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Avoiding Postoperative Wound Complications in Total Joint Arthroplasty
The Journal of Arthroplasty xxx (2018) 1e4
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Avoiding Postoperative Wound Complications in Total Joint Arthroplasty Giles R. Scuderi, MD * Northwell Orthopedic Institute, New York, NY
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 January 2018 Accepted 18 January 2018 Available online xxx
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. © 2018 Published by Elsevier Inc.
Keywords: total knee arthroplasty total joint arthroplasty wound complications wound drainage periprosthetic infection
Avoidance of early wound complications is critical to the success of total joint arthroplasty (TJA). The magnitude of postoperative complications can be as simple as quickly resolving wound drainage and small superficial eschars, 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 pathway should be addressed to avoid this complication: (1) modifiable patient risk factors need to be optimized; (2) meticulous surgical technique should be implemented; and (3) an algorithmic approach used in response to persistent drainage [1]. Preoperative Evaluation Modifiable risk factors such as diabetes mellitus, anemia, rheumatoid arthritis, smoking, obesity, and malnutrition all negatively affect wound healing and are associated with increased soft tissue complications [2]. The preoperative evaluation should optimize the patient and address any medical comorbidity that may negatively impact the clinical outcome. While limited research has been performed on precise perioperative blood glucose values to
The author of this paper has disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2018.01.025. * Reprint requests: Giles R. Scuderi, MD, Northwell Orthopedic Institute, 210 East 64th Street, New York, NY 10065. https://doi.org/10.1016/j.arth.2018.01.025 0883-5403/© 2018 Published by Elsevier Inc.
prevent wound complications, early preoperative medical assessment should be arranged to develop a perioperative diabetes management strategy and to identify and optimize other comorbidities [3e5]. Current evidence also implicates anemia as a contributing factor for complications of wound healing [6,7]. Rheumatoid arthritis is treated with complex drug regimens including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and disease-modifying antirheumatic drugs (DMARDs), all of which may affect wound healing. In addition, the pathology of rheumatoid arthritis is associated with a 2 to 3 times greater risk of a surgical site infection than that of osteoarthritis [8]. Recent guidelines provide recommendations for the management of patients undergoing elective TJA [9]. Nonbiologic DMARDs may be continued throughout the perioperative period in patients with rheumatic diseases undergoing elective TJA. Biologic DMARDs should be withheld at least one dosing cycle before elective TJA and restarted after evidence of wound healing, which is typically 2 weeks after surgery. Current smokers have increased rates of superficial wound infection and wound dehiscence compared to nonsmokers, as nicotine and the byproducts of smoking cause vasoconstriction via diminished oxygen transport and metabolism at cessation before TJA [10]; Moller et al [11] evaluated the effects of smoking intervention, including counseling and nicotine replacement, 6 to 8 weeks before total knee or hip arthroplasty compared with no intervention and demonstrated a significantly decreased overall complication rate in the smoking cessation group (18% vs 52%). Counseling obese patients about weight loss, including bariatric surgery, before TJA is advisable [12]; however, it should be emphasized that complication rates are high, whether one has
2
G.R. Scuderi / The Journal of Arthroplasty xxx (2018) 1e4
bariatric surgery before or after TJA [13]. Proper wound healing and immune function is dependent on optimized nutrition, and malnutrition should be addressed on an individual basis before elective orthopedic procedures [14,15]. A serum albumin level of <3.5 g/dL, total lymphocyte count of <1500/mm3, or transferrin level <200 mg/dL is associated with increased incidence of wound complications [4,16]. Surgical Considerations The surgical approach has a significant impact on the ultimate outcome, especially when prior surgery has been performed. The presence of prior incisions should be taken into consideration when determining the ideal approach in total knee arthroplasty (TKA). When multiple old scars are present, it is safer to use the most lateral vertical incision because the blood supply to the skin is more medially biased, and the medial skin flap will have a more robust circulation. The medial subcutaneous flap should be developed below the deep fascia because the vascular anastomosis is superficial to the deep fascia. Transverse incisions should be crossed at 90 [17]. Short oblique incisions may be incorporated into a new vertical incision provided it is near the midline. Ideal spacing between multiple vertical incisions includes a 5- to 7-cm skin bridge, as closer parallel incisions may compromise the epidermal blood supply [18,19]. Skin bridges shorter than 2.5-5 cm between the existing and new incisions should be avoided. The skin incision should be of adequate length to prevent excessive tension on the wound edges. The apex should form a V (V sign) indicating that the skin is not under any undo tension. Should the V flatten out to become a U (U sign), the skin is under excessive tension, and the incision should be extended to prevent tearing and iatrogenic injury [20]. Meticulous hemostasis is imperative to prevent postoperative hematoma and persistent drainage. Any vessels exposed during
