Running head: AN INTEGRATIVE REVIEW: WOUND THERAPY 1

An Integrative Review: Wound Therapy

Kylie Banks

Bon Secours Memorial College of Nursing

NUR 4122 Nursing Research

April 4, 2017

I Pledge Honor CodeKylie Banks

AN INTEGRATIVE REVIEW: WOUND THERAPY 2

Abstract

The purpose of this integrative review is to evaluate literature regarding the use of negative

pressure wound therapy in patients with diabetic foot ulcers. Diabetes causes decreased tissue

perfusion and neuropathy, which reduces the ability to heal leading to potential long-term

complications. Negative pressure wound therapy is a commonly used treatment for complex

chronic wounds like diabetic foot ulcers. The research design is an integrative review. The search

method for obtaining research articles was established by using the computer-based search

engines PubMed and EBSCO. The results and findings displayed the advantages of using

negative pressure wound therapy and discussed one possible disadvantage. The advantages

include a rapid rate of wound healing, improved tissue granulation, increased blood vessel

growth, and decreased complications. The limitations of the review include limited number of

articles relating to chronic diabetic foot ulcers, the researchers lack of experience, and using

only 5 articles for the review. The implications indicate that negative pressure wound therapy

can significantly reduce long-term complications and improve quality of life for diabetic patients

with chronic wounds. One of the recommendations is the need for more research to be conducted

to establish more evidence for the advantages and disadvantages of using negative pressure

wound therapy.
AN INTEGRATIVE REVIEW: WOUND THERAPY 3

An Integrative Review: Wound Therapy

The purpose of this integrative review is to examine the literature relating to the use of

negative pressure wound therapy in patients with diabetic foot ulcers. Patients with diabetic foot

ulcers have neuropathy, decreased circulation, and a diminished ability to heal which puts them

at risk for infection and amputation (Sharma et al., 2017). The presence of this condition makes

treatment more difficult and requires rigorous management. Treatment options like negative

pressure wound therapy can rapidly increase the rate of wound healing among patients and

improve outcomes. This form of therapy is vital to prevent amputations and improve ambulation

and mobility among patients with chronic diabetic wounds. Negative pressure wound therapy

increases the rate of healing in comparison to standard dressing treatments (Yang et al., 2014).

The use of negative pressure therapy in chronic diabetic wounds increases perfusion, rapidly

promotes tissue granulation formation, and dramatically decreases the wound size. This topic

interests the researcher due to the severity and devastating long-term impact chronic wounds can

have on the diabetic patient population. The proposed PICO question by the researcher is as

follows: Does the use of negative pressure wound therapy influence the rate of healing in

patients who have diabetic foot ulcers?

Design and Research Methods

The design of the research is an integrative review. The search for research

articles was established by using the computer-based search engines PubMed and EBSCO. The

specific database used within these search engines was the Nursing Reference Center. The words

and phrases used within the search included, negative pressure wound therapy, diabetic

patients, foot ulcer, foot wound, and wound therapy. The search was narrowed to articles

published in English between 2011-2017, peer-reviewed, and quantitative or qualitative journal

AN INTEGRATIVE REVIEW: WOUND THERAPY 4

articles. The search generated 107 articles from PubMed and 169 articles from EBSCO. The

search results displayed many articles pertaining to negative pressure wound therapy. However,

only five articles were selected for this review and all of the articles were quantitative. These five

articles were selected based on the following inclusion criteria: chronic foot wounds, negative

pressure wound therapy, and diabetic patient population. The articles selected also had to relate

to the researchers stated PICO question which is as follows: Does the use of negative pressure

wound therapy influence the rate of healing in patients who have diabetic foot ulcers? Articles

that did not meet these criteria were omitted from the review.

Findings and Results

The findings and results of four out of the five reviewed studies revealed that negative

pressure wound therapy rapidly increases the rate of wound healing among diabetic patients with

chronic foot ulcers (Nather, Hong, Lin, & Sakharam, 2011; Sharma, et al., 2017; Ulusal, Sahin,

Ulusal, Cakmak, & Tuncay, 2011; & Yang et al., 2014). However, one of the studies indicated

that negative pressure wound therapy decreases wound healing by reducing oxygenation to the

tissues through compression (Jung et al., 2014). A summary of the complied research is located

in the Appendix 1. The researcher formed this review around two main themes. These themes

include rate of wound healing and ambulation.

