Journal Reading:

Comparisons of Negative Pressure Wound Therapu and

Ultrasonic Debridement for Diabet Foot Ulcers: A Network
Meta Analysis
Harningtyas Alifin Jasmin
11141030000048

Mentor: dr. Witra Irfan SpB(K)V

Coassisstant of Surgery RSUP Fatmawati
UIN Syarif Hidayatullah Jakarta
1438 H/2018 M
INTRODUCTION
• Diabetic foot ulcer happens more than 15% of diabetes mellitus

• Hunt’s study: prevalence DFU 4-10% on DM, lifetime incidence 10-25%

• Standard therapy for DFU: glucose control management infection,

debridement, off-loadinggg high pressure, dressing
INTRODUCTION (CONT.)
• Negative pressure wound therapy: a non-invasive adjunctive therapy system
applies controlled negative pressure using vaccum sealing drainage (VSD) or
vaccum assisted closire (VAC) device to help promote wound healing by
removing fluid from open wounds through a sealed dressing & tubing which is
connected to a collection container device

• Ultrasound therapy: non contact wound therapy to promote healing through

the cleansing & debridement of wounds
OBJECTIVE
• Compare the strength and weakness of negative wound pressure therapy with
ultrasound debridement for diabetic foot ulcers
METHOD: SEARCH STRATEGY
• Medical literature up to January 2015, bases Pubmed, ovid EMBASE, Web of Science,
Cochrane Library

• String: (“Negative Pressure Wound Therapy” or “Vaccum Assisted Closure” or “Vaccum

Sealing Drainage”) or (“Ultrasound” or “Ultrasonic”) and (“Diabetic Foot” or “Diabetic
Wound” or “Diabetic Ulcer”)

• Chinese biomedicine literature

• Reference list & include studies searched manually

• Only conducted in human

METHOD: INCLUSION & EXCLUSION
• Clinical randomized and non clinical randomized reporting eficacy & safety:
• Inclusion:
• Diabetes patient
• Compared studies
• Outcome: healed ulcers, time to wound closure, decrement in area wound, secondary amputation

• Exclusion:
• Single arm design
• Primary endpoints were missing
• Dual submisions
METHOD: DATA EXTRACTION
• 2 investigators independently assesed the quality of trials, the third author
resolved disagreement

• Modified Jada score: tool to evaluate the quiality analysis of methodology

(randomization, blinding and withdrawal from study)
• 1 – 2: low quality
• 3 – 4: middle quality
• 5 – 7: high quality
METHOD: MISSING DATA
• Standar deviation of mean value of 4 studies were missing (time to wound
closure, decrement)
• Solutions:
• Remove the missing data
• Similar studies could be reference  the choice of this study
• Through calculating if CI is known
METHOD: NETWORK META-ANALYSIS
• Compare direct and indirect evidence of class or agents using the Bayesian
Markov-chain Monte Carlo method

• Traditional meta-analyses compare one intervention with another at a time

and combine evidence directly from head-to-head clinical trials

• Network meta analysis combines effect sizes for all possible comparison
METHOD: STATISTICAL ANALYSIS
• Using software R (X64, 3.1.2, packages including gemtc and rjags)

• Output  forest plot

• Random effect model  varied population studies

RESULT
• 715 (February 2015)  excluded basiss of title and abstract  134 studies
 63 were rejected (beyond inclusion)

• 71 read manulally, 39 excluded (data redudancy, extension study)  32 met

the criteria (12 studies published in English, 19 of Chinese)

• 32 studies = 2880 diabetes patient

• Using Texas Diabetic Wound Classification System or Wagner Scale

RESULT
• Healed ulcer  20 studies
• NPWT (VAC & VSD) and UD significantly improved foot ulcer healing than standard
wound care; OR 2.8[1.9, 4.2], 3.9[2.3, 7], 3.2[1.2, 9.1]
• No significance was observed between VAC and VSD compared to UD; OR 0.86[0.28,
2.6], 1.2[0.38, 4]

• Time to wound closure  15 studies

• NPWT (VAC & VSD) and UD significantly shorter than standard wound care; standard
mean difference -18[-29, -6.6], -22[-38, -6.3], -23[-46, 0.2]
• VAC or VSD were as effient as UD; standard mean difference 5.2[-20, 31] and 1.1[-27,
29]
RESULT
• Decrement in ulcer area  10 studies
• VAC & VSD group had significant differences in ulcer area than stadard wound care,
mean difference -18[-29, -6.7], -22[-38, -6.1]
• No significance between UD and VAC & VSD group, standard mean difference 4.9[-21,
31], 0.93[-27, 29]

• Secondary amputations  7 studies

• Incidence secondary amputation in NPWT 3.2% (12/376) while standard wound care
11.1% (43/386)
DISCUSSION
• From 32 studies, there was no significant difference between NPWT and UD in
efficacy and safety, but both better to standard wound care

• 2 systematic reviews of The International Working Group of the Diabetic Foot

on NPWT conclude NPWT possibly partially effective for DFU