the dissection should be cauterized, as an expanding wound hematoma is associated with wound drainage. Hemostasis may be done with any combination of electrocautery devices, pharmacologic and intravenous hemostatic agents, and recently with either intravenous or local application of tranexamic acid [21e23]. A water-tight closure of the arthrotomy and tension-free closure of the deep fascia, subcutaneous layer, and skin with correct wound-edge alignment is paramount to prevent skin necrosis and potential drainage. Appropriate closure of the distal aspect wound over the patellar tendon and medial tibia is especially important, as most patients who develop wound complications start with early postoperative serous drainage at this site [17]. The routine of primary wound closure over a drain remains debatable. Postoperative Evaluation and Treatment Serosanguinous drainage after TKA is not uncommon. Drainage affects 1% to 10% of patients undergoing primary TJA [3,4,24,25]. Persistent incisional drainage after TKA is defined as continued drainage from the operative wound for greater than 72 hours, and substantial drainage beyond this time should be considered abnormal [26]. While drainage requires close monitoring, the majority of cases resolve spontaneously without a need for surgical intervention. Early postoperative wound drainage requires close observation and determination of the etiology. A diligent evaluation of wound drainage should follow a systematic approach [1] (Fig. 1). It is important to determine whether the drainage is either superficial or deep and whether it involves a benign or infectious process [26]. Immediate postoperative drainage within the first 72 hours is typically serosanguinous and involves the superficial tissue layers. Persistent drainage beyond 72 hours may be the result of a dissolving hematoma or fat ischemia and necrosis and may also
Fig. 1. An algorithmic approach to postoperative wound drainage. Simons MJ, Nirav A, Scuderi GR: Acute wound complications after total knee arthroplasty: prevention and management. JAAOS 2017; 25(8), 547-555.
G.R. Scuderi / The Journal of Arthroplasty xxx (2018) 1e4
constitute fluid from a deep capsular defect that should be surgically repaired. After 72 hours, drainage is no longer benign and may be considered potentially infectious [26]. When faced with primary wound complications, it is essential to aggressively treat the problem to diminish the risk of a secondary deep periprosthetic infection. Patients with a draining wound on postoperative days 2-3 should remain in the hospital for close clinical monitoring and may initially be treated with a compressive dry dressing. The compressive dressing may be all that is needed for a majority of wounds, especially if the drainage is superficial and diminishes acutely. Wounds should be inspected periodically until dry. When wound drainage is noted, physiotherapy, specifically knee range of motion, should be temporarily limited for 24-48 hours. Anticoagulation status should be reviewed and consideration should be given to short-term cessation of anticoagulation depending on the pharmacologic agent prescribed. Patients treated with low-molecular-weight heparin for prophylaxis have shown longer times to achieve a dry surgical wound, compared to those treated with aspirin and mechanical compression devices or warfarin [27]. When anticoagulation medications are discontinued, mechanical venous thromboembolism prophylaxis may be continued or initiated. Incisions with drainage after the second or third postoperative day are indicated for negative-pressure wound therapy (NPWT) [28]. Webb [24] reported that 10% of elective hip and knee surgeries that had serous drainage at or beyond the second postoperative day were correctable with NPWT. Dry wounds can be expected with NPWT in the majority of cases within 24 hours after one application. In hip arthroplasty patients with persistent draining wounds, Hansen et al [29] recently found resolution in 76% of patients treated with NPWT. The 2013 Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection had a strong consensus that a persistently draining wound for greater than 5-7 days should undergo surgical intervention to prevent a deep periprosthetic joint infection [26]. They noted it is reasonable to wait until postoperative day 5, as this interval to a dry wound may be affected by anticoagulation. Beyond this time, it is important to exclude and prevent a deep infection, and aspiration of the knee joint should be performed either preoperatively or intraoperatively. Joint aspiration helps determine whether drainage is from a structural defect of the arthrotomy or an acute deep infection. Although cell count data from fluid aspiration in the acute postoperative period may have confounding variables, Bedair et al [30] found that infection may be presumed for values above 28,000 white blood cells per microliter and 89% polymorphonuclear cells. There is currently no evidence to demonstrate that reflexive administration of antibiotics improves the outcome of a draining wound or reduces the occurrence of a surgical site infection. While there is concern that early surgical intervention may increase the risk of periprosthetic infection by potentially contaminating a sterile joint, recent evidence suggests that prompt intervention likely reduces the risk of wound breakdown and deep infection by limiting retrograde skin contamination [1,3,4,25]. Once a problem wound has been established, interventions at minimum include a superficial incisional exploration, excising necrotic skin edges and evacuating any hematoma. If the joint capsule is compromised, treatment should include opening the fascia, performing a thorough irrigation and debridement with synovectomy, and removal of all contaminated tissue. To promote healing in cases with soft tissue deficiency, NPWT may help prevent additional tissue necrosis by reducing edema and minimizing shear forces. In the setting of more severe soft tissue defects, coverage with rotational muscle flaps with skin graft or other advanced reconstructive
3
techniques may be necessary. Deep cultures should be taken at the time of surgery to give guidance on antibiotic therapy should an infection be present.