Rate of Wound Healing

Four out of the five articles agreed that negative pressure wound therapy rapidly

increases the rate of wound healing in chronic diabetic foot ulcers. (Nather et al., 2011; Sharma

et al., 2017; Ulusal et al., 2011; & Yang et al., 2014). In the quantitative study by Nather et al.

(2011), it was established that negative pressure wound therapy using a Vacuum Assisted

Closure (V.A.C.) dressing promotes rapid wound healing of chronic diabetic ulcers. The purpose
AN INTEGRATIVE REVIEW: WOUND THERAPY 5

of this study was to determine whether or not negative pressure wound therapy using a V.A.C.

dressing would increase the rate of healing among patients with diabetic wounds. The sampling

method of this study included five patients with chronic diabetic wounds. The type of data

collected consisted of assessing the wound for granulation formation, reduction in wound size,

and signs of possible complications like infection. The method for collecting data involved

debridement of the wound before applying the V.A.C. dressing and assessing the wound and

changing the dressing every 48-72 hours. During each assessment the size of the wound was

measured in square centimeters to the nearest square millimeter to determine if the wound size

had decreased. Infection markers like white blood cell count, C-reactive protein, and erythrocyte

sedimentation rate were also collected on arrival to the hospital and after V.A.C. therapy. The

results of the infection markers after V.A.C therapy were analyzed to determine if rapid wound

healing had occurred. The significant findings were that all five patients had displayed rapid

signs of wound healing over a period of 20-45 days with 100% wound granulation and no signs

of complications. These results display evidence that patients with diabetic foot ulcers have an

increased rate of wound healing.

The quantitative, prospective time bound, and comparative study conducted by Sharma et

al. (2017), studied the efficiency of negative pressure wound therapy in chronic diabetic ulcers

over a year. Fifteen patients were studied at the Department of General Surgery at Indira Gandhi

Medical College and Hospital. The method of this study involved assessing the characteristics of

each wound at every dressing change. These characteristics were appearance of granulation

tissue, reduction in ulcer size, and length of hospital stay. The characteristics of the wound were

documented over a year and analyzed to determine if a rapid rate of wound healing had occurred

using negative pressure wound therapy. The significant findings of the study indicate that all the
AN INTEGRATIVE REVIEW: WOUND THERAPY 6

patients had complete wound closure, 100% tissue granulation, and the average time of healing

occurred over an average of 41.2 days. These results support that a rapid rate of wound healing

happens with the use of negative pressure wound therapy.

The comparative, quantitative study by Ulusal et al. (2011), compared the use of standard

wet dressing treatment to negative pressure wound therapy performed with using a Vacuum

Assisted Closure (V.A.C.) device in patients with diabetic foot ulcers. This study evaluated 36

patients with diabetic foot ulcers in a clinical follow-up setting between 2000 and 2008. The

patients were divided into two separate groups. The data collected was the average length of

hospital stay, the limb salvage rate, and reduction of wound size. The method for collecting data

consisted of assessing each patients progress in both groups and then analyzing the results. The

study analyzed length of hospital stay and limb salvation of the two groups to determine which

treatment was more efficient. The first group that used standard wet dressings had minor or

major limb amputations after treatment and the average hospital stay was 59 days. The second

group of patients who used negative pressure wound therapy with the V.A.C. device had no

amputations after treatment and the average length of hospital stay was 32 days. These results are

significant because they prove that negative pressure wound therapy using the V.A.C. device

rapidly improves the rate of wound healing of chronic diabetic foot ulcers compared to the

standard wet dressing.

