https://orcid.org/0009-0004-2216-5049
Figures
Abstract
Background
Negative pressure wound therapy (NPWT) has become a popular treatment option for sternal wound infection (SWI). However, it remains uncertain whether the therapeutic benefits of NPWT are superior to conventional wound care. This study aimed to systematically evaluate the therapeutic effects of NPWT on SWI compared to conventional wound care through meta-analysis.
Methods
A comprehensive search of PubMed, Web of Science, Embase, and the Cochrane Library databases was conducted from inception to April 29, 2024 for all potential studies. The pooling of dichotomous outcome data was achieved using relative risk (RR), with results presented within a 95% confidence interval (CI). We utilized the standard mean difference (SMD) and 95% CI for continuous outcomes. Heterogeneity test, publication bias assessment, sensitivity analysis, and trial sequential analysis (TSA) were conducted. Publication bias was detected through the Begg’s and Egger’s tests. Software R 4.3.1, Stata 12.0, and TSA v0.9.5.10 Beta software were utilized for all analyses.
Results
Out of 1832 articles identified, 10 were included in this study. The overall results revealed that NPWT significantly decreased the sternal wound reinfection (SWRI) rate (RR [95% CI] = 0.179 [0.099 to 0.323], 95% prediction interval [PI]: 0.082 to 0.442), in-hospital mortality (RR [95% CI] = 0.242 [0.149 to 0.394], 95% PI: 0.144 to 0.461), and shortened the length of intensive care unit (ICU) stay (SMD [95% CI] = −0.601 [−0.820 to −0.382], 95% PI: −1.317 to 0.128) compared with conventional wound care. There was no significant difference in length of hospital stay (SMD [95% CI] = −0.402 [−0.815 to 0.012], 95% PI: −1.801 to 0.998) and treatment duration (SMD [95% CI] = −0.398 [−1.646 to 0.849], 95% PI: −16.340 to 15.543) between the NPWT group and control group. Further subgroup analysis demonstrated the benefits of NPWT in shortening hospitalization length in the European population (p < 0.05).
Citation: He S, Tang N, Li S (2025) Comparison of negative pressure wound therapy with conventional wound care in the treatment of sternal wound infection after cardiac surgery: A meta-analysis with trial sequential analysis. PLoS One 20(8): e0328771. https://doi.org/10.1371/journal.pone.0328771
Editor: Eyüp Serhat Çalık, Ataturk University Faculty of Medicine, TÜRKIYE
Received: September 5, 2024; Accepted: July 3, 2025; Published: August 7, 2025
Copyright: © 2025 He et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
1. Introduction
Cardiac surgery, often necessitating a sternotomy, serves as a life-saving intervention for numerous patients requiring procedures such as aortic root replacement, coronary artery bypass grafting, and valve repair or replacement. Concurrently, individuals who have undergone sternotomy are susceptible to sternal wound infection (SWI) [1]. Research suggested that the occurrence of SWI following cardiac surgery varies from 0.9% to 20% [2]. Critical instances of SWI can instigate organ failure impacting the heart, lung, and kidney, and can even result in death. The associated mortality rate ranges from 10% to 30% [3]. SWI is categorized into two types based on the severity and depth of the infection: superficial SWI (SSWI) which is limited to the subcutaneous tissue, skin, and deep fascia, and deep SWI (DSWI) which can impact sternum, muscle tissue, sub sternum, and mediastinum [4]. DSWI can delay recovery, prolong hospital stay, hinder functional status, and adversely affect a patient’s quality of life [5–7]. The most catastrophic outcomes of patients with SWI include osteomyelitis, sepsis, bypass graft erosion, ventricular rupture, and mediastinitis [8]. It is worth mentioning that the mortality associated with mediastinal infection remains significantly high, ranging from 3%−35% [9]. Therefore, immediate diagnosis and execution of efficient treatments for SWI are of utmost importance.
