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Outcome of Direct Anterior Total Hip Arthroplasty Complicated by Superficial Wound Dehiscence Requiring Irrigation and Debridement
The Journal of Arthroplasty 34 (2019) 1492e1497
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Complications - Other
Outcome of Direct Anterior Total Hip Arthroplasty Complicated by Superficial Wound Dehiscence Requiring Irrigation and Debridement Joseph M. Statz, MD, Nicholas C. Duethman, MD, Robert T. Trousdale, MD, Michael J. Taunton, MD * Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 January 2019 Received in revised form 21 February 2019 Accepted 6 March 2019 Available online 12 March 2019
Background: Superficial wound dehiscence after total hip arthroplasty (THA) performed through the direct anterior approach (DAA) can be treated with superficial irrigation and debridement (I&D). The incidence and treatment of this complication has been described, but there are little data on the outcomes after a superficial I&D have not been described. The purpose of this paper was to examine the clinical outcomes of DAA THAs requiring postoperative superficial I&D. Methods: A retrospective review of 1573 THAs performed using the DAA were identified utilizing a prospectively collected, single-institution joint registry. Of these 1573 cases, 18 THAs in 18 patients (1.1%) underwent a superficial I&D for superficial wound dehiscence. Outcomes studied included prosthetic joint infection (PJI) after superficial I&D, revisions, re-reoperations, complications, and clinical outcome scores. Results: Survivorship from superficial I&D at 1, 2, and 5 years postoperatively was 98.6% at all time points. In the 18 patients who underwent superficial I&D, this was performed an average of 37 (range 1283) days after their THA. Female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P ¼ .0271) was associated with a higher risk of undergoing superficial I&D as was body mass index >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037). At average follow-up of 2.2 (range 0.2-5.5) years, 0 patients developed PJI. Complications included femoral revision for a painful fibrously ingrown femoral component (1), pulmonary embolus (1), and death from respiratory failure (1). Postoperative Harris Hip Scores averaged score was 86.8 (range 57-99). Conclusions: Superficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%2% of patients with low risk of subsequent PJI. © 2019 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty direct anterior approach superficial wound dehiscence irrigation and debridement prosthetic joint infection
Superficial wound dehiscence is a known complication associated with total hip arthroplasty (THA) performed through the direct anterior approach (DAA) with a rate of about 1%-2% [1e8].
Investigation was performed at the Mayo Clinic, Rochester, MN. One or more of the authors of this paper have 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.2019.03.020. Sources of Funding: No external sources of funding were utilized for this study. * Reprint requests: Michael J. Taunton, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905. https://doi.org/10.1016/j.arth.2019.03.020 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Authors have attributed this complication to a combination of skin quality and incision location. The skin quality around the anterior hip is thin, making closure more difficult and less stout than in the lateral or posterior skin. The incision is also near to, or sometimes overlapping, the inguinal and waist creases. This can lead to the incision being exposed to infectious organisms that reside within the moist environment of these folds which are also difficult for patients to clean, especially if the patient is obese. Furthermore, the incision can experience a large amount of shear force with hip movement due to these folds. All of this together can lead to separation of the skin edges and failure of the wound to heal. Although superficial wound dehiscence can sometimes heal nonoperatively with a combination of local wound care and antibiotics, performing a superficial irrigation and debridement (I&D) is a reasonable option to close the skin, treat accompanying
J.M. Statz et al. / The Journal of Arthroplasty 34 (2019) 1492e1497
superficial infection, and protect the underlying THA prosthesis [4]. Although the incidence and treatment of this complication have been described, the data on outcomes of THAs after a superficial I&D for wound dehiscence are limited. The purpose of this article was to examine the clinical outcomes of THAs performed through the DAA that required postoperative superficial I&D. Patients and Methods After approval from our institutional review board, we performed a retrospective review of a prospectively collected singleinstitution total joint registry. This registry follows up all patients after joint arthroplasties at time points of 1 year, 2 years, 5 years, and then every 5 years thereafter. If patients are unable to return, they are asked to complete a validated outcomes questionnaire and send radiographs. Patient Selection and Demographics We identified 1573 THAs performed using the DAA between August 26, 2010 and July 11, 2018. Each surgery was performed by one of the two fellowship-trained hip and knee arthroplasty surgeons. Of these 1573 cases, there were 18 THAs in 18 patients (1.1%) who underwent a superficial I&D, all for superficial wound dehiscence. The demographic information is shown in Table 1. Operative Technique THA using the DAA was performed for all 1573 patients as previously described [4,9]. This technique uses a traction table and intraoperative fluoroscopy. The incision was placed over the tensor fascia lata (TFL) muscle belly and the hip was approached through the TFL investing fascia. After implants were placed, thorough irrigation of the joint and superficial tissues was performed followed by closure of the joint capsule with absorbable suture. The TFL investing fascia was then closed with absorbable suture followed by closure of the subcutaneous fat and skin with absorbable sutures. Either Steri-Strips (3M, St. Paul, MN,) with an overlying layer of Dermabond (Ethicon, Somerville, New Jersey) or Dermabond Prineo (Ethicon, Somerville, New Jersey) was placed on the skin surface. Mean operating time from incision to closure was 96 (range 54-222) minutes. The 18 patients who underwent a superficial I&D all had the affected areas of their incisions excised with an elliptical incision. A
Table 1 Demographic Information of the Total Hip Arthroplasties Performed in This Study. Demographic Variable All patients Total number Age at surgery (y) Laterality (left/right) BMI (kg/m2) Weight (kg) Height (cm) Male/female Patients undergoing superficial I&D Total number Age at surgery (y) Laterality (left/right) BMI (kg/m2) Weight (kg) Height (cm) Male/female Data are presented as mean (range) or n (%). BMI, body mass index; I&D, irrigation and debridement.