Yang et al. (2014), evaluated the effects of using negative pressure wound therapy versus

traditional gauze therapy. The study was quantitative, experimental, and comparative and it

focused on gaining molecular insight on wound healing while comparing these two forms of

therapy. Thirty patients who had chronic non-healing diabetic foot ulcers were selected at

random. The patients were divided into two separate groups. One group used negative pressure
AN INTEGRATIVE REVIEW: WOUND THERAPY 7

wound therapy and a V.A.C. device. The second group was treated with a traditional gauze

dressing. Granulated tissue was collected before and after treatment in both groups. The

granulated tissue was further studied using Western blot analysis, histological analysis, and

immunohistochemistry analysis. The data was then further analyzed using SPS 13.0 software and

one-way analysis of variance. The significant findings indicated increased granulated tissue

formation, development of fibroblasts and collagen, wound contraction, and formation of new

vessels with the use of negative pressure wound therapy. The use of negative pressure wound

therapy showed dramatic increased rate of wound healing compared to traditional gauze therapy.

Though the majority of the studies indicate improved rate of healing using negative

pressure wound therapy, the study by Jung et al. (2014), suggests that negative pressure wound

therapy inhibits wound healing by reducing oxygenation to the tissues. The purpose of this study

was to evaluate the effect of negative pressure wound therapy on tissue oxygenation in the feet of

diabetic patients. The type of study was experimental, comparative, and quantitative that

involved measuring the transcutaneous partial oxygen (TcPo2) pressures of the unwounded foot

in diabetic patients who have foot ulcers. Twenty-one patients at the Diabetic Wound Center of

Korea University Guro Hospital were studied between April and May 2014. The patients were

separated into two groups. One group had a TcPo2 pressure setting above 40 mmHg and the other

group had a setting of less than 40 mmHg. Each patient had diabetes for at least 5 years and had

a chronic diabetic foot ulcer. A TcPo2 sensor was attached to the unwounded foot in each of the

patients. The TcPo2 levels were measured before, during, and after the use of negative pressure

wound therapy. Each of the patients TcPo2 level was analyzed using the Wilcoxon test. The

results of the two groups were then analyzed and compared using the Mann-Whitney U test. The

statistical analysis was performed using SPSS Statistics version 20.0 for Windows. The
AN INTEGRATIVE REVIEW: WOUND THERAPY 8

significant findings indicated that the TcPo2 levels of each patient were considerably decreased

proving that tissue oxygenation and perfusion is greatly diminished when using negative pressure

wound therapy in patients with diabetes.

Improved Ambulation

Two out of the five studies indicate that negative pressure wound therapy improves

mobility and ambulation among chronic diabetic wound sufferers (Nather et al., 2011; & Ulusal

et al., 2011). Negative pressure wound therapy using the vacuum assisted pressure (V.A.C.)

device allows more comfortable and practical placement of the device on the wound. This

placement allows the patient to be freely mobile by post-operative day two after debridement

surgery. The use of negative pressure wound therapy increases perfusion and tissue oxygenation,

which prevents amputation and decreases the need for prostheses. Therefore, mobility and

ambulation are improved among patients with diabetic ulcers.

Nather et al. (2011), states that the use of negative pressure wound therapy and the

V.A.C. device allows the suction pad of the dressing to be placed exterior side of the foot and

away from the weight bearing area. This allows patients to freely ambulate by the second post-

operative day and continue ambulation throughout their treatment. The placement of the suction

pad allows patients to wear protective shoes, which promotes ambulation and helps decrease

future injuries.

The study by Ulusal et al. (2011), indicated that negative pressure wound therapy using a

V.A.C. device prevented amputation, the need for prostheses, and allowed patients with diabetic

foot ulcers to ambulate without difficulty. None of the patients using this form of therapy needed

to use prostheses and were able to ambulate without difficulty. In comparison, patients who used
AN INTEGRATIVE REVIEW: WOUND THERAPY 9

standard dressing treatment had minor or major amputations and required the use of prostheses to

be mobile.

Discussion and Implications

The findings of the integrative review discuss the efficiency of using negative pressure

wound therapy in chronic diabetic foot ulcers, which supports the researchers proposed PICO

question. The PICO question aimed to evaluate the use of negative pressure wound therapy and

its influence on the rate of wound healing in patients who have diabetic foot ulcers. There are an

abundant amount of studies that support an improved rate of healing in diabetic ulcers among

this population. The studies by Sharma et al. (2017), and Yang et al. (2014), clearly indicate that

negative pressure wound therapy is a more effective treatment than standard gauze dressings and

causes a rapid rate of wound healing in diabetic foot ulcers. The evidence provided by Yang et

al. (2014), distinctly displays increased granulation of tissue, collagen, wound contractions, and

increased blood vessel formation indicates rapid wound healing. According to the studies by

Nather et al. (2011), and Ulusal et al. (2011), negative pressure wound therapy has an increased

rate of wound healing which is displayed by improved tissue granulation and wound closure rate.