Conventional approaches to SWI management include re-closing the sternum after surgical debridement, wound debridement, and catheter irrigation of the wound bed using antimicrobial or antiseptic solutions [10]. Innovations in this field led to the adoption of open treatment and secondary closure. Traditionally, the wound bed has been loosely filled with gauze that not only soaks up the discharge and allows for air circulation but also maintains the necessary moisture to aid in the healing process. This gauze is routinely replaced every several days to promote the formation of a clean wound with healthy granulation tissue [11]. Conventional wet-to-dry dressings were employed to establish a sterile and damp environment that also helped to absorb surplus drainage from the wound. Yet, these dressings necessitated frequent replacements and could be uncomfortable to remove [12]. Addressing these challenges, Obdeijn et al. proposed the use of negative pressure wound therapy (NPWT) subsequent to SWI debridement [13]. NPWT, often referred to as vacuum-assisted closure, has markedly improved the management of open sternal wounds. The process of suctioning excess tissue fluid aids in preventing the formation of haematoma or seroma [14]. The application of negative pressure boosts perfusion, which in turn expedites the healing process. This approach also mitigates the risk of ischaemic wound necrosis, thereby preventing wound breakdown and promoting primary wound healing, particularly in watershed regions [15].
Several investigations have determined that NPWT is a reliable and beneficial approach to SWI in contrast to conventional methods [16,17]. Despite advancements in society guidelines regarding temperature management, preoperative shaving, glucose control, and prophylactic antibiotic administration to prevent infection prior to and during surgery, the evidence supporting the standard SWI management post-cardiac surgery remains a subject of debate. Furthermore, there is an absence of a comprehensive analysis comparing NPWT with conventional treatment for SWI. Consequently, we conducted a meta-analysis to systematically evaluate the effects of NPWT versus conventional wound care for SWI.
2. Methods
2.1 Study protocol
This study was executed in strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [18]. Prior to its commencement, the study’s protocol was duly registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42024537895).
2.2 Literature search
An exhaustive literature search was carried out on January 22, 2024, encompassing PubMed, Web of Science, Embase, and the Cochrane Library databases to identify all potential studies. The search was confined to English-language articles published from inception of each database to January 22, 2024. The following search items were used: (“negative pressure therapy” OR “negative pressure wound therapy” OR “negative-pressure wound therapy” OR “negative pressure wound treatment” OR “NPWT” OR “vacuum-assisted closure” OR “vacuum therapy”) AND (“sternotomy” OR “sternotomies” OR “sternal wound infection” OR “sternal wound-related infection” OR “mediastinitis” OR “mediastinum inflammation”). An updated literature search was conducted on April 29, 2024. To supplement this search, the reviewers scrutinized references within chosen articles and reviews. The detailed search strategy can be found in S1 File.
2.3 Study selection
Research was considered for inclusion if it satisfied the following conditions: (1) Cohort studies or randomized controlled trials (RCTs); (2) Studies exploring the therapeutic effects of NPWT on SWI; (3) Intervention arm: NPWT system, including vacuum assisted closure, vacuum sealing drainage, or topical negative pressure; (4) Control arm: conventional wound care, including conventional dressing therapy, closed or open irrigation, or open packing; (5) Outcomes: sternal wound reinfection (SWRI) rate, in-hospital mortality, length of hospital stay, intensive care unit (ICU) stay, and treatment duration. Reinfection was defined as the recurrence of infection after an initial infection-free period, evidenced by the resolution of clinical symptoms (e.g., absence of fever, normalized white blood cell count, and negative microbiological cultures). Criteria for exclusion included: (1) Case-control or single-arm studies; (2) The study population consisted of infants or children; (3) Studies without relevant outcomes; (4) Conference abstracts, reviews, letters and case reports.
2.4 Data extraction
Data and information from the included studies were independently extracted by two investigators. Any discordance between the two reviewers was rectified through deliberation or by involving a third reviewer. Excel spreadsheets served as the tool for data extraction. The information harvested from each study comprised the following elements: the lead author’s name along with the year of publication, research design, the country where the study was conducted, surgery type, sample size and age of participants, NPWT types, and outcomes. SWRI rate and in-hospital mortality were the primary outcomes; length of hospital stay, ICU stay, and treatment duration were the secondary outcomes.
