|
1
|
Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Kavolus JJ. The Cost-Effectiveness of Closed Incisional Negative Pressure Wound Therapy for Infection Prevention after Revision Total Knee Arthroplasty. J Knee Surg 2022; 35:1301-1305. [PMID: 33511588 DOI: 10.1055/s-0041-1724137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses.
Collapse
Affiliation(s)
- Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | | | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Joseph J Kavolus
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
|
2
|
Polymicrobial Colonization of Prosthetic Joint Infections Treated With Open Wound Management. J Arthroplasty 2022; 37:S653-S656. [PMID: 35283231 DOI: 10.1016/j.arth.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Open wound management in prosthetic joint infection (PJI) patients has been used in problematic dehisced wounds hoping to stimulate granulation tissue and closure. However, infections that start as a monomicrobial PJI can become polymicrobial with resultant worse outcomes following open wound management. This study assessed the relationship between open wound management and the development of polymicrobial periprosthetic joint infections. METHODS We reviewed patients referred with a synovial cutaneous fistula. Patients with an open wound measuring less than 2 cm and less than two weeks of open wound management were excluded. Variables included original organisms cultured, type and length of open wound management, and organisms cultured at the time of revision infection surgery. RESULTS Of the 65 patients with a previous monomicrobial infection treated with open wound management, 22/65 (34%) progressed to a polymicrobial infection. Thirty (46%) wounds were packed open with gauze, 20 (31%) were managed with negative pressure wound therapy, and 15 (23%) had surface dressings only. Of the 22 patients who converted to a polymicrobial infection, only 10 (45%) were infection free at follow-up. In contrast, 30 of 43 patients (70%) whose infections remained monomicrobial were infection free at follow-up. CONCLUSION Open wound management can lead to conversion from a monomicrobial to a polymicrobial PJI, a rate of 34% in this series. Open prosthetic wound management should be discontinued for a fear of converting a monomicrobial infection to a difficult to treat polymicrobial infection. Surgeons must be prudent in the use of open wound management. LEVEL OF EVIDENCE Level IV, Retrospective Case Series.
Collapse
|
|
3
|
Mortazavi SMJ, Razzaghof M, Ghasemi MA. Parsonage-Turner Syndrome and Closed-Incision Negative-Pressure Wound Therapy After Total Hip Arthroplasty in a Case of Marfan Syndrome. Arthroplast Today 2022; 14:1-5. [PMID: 35097175 PMCID: PMC8783111 DOI: 10.1016/j.artd.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022] Open
Abstract
Negative pressure wound therapy (NPWT) is a postoperative wound care method, which has recently become an ongoing field of research in hip and knee arthroplasty. We report the successful management of wound dehiscence and infection after THA in a case of Marfan syndrome by closed-incision negative-pressure wound therapy (ciNPWT). Our patient also developed a rare postoperative neurologic complication, that is, Parsonage-Turner syndrome (PTS). To our knowledge, this is the first report of PTS and ciNPWT use for SSI after THA in a Marfan patient. As wound dehiscence and infection can occur after THA in Marfan patients, we propose ciNPWT as an option to treat or even prevent (prophylactic use) such complications in this rare group of patients.
Collapse
Affiliation(s)
- Seyed Mohammad Javad Mortazavi
- Corresponding author. Imam Khomeini Hospital Complex, North Chamran Highway, East Baqerkhan Street, Tehran 1419733141, IR Iran. Tel.:+98 21 66581586.
| | | | | |
Collapse
|
|
4
|
Almeida RP, Mokete L, Sikhauli N, Sekeitto AR, Pietrzak J. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Rev 2021; 6:872-880. [PMID: 34760287 PMCID: PMC8559557 DOI: 10.1302/2058-5241.6.200054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive. PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics. Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI. Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described. The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available. Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054
Collapse
Affiliation(s)
- Richard Peter Almeida
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Lipalo Mokete
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkhodiseni Sikhauli
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Allan Roy Sekeitto
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jurek Pietrzak
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
|
5
|
Subcuticular Barbed Suture and Skin Glue Wound Closure Decreases Reoperation and Length of Stay in Geriatric Hip Fractures When Compared With Staples. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202110000-00005. [PMID: 34605793 PMCID: PMC8492365 DOI: 10.5435/jaaosglobal-d-21-00205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients with geriatric hip fracture are notoriously frail and at risk for complications. Persistent postoperative wound drainage can lead to prolonged hospital stay, increased risk for infection, and need for revision surgery. The purpose of this study was to determine the effect of wound closure technique, barbed monofilament subcuticular suture and skin glue versus staples on rates of intervention for wound drainage and length of hospital stay after geriatric hip fracture fixation. METHODS A retrospective review of isolated hip fractures in patients older than 60 years at a single institution over a 3-year period was done. Hip fractures included femoral neck, intertrochanteric, and subtrochanteric femur fractures treated with internal fixation or arthroplasty. Skin closure technique, at the discretion of the operating surgeon, included either barbed subcuticular monofilament suture and skin glue or staples. Charts and radiographs were reviewed to determine patient characteristics, Charlson Comorbidity Index, type of wound closure, length of stay, and interventions for persistent wound drainage. RESULTS There were 175 patients in the barbed suture and skin glue group and 211 patients in the staples group. The barbed suture group had an average postsurgical length of stay of 5.0 days which was significantly lower than the staples group (7.0 days, P < 0.00001). In the staples group, 17 patients (8%) required incisional negative pressure wound therapy due to wound drainage with five patients (2.4%) returning to the operating room secondary to persistent wound drainage. No patients were observed in the barbed suture group that required intervention for wound drainage. DISCUSSION Barbed suture and skin glue closure is associated with markedly shorter hospital stay and fewer interventions for wound drainage when compared with staples after surgical treatment of geriatric hip fractures.
