Diabetic foot ulcers precede most diabetes-related lower-limb amputations, and wounds that fail to heal on standard care are a major driver of disability and cost. Negative pressure wound therapy (NPWT) applies controlled subatmospheric pressure through a sealed dressing and has become a common adjunct in complex wounds. Its role in diabetic foot care, however, is more nuanced than its widespread use suggests. This article summarizes what recent systematic reviews and international guidelines conclude.
How NPWT Is Thought to Work
A foam or gauze filler is placed in the wound, covered with an adhesive drape, and connected to a pump that applies suction. Proposed mechanisms include removal of excess exudate, reduction of tissue edema, mechanical deformation of the wound bed that stimulates cell proliferation, and promotion of granulation tissue. These effects are most relevant in deep or postoperative wounds, where dead space and drainage are practical problems. NPWT does not replace the fundamentals of diabetic foot care: adequate perfusion, infection control, debridement, and effective offloading.
Evidence From Meta-Analyses
Favourable pooled results
Du and colleagues (2025) appraised eight overlapping meta-analyses of NPWT in diabetic foot ulcers, each drawing on roughly 8 to 14 randomized trials. In the highest-quality review they identified, NPWT was associated with a higher likelihood of healing (risk ratio 1.46; 95% CI 1.22–1.76) and a lower amputation risk (risk ratio 0.69; 95% CI 0.50–0.96), with shorter time to granulation tissue formation and no significant difference in adverse events compared with controls.
More cautious findings
Not every review reaches the same conclusion. Dalmedico and colleagues (2024) systematically reviewed 14 studies. Most trials reporting wound area reduction favoured NPWT, and several reported fewer amputations. Yet a meta-analysis of three trials (90 participants) comparing NPWT with saline gauze showed no difference in complete healing (risk ratio 1.00; 95% CI 0.91–1.10). The authors noted methodological limitations and clinical heterogeneity across studies. Differences in wound type, dressing comparators, treatment duration, and outcome definitions make pooled estimates difficult to interpret.
Postoperative Wounds Versus Non-Surgical Ulcers
The clearest randomized evidence comes from wounds created by surgery. In a multicentre trial of partial diabetic foot amputation wounds, Armstrong and Lavery (2005) reported that NPWT was associated with a higher proportion of healed wounds and faster healing than standard moist wound care. That trial is older than the period reviewed here but remains foundational and helps explain why later guidelines distinguish between wound types.
The 2023 update of the International Working Group on the Diabetic Foot (IWGDF) guideline on interventions to enhance healing (Chen et al.) draws that distinction explicitly. It suggests considering NPWT as an adjunct to standard care for postsurgical diabetes-related foot wounds (conditional recommendation, low certainty of evidence). For non-surgical diabetes-related foot ulcers, it recommends against NPWT as an adjunct to standard care (strong recommendation, low certainty of evidence). The wording reflects the limited quality of the trials rather than proof of harm: many studies were small, unblinded, or at risk of bias.
Practical Considerations
Interpretation of NPWT trials depends on several factors. First, a wound must be suitable: adequate arterial supply, absence of untreated infection or osteomyelitis, and debrided tissue are generally prerequisites. Second, the comparator matters, since results against basic gauze may differ from results against modern advanced dressings. Third, offloading and glycemic control continue to influence outcomes regardless of the device used. Finally, the reported benefits must be weighed against practical burdens, including device cost, dressing-change frequency, and the need for patient adherence to carrying a portable pump.
Key Takeaways
NPWT has moderate support as an adjunct for healing postsurgical diabetic foot wounds, with some meta-analyses suggesting improved healing and fewer amputations. Evidence for non-surgical ulcers is less convincing, and current IWGDF guidance advises against routine use in that setting. Higher-quality, adequately powered randomized trials with standardized outcomes are still needed. Across all wound types, NPWT remains an adjunct to, not a substitute for, revascularization when indicated, infection management, debridement, and offloading.
References
- Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024.
- Du et al. Efficacy and safety of negative pressure wound therapy in diabetic foot ulcers: a cross-sectional analysis of overlapping meta-analyses. Diabetes, Metabolic Syndrome and Obesity. 2025.
- Dalmedico MM, do Rocio Fedalto A, Martins WA, et al. Effectiveness of negative pressure wound therapy in treating diabetic foot ulcers: a systematic review. Wounds. 2024.
- Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. The Lancet. 2005.
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