Preoperative negative pressure wound therapy is associated with lower flap necrosis and selected postoperative complications in high-risk older adults undergoing stage IV pressure ulcer flap reconstruction: a propensity score–matched cohort study

Abstract Flap reconstruction for stage IV pressure ulcers remains challenging in older adults with overlapping nutritional, infectious, and wound-related risk factors. Negative pressure wound therapy (NPWT) may improve preoperative wound bed optimization, but its clinical value in high-risk reconstructive populations remains insufficiently defined. This single-center retrospective cohort study included high-risk adults aged ≥60 years who underwent flap reconstruction for stage IV pressure ulcers between January 2017 and December 2023. High-risk status was defined as the presence of at least two of six prespecified domains: nutritional impairment, systemic comorbidities, infection burden, advanced age, anatomical complexity, and recurrence history. Among 497 screened patients, 367 met high-risk criteria. After 1:1 propensity score matching, 140 patients receiving preoperative NPWT and 140 receiving conventional care were included in the final analysis. The primary outcome was postoperative flap necrosis within 90 days. Secondary outcomes included postoperative infection, wound dehiscence, reoperation, drainage volume, postoperative hospital stay, and six-month recurrence. Postoperative flap necrosis occurred in 19 of 140 patients (13.6%) in the NPWT group and 35 of 140 patients (25.0%) in the non-NPWT group (P = 0.018). In the four-variable multivariable logistic regression model, preoperative NPWT was associated with lower adjusted odds of flap necrosis (OR 0.47, 95% CI 0.25–0.88), whereas wound area ≥60 cm² was associated with higher odds (OR 2.42, 95% CI 1.21–4.82). NPWT was also associated with lower rates of postoperative infection (13.6% vs. 22.9%, P = 0.042) and wound dehiscence (9.3% vs. 18.6%, P = 0.031), as well as lower cumulative drainage volume during postoperative days 1–3 (207 ± 84 mL vs. 234 ± 88 mL, P = 0.009). Reoperation, six-month recurrence, and postoperative hospital stay were numerically lower in the NPWT group but did not reach statistical significance. Exploratory subgroup analyses showed odds ratios below 1.0 across the five clinically selected strata, although estimates were imprecise in several subgroups and no formal interaction testing was performed. In this retrospective propensity score–matched cohort, preoperative NPWT was associated with lower flap necrosis, fewer selected postoperative complications, and lower early drainage volume in high-risk older adults undergoing stage IV pressure ulcer flap reconstruction. These observational findings warrant prospective confirmation before routine or subgroup-specific treatment recommendations are made.