Collapse
|
|
6
|
Doman DM, Young AM, Buller LT, Deckard ER, Meneghini RM. Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study. J Arthroplasty 2021; 36:3437-3442. [PMID: 34140207 DOI: 10.1016/j.arth.2021.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing. METHODS One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m2, autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation. RESULTS Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications. CONCLUSION Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.
Collapse
Affiliation(s)
- David M Doman
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA
| | | | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
|
7
|
Ailaney N, Johns WL, Golladay GJ, Strong B, Kalore NV. Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2021; 36:2402-2411. [PMID: 33358608 DOI: 10.1016/j.arth.2020.11.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/15/2020] [Accepted: 11/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed. RESULTS SSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01). CONCLUSION ciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.
Collapse
Affiliation(s)
- Nikhil Ailaney
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - William L Johns
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
| | - Benjamin Strong
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
| | - Niraj V Kalore
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
| |
Collapse
|
|
8
|
Canbek U, Dibek E, Akgun U, Col B, Canbek TD, Aydogan NH, Usmanov N, Kasap M, Akpinar G. Analysis of the fluid biochemistry in patients with prolonged wound drainage after hip hemiarthroplasty. Injury 2021; 52:918-925. [PMID: 33059924 DOI: 10.1016/j.injury.2020.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The origin and content of prolonged wound drainage (PWD) after arthroplasty remain uncertain. In this study, we performed the biochemical, biological and advanced proteomic analysis of the drainage fluid collected from PWD patients following hip hemiarthroplasty (HA). METHODS Data of 28 patients who developed PWD after HA were prospectively analyzed. After examining the biochemical content of the drainage fluid collected on postoperative day 6, to find out if the drainage fluid was transudate or exudate, it was compared with the patient's serum values according to the Light criteria. Subsequently, biological and proteomic analyzes of both drainage fluid and serum were performed. The similarities and differences in terms of protein concentrations, protein identities were examined. In the drainage fluid, we analyzed lymph-specific proteins. RESULTS 16 patients with PWD were male (61.1%), 12 were female (38.9%), and the mean age of all patients was 79.64 ± 8.44 (65-95). Biochemical test results of the drainage fluid / serum were as follows: Total protein: 2.1 / 5.2 g/dl, albumin: 1.3 / 3.1 g/dl, lactate dehydrogenase (LDH): 121/324 U/l, cholesterol: 28/160 mg/dl, triglyceride: 37/122 mg/dl, sodium (Na): 140/ 140mg/dl, potassium (K): 4.1/ 4.1 mg/dl. pH of the drainage fluid was 7.6. According to these biochemical values, drainage fluid was classified as transudate. As a result of protein identification, fibrinogen beta chain, keratin type 1, creatine kinase M-type protein were detected in drainage fluid. Subsequent western analysis revealed that, gliseraldehyde-3-phosphate dehydrogenase (GAPDH) and beta actin antibody were detected in the drainage fluid but not in serum. CONCLUSION Despite the similarity in serum and transudative PWD fluid in terms of biochemical content, we found that when we carried out further proteomic analysis, PWD contains lymph-specific proteins. Unlike PWD, these proteins were not determined in serum. PWD fluid can be also called as lymphorrhea. PWD fluid with abundant proteins may also provide an appropriate environment for the growth of microorganisms.
Collapse
Affiliation(s)
- Umut Canbek
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey.
| | - Esra Dibek
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Ulas Akgun
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Bekir Col
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Tugba Dubektas Canbek
- Mugla Sitki Kocman University Training and Research Hospital, Department of Internal Medicine, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Nosirzhon Usmanov
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Murat Kasap
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
| | - Gurler Akpinar
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
| |
Collapse
|
|
9
|
Singh V, Shahi A, Saleh U, Tarabichi S, Oliashirazi A. Persistent Wound Drainage among Total Joint Arthroplasty Patients Receiving Aspirin vs Coumadin. J Arthroplasty 2020; 35:3743-3746. [PMID: 32788061 DOI: 10.1016/j.arth.2020.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/20/2020] [Accepted: 07/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis. METHODS Retrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes. RESULTS The prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2). CONCLUSION Use of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.