2.5 Risk of bias assessment
The quality of the incorporated cohort research was assessed based on the Newcastle-Ottawa scale (NOS) [19]. Each study was rated on a scale of 0–9, with scores of 0–3, 4–6, and 7–9 indicating low, moderate, and high quality, respectively. We used the modified Jadad scale to assess the potential bias of RCTs [20]. Studies scoring between 0 and 3 were deemed low quality, whereas those with scores from 4 to 7 were considered high quality. The NOS and the modified Jadad scale were applied by two independent reviewers and any disputes were settled by consulting a third investigator.
2.6 Statistical analysis
The pooling of dichotomous outcome data was achieved using relative risk (RR) with results presented within a 95% confidence interval (CI). For continuous outcomes, we utilized the standard mean difference (SMD) and 95% CI. The Cochran’s Q statistic, Higgin’s I2 test, and 95% prediction interval (PI) were utilized to evaluate the overall heterogeneity of the study [21,22]. Heterogeneity was deemed acceptable if the p > 0.10 or I2 ≤ 50%. In the absence of significant heterogeneity, a fixed-effect model was chosen; otherwise, a random-effects model was applied [23]. To verify the robustness of the current analysis, we performed a sensitivity analysis using the leave-one-out method. Publication bias was determined through the Begg’s and Egger’s tests, supplemented by the visual interpretation of funnel plots [24,25]. The trim-and-fill method was chosen for quantitative adjustments in the presence of any publication bias [26]. All statistical analyses were conducted using Stata 12.0 and R software 4.3.1. A two-sided p < 0.05 was considered statistically significant.
2.7 Trial sequential analysis
In our study, a trial sequential analysis (TSA) was implemented to evaluate the robustness of the evidence and adjust for potential statistical errors [27]. Utilizing TSA software version 0.9.5.10 Beta (available at www.ctu.dk/tsa), we determined the required information size (RIS) along with the trial sequential monitoring boundaries. The establishment of O’Brien-Fleming α-spending boundaries involved a two-side approach with a preset 5% type I error rate and an 80% statistical power. The crossing of the cumulative Z-curve over either the RIS or the trial sequential monitoring boundary negated the need for additional research, thereby providing definitive evidence to either corroborate or refute the effect of the intervention.
3. Results
3.1 Study selection procedure
Fig 1 outlines the selection process for the study. The initial search surfaced 1832 studies of potential relevance. Upon the removal of 649 repeated records, 1183 articles were left for review. These articles underwent a title/abstract screening, resulting in the dismissal of 1108 articles due to lack of relevance. A subsequent comprehensive review of the remaining 75 full texts led to the exclusion of 65 articles: 12 researches were single-arm studies; 9 articles were case reports; 28 studies failed to provide the required outcomes; and 16 studies explored the preventive effects of NPWT on SWI. Ultimately, 10 studies were included in the meta-analysis [11,12,28–35].
3.2 Study characteristics and quality assessment
Table 1 describes the characteristics of the studies incorporated into our analysis. Each of these studies, all of which were retrospective cohort studies, were conducted in various locations across Europe and Asia between the years 2010 and 2023. The group treated with NPWT comprised 469 participants, in contrast to the control group, which consisted of 413 individuals. 7 studies documented participants who had undergone sternotomy procedures, inclusive of median sternotomy. Conversely, 3 studies did not specify whether participants had undergone sternotomy, only indicating that these patients had been subjected to cardiac or open heart surgery. Additionally, the categories of SWI patients incorporated those with DSWI and mediastinitis. All studies have reported the therapeutic impacts of NPWT on SWI. The overall scores of these 10 retrospective cohort studies ranged from 7 to 9, indicating a low risk of bias. The detailed evaluation of study quality was provided in S1 Table in S2 File.
