The incision-care insight that could transform orthopedic surgery

Real-world data comparing two negative-pressure wound therapy devices suggests lower pressure may drive better outcomes.

Around seven million orthopedic surgeries take place in the U.S. every year¹, many of them total joint arthroplasty procedures.² While most progress smoothly, surgical site complications (SSCs), including infections which affect up to 9% of cases^3–6 and can significantly increase length of stay and cost. A standard hip replacement may cost $16,398 with a three-day stay; add an SSI, and hospitalization often extends by five more days, almost doubling costs.⁷

For years, orthopedic teams have increasingly used single-use, prophylactic negative pressure wound therapy (sNPWT) to reduce these complications. These dressings support healing by applying continuous suction and removing fluid.

“A wound complication or infection following orthopedic surgery is a very expensive problem and can be devastating for patients. We know negative pressure wound therapy helps reduce surgical site complications.” Ravi Bashyal, MD, NorthShore University Health System (study author)

Two sNPWT approaches dominate: -125mmHg devices such as Prevena™, which use higher pressure and a canister to collect fluid; and -80mmHg devices like the PICO™ System, which are canisterless and allow fluid to evaporate through the dressing.^8–10 Both are widely used – but until now, no study had compared their impact on clinical outcomes, costs and resource use.

A new real-world evaluation of more than 17,000 orthopedic cases offers the first head-to-head evidence, suggesting the lower-pressure, canisterless option may deliver superior performance.

A first-of-its-kind comparison

The study, published in Journal of Wound Care, analysed 8,634 orthopedic cases treated with PICO™ NPWT and 8,634 cases treated with Prevena™, using 2017 – 2022 data from the Premier PINC AI™ Healthcare Database. This claims database represents roughly 25% of U.S. inpatient admissions across a range of hospital types.^11,12

“We know NPWT works. What we haven’t had until now is comparative data for different devices.”

Adam Wright, MD, Plano Orthopedic and Sports Medicine Center (study coauthor)

Before this research, no investigation had explored whether variation in device design or pressure levels translated into meaningful differences in clinical or economic endpoints.

Why modes of action matter

Pressure intensity and how it is distributed are major differentiators. PICO™ applies consistent, even pressure across the incision and surrounding tissue. Prevena™ applies higher, more localized suction directly over the incision.^8–10

Structural design also plays a role. PICO™ NPWT is canisterless, using a high-moisture-vapor-transmission dressing that allows up to 80% of fluid to evaporate.^8,13 Prevena™, by contrast, uses a foam filler and canister to draw and store fluid.⁹

Researchers noted these differences might influence blood flow, tissue adhesion and blistering risk—factors that ultimately affect outcomes.¹⁴

“This study starts to look at the nuances of NPWT types to help guide selection.” Ravi Bashyal, MD

Less pressure, better performance

Across all major endpoints, the PICO™ System was associated with significantly better outcomes:*

Clinical outcomes

• Lower unadjusted SSI incidence (0.23% vs 0.32%)^15,*
• 63.9% lower dehiscence rate (0.07% vs 0.21%)¹⁵

*Associated with a better outcome, but is not significant

Costs

• 21–22% lower unadjusted costs at index admission, 30 days and 90 days post-op¹⁵

Healthcare resource utilization

• Relative length of stay reduced by nearly 30% (2.43 vs 3.10 days)¹⁵

These findings support the idea that lower, evenly distributed NPWT may reduce complications and downstream resource use. PICO reduces complications which would be caused at higher pressure levels.

Wright added that pressure intensity matters at the bedside, too:

“With high-suction devices, the biggest downside is blistering, especially in patients with fragile skin. Between the two devices, I see far less blistering with PICO. More suction is not always better.”

Why this matters now

Demand for orthopedic procedures is rising.¹⁶ By 2030, 1.4 billion people will be aged 60+,¹⁶ and the global orthopedics market is projected to grow 3.1% annually through 2027.¹⁷ At the same time, diabetes¹⁸, hypertension¹⁹ and obesity²⁰ – which are major risk factors for post-operative complications continue to increase.²¹

Against this backdrop, reducing surgical site complications is clinically essential and economically unavoidable.

“Clinicians must be fiscally responsible and understand the nuances between sNPWT devices. Selecting the right device can help improve outcomes and prevent downstream costs.” Ravi Bashyal, MD

Growing body of evidence

The study adds important nuance to NPWT practice: not all devices perform the same. The PICO™ System offers lower, steadier pressure in a canisterless form which was associated with reduced SSIs, fewer complications, shorter stays¹⁴ and lower total costs and it’s low relative unit cost.^8,9

These findings also complement the growing evidence supporting prophylactic use of incisional negative pressure wound therapy (iNPWT) across surgery. A recent meta-analysis presented at the International Consensus Meeting 2025 concluded that “The use of iNPWT is recommended to minimize the risk of SSI in adult patients with primarily closed surgical incisions after lower extremity/acetabular fracture surgery and joint arthroplasty of the hip and knee.” Meta-analysis

Presenters featured in this material may include external healthcare professionals, as indicated in the material content.  The healthcare professional presenter(s) featured are paid consultant(s) of Smith+Nephew.

For more information on the PICO™ System visit: https://www.possiblewithpico.com/home

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