Collapse
Affiliation(s)
| | - Alisina Shahi
- Cooper Bone and Joint Institute at Cooper University Hospital, Camden, NJ
| | - Usama Saleh
- Orthopaedic Department, Med Care Hospital, Dubai, UAE
| | | | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV
| |
Collapse
|
|
10
|
Goswami K, Stevenson KL, Parvizi J. Intraoperative and Postoperative Infection Prevention. J Arthroplasty 2020; 35:S2-S8. [PMID: 32046826 DOI: 10.1016/j.arth.2019.10.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 10/29/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
Implementation of strategies for prevention of surgical site infection and periprosthetic joint infection is gaining further attention. We provide an overview of the pertinent evidence-based guidelines for infection prevention from the World Health Organization, the Centers for Disease Control and Prevention, and the second International Consensus Meeting on Musculoskeletal Infection. Future work is needed to ascertain clinical efficacy, optimal combinations, and the cost-effectiveness of certain measures.
Collapse
Affiliation(s)
- Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| |
Collapse
|
|
11
|
Reduced wound leakage in arthroplasty with modified wound closure: a retrospective cohort study. Arch Orthop Trauma Surg 2019; 139:1505-1510. [PMID: 30911829 DOI: 10.1007/s00402-019-03178-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Wound leakage has been shown to increase the risk of prosthetic joint infections (PJIs) in primary total hip (THA) and knee arthroplasty (unicondylar and total knee arthroplasty; KA). The aim of this study is to determine whether the addition of a continuous subcuticular bonding stitch to a conventional three-layer closure method reduces the incidence of prolonged wound leakage and PJIs after THA and KA. MATERIALS AND METHODS This retrospective cohort study included all patients receiving a THA or KA. Patients in the control group with a three-layer closure method had surgery between November 1st 2015 and October 31st 2016, and were compared to the study group with a four-layer closure method that had surgery between January 1st 2017 and December 31st 2018. The primary outcome was incidence of prolonged wound leakage longer than 72 h. Differences were evaluated using logistic regression. Incidence of PJIs was the secondary outcome. RESULTS A total of 439 THA and 339 KA in the control group and 460 THA and 350 KA in the study group were included. In the control group, 11.7% of the patients had a prolonged leaking wound compared to 1.9% in the study group (p < 0.001). The modified wound closure method showed a protective effect for obtaining prolonged wound leakage; odds ratios were 0.09 (95% CI 0.04-0.22; p < 0.001) for THA and 0.21 (95% CI 0.10-0.43; p < 0.001) for KA. PJIs decreased from 1.54 to 0.37% (p = 0.019). CONCLUSIONS The addition of a continuous subcuticular bonding stitch reduces the incidence of prolonged wound leakage and PJIs after THA and KA compared to a conventional three-layer wound closure method. The large reduction of incidence in wound leakage and PJIs in this study, combined with relatively negligible cost and effort of the modified wound closure method, would advocate for implementing this wound closure method in arthroplasty.
Collapse
|
|
12
|
Soft Tissue Issues and Considerations in Total Knee Arthroplasty. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
|
13
|
Dyck BA, Bailey CS, Steyn C, Petrakis J, Urquhart JC, Raj R, Rasoulinejad P. Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study. J Neurosurg Spine 2019; 31:430-439. [PMID: 31075767 DOI: 10.3171/2019.2.spine18947] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 02/13/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection. METHODS A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups. RESULTS Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%). CONCLUSIONS Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors' proof of concept and strongly support the need for a prospective randomized trial.
Collapse
Affiliation(s)
- Bailey A Dyck
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 3Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario; and
| | - Christopher S Bailey
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 2Lawson Health Research Institute
- 3Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario; and
| | - Chris Steyn
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 3Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario; and
| | - Julia Petrakis
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 4Arthur Labatt School of Nursing, University of Western Ontario, London, Ontario, Canada
| | - Jennifer C Urquhart
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 2Lawson Health Research Institute
| | - Ruheksh Raj
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 2Lawson Health Research Institute
| | - Parham Rasoulinejad
- 1Combined Orthopaedic and Neurosurgical Spine Program, London Health Sciences Centre
- 2Lawson Health Research Institute
- 3Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario; and
| |
Collapse
|
|
14
|
Outcomes of Superficial and Deep Irrigation and Debridement in Total Hip and Knee Arthroplasty. J Arthroplasty 2019; 34:1452-1457. [PMID: 30962091 DOI: 10.1016/j.arth.2019.03.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Following total knee arthroplasty and total hip arthroplasty, wound-related problems and deep periprosthetic joint infection may present in a similar fashion. Irrigation and debridement (I&D) has a great role in management of patients with early infection. The question that often arises is how to tell the difference between superficial and deep infection. This study evaluated the role and outcomes of both superficial and deep I&D in patients with wound-related issues and/or suspected periprosthetic joint infection. METHODS A retrospective study was conducted evaluating patients who underwent I&D within 28 days of total joint arthroplasty. A total of 176 cases with a minimum of 1-year follow-up were identified, and clinical records were reviewed in detail. Reoperations included superficial (fascia not opened) or deep (fascia opened) I&D. Failure was defined as the need for further surgical intervention within 1 year of initial I&D. RESULTS The overall success for superficial I&D was 84.28% vs 68.86% for deep I&D. The success of both deep and superficial I&D was higher if the I&D was performed closer to the index surgery. Superficial I&D in patients with a positive joint aspiration or evidence of intraoperative purulence or those in whom had no subcutaneous fluid had higher failure rates. CONCLUSION Superficial I&D is a viable option in patients with wound-related issues as long as joint aspiration is performed to rule out infection involving the prosthesis. If there are findings of no fluid or purulence, fascia may need to be opened and the deeper tissues explored.