3.3 Overall analysis of primary and secondary outcomes
There were 6 studies focused on the outcome of SWRI rate. Pooled results from the fixed-effects model (I2 = 0%, Tau2 = 0) indicated that NPWT significantly reduced the SWRI rate compared with the conventional wound care (RR [95% CI] = 0.179 [0.099 to 0.323], 95% PI: 0.082 to 0.442). A total of 8 studies furnished data on in-hospital mortality. The evidence, obtained from the fixed-effects model (I2 = 0%, Tau2 = 0), unveiled a lower in-hospital mortality when NPWT was employed, as opposed to conventional wound care (RR [95% CI] = 0.242 [0.149 to 0.394], 95% PI: 0.144 to 0.461) (Table 2, Fig 2).
(A) Sternal wound reinfection rate; (B) In-hospital mortality.
4 studies addressed the outcome of ICU stay. No notable heterogeneity was discerned across these studies (I2 = 18.1%, Tau2 = 0.0121). Findings from the fixed-effects model indicated a significant decrease in ICU stay duration with NPWT in comparison to conventional wound care (SMD [95% CI] = −0.601 [−0.820 to −0.382], 95% PI: −1.317 to 0.128). There were 7 studies and 3 studies, focused on the outcomes of hospital stay length and treatment duration, respectively. Pooled results from the random-effects model (hospital stay: I2 = 83.0%, Tau2 = 0.2519; treatment duration: I2 = 96.4%, Tau2 = 1.1691) suggested that compared with conventional wound care, NPWT seem to shorten the length of hospital stay (SMD [95% CI] = −0.402 [−0.815 to 0.012], 95% PI: −1.801 to 0.998) and treatment duration (SMD [95% CI] = −0.398 [−1.646 to 0.849], 95% PI: −16.340 to 15.543), but without statistical significance (Table 2, Fig 3).
(A) Intensive care unit stay; (B) Length of hospital stay; (C) Treatment duration.
3.4 Subgroup analysis of primary and secondary outcomes
Subgroup analyses were performed only for groups with at least 2 included studies. Analysis stratified by patient ethnicity revealed that that NPWT significantly diminished SWRI rate (RR [95% CI] = 0.179 [0.099 to 0.323], 95% PI: 0.082 to 0.442; I2 = 0%, Tau2 = 0) and in-hospital mortality (RR [95% CI] = 0.235 [0.138 to 0.400], 95% PI: 0.131 to 0.494; I2 = 0%, Tau2 = 0), shortened the ICU stay (SMD [95% CI] = −0.601 [−0.820 to −0.382], 95% PI: −1.317 to 0.128; I2 = 18.1%, Tau2 = 0.0121) and length of hospital stay (SMD [95% CI] = −0.317 [−0.503 to −0.130], 95% PI: −0.825 to 0.226; I2 = 23.8%, Tau2 = 0.0148), and prolonged duration of treatment (SMD [95% CI] = 0.277 [0.010 to 0.544]; I2 = 1.1%, Tau2 = 0.0005) compared with conventional wound care in the European population (Table 3, S1–S5 Figs of S3 File).
Categorizing the data by types of surgery, it was observed that for those patients who had a median sternotomy, NPWT notably lessened the SWRI rate (RR [95% CI] = 0.179 [0.099 to 0.323], 95% PI: 0.088 to 0.415; I2 = 0%, Tau2 = 0) and in-hospital mortality (RR [95% CI] = 0.255 [0.155 to 0.418], 95% PI: 0.147 to 0.478; I2 = 0%, Tau2 = 0), and abbreviated ICU stay (SMD [95% CI] = −0.601 [−0.820 to −0.382], 95% PI: −1.129 to −0.060; I2 = 0%, Tau2 = 0) compared to conventional wound care. However, no significant difference was observed in the length of hospital stay and treatment duration between the NPWT group and control group in patients who underwent median sternotomy (all p > 0.05) (Table 3, S1–S5 Figs of S3 File).