Summary Postoperative wound complications can severely compromise the generally excellent outcomes of TJA. Modifiable patient factors should be addressed preoperatively to optimize wound healing potential. Meticulous surgical technique is important with careful handling of the soft tissues and appropriate hemostasis. When an acute wound problem occurs, the guiding principle is close monitoring and aggressive prophylactic intervention to resolve the wound problem before a secondary periprosthetic infection develops. Surgical intervention should take place within 5-7 days in the setting of persistent drainage or skin necrosis to reduce the likelihood of a deep infection.
References [1] Simons MJ, Nirav A, Scuderi GR. Acute wound complications after total knee arthroplasty: prevention and management. JAAOS 2017;25:547e55. [2] Moucha CS, Clyburn T, Evans RP, Prokuski L. Modifiable risk factors for surgical site infection. J Bone Joint Surg Am 2011;93:398e404. [3] Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 2009;91:48e54. [4] Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368e71. [5] England SP, Stern SH, Insall JN, Windsor RE. Total knee arthroplasty in diabetes mellitus. Clin Orthop Relat Res 1990;260:130e4. [6] Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997;63:356e61. [7] Rohrich RJ. Current concepts in wound healing: update 2011. Plast Reconstr Surg 2011;127(Suppl 1):1Se2S. [8] Jonsson K, Jensen JA, Goodson 3rd WH, Scheuenstuhl H, West J, Hopf HW, et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Ann Surg 1991;214:605e13. [9] Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American association of hip and knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty 2017;32: 2628e38. [10] Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am 2015;97:1049e58. [11] Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002;359:114e7. [12] Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty 2013;28:714e21. [13] Severson EP, Singh JA, Browne JA, Trousdale RT, Sarr MG, Lewallen DG. Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study. J Arthroplasty 2012;27:1696e700. [14] Smith TK. Prevention of complications in orthopedic surgery secondary to nutritional depletion. Clin Ortho Relat Res 1987;227:91e7. [15] Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg 2014;22:193e9. [16] Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty 1991;6:321e5. [17] Sanna M, Sanna C, Caputo F, Piu G, Salvi M. Surgical approaches in total knee arthroplasty. Joints 2013;1:34e44. [18] Garbedian S, Sternheim A, Backstein D. Wound healing problems in total knee arthroplasty. Orthopedics 2011;34:e516e8. [19] Younger AS, Duncan CP, Masri BA. Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg 1998;6:55e64. [20] Scuderi GR. Minimally invasive total knee arthroplasty. Am J Orthop 2006;35: 7e11. [21] Plymale MF, Capogna BM, Lovy AJ, Adler ML, Hirsh DM, Kim SJ. Unipolar vs bipolar hemostasis in total knee arthroplasty: a prospective randomized trial. J Arthroplasty 2012;27:1133e7.
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[22] Levine BR, Haughom B, Strong B, Hellman M, Frank RM. Blood management strategies for total knee arthroplasty. J Am Acad Orthop Surg 2014;22: 361e71. lez JC, Jordan M, [23] Aguilera X, Martinez-Zapata MJ, Bosch A, Urrútia G, Gonza et al. Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial. J Bone Joint Surg Am 2013;95:2001e7. [24] Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg 2002;10:303e11. [25] Weiss AP, Krackow KA. Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285e9. [26] Parvizi J, Gehrke T, Chen AF. Proceedings of the International consensus on periprosthetic joint infection. Bone Joint J 2013;95-B:1450e2.