Collapse
|
|
15
|
Shahi A, Boe R, Bullock M, Hoedt C, Fayyad A, Miller L, Oliashirazi A. The risk factors and an evidence-based protocol for the management of persistent wound drainage after total hip and knee arthroplasty. Arthroplast Today 2019; 5:329-333. [PMID: 31516977 PMCID: PMC6728765 DOI: 10.1016/j.artd.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 05/03/2019] [Accepted: 05/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJIs), arguably the most dreaded complication after total joint arthroplasty (TJA). The aim of this study was to identify the risk factors for PWD and provide a stepwise management protocol for it. Methods A retrospective review of 4873 TJAs was performed. After determining patients with PWD, a logistic regression model was designed to identify the risk factors using Charlson and Elixhauser comorbidity indexes. Finally, the protocol that was instituted for the management of PWD and its success rate was presented. Results The prevalence of PWD was 6.2% (302 of 4873). Of these, 196 did not require any surgical interventions, and drainage stopped with local wound care. 106 patients required surgical intervention, of which, 64 underwent superficial irrigation and debridement and 42 underwent deep irrigation and debridement with modular components exchange. Patients with PWD had significantly higher rates of PJI (odds ratio [OR]: 16.9; 95% confidence interval [CI]: 9.1-31.6). Risks factors were diabetes (OR: 21.2; 95% CI: 12.8-25.1), morbid obesity (OR: 17.3; 95% CI: 14.7-21.5), rheumatoid arthritis (OR: 14.2; 95% CI: 11.7-16.5), chronic alcohol use (OR: 4.3; 95% CI: 2.3-6.1), hypothyroidism (OR: 2.8; 95% CI: 1.3-4.2), and female gender (OR: 1.9; 95% CI: 1.1-2.2). Conclusions Several modifiable risk factors of PWD were identified. Surgeons must be cognizant of these comorbidities and optimize patients’ general health before an elective TJA. Our results demonstrated that PWD ceased in about 65% of the patients with local wound care measures alone. Patients with PWD were at substantially higher risk for PJI.
Collapse
Affiliation(s)
- Alisina Shahi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA.,Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Richie Boe
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Matthew Bullock
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Chris Hoedt
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Azzam Fayyad
- Medcare Orthopedics and Spine Hospital, Dubai, UAE
| | - Lawrence Miller
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| |
Collapse
|
|
16
|
Abstract
Use of negative-pressure therapy (NPT) is a well-established therapy for chronic, open, contaminated wounds, promoting formation of granulation tissue and healing. The application of NPT after primary closure (ie, incisional NPT) has also been shown to reduce surgical site infection and surgical site occurrence in high-risk procedures across multiple disciplines. Incisional NPT is believed to decrease edema and shear stress, promote angiogenesis and lymphatic drainage, and increase vascular flow and scar formation. Incisional NPT may be considered when there is a high risk of surgical site occurrence or surgical site infection, particularly in procedures with nonautologous implants, such as hernia mesh or other permanent prosthetics. Here we discuss the proposed physiologic mechanism as demonstrated in animal models and review clinical outcomes across multiple specialties.
Collapse
|
|
17
|
Newman JM, Siqueira MBP, Klika AK, Molloy RM, Barsoum WK, Higuera CA. Use of Closed Incisional Negative Pressure Wound Therapy After Revision Total Hip and Knee Arthroplasty in Patients at High Risk for Infection: A Prospective, Randomized Clinical Trial. J Arthroplasty 2019; 34:554-559.e1. [PMID: 30545653 DOI: 10.1016/j.arth.2018.11.017] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/19/2018] [Accepted: 11/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications. METHODS A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively. RESULTS The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 [23.8%] vs 8 [10.1%], P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 [23.8%] vs 16 [20.3%], P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 [12.5%] vs 2 [2.5%], P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68). CONCLUSION ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty.