These quantitative studies by Nather et al. (2011), and Ulsual et al. (2011), provide evidence of

improved ambulation among patients with diabetic foot ulcers using negative pressure wound

therapy. These studies display evidentiary support that negative pressure wound therapy

increases perfusion, tissue growth, and oxygenation which causes an increased rate of wound

healing. There is overwhelming evidence that positively supports the use of negative pressure

wound therapy. However, unlike the previous studies, Jung et al. (2014), indicates that negative

pressure wound therapy can significantly decrease tissue oxygenation in chronic diabetic foot

wounds. Due to the conflicting evidentiary support on the use of negative pressure wound
AN INTEGRATIVE REVIEW: WOUND THERAPY 10

therapy, the researcher recommends that more research must be done to provide clarity on the

use of this therapy. Another recommendation for further research is to only test the wounded

diabetic foot and not the unwounded foot like Jung et al. (2014), did in that study.

The implications of the findings suggest that the use of negative pressure wound therapy

positively impacts patients with diabetic foot ulcers. This form of therapy decreases the need for

amputations and improves the rate of healing. Integrating negative pressure wound therapy as a

first line treatment option for every chronic diabetic wound sufferer would significantly reduce

long term complications and improve quality of life. This form of therapy should be an optional

form of treatment in every major hospital to provide the best care for patients.

Limitations

There are several limitations recognized by the researcher that have influenced this

integrative review. The search results provided many studies based on negative pressure wound

therapy but displayed limited results pertaining to its use in diabetic patients. This review was

conducted exclusively by a novice researcher who has a lack of experience with performing an

integrative review. The assignment criteria limited the number of articles to five that were

published within the last 5 years.

Conclusion

The results of this integrative review demonstrate the significance of using negative

pressure wound therapy in the treatment of patients with chronic diabetic foot ulcers. The

valuable findings of this review include improved perfusion, increased growth of granulated

tissue, collagen formation, and rapid wound closure rate using negative pressure wound therapy.

The use of this form of therapy is beneficial for improving ambulation and mobility among

patients with chronic diabetic wounds and preventing further amputation. This review provides
AN INTEGRATIVE REVIEW: WOUND THERAPY 11

both positive and negative results which allows for a more well-rounded view of the efficiency

of negative pressure wound therapy. The results of this review fully support the researchers

proposed PICO question and provide evidence of a rapid improvement of wound healing when

using negative pressure wound therapy in chronic diabetic foot ulcers.

AN INTEGRATIVE REVIEW: WOUND THERAPY 12

References

Jung, J. A., Yoo, K. H., Han, S. K., Lee, Y. N., Jeong, S. H., Dhong, E. S., & Woo-Kyung Kim,

W. K. (2016). Influence of negative-pressure wound therapy on tissue oxygenation in

diabetic feet. Advances In Skin & Wound Care, 29(8), 364-370. doi:

10.1097/01.ASW.0000483038.18331.a4

Nather, A., Hong, N. Y., Lin, W. K., & Sakharam, J. A. (2011). Effectiveness of bridge V.A.C.

dressings in the treatment of diabetic foot ulcers. Diabetic Foot & Ankle 2. 1-7. DOI:

10.3402/dfa.v2i0.5893

Sharma, D., Signh, B., Jaswal, K. S., Thakur, V., Nanda, V., & Nabh, R. (2017). Effectiveness of

negative pressure wound therapy in the management of chronic diabetic ulcers: A

prospective study. International Surgery Journal 4(4). 1313-1318. DOI: 10.18203/2349-

2902.isj20171134

Ulusal, A. E., Sahin, M. S., Ulusal, B., Cakmak, G., & Tuncay, C. (2011). Negative pressure

wound therapy in patients with diabetic foot. Acta Orthop Traumatol Turc 45(4). 254-

