucidated. As for the fracture healing, no RCT evidence
was found. The evidence from the cohort studies failed to find any
advantage or disadvantage of NPWT compared with the conventional
wound dressings. But this might be due to the preoperative intergroup
incomparability or the inadequate sample size. A further study is needed
before a definitive conclusion is obtained. Only one RCT in this
systematic review indicated that NPWT could improve the life quality of the
infected open fracture patients in the physical component score of SF-36,
but this conclusion still required further confirmation. A previous
systematic review by Janssen and his colleagues had an opposite
conclusion, which stated that use of NPWT in treatment of wounds may
lead to a short-term decrease in the patient life quality because of anxiety
[34]. However, it could be noted that seven different scales with various
dimensions and emphases were adopted, and that different types of
patients including those suffering acute trauma, chronic ulcer and diabetic
foot were included in the studies involved in the analysis of Jansen’s
review. Direct combination of the results of these clinically heterogenic
studies into a single conclusion about life quality may lead to concealment
of certain components by others. While subgroup analysis is hampered by
the limited sample size. Therefore, we think that the effects of NPWT on
the patient life quality for the open fracture treatment should be further
studied before a concrete conclusion is obtained.