Negative Pressure Wound Therapy as a Bridge to Definitive Reconstruction in Complex Extremity Trauma: A Systematic Review and Meta-Analysis.

Complex extremity injuries, including open fractures, particularly Gustilo-Anderson type IIIB and IIIC injuries, continue to be a major challenge for all types of institutions and levels of healthcare, a surgical challenge even in specialized trauma centers or hospitals with trained staff characterized by extensive soft tissue defects, bone exposure, and high rates of infection, flap failure, and secondary amputation. Finding the best strategy to reduce morbidity and complications of these injuries remains a challenge for plastic surgery. Negative pressure wound therapy (NPWT) has played an important role as a temporary "bridging" strategy between initial surgical debridement and definitive soft tissue reconstruction. This article is a systematic review and meta-analysis that evaluates the efficacy and safety of NPWT as a bridging therapy before definitive soft-tissue reconstruction in adult patients with complex extremity injuries, compared with conventional dressings or immediate reconstructive procedures. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. They were prospectively registered with PROSPERO(CRD420261359962), aimed to evaluate and synthesize evidence from comparative studies published between 2009 and 2025. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa scale for observational studies. The certainty of the evidence was assessed using the GRADE approach. The evidence reveals an interesting comparison between large, multicenter RCTs and smaller, single-center studies. The two highest-quality trials, the Wound Management of Open Lower Limb Fractures (WOLLF) RCT (n=460) and the Wound Healing in Surgery for Trauma (WHiST) RCT (n=1548), found no statistically significant reduction in rates of deep surgical site infections. The Cochrane review, which combined four RCTs (596 participants), found an uncertain reduction in the risk of infection (RR 0.48, 95% CI 0.20-1.13; very low-certainty evidence). In contrast, multiple smaller RCTs from single-center, resource-limited settings reported statistically significant reductions in acute wound infection (7.5-10% with NPWT vs 25-42% with conventional dressings). A meta-analysis of 10 RCTs (n=2780) found a significant reduction in the overall risk of infection (pooled MD 0.70, 95% CI 0.54-0.90, p=0.005). NPWT consistently allowed for a lower reconstructive ladder, replacing the free flap with skin graft coverage in multiple series, and retrospective data suggest a possible reduction in flap failure rates (6% vs 11%). NPWT as a bridging therapy for complex extremity trauma offers context-dependent benefits. The greatest benefit is expected for Gustilo IIIB/IIIC injuries in resource-limited settings with high baseline contamination and limited reconstructive capacity. In specialized trauma centers with sufficient resources and early debridement, standard wound management achieves equivalent results at a lower cost and with a lower incidence of adverse events. NPWT-d should be considered a superior alternative when available. High-quality, randomized clinical trials specifically designed to evaluate NPWT as a bridging strategy to flap surgery are needed.