[27] Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 2007;89:33e8. [28] Cooper HJ, Bas MA. Closed-Incision negative-pressure therapy versus antimicrobial dressings after revision hip and knee surgery: a comparative study. J Arthroplasty 2016;31:1047e52. [29] Hansen E, Durinka JB, Costanzo JA, Austin MS, Deirmengian GK. Negative pressure wound therapy is associated with resolution of incisional drainage in most wounds after hip arthroplasty. Clin Ortho Relat Res 2013;471: 3230e6. [30] Bedair H, Ting N, Jacovides C, Saxena A, Moric M, Parvizi J, et al. The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res 2011;469:34e40.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Avoiding Postoperative Wound Complications in Total Joint Arthroplasty Giles R. Scuderi, MD * Northwell Orthopedic Institute, New York, NY
a r t i c l e i n f o
a b s t r a c t
Article history: Received 6 January 2018 Accepted 18 January 2018 Available online xxx
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. © 2018 Published by Elsevier Inc.
Keywords: total knee arthroplasty total joint arthroplasty wound complications wound drainage periprosthetic infection
Avoidance of early wound complications is critical to the success of total joint arthroplasty (TJA). The magnitude of postoperative complications can be as simple as quickly resolving wound drainage and small superficial eschars, 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 pathway should be addressed to avoid this complication: (1) modifiable patient risk factors need to be optimized; (2) meticulous surgical technique should be implemented; and (3) an algorithmic approach used in response to persistent drainage [1]. Preoperative Evaluation Modifiable risk factors such as diabetes mellitus, anemia, rheumatoid arthritis, smoking, obesity, and malnutrition all negatively affect wound healing and are associated with increased soft tissue complications [2]. The preoperative evaluation should optimize the patient and address any medical comorbidity that may negatively impact the clinical outcome. While limited research has been performed on precise perioperative blood glucose values to
The author of this paper has disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2018.01.025. * Reprint requests: Giles R. Scuderi, MD, Northwell Orthopedic Institute, 210 East 64th Street, New York, NY 10065. https://doi.org/10.1016/j.arth.2018.01.025 0883-5403/© 2018 Published by Elsevier Inc.
prevent wound complications, early preoperative medical assessment should be arranged to develop a perioperative diabetes management strategy and to identify and optimize other comorbidities [3e5]. Current evidence also implicates anemia as a contributing factor for complications of wound healing [6,7]. Rheumatoid arthritis is treated with complex drug regimens including corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and disease-modifying antirheumatic drugs (DMARDs), all of which may affect wound healing. In addition, the pathology of rheumatoid arthritis is associated with a 2 to 3 times greater risk of a surgical site infection than that of osteoarthritis [8]. Recent guidelines provide recommendations for the management of patients undergoing elective TJA [9]. Nonbiologic DMARDs may be continued throughout the perioperative period in patients with rheumatic diseases undergoing elective TJA. Biologic DMARDs should be withheld at least one dosing cycle before elective TJA and restarted after evidence of wound healing, which is typically 2 weeks after surgery. Current smokers have increased rates of superficial wound infection and wound dehiscence compared to nonsmokers, as nicotine and the byproducts of smoking cause vasoconstriction via diminished oxygen transport and metabolism at cessation before TJA [10]; Moller et al [11] evaluated the effects of smoking intervention, including counseling and nicotine replacement, 6 to 8 weeks before total knee or hip arthroplasty compared with no intervention and demonstrated a significantly decreased overall complication rate in the smoking cessation group (18% vs 52%). Counseling obese patients about weight loss, including bariatric surgery, before TJA is advisable [12]; however, it should be emphasized that complication rates are high, whether one has
2
G.R. Scuderi / The Journal of Arthroplasty xxx (2018) 1e4
bariatric surgery before or after TJA [13]. Proper wound healing and immune function is dependent on optimized nutrition, and malnutrition should be addressed on an individual basis before elective orthopedic procedures [14,15]. A serum albumin level of <3.5 g/dL, total lymphocyte count of <1500/mm3, or transferrin level <200 mg/dL is associated with increased incidence of wound complications [4,16]. Surgical Considerations The surgical approach has a significant impact on the ultimate outcome, especially when prior surgery has been performed. The presence of prior incisions should be taken into consideration when determining the ideal approach in total knee arthroplasty (TKA). When multiple old scars are present, it is safer to use the most lateral vertical incision because the blood supply to the skin is more medially biased, and the medial skin flap will have a more robust circulation. The