Collapse
Affiliation(s)
- Jared M Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| |
Collapse
|
|
18
|
Al-Houraibi RK, Aalirezaie A, Adib F, Anoushiravani A, Bhashyam A, Binlaksar R, Blevins K, Bonanzinga T, Chih-Kuo F, Cordova M, Deirmengian GK, Fillingham Y, Frenkel T, Gomez J, Gundtoft P, Harris MA, Harris M, Heller S, Jennings JA, Jiménez-Garrido C, Karam JA, Khlopas A, Klement MR, Komnos G, Krebs V, Lachiewicz P, Miller AO, Mont MA, Montañez E, Romero CA, Schwarzkopf R, Shaffer A, Sharkey PF, Smith BM, Sodhi N, Thienpont E, Villanueva AO, Yazdi H. General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S157-S168. [PMID: 30360978 DOI: 10.1016/j.arth.2018.09.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
|
19
|
Chotanaphuti T, Courtney PM, Fram B, In den Kleef NJ, Kim TK, Kuo FC, Lustig S, Moojen DJ, Nijhof M, Oliashirazi A, Poolman R, Purtill JJ, Rapisarda A, Rivero-Boschert S, Veltman ES. Hip and Knee Section, Treatment, Algorithm: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S393-S397. [PMID: 30348575 DOI: 10.1016/j.arth.2018.09.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
|
|
20
|
Management of Closed Incisions Using Negative-Pressure Wound Therapy in Orthopedic Surgery. Plast Reconstr Surg 2019; 143:21S-26S. [DOI: 10.1097/prs.0000000000005308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
|
21
|
Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review. J Arthroplasty 2019; 34:175-182. [PMID: 30245124 DOI: 10.1016/j.arth.2018.08.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection. METHODS This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process. RESULTS Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment. CONCLUSION Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial.
Collapse
|
|
22
|
Anatone AJ, Shah RP, Jennings EL, Geller JA, Cooper HJ. A risk-stratification algorithm to reduce superficial surgical site complications in primary hip and knee arthroplasty. Arthroplast Today 2018; 4:493-498. [PMID: 30560182 PMCID: PMC6287286 DOI: 10.1016/j.artd.2018.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/09/2018] [Accepted: 09/11/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Surgical site complications (SSCs) are the most common cause for readmission after total joint arthroplasty (TJA), increasing costs while predisposing to inferior long-term outcomes. Prophylactic use of closed-incision negative pressure therapy (ciNPT) may lower the risk of these complications, especially in high-risk populations, but appropriate-use guidelines are lacking for patients undergoing primary TJA. We sought to develop a risk-stratification algorithm to guide use of ciNPT dressings and test its use in normalizing the rate of superficial SSCs among high-risk groups. METHODS We reviewed 323 consecutive primary TJAs, where 38% of those patients considered at elevated risk were risk-stratified to receive ciNPT dressings. An individual risk score was developed, assigning points based on patient-specific risk factors. We identified a historical control population of 643 patients who all received the same postoperative dressing to test the impact of this risk score. RESULTS Compared with historical controls, we observed a modest but significant improvement in superficial SSCs after implementation of risk-stratification (12.0% vs 6.8%; P = .013). Among high-risk patients, there was a marked improvement in SSCs when treated prophylactically with ciNPT dressings as compared with historical controls (26.2% vs 7.3%; P < .001). Low-risk patients, who continued to be treated with standard postoperative dressings, demonstrated no significant improvement (8.6% vs 6.5%; P = .344). CONCLUSIONS ciNPT dressings are effective at reducing and normalizing risks of superficial SSCs among high-risk primary arthroplasty patients. The proposed risk-stratification algorithm may help identify those patients who benefit most from these dressings.
Collapse
Affiliation(s)
| | | | | | | | - H. John Cooper
- Department of Orthopedic Surgery, Columbia University Medical Center New York, NY, USA
| |
Collapse
|
|
23
|
Curley AJ, Terhune EB, Velott AT, Argintar EH. Outcomes of Prophylactic Negative Pressure Wound Therapy in Knee Arthroplasty. Orthopedics 2018; 41:e837-e840. [PMID: 30321445 DOI: 10.3928/01477447-20181010-02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 06/26/2018] [Indexed: 02/03/2023]
Abstract
Negative pressure wound therapy is becoming more commonly used to prevent wound complications in joint arthroplasty, although few studies have assessed its outcomes compared with those of a traditional dry sterile dressing. This retrospective study assessed complications that required return to the operating room in a cohort of patients who received a dry sterile dressing (n=159) vs negative pressure wound therapy (n=32). There were significantly more overall complications (P=.0293) in the dry sterile dressing group (23.3%) compared with the negative pressure wound therapy group (6.3%); however, these findings were not statistically significant when each individual complication was compared separately. The infection rate in the dry sterile dressing group and the negative pressure wound therapy group was 5.7% and 0%, respectively (P=.3607). A larger, prospective study is needed to confirm the lower infection rate and before any definitive conclusions can be reached. [Orthopedics. 2018; 41(6):e837-e840.].