260. DOI: 10.3944/AOTT.2011.2283

Yang, S. L., Han, R., Liu, Y., Hu, L. Y., Li, X. L., & Zhu, L. Y. (2014). Negative pressure

wound therapy is associated with up-regulation of bFGF and ERK in human diabetic

foot wounds. Wound Repair and Regeneration 22. 548-554. DOI: 10.1111/wrr.12195
AN INTEGRATIVE REVIEW: WOUND THERAPY 13
Appendix 1
Table of Quantitative Evidence

First Author Jae-A. Jung, MD (2014) Professor in the Department of Plastic Surgery at Jorea University
(Year)/Qualifications Guro Hospital, Seoul, South Korea.
Background/Problem Negative pressure wound therapy (NPWT) is commonly used among the treatment for chronic
Statement diabetic wounds. Some studies reported that NPWT increases blood flow and tissue oxygenation in
chronic wounds. This study indicates that NPWT may decrease tissue oxygenation and perfusion in
the wound beds. This causes more harm due to the combination of the compressing sponge dressing
negative pressure.
Conceptual/theoretical The conceptual/theoretical framework was no discussed.
Framework
Design/ This design of the study was experimental, comparative, and quantitative. Transcutaneous partial
Method/Philosophical oxygen pressures (TcPo2) sensors were attached to the tarsometatarsal area of the unwounded foot.
Underpinnings A negative pressure of -125mmHg was applied unto the TcPo2 pressure maintained a steady state.
The TcPo2 level was measured before, during, and after the NPWT. The philosophical
underpinnings were not discussed.
Sample/ Setting/Ethical 21 patients (4 women and 17 men) with diabetic foot ulcers were used in this study. The mean age
Considerations of participants was 55.7 years old. Each patient had diabetes for at least 5 years. The setting took
place at the Diabetic Wound Center of Korea University Guro Hospital in April and May 2014.
Informed consent was obtained by all participants. The study was approved by the institutional
review board of Korea University Guro Hospital.
Major Variables Studied (and The study analyzed the effects of NPWT on tissue oxygenation in diabetic foot wounds using a
their definition), if GranuFoam dressing. The TcPo2 pressures were set at less than 40 mmHg for one group and greater
appropriate than 40 mmHg for the second group and then compared.

Measurement Tool/Data
Collection Method
Data Analysis
TcPo2 pressures were measured using a PF 5040 TcPo2 unit and PeriSoft software. The TcPo2 sensor
and electrode were attached to the dorsum of the unwounded foot in the tasometatarsal area in the
first intermetatarsal space. The baseline TcPo2 was measured. A polyurethane foam dressing
(GranuFoam dressing) was attached on top of the electrode and administered a suction pressure of -
125 mmHg until a steady state was maintained. The TcPo2 levels were compared before, during, and
after NPWT was applied.
Each patients TcPo2 pressure level was analyzed by the Wilcoxon test. The TcPo2 levels of the two
AN INTEGRATIVE REVIEW: WOUND THERAPY
Findings/Discussion
Appraisal/Worth to practice
14
groups were analyzed and compared using the Mann-Whitney U test. The statistical analysis was
performed using SPSS Statistics version 20.0 for Windows.
The TcPo2 levels of each participant were decreased. The average time required to reach a steady
state using NPWT was 25.8 minutes. The first group with the TcPo2 level set at less than 40mmHg
showed a 77% decreased in TcPo2 pressure while using NPWT. The second group with the TcPo2
level of greater than 40mmHg showed an 87% decrease in TcPo2 pressure while using NPWT.
These results indicate that tissue oxygenation and perfusion is greatly decreased underneath NPWT
dressings in patients with diabetes.
The pressure stimulated by negative pressure wound therapy greatly decreases tissue oxygenation in
diabetic patients. The compression stimulated by the dressing must be closely monitored to prevent
further complications in this patient population.
AN INTEGRATIVE REVIEW: WOUND THERAPY 15