medial subcutaneous flap should be developed below the deep fascia because the vascular anastomosis is superficial to the deep fascia. Transverse incisions should be crossed at 90 [17]. Short oblique incisions may be incorporated into a new vertical incision provided it is near the midline. Ideal spacing between multiple vertical incisions includes a 5- to 7-cm skin bridge, as closer parallel incisions may compromise the epidermal blood supply [18,19]. Skin bridges shorter than 2.5-5 cm between the existing and new incisions should be avoided. The skin incision should be of adequate length to prevent excessive tension on the wound edges. The apex should form a V (V sign) indicating that the skin is not under any undo tension. Should the V flatten out to become a U (U sign), the skin is under excessive tension, and the incision should be extended to prevent tearing and iatrogenic injury [20]. Meticulous hemostasis is imperative to prevent postoperative hematoma and persistent drainage. Any vessels exposed during
the dissection should be cauterized, as an expanding wound hematoma is associated with wound drainage. Hemostasis may be done with any combination of electrocautery devices, pharmacologic and intravenous hemostatic agents, and recently with either intravenous or local application of tranexamic acid [21e23]. A water-tight closure of the arthrotomy and tension-free closure of the deep fascia, subcutaneous layer, and skin with correct wound-edge alignment is paramount to prevent skin necrosis and potential drainage. Appropriate closure of the distal aspect wound over the patellar tendon and medial tibia is especially important, as most patients who develop wound complications start with early postoperative serous drainage at this site [17]. The routine of primary wound closure over a drain remains debatable. Postoperative Evaluation and Treatment Serosanguinous drainage after TKA is not uncommon. Drainage affects 1% to 10% of patients undergoing primary TJA [3,4,24,25]. Persistent incisional drainage after TKA is defined as continued drainage from the operative wound for greater than 72 hours, and substantial drainage beyond this time should be considered abnormal [26]. While drainage requires close monitoring, the majority of cases resolve spontaneously without a need for surgical intervention. Early postoperative wound drainage requires close observation and determination of the etiology. A diligent evaluation of wound drainage should follow a systematic approach [1] (Fig. 1). It is important to determine whether the drainage is either superficial or deep and whether it involves a benign or infectious process [26]. Immediate postoperative drainage within the first 72 hours is typically serosanguinous and involves the superficial tissue layers. Persistent drainage beyond 72 hours may be the result of a dissolving hematoma or fat ischemia and necrosis and may also
Fig. 1. An algorithmic approach to postoperative wound drainage. Simons MJ, Nirav A, Scuderi GR: Acute wound complications after total knee arthroplasty: prevention and management. JAAOS 2017; 25(8), 547-555.
G.R. Scuderi / The Journal of Arthroplasty xxx (2018) 1e4
constitute fluid from a deep capsular defect that should be surgically repaired. After 72 hours, drainage is no longer benign and may be considered potentially infectious [26]. When faced with primary wound complications, it is essential to aggressively treat the problem to diminish the risk of a secondary deep periprosthetic infection. Patients with a draining wound on postoperative days 2-3 should remain in the hospital for close clinical monitoring and may initially be treated with a compressive dry dressing. The compressive dressing may be all that is needed for a majority of wounds, especially if the drainage is superficial and diminishes acutely. Wounds should be inspected periodically until dry. When wound drainage is noted, physiotherapy, specifically knee range of motion, should be temporarily limited for 24-48 hours. Anticoagulation status should be reviewed and consideration should be given to short-term cessation of anticoagulation depending on the pharmacologic agent prescribed. Patients treated with low-molecular-weight heparin for prophylaxis have shown longer times to achieve a dry surgical wound, compared to those treated with aspirin and mechanical compression devices or warfarin [27]. When anticoagulation medications are discontinued, mechanical venous thromboembolism prophylaxis may be continued or initiated. Incisions with drainage after the second or third postoperative day are indicated for negative-pressure wound therapy (NPWT) [28]. Webb [24] reported that 10% of elective hip and knee surgeries that had serous drainage at or beyond the second postoperative day were correctable with NPWT. Dry wounds can be expected with NPWT in the majority of cases within 24 hours after one application. In hip arthroplasty patients with persistent draining wounds, Hansen et al [29] recently found resolution in 76% of patients treated with NPWT. The 2013 Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection had a strong consensus that a persistently draining wound for greater than 5-7 days should undergo surgical intervention to prevent