Upon classifying patients based on the specific type of SWI, the subgroup analysis results indicated that compared with conventional wound care, NPWT was found to significantly curtail the SWRI rate (RR [95% CI] = 0.177 [0.072 to 0.433], 95% PI: 0.0005 to 60.051; I2 = 0%, Tau2 = 0) and in-hospital mortality (RR [95% CI] = 0.175 [0.062 to 0.489], 95% PI: 0.019 to 1.771; I2 = 0%, Tau2 = 0) in patients with DSWI, but it did not notably alter the ICU stay and the length of hospital stay (all p > 0.05). Further subgroup analysis suggested that for the patients with mediastinitis, NPWT significantly diminished the SWRI rate (RR [95% CI] = 0.181 [0.082 to 0.397], 95% PI: 0.001 to 34.101; I2 = 0%, Tau2 = 0) and in-hospital mortality (RR [95% CI] = 0.277 [0.160 to 0.478], 95% PI: 0.089 to 0.885; I2 = 0%, Tau2 = 0), reduced the stay of ICU (SMD [95% CI] = −0.656 [−0.920 to −0.393]; I2 = 0%, Tau2 = 0), but had no effect on hospital stay and treatment duration (all p > 0.05) (Table 3, S1–S5 Figs of S3 File).
3.5 Trial sequential analysis results
Fig 4 presented the trajectory of cumulative Z-curves pertaining to SWRI rate and in-hospital mortality, which intersect with both the RIS threshold and the trial sequential monitoring boundary. This convergence suggested a robust inference can be drawn regarding SWRI rate as well as in-hospital mortality. In contrast, the cumulative Z-curves corresponding to ICU stay, hospital stay and treatment duration failed to cross either the RIS boundary or the trial sequential monitoring boundary. This indicated that the capability to reach a definitive conclusion about ICU stay, hospital stay and treatment duration was somewhat constrained, potentially due to the existence of false positives (Fig 5).
(A) Sternal wound reinfection rate; (B) In-hospital mortality. Uppermost and lowermost red curves represent trial sequential monitoring boundary lines for benefit and harm, respectively. Inner red lines represent the futility boundary. Blue line represents evolution of cumulative Z-score. Horizontal green lines represent the conventional boundaries for statistical significance. Cumulative Z-curve crossing the trial sequential monitoring boundary or the RIS boundary provides firm evidence of effect.
(A) ICU stay; (B) Length of hospital stay; (C) Treatment duration. Uppermost and lowermost red curves represent trial sequential monitoring boundary lines for benefit and harm, respectively. Inner red lines represent the futility boundary. Blue line represents evolution of cumulative Z-score. Horizontal green lines represent the conventional boundaries for statistical significance. Cumulative Z-curve crossing the trial sequential monitoring boundary or the RIS boundary provides firm evidence of effect.
3.6 Sensitivity analysis and publication bias
Sensitivity analysis and publication bias tests were exclusively executed for primary and secondary outcomes incorporating ≥ 6 studies. We employed a leave-one-out approach for sensitivity analysis to further verify the stability of our findings. The results suggested that Akbayrak et al.’s study may contribute to the high heterogeneity in the outcome of hospital stay length (S6 Fig of S3 File). Results from the Begg’s and Egger’s tests revealed that no significant publication bias existed in the results of in-hospital mortality and hospital stay. Nevertheless, potential publication bias might be present in the outcome related to SWRI rate (Begg’s test: p = 0.260, Egger’s test: p = 0.022). Further trim-and-fill technique was employed to adjust for publication bias. A comparison of the adjusted results with the original findings showed negligible differences, implying that the findings on SWRI rate maintain their reliability. The funnel plots were visualized in S7 Fig of S3 File.