First Author Aziz Nather (2011) Department of Orthopedic Surgery, Yong Loo Lin School of Medicine,
(Year)/Qualifications National University of Singapore.
Background/Problem Diabetic foot ulcers are found in 10-15% of patients who have diabetes. Healing of these ulcers is
Statement difficult, involves a lengthy hospital stay, and rigorous wound management. Negative pressure
wound therapy using the Vacuum Assisted Closure (V.A.C.) Therapy System has been found to
have significantly faster wound healing rates in diabetic foot ulcers.
Conceptual/theoretical The conceptual/theoretical framework was not discussed within this study.
Framework
Design/ The design was a quantitative and prospective study. The philosophical underpinnings were not
Method/Philosophical discussed.
Underpinnings
Sample/ Setting/Ethical Five patients were studied by the National University Hospital, Singapore over a period of 22-48
Considerations days. There were 5 males and 1 female patient with an average age of 58.8 years. The requirements
indicated that the patients must have open ray amputation wounds (3 patients) and wound post-
drainage for abscess that had exposure of deep structures like the fascia and tendon (2 patients).
The ethical considerations were not discussed within this study.
Major Variables Studied (and The study evaluated the V.A.C. dressing and its efficiency in promoting wound bed granulation and
their definition), if closure in diabetic foot ulcers.
appropriate The suction pad of the V.A.C. dressing was applied to the lateral side of the foot proximally in all 5
patients which allowed for mobilization during the therapy.
Measurement Tool/Data The negative pressure wound therapy delivered by the V.A.C. Granufoam Bridge dressing was
Collection Method applied by medical personnel intraoperatively during the debridement procedure and applied
postoperatively by trained staff nurses. The settings of negative pressure therapy were set to the
manufacturer guidelines of -125mmHg. Dressing changes and wound assessment were conducted
every 48-72 hours. The wounds were assessed for degree of granulation, reduced wound size, and
any possible signs of complications like infection or necrosis. The size of the wound was measured
by placing two pieces of transparent plastic sheets directly on the wound and marking the outline of
the wound size. The outer transparent sheet was then placed over calibrated graph paper and
measured in square centimeters to the nearest square millimeter.
Data Analysis The infection markers on arrival of hospitalization and after V.A.C. therapy were analyzed. These
included white blood cells (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate
(ESR).
AN INTEGRATIVE REVIEW: WOUND THERAPY
Findings/Discussion
Appraisal/Worth to practice
16
The wound was swabbed before V.A.C. and indicated what bacteria was present in the wound. The
wound was swabbed again and results indicated no bacteria were found after V.A.C. therapy.
The length of therapy, number of V.A.C. dressing changes, number of surgical debridements, and
time (days) to complete microbial clearance were analyzed for each patient.
The wound area and changes of the wound were also assessment for each patient.
All 5 patients displayed signs of wound granulation within 4 to 8 days after starting V.A.C. therapy.
Each patient achieved 100% wound granulation over a period 20-45 days. The V.A.C. Granufoam
Bridge Dressing showed wound reduction of 32.8%. No complications were noted in each of the
patients wound sites. The key advantage of using a V.A.C. dressing is the ability to apply the
suction pad on the lateral side which increases mobility. Patients were able to ambulate on the
affected limb using protective footwear or using crutches by the second post-operative day.
Negative pressure wound therapy using the V.A.C. displays rapid wound healing in each of the
patients. V.A.C. dressings allow the patient to ambulate by the second post-operative day.
AN INTEGRATIVE REVIEW: WOUND THERAPY
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
17
Dhruv Sharma (2017) Medical Doctor at Department of General Surgery, Indira Gandhi
Medical College and Hospital, Shimla, Himachal Pradesh, India.
Chronic diabetic ulcers involve complex treatment and are challenging to manage. Negative
pressure wound therapy (NPWT) is commonly used for difficult wounds but the research on its
efficiency is limited.
The conceptual/theoretical framework was not discussed.
The design was a quantitative, prospective time bound comparative study. The method of this study
included examining and treating diabetic ulcers with NPWT. The rate of wound closure and
appearance of tissue granulation was assessed. The philosophical underpinnings were not discussed.
30 patients were reviewed, however only 15 participants were selected for this study. These 15
patients were admitted to the Department of General Surgery, IGMC, Shimla, India in July 2015
through June 2016 were used in this study. Each patient had a chronic non-healing diabetic ulcer.
The study took place over 1 year and included 11 men and 4 women. The average age of
participants was 54.4 years. The Institutional Ethics Committee approved this study.
The major variables within this study were the time for complete wound closure to occur and the
time for granulation of tissue to appear in chronic diabetic patients.
Each wound was irrigated and debrided prior to apply the NPWT dressing. NPWT was administered
via a polyurethane foam dressing, a Silicone catheter, a transparent adhesive covering and
continuous pressure at -125 mmHg and -150mmHg for all patients. The NPWT dressing was
changed every 5 days and repeated debridements were done when necessary. Wound
characteristics were recorded at every dressing change and treatment occurred until the ulcer
completely closed.
Data was analyzed based on wound closure rate, lack of drainage, and no longer needed dressing
changes. The time, appearance of granulation tissue, reduction of ulcer size, and duration of hospital
stay were also analyzed.
All 15 patients had complete wound closure. The average time of wound healing was 41.2 days. The
results indicate the time for the first appearance of granulated tissue, the time for 100% tissue
granulation to occur, and complete wound healing among all patients was attained at a rapid rate.
There were no amputations or complications among the patients. NPWT has a high success rate due
AN INTEGRATIVE REVIEW: WOUND THERAPY 18