a deep periprosthetic joint infection [26]. They noted it is reasonable to wait until postoperative day 5, as this interval to a dry wound may be affected by anticoagulation. Beyond this time, it is important to exclude and prevent a deep infection, and aspiration of the knee joint should be performed either preoperatively or intraoperatively. Joint aspiration helps determine whether drainage is from a structural defect of the arthrotomy or an acute deep infection. Although cell count data from fluid aspiration in the acute postoperative period may have confounding variables, Bedair et al [30] found that infection may be presumed for values above 28,000 white blood cells per microliter and 89% polymorphonuclear cells. There is currently no evidence to demonstrate that reflexive administration of antibiotics improves the outcome of a draining wound or reduces the occurrence of a surgical site infection. While there is concern that early surgical intervention may increase the risk of periprosthetic infection by potentially contaminating a sterile joint, recent evidence suggests that prompt intervention likely reduces the risk of wound breakdown and deep infection by limiting retrograde skin contamination [1,3,4,25]. Once a problem wound has been established, interventions at minimum include a superficial incisional exploration, excising necrotic skin edges and evacuating any hematoma. If the joint capsule is compromised, treatment should include opening the fascia, performing a thorough irrigation and debridement with synovectomy, and removal of all contaminated tissue. To promote healing in cases with soft tissue deficiency, NPWT may help prevent additional tissue necrosis by reducing edema and minimizing shear forces. In the setting of more severe soft tissue defects, coverage with rotational muscle flaps with skin graft or other advanced reconstructive
3
techniques may be necessary. Deep cultures should be taken at the time of surgery to give guidance on antibiotic therapy should an infection be present.
Summary Postoperative wound complications can severely compromise the generally excellent outcomes of TJA. Modifiable patient factors should be addressed preoperatively to optimize wound healing potential. Meticulous surgical technique is important with careful handling of the soft tissues and appropriate hemostasis. When an acute wound problem occurs, the guiding principle is close monitoring and aggressive prophylactic intervention to resolve the wound problem before a secondary periprosthetic infection develops. Surgical intervention should take place within 5-7 days in the setting of persistent drainage or skin necrosis to reduce the likelihood of a deep infection.
References [1] Simons MJ, Nirav A, Scuderi GR. Acute wound complications after total knee arthroplasty: prevention and management. JAAOS 2017;25:547e55. [2] Moucha CS, Clyburn T, Evans RP, Prokuski L. Modifiable risk factors for surgical site infection. J Bone Joint Surg Am 2011;93:398e404. [3] Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 2009;91:48e54. [4] Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368e71. [5] England SP, Stern SH, Insall JN, Windsor RE. Total knee arthroplasty in diabetes mellitus. Clin Orthop Relat Res 1990;260:130e4. [6] Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997;63:356e61. [7] Rohrich RJ. Current concepts in wound healing: update 2011. Plast Reconstr Surg 2011;127(Suppl 1):1Se2S. [8] Jonsson K, Jensen JA, Goodson 3rd WH, Scheuenstuhl H, West J, Hopf HW, et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients. Ann Surg 1991;214:605e13. [9] Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American association of hip and knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty 2017;32: 2628e38. [10] Duchman KR, Gao Y, Pugely AJ, Martin CT, Noiseux NO, Callaghan JJ. The effect of smoking on short-term complications following total hip and knee arthroplasty. J Bone Joint Surg Am 2015;97:1049e58. [11] Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002;359:114e7. [12] Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty 2013;28:714e21. [13] Severson EP, Singh JA, Browne JA, Trousdale RT, Sarr MG, Lewallen DG. Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study. J Arthroplasty 2012;27:1696e700. [14] Smith TK. Prevention of complications in orthopedic surgery secondary to nutritional depletion. Clin Ortho Relat Res 1987;227:91e7. [15] Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg 2014;22:193e9. [16] Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty 1991;6:321e5. [17] Sanna M, Sanna C, Caputo F, Piu G, Salvi M. Surgical approaches in total knee arthroplasty. Joints 2013;1:34e44. [18] Garbedian S, Sternheim A, Backstein D. Wound healing problems in total knee arthroplasty. Orthopedics 2011;34:e516e8. [19] Younger AS, Duncan CP, Masri BA. Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg 1998;6:55e64. [20] Scuderi GR. Minimally invasive total knee arthroplasty. Am J Orthop 2006;35: 7e11. [21] Plymale MF, Capogna BM, Lovy AJ, Adler ML, Hirsh DM, Kim SJ. Unipolar vs bipolar hemostasis in total knee arthroplasty: a prospective randomized trial. J Arthroplasty 2012;27:1133e7.
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