4. Discussion
In the realm of SWI management, the application of NPWT has become increasingly prevalent. The technology behind NPWT involves specialized dressings connected to a device that generates negative pressure, uniformly applied across sealed post-surgical wounds [36,37]. A sterile, adhesive film seals the wound and adjacent skin, with a vacuum pump linked via a tube to create suction [37]. This system can administer pressures from −75 to −125 mmHg, facilitating the removal of wound fluids into a sterile container [38–40]. When contrasted with ordinary post-debridement drainage tube drainage, NPWT after wound infection has shown to enhance treatment outcomes, alleviate patient discomfort, and provide a sustained effect akin to ongoing debridement [4]. A systematic review has previously indicated that NPWT offers clinical advantages over other wound care strategies for SWI, including reduced hospitalization time, lower reinfection rates, and a decrease in early mortality [41]. Through a meta-analysis, our study demonstrated that compared with conventional wound care, NPWT notably decreased the incidence of SWRI and in-hospital mortality, as well as shortened the ICU stay in SWI patients. However, there were no significant differences in length of hospital stay and treatment duration between SWI patients receiving NPWT and those receiving conventional therapy.
NPWT can stimulate a hydrostatic pressure differential within the venous system, fostering improved blood circulation. This process aids in the efficient reduction of local osmotic active molecules, lessening tissue swelling, minimizing damage to the microcirculation, and preserving tissue blood supply. It also helps decrease residual irrigation fluid and inflammatory exudate, significantly alleviating patient discomfort. This mechanism potentially expedites patient recovery and minimizes the duration of hospital stays [28,39,42,43]. While our research has yet to confirm an advantage of NPWT over conventional wound care in reducing hospital length of stay, the pooled results suggested a trend toward shorter hospital stay, albeit without achieving statistical significance (SMD = −0.402, p = 0.057). Therefore, our findings regarding length of hospital stay may be subject to future refinement and updating as new studies are incorporated into the analysis. In addition, it has been proposed that the introduction of a sealed wound medium helps maintain the integrity of the sealed incision edges, spurring cellular proliferation and instigating angiogenesis [39,44,45]. This process drains extracellular fluid, facilitating the removal of exudative material and tissue edema. It also augments blood flow to the wound site, thereby enhancing tissue perfusion and boosting the circulation of antibiotics and immune cells [36,37,44]. These elements help thwart the advancement of infection and the emergence of sternal wound complications by inhibiting bacteria capable of forming colonies and promoting the generation of granulation tissue [39,44,45]. By inhibiting the advancement of infection and curtailing sternal wound complications, a reduction in the incidence of SWRI and in-hospital mortality among SWI patients can be achieved to a certain extent. This could explain the observed benefits of NPWT in reducing both SWRI rate and in-hospital mortality in our study. Furthermore, present studies showed that despite the relatively high expenses linked to NPWT equipment and care [46], its effectiveness in reducing hospital durations and enhancing clinical results affirms its cost-efficiency [47,48]. Further cost-effectiveness analyses also support NPWT as a therapeutic option offering substantial economic advantages [49].
Of note, our subgroup analysis results suggested that NPWT had a significant impact on reducing the SWRI rate, in-hospital mortality and ICU stay duration when compared to conventional treatment in patients with mediastinitis. Mediastinitis is identified as DSWIs accompanied by sternal osteomyelitis, with or without infection in the retrosternal space [50]. Diagnostic criteria for mediastinitis encompass sternal dehiscence, chest pain, purulent discharge, fever, and/or the isolation of microorganisms in mediastinal drainage cultures [51]. Sternal instability can contribute to the development of DSWI, which may be followed by skin deterioration and bacterial infiltration into deeper tissues. Initial treatment for mediastinitis involved surgical revisions accompanied by multiple open dressing changes, followed by either sternal rewiring or secondary healing. In cases where rewiring was not possible, muscle flaps were typically used. This treatment protocol was employed for an extended period, yet the mortality rate ranged from 10% to 47% as reported by various researchers [16,17,52]. The primary drawback of open dressings was thoracic instability, which was crucial for effective mechanical ventilation or spontaneous respiration. Prolonged immobilization increased the risk of further complications such as muscle weakness, thrombosis, and pneumonia [16]. Utilizing NPWT for mediastinitis situations has demonstrated advantageous results. These encompass an increase in parasternal blood circulation, a decrease in bacterial occupancy, and a hastened healing process of wounds owing to the development of granulation tissue [12]. Several researches have underscored the importance of NPWT in treating mediastinitis [34,52]. An extensive survey spanning 12 years, conducted by Lonie et al., disclosed a correlation between the use of NPWT and a reduced frequency of post-surgical complications requiring additional surgery post definitive wound sealing [53]. Remarkably, in their research, all patients treated with NPWT avoided the necessity for sternum rewiring, suggesting a supplementary benefit in stabilizing the sternum. Akbayrak et al.’s recent investigation demonstrated that the utilization of NPWT, in contrast to conventional treatment methods, led to notable reductions in metrics such as duration of hospital stay, overall treatment period, and in-hospital mortality rate [28]. The adoption of NPWT has lessened the requirement for intricate sternal closure procedures in patients with mediastinitis compared to conventional methods. This shift heralds the advent of more streamlined and economically efficient techniques [41,54].