to removing excessive interstitial drainage, increasing angiogenesis and perfusion, and increasing
the rate of tissue granulation.

Appraisal/Worth to practice This study proves that NPWT using a vacuum assisted closing device is the most effective treatment
for chronic diabetic ulcers in comparison to conventional dressings.
AN INTEGRATIVE REVIEW: WOUND THERAPY 19

First Author Ali Ulusal (2011) Department of Orthopedics and Traumatology, Faculty of Medicine,
(Year)/Qualifications Balikesir University.
Background/Problem Damage to the autonomic nervous system and microcirculation causes deterioration of skin integrity
Statement and poor perfusion in diabetic foot wounds. Diabetic wounds can easily become infected and are
difficult to treat. Invasive wound therapy is needed to treat infection and promote optimal tissue
growth.
Conceptual/theoretical The conceptual/theoretical framework was not discussed within this study.
Framework

Design/ The design of the study is quantitative and comparative. The method looked at the results of using
Method/Philosophical standard dressing treatment in comparison with using negative pressure wound therapy via a V.A.C.
Underpinnings device in diabetic patients with foot ulcers. The philosophical underpinnings were not discussed.

Sample/ Setting/Ethical 35 patients with diabetic foot ulcers were assessed between 2000-2008.
Considerations There were 9 women and 26 men. The age range was 42-90 years old. All of the patients had
severely infected foot wounds. The study occurred in a clinical follow-up setting but the exact
location was not discussed. Ethical considerations were not discussed in this study as well.

Major Variables Studied (and The major variables in this study include comparing standard wet dressings with negative pressure
their definition), if wound therapy using the vacuum-assisted closure device (V.A.C.) in patients with diabetic foot
appropriate ulcers. Two separate groups were used within this comparison.

Measurement Tool/Data
Collection Method
The study assessed 35 patients with diabetic foot wounds and separated them into two groups. Each
patient had severely infected necrotic wounds and had a Wagner Grade 3 or Grade 4, which
classifies the stage of diabetic foot disease. The first group consisted of 20 patients (16 men and 4
women). Group 1 was treated with standard wet dressings and wound debridement. The second
group consisted of 15 patients (10 men and 5 women). Group 2 underwent wound debridement
followed by treatment via negative pressure wound therapy using the V.A.C. dressing. Group 2
patients had the V.A.C. dressing every two days. Negative pressure wound therapy was
administered via a KCI branded V.A.C. device. These patients were treated with -125mmHG
continuous negative pressure during the first two sessions. Intermittent treatment at the same
pressure was administered with 5 minutes of negative pressure and then a 2 minute break from
therapy. Each patient also received antibiotic therapy based on his or her personal needs. During the
treatment the department of endocrinology collaborated with the researchers to closely monitor
AN INTEGRATIVE REVIEW: WOUND THERAPY
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
20
glucose levels. The treatment was considered a success based on length of hospitalization and limb
recovery.
The data analysis was based on the length of hospitalization and limb salvation.
The average hospitalization of group 1 (patients treated with standard wet dressings) was 59 days.
The average length of hospitalization of group 2 (patients treated with V.A.C. dressing) was 32
days. Each of the patients in group 1 received limb amputation after standard wet dressing
treatment. Half of the patients had major amputations and the other half had minor amputations. The
use of prostheses was used among group 1 patients. Group 2 patients had complete wound healing
in 10 out of 16 patients (63%) and did not lose any extremities following V.A.C. treatment. Patients
in group 2 stated that they preferred the V.A.C. treatment because it was more comfortable and had
less leaking and smell compared to the standard dressing.
Negative pressure wound therapy using the V.A.C. dressing improves the rate of healing compared
to standard wet dressing treatment. The V.A.C. dressing allowed all of the patients to avoid limb
amputation and walk without the use of prosthetics.
AN INTEGRATIVE REVIEW: WOUND THERAPY 21

