Negative Pressure Darwinism: Survival of the Fittest Paradigm

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Author(s): 
Michael Miller, DO; Farhad Bybordi, MEdM

Abstract: The use of negative pressure for wound healing has been based on a set of parameters and devices that until recently were combined into a single paradigm. Despite historical and more recent evidence providing viable alternative considerations, it is only recently that this paradigm and its tenets have come into question. As the understanding of the limits of the current paradigm and specific instances of its benefits and drawbacks are identified, shifts in the paradigm must take place if the therapy is to evolve, develop, and continue to be efficacious. The pertinence of the concept of survival of the fittest is used to explore the need for a paradigm shift in negative pressure wound therapy.





Address correspondence to:
Michael Miller, DO
The Wound Healing Center
2900 16th Street
Bedford, IN 47421
Phone: 812-798-2091
E-mail: doc@docmillers.com





     The field of negative pressure wound therapy (NPWT) has had a dramatic expansion in terms of technologic reproduction, but there is a question as to whether there has been a definitive and identifiable change in the conceptualization, applications, and outcomes as newer versions are considered and enacted.

     In 1997, the first commercial incarnation of NPWT entered the market. With it came concepts within this new paradigm that at first were met with skepticism. These included: using an open cell polyurethane foam inserted into a non-sterile wound for a period exceeding 23 hours without changing it; sealing the wound with a plastic film that “prevented the air from getting to the wound”; attaching a tube to the sealed foam/wound that allowed for a direct connection with the outside; keeping the drainage in an attached container for more than 24 hours without emptying it, and many other then controversial considerations. Despite these early concerns, the success of the technology and paradigm(s) it created led to major advances in wound healing and subsequent commercial success. It can be shown that there were earlier recorded uses of negative pressure; however, the creation and acceptance of this particular paradigm was due to its multi-factorial considerations such as the level of suction, wound contact medium, method of application, and of course, the pump technology, which led to improved healing outcomes.

     An upstart company, led by a 2004 legal victory, forced the door open and allowed a limited juxtaposition of technologies and a challenge to the established paradigm. Since there is now a variation on an established technology, the terms “gold standard” and “perfect” must be evaluated and considered. For a technology and/or paradigm to be perfect it must have no shortcomings, no faults—in essence it is a one size fits all technology. In contrast, the term gold standard recognizes the temporal advantages and benefits of a given paradigm. It recognizes that at a given time, in a given place, under a given set of circumstances, that the paradigm was the best available. It allows for a change in any of these variables, but more importantly, recognizes that the changes in these and other variables allow for changes in the paradigm with an equal potential for improvement or worsening.

     With these concepts in mind, the progression of scientific technologies must follow the basic tenets of British economist Herbert Spencer who transitioned from Charles Darwin’s biologic theories of natural evolution to that of sociologic, and subsequently economic events. It was he who coined the phrase “Survival of the Fittest” in his book Social Statics. Technology must be adaptable. “The more adaptability, the greater the viability.”1 The question before us is simple: Is the initial and prevalent NPWT paradigm perfect or the gold standard? If “perfect,” then why should there be any other viable alternatives expected to survive?

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