Collapse
|
|
24
|
Avoiding Postoperative Wound Complications in Total Joint Arthroplasty. J Arthroplasty 2018; 33:3109-3112. [PMID: 29475573 DOI: 10.1016/j.arth.2018.01.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/18/2018] [Indexed: 02/01/2023] Open
Abstract
Avoidance of early wound complications is critical to the success of total joint arthroplasty. The magnitude of postoperative complications can be as simple as quickly resolving wound drainage, to persistent wound drainage and full-thickness soft tissue necrosis. Persistent postoperative drainage and wound complications can lead to a devastating deep periprosthetic infection. Attention to several steps in the clinical and perioperative pathway should be addressed to avoid this complication including addressing modifiable patient risk factors, implementing meticulous surgical technique, and following an algorithmic approach in response to persistent wound drainage.
Collapse
|
|
25
|
Giannini S, Mazzotti A, Luciani D, Lullini G, Tedesco G, Andreoli I, Cadossi M, Faldini C. Postoperative wound management with negative pressure wound therapy in knee and hip surgery: a randomised control trial. J Wound Care 2018; 27:520-525. [DOI: 10.12968/jowc.2018.27.8.520] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sandro Giannini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy
| | - Antonio Mazzotti
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Deianira Luciani
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giada Lullini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Tedesco
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Isabella Andreoli
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Matteo Cadossi
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cesare Faldini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
|
26
|
Abstract
Wound complications and surgical site infections after orthopaedic procedures result in substantial morbidity and costs. Traditional postoperative wound care consists of applying sterile, dry gauze and abdominal pads to the surgical site, with more frequent dressing changes performed in cases in which wound drainage is excessive. Persistent incisional drainage is of particular concern because it increases the risk of deep infection. The use of closed incision negative-pressure wound therapy (ciNPWT) to manage delayed wound healing was first reported a decade ago, and the benefits of this treatment modality include wound contraction with diminished tensile forces, stabilization of the wound environment, decreased edema and improved removal of exudate, and increased blood and lymphatic flow. Numerous trauma, plastic surgery, and general surgery studies have demonstrated that ciNPWT improves wound healing. In orthopaedic surgery, ciNPWT has been shown to be clinically effective for incisions at high risk for perioperative complications. However, specific indications for ciNPWT continue to be defined.
Collapse
|
|
27
|
Abstract
Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.
Collapse
|
|
28
|
Wagenaar FC, Löwik CA, Stevens M, Bulstra SK, Pronk Y, van den Akker-Scheek I, Wouthuyzen-Bakker M, Nelissen RG, Poolman RW, van der Weegen W, Jutte PC. Managing persistent wound leakage after total knee and hip arthroplasty. Results of a nationwide survey among Dutch orthopaedic surgeons. J Bone Jt Infect 2017; 2:202-207. [PMID: 29188171 PMCID: PMC5704001 DOI: 10.7150/jbji.22327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/24/2017] [Indexed: 11/23/2022] Open
Abstract
Background: Persistent wound leakage after joint arthroplasty is a scantily investigated topic, despite the claimed relation with a higher risk of periprosthetic joint infection. This results in a lack of evidence-based clinical guidelines for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. Without such guideline, clinical practice in orthopaedic hospitals varies widely. In preparation of a nationwide multicenter randomized controlled trial on the optimal treatment of persistent wound leakage, we evaluated current Dutch orthopaedic care for persistent wound leakage after joint arthroplasty. Methods: We conducted a questionnaire-based online survey among all 700 members of the Netherlands Orthopaedic Association, consisting of 23 questions on the definition, classification, diagnosis and treatment of persistent wound leakage after joint arthroplasty. Results: The questionnaire was completed by 127 respondents, representing 68% of the Dutch hospitals that perform orthopaedic surgery. The results showed wide variation in the classification, definition, diagnosis and treatment of persistent wound leakage among Dutch orthopaedic surgeons. 56.7% of the respondents used a protocol for diagnosis and treatment of persistent wound leakage, but only 26.8% utilized the protocol in every patient. Most respondents (59.1%) reported a maximum period of persistent wound leakage before starting non-surgical treatment of 3 to 7 days after index surgery and 44.1% of respondents reported a maximum period of wound leakage of 10 days before converting to surgical treatment. Conclusions: The wide variety in clinical practice underscores the importance of developing an evidence-based clinical guideline for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. To this end, a nationwide multicenter randomized controlled trial will be conducted in the Netherlands, which may provide evidence on this important and poorly understood topic.
Collapse
Affiliation(s)
| | - Claudia A.M. Löwik
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sjoerd K. Bulstra
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvette Pronk
- Research Department, Kliniek Viasana, Mill, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Paul C. Jutte
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
|
29
|
Abstract
Normal wound healing with avoidance of early wound complications is critical to the success of total knee arthroplasty. The severity of acute complications includes less morbid problems, such as quickly resolved drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft-tissue coverage. To achieve proper healing, surgeons must respond to persistent drainage by addressing modifiable patient risk factors, using meticulous surgical technique, and implementing an algorithmic approach to treatment.
