Innovation in medicine has brought innumerable improvements in patient care. For example, as late as the Vietnam War era, femoral shaft fractures were frequently treated with prolonged periods of traction—until intramedullary rods gained popularity because they helped patients mobilize soon after the injury. Similarly, negative-pressure wound therapy (NPWT) gained popularity in the 1990s because it was so helpful with treating open wounds in orthopaedics. NPWT has been a mainstay in the treatment of Wounded Warriors with blast injuries during the last 18 years of conflicts in Afghanistan, Iraq, and other war zones. But medical innovations such as NPWT often come with a high cost, which has made access to commercial NPWT unfeasible in many low-income, resource-challenged countries. Sadly, those places are also home to many patients who sustain devastating soft-tissue injuries.
In the November 20, 2019 issue of JBJS, Cocjin et al. from the Philippines report results from a randomized controlled trial that compared 7-day outcomes from a commercially available NPWT system to those from an innovative, low-cost system that the authors developed locally and have been using at their institution since the mid-2000s. This home-grown system consists of an aquarium pump converted into a reusable vacuum source, along with basic hospital supplies such as surgical gauze, tubing, and plastic food wrap. The authors also compared the cost of the two systems.
For most of the measured clinical outcomes, Cocjin et al. found that their innovative NPWT system was noninferior to the commercially available system. It was actually better (but not significantly so) in terms of time of application, pain during dressing changes, and wound-contraction percentages. There were no complications with either system, and the system made from the aquarium pump and hospital supplies cost 7 times less than the commercial device ($63.75 compared to $491.38 USD). The converted aquarium-pump system can be used up to 20 times, making its per-use cost as low as $3.
Innovation is vital to advancing orthopaedics. But we must also remember that low-cost innovation is equally important for a large portion of the worldwide patient and provider population that is resource-constrained. I applaud Cocjin et al. for sharing their locally developed innovation with the wider orthopaedic community. Although further validating studies are needed, this “homemade” NPWT system has the potential to bring to a large portion of the world a cost-effective alternative to a wound-management technique that has become a mainstay in more affluent settings over the past 2 decades.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Orthopaedic surgery is generally a discipline where functional restoration and pain relief take precedence over esthetics. However, all practicing surgeons know that how incisions appear is important to many patients and their families. This is especially true in pediatric orthopaedics, where parents feel a responsibility to limit any adverse experiences their child may have.
In the August 17, 2016 edition of The Journal, Davids et al. provide our community with an important contribution regarding some basic principles of scar management in children—in this case, kids with cerebral palsy who had a second surgery to remove an implant. The take-home message is that scars that are acceptably thin with minimal discoloration are safe to treat and do well cosmetically with a repeat incision through the original scar. Scars that are broad and/or discolored basically end up with the same appearance when the implant is removed through excision (a second incision about the margins of the first incision) and layer closure.
This field is ripe for further investigation, and careful attention to methodology will be very important. Interventions that deserve additional study include topical and intralesional treatments for healing incisions, the impact of immobilization on the quality of scars below the knee, and the effects on scars of limited weight bearing, to name a few. Similar investigations in select groups of adults with scars about the shoulder, knee, and ankle will also be welcome additions to this objective evaluation of surgical-incision outcomes by Davids et al.
Marc Swiontkowski, MD