Additionally, our subgroup analysis revealed a significant decrease in the occurrence of SWRI and in-hospital death rate in patients who had median sternotomy and were treated with NPWT, when compared to conventional wound care. Since several studies included in our analysis did not specify the type of sternotomy that SWI patients received, such as in the research conducted by Saltarocchi et al., where the subjects were identified as DSWI patients who had undergone cardiac surgery [32], it’s currently impossible to contrast the therapeutic impacts of NPWT on SWI across diverse sternotomy types. Therefore, additional updates for the subgroup analysis results based on different types of sternotomy in the future are warranted. Interestingly, NPWT was found to be associated with lower SWRI rate and in-hospital death rate, shorter ICU and hospital stays, and longer treatment duration in the European population. This observation is predominantly based on the fact that the majority of the studies included in our analysis were carried out in Europe. Only a single Asian study indicated no significant disparity between the NPWT group and conventional treatment group in terms of hospital stay duration [12]. Another investigation from Turkey revealed that the NPWT group experienced significant decreases in overall treatment duration, length of hospital stay, and in-hospital death rate compared to the group receiving conventional treatment [28]. These findings suggest potential regional variations in NPWT’s effectiveness, necessitating further research to elucidate the differential impact across diverse ethnic populations.
This study has some limitations. First, the challenges associated with implementing relevant RCTs allowed this study to combine findings only from retrospective cohort studies, which inevitably left our results subject to recall bias. Nevertheless, given the substantial advantages demonstrated by NPWT in existing evidence, conducting further RCTs may present ethical concerns. Specifically, randomly assigning patients to potentially less effective conventional treatments could expose them to unnecessary risks. Consequently, we recommend that further prospective cohort studies be conducted in specific contexts (e.g., resource-limited settings or the introduction of new technologies) to supplement the current evidence, rather than initiating new RCTs. Second, the majority of the included studies did not report the long-term outcomes of NPWT (e.g., quality of life and survival outcomes), hence, this study was confined to assessing the short-term effects of NPWT on SWI. The long-term implications of NPWT for SWI patients warrant further investigation. Additionally, more clinical indicators assessing the effect of NPWT on SWI, such as wound healing speed, deserve further exploration. Third, most of the studies included were conducted in Europe, with only one conducted in Asia, which somewhat limits the generalizability of our results to the global population. Fourth, TSA results suggested that additional studies and larger sample sizes are needed to obtain more stable and reliable results regarding ICU stay, length of hospital stay, and treatment duration.
5. Conclusion
In summary, our study indicated that compared with conventional wound care, NPWT notably decreased the incidence of SWRI, in-hospital mortality, and ICU stay. Further subgroup analyses suggested that NPWT could shorten the length of hospitalization in the European population.
Supporting information
S2 File. Risk of bias and quality assessments for each study.
https://doi.org/10.1371/journal.pone.0328771.s003
(DOCX)
S3 File. Subgroup analysis, sensitivity analysis and publication bias.
https://doi.org/10.1371/journal.pone.0328771.s004
(DOCX)
S1 Data. Excluded studies with reasons for exclusion.
https://doi.org/10.1371/journal.pone.0328771.s005
(XLSX)
S2 Data. Extracted data and used for analysis.
https://doi.org/10.1371/journal.pone.0328771.s006
(XLSX)
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