Collapse
|
|
30
|
Helito CP, Bueno DK, Giglio PN, Bonadio MB, Pécora JR, Demange MK. NEGATIVE-PRESSURE WOUND THERAPY IN THE TREATMENT OF COMPLEX INJURIES AFTER TOTAL KNEE ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2017. [PMID: 28642657 PMCID: PMC5474419 DOI: 10.1590/1413-785220172502169053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To present an experience with negative-pressure wound therapy (NPWT) in the treatment of surgical wounds in patients treated for infections after total knee arthroplasty (TKA) with or without dehiscence and prophylaxis in wounds considered at risk of healing problems. METHODS We prospectively evaluated patients with TKA infection with or without surgical wound dehiscence and patients with risk factors for infection or surgical wound complications treated with Pico(r) device for NPWT in addition to standard treatment of infection or dehiscence in our institution. We considered as an initial favorable outcome the resolution of the infectious process and the closure of the surgical wound dehiscences in the treated cases and the good progression of the wound without complicating events in the prophylactic cases. RESULTS We evaluated 10 patients who used Pico(r) in our service. All patients had a favorable outcome according to established criteria. No complications were identified regarding the use of the NPWT device. The mean follow-up of the patients after the use of the device was 10.5 months. CONCLUSION The NPWT can be safely used in wound infections and complications following TKA with promising results. Long-term randomized prospective studies should be conducted to prove its effectiveness. Level of Evidence IV, Case Series.
Collapse
|
|
31
|
Harvin WH, Stannard JP. Negative-Pressure Wound Therapy in Acute Traumatic and Surgical Wounds in Orthopaedics. JBJS Rev 2016; 2:01874474-201404000-00004. [PMID: 27490869 DOI: 10.2106/jbjs.rvw.m.00087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- William H Harvin
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030
| | - James P Stannard
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212
| |
Collapse
|
|
32
|
Abstract
The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation.
Collapse
Affiliation(s)
- S Heller
- Rothman Institute of Orthopaedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, 19107, USA
| | - M Rezapoor
- Rothman Institute of Orthopaedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, 19107, USA
| | - J Parvizi
- Rothman Institute of Orthopaedics at Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, 19107, USA
| |
Collapse
|
|
33
|
Willy C, Agarwal A, Andersen CA, Santis GD, Gabriel A, Grauhan O, Guerra OM, Lipsky BA, Malas MB, Mathiesen LL, Singh DP, Reddy VS. Closed incision negative pressure therapy: international multidisciplinary consensus recommendations. Int Wound J 2016; 14:385-398. [PMID: 27170231 PMCID: PMC7949983 DOI: 10.1111/iwj.12612] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/05/2016] [Indexed: 12/13/2022] Open
Abstract
Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words ‘prevention’, ‘negative pressure wound therapy (NPWT)’, ‘active incisional management’, ‘incisional vacuum therapy’, ‘incisional NPWT’, ‘incisional wound VAC’, ‘closed incisional NPWT’, ‘wound infection’, and ‘SSIs’ identified peer‐reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m2); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high‐risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.
Collapse
Affiliation(s)
- Christian Willy
- Department of Traumatology and Orthopaedic, Septic and Reconstructive Surgery, Research and Treatment Center for Complex Combat Injuries, Wound Centre Berlin, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Animesh Agarwal
- Division of Orthopaedic Traumatology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Charles A Andersen
- Vascular/Endovascular/Limb Preservation Surgery Service, Madigan Army Medical Center, Tacoma, WA, USA
| | - Giorgio De Santis
- Plastic, Reconstructive, Microvascular and Aesthetic Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Allen Gabriel
- Plastic Surgery, PeaceHealth Medical Group, Vancouver, WA, USA
| | - Onnen Grauhan
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Omar M Guerra
- Surgery, Suburban Surgical Associates, St. Louis, MO, USA
| | | | - Mahmoud B Malas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lars L Mathiesen
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Devinder P Singh
- Division of Plastic Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
| | - V Sreenath Reddy
- TriStar CV Surgery, Centennial Heart and Vascular Center, Nashville, TN, USA
| |
Collapse
|
|
34
|
Siqueira MBP, Ramanathan D, Klika AK, Higuera CA, Barsoum WK. Role of negative pressure wound therapy in total hip and knee arthroplasty. World J Orthop 2016; 7:30-37. [PMID: 26807353 PMCID: PMC4716568 DOI: 10.5312/wjo.v7.i1.30] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/15/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
Negative-pressure wound therapy (NPWT) has been a successful modality of wound management which is in widespread use in several surgical fields. The main mechanisms of action thought to play a role in enhancing wound healing and preventing surgical site infection are macrodeformation and microdeformation of the wound bed, fluid removal, and stabilization of the wound environment. Due to the devastating consequences of infection in the setting of joint arthroplasty, there has been some interest in the use of NPWT following total hip arthroplasty and total knee arthroplasty. However, there is still a scarcity of data reporting on the use of NPWT within this field and most studies are limited by small sample sizes, high variability of clinical settings and end-points. There is little evidence to support the use of NPWT as an adjunctive treatment for surgical wound drainage, and for this reason surgical intervention should not be delayed when indicated. The prophylactic use of NPWT after arthroplasty in patients that are at high risk for postoperative wound drainage appears to have the strongest clinical evidence. Several clinical trials including single-use NPWT devices for this purpose are currently in progress and this may soon be incorporated in clinical guidelines as a mean to prevent periprosthetic joint infections.