First Author Shao-Ling Yang PhD (2014) - Department of Endocrinology, Peace Hospital PLA,
(Year)/Qualifications Department of Neurology, The First Affiliated Hospital of Hebei Medical University, and
Department of Biochemistry and Molecular Biology, Traditional Chinese Medical College,
Laboratory of Medical Biotechnology of Hebei Province.
Background/Problem Patients with diabetes develop chronic foot ulcers than can be costly to treat and cause increased
Statement morbidity. Diabetic patients can develop neuropathy and vasculopathy, which increases the risk of
infection and leads to foot ulcers that can lead to tissue damage. These patients require more
effective wound therapy treatment like negative pressure wound therapy to improve the rate of
healing.
Conceptual/theoretical The conceptual/theoretical framework was not discussed within this study.
Framework

Design/ The design was a quantitative, experimental, and comparative study. It was a randomized clinical
Method/Philosophical trial regulated by the Chinese Clinical Trial Register. The philosophical underpinnings were not
Underpinnings discussed.

Sample/ Setting/Ethical
Considerations
35 patients with diabetic foot ulcers were screened and 30 patients were selected for the clinical trial
between January 2010 and December 2012. Patients had to have a chronic non-healing diabetic foot
wound for greater than 1 month. The age range was between 50 and 70 years old. The ankle brachial
index was between 0.5-0.8, and transcutaneous oxygen pressure was between 20-40mmHg.
Informed consent was received and approved for all participants by the Ethical Review Board for
Research at Bethune International Peace Hospital.

Major Variables Studied (and The participants were divided into two equal groups. One group receiving therapy via negative
their definition), if pressure wound therapy and the other group (the control group) receiving conventional gauze
appropriate treatment. The major variables included wound closure rate, formation of granulated tissue and
growth, collagen production, and wound contraction.

Measurement Tool/Data
Collection Method
Granulated tissue was collected from both groups before and after treatment and analyzed with
hematoxylin, eosin, and Massons trichrome staining methods. The first sample was collected on
day 0 before using treatment and the second sample was collected on day 7 after the use of
treatment. The biopsies were collected in two parts. One part was used for immunocytochemical
staining of the basic fibroblast growth factor (bFGF) using a streptavidin-biotin complex system
(SABC). The other part was stored at -80 degrees for Western blot analysis of bFGF and
AN INTEGRATIVE REVIEW: WOUND THERAPY
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
22
extracellular signal-regulated kinase (ERK). Negative pressure wound therapy was applied via
VAC therapy and used a negative pressure of -125mmHg.
Immunohistochemistry, Western blot, histological and collagen analyses were used to evaluate
expression of bFGF and ERK, which indicate improved rate of wound healing. Data was analyzed
using SPS 13.0 software and one-way analysis of variance. P < 0.05 was considered significant.
The major findings discussed within the study are that endogenous levels of bFGF and the
activation of the ERK 1/2 signaling pathway were increased in diabetic foot wounds during the 7
day period. These results indicate an increased rate of wound healing using negative pressure wound
therapy. The findings indicated increased granulated tissue, fibroblasts, collagen, wound
contraction, and formation of vessels using negative pressure wound therapy in comparison of using
conventional gauze therapy.
Negative pressure wound therapy increases the rate of wound healing in chronic diabetic foot ulcers
in comparison to conventional gauze dressings.