Collapse
|
|
35
|
|
|
36
|
Matsumoto T, Parekh SG. Use of Negative Pressure Wound Therapy on Closed Surgical Incision After Total Ankle Arthroplasty. Foot Ankle Int 2015; 36:787-94. [PMID: 25736324 DOI: 10.1177/1071100715574934] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wound healing problems of the anterior ankle incision are among the most common complications after total ankle arthroplasty, possibly resulting in exposure of the prostheses and infection. The aim of this study was to investigate the role of negative pressure wound therapy (NPWT) in decreasing the rate of wound healing problems after total ankle arthroplasty. METHODS This is a retrospective cohort study including consecutive patients who underwent total ankle arthroplasty by a single surgeon at a single institution between 2009 and 2013. The incisional negative pressure dressing was applied to all patients who underwent total ankle arthroplasty between 2012 and 2013 with a continuous application of -80 mm Hg negative pressure for 6 days postoperatively. The control group consisted of patients who underwent total ankle arthroplasty between 2009 and 2012 with a conventional nonadherent gauze dressing. Seventy-four patients were involved in this study: 37 in the control group and 37 in the incisional NPWT group. RESULTS All patients tolerated the incisional NPWT to completion without any dressing failures or skin problems. Both groups showed similar distributions in demographics and perioperative risk factors for wound healing. There were 9 (24%) wound healing problems in the control group and 1 (3%) in the incisional NPWT group. Incisional NPWT was found to reduce wound healing problems with an odds ratio of 0.10 (95% CI, 0.01-0.50; P = .004). CONCLUSIONS Our study demonstrated that there was a decreased incidence of wound healing problems following total ankle arthroplasty with incisional NPWT dressings. This is the first study evaluating the efficacy of incisional NPWT as an adjunct treatment for wound healing after total ankle arthroplasty. LEVEL OF EVIDENCE Level III, retrospective comparative study.
Collapse
Affiliation(s)
- Takumi Matsumoto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Selene G Parekh
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA Duke Fuqua School of Business, Durham, NC, USA
| |
Collapse
|
|
37
|
|
|
38
|
Ghanem E, Heppert V, Spangehl M, Abraham J, Azzam K, Barnes L, Burgo FJ, Ebeid W, Goyal N, Guerra E, Hitt K, Kallel S, Klein G, Kosashvili Y, Levine B, Matsen L, Morris MJ, Purtill JJ, Ranawat C, Sharkey PF, Sierra R, Stefansdottir A. Wound management. J Orthop Res 2014; 32 Suppl 1:S108-19. [PMID: 24464883 DOI: 10.1002/jor.22554] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
|
39
|
Karlakki S, Brem M, Giannini S, Khanduja V, Stannard J, Martin R. Negative pressure wound therapy for managementof the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication. Bone Joint Res 2013; 2:276-84. [PMID: 24352756 PMCID: PMC3884878 DOI: 10.1302/2046-3758.212.2000190] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objectives The period of post-operative treatment before surgical wounds
are completely closed remains a key window, during which one can
apply new technologies that can minimise complications. One such
technology is the use of negative pressure wound therapy to manage
and accelerate healing of the closed incisional wound (incisional
NPWT). Methods We undertook a literature review of this emerging indication
to identify evidence within orthopaedic surgery and other surgical
disciplines. Literature that supports our current understanding
of the mechanisms of action was also reviewed in detail. Results A total of 33 publications were identified, including nine clinical
study reports from orthopaedic surgery; four from cardiothoracic
surgery and 12 from studies in abdominal, plastic and vascular disciplines.
Most papers (26 of 33) had been published within the past three
years. Thus far two randomised controlled trials – one in orthopaedic
and one in cardiothoracic surgery – show evidence of reduced incidence
of wound healing complications after between three and five days
of post-operative NPWT of two- and four-fold, respectively. Investigations
show that reduction in haematoma and seroma, accelerated wound healing
and increased clearance of oedema are significant mechanisms of
action. Conclusions There is a rapidly emerging literature on the effect of NPWT
on the closed incision. Initiated and confirmed first with a randomised
controlled trial in orthopaedic trauma surgery, studies in abdominal,
plastic and vascular surgery with high rates of complications have
been reported recently. The evidence from single-use NPWT devices
is accumulating. There are no large randomised studies yet in reconstructive
joint replacement. Cite this article: Bone Joint Res 2013;2:276–84.
Collapse
Affiliation(s)
- S Karlakki
- Robert Jones Agnes Hunt Orthopaedic Hospital, ArthroplastyDepartment, Oswestry SY10 7AG, UK
| | | | | | | | | | | |
Collapse
|