Value 1573 64 716 30 83.9 170 799
(100%) (19-97) (46%)/857 (54%) (14-60)
18 61 12 35 96 165 3
(1.1%) (47-80) (67%)/6 (33%) (25-45) (66-122) (154-191) (17%)/15 (83%)
(138-200) (51%)/774 (49%)
1493
thorough inspection of the TFL investing fascial closure was performed. If the fascia had no defects in it, the joint was not entered, and the I&D remained superficial to the fascia. The skin was then closed with absorbable monofilament sutures in the dermal layer and nonabsorbable sutures in the skin. This was covered with a negative-pressure dressing. If the fascia was violated and there was a path to the joint, a deep I&D with head-liner exchanged was performed, and these patients were not included in this cohort. Cultures were taken from the superficial tissues in 13 of 18 (72%) cases. An average of 1.3 cultures were taken (range 0-4), and the cultures grew a variety of organisms (Table 2). Postoperative antibiotic regimen also varied and was determined by the operative surgeon and infectious disease specialists. All patients received 24 hours of perioperative intravenous antibiotics. Additional intravenous antibiotics were administered to 5 (28%) patients. Of these 5 patients, 4 (22%) received additional oral antibiotics. Of these 4 patients, 2 (11%) were placed on lifelong oral antibiotic suppression, 1 of which was for acute prosthetic joint infection (PJI) of a separate total knee arthroplasty. There were 12 (67%) patients who received 24 hours of perioperative intravenous antibiotics then only oral antibiotics for no longer than 3 weeks postoperatively. There was 1 (6%) patient who received only 24 hours of perioperative intravenous antibiotics. Outcomes Assessment The primary outcome of interest was survivorship from PJI after superficial I&D, which we defined according to the criteria set forth by the Musculoskeletal Infection Society [10]. Secondary outcomes studied included revisions, re-reoperations, complications, and clinical outcomes scores. Statistical Methods Statistical analysis was carried out using JMP version 13.0 (SAS Institute, Inc, Cary, NC). Kaplan-Meier survivorship analysis was utilized. Cox regression analysis, Fisher’s exact test, and the Wilcoxon rank-sum test were used to compare differences in outcomes based on variables of interest. An alpha level of 0.05 was used to determine statistical significance. Results Survivorship From Superficial I&D Superficial I&D occurred in 18 of 1573 (1.1%) THAs performed through a DAA. All these occurred within 83 days of THA implantation at an average of 37 (range 12-83) days postoperatively. Kaplan-Meier survivorship analysis showed a survivorship from
Table 2 Patient Hip Cultures in the Present Study. Infectious Organism
N ¼ 18
MSSA MRSA Enterococcus faecalis Finegoldia magna Prevotella disiens Polymicrobial No growth No cultures taken
3 1 1 1 1 3 3 5
(17%) (6%) (6%) (6%) (6%) (17%) (17%) (28%)
Data are presented as n (%). MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus.
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superficial I&D at 1-, 2-, and 5-years postoperatively of 98.6% ± 0.3% at all time points (Fig. 1). Using Fisher’s exact test, female gender was associated with higher risk of undergoing superficial I&D (P ¼ .0037) as was body mass index (BMI) >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037). The rate of superficial I&D was 2.16% (14/649) for patients with a BMI >30 kg/m2, 4.06% (11/271) for those with a BMI >35 kg/m2, and 6.90% (4/58) for those with a BMI >40 kg/m2. In comparison, the rate of superficial I&D was 0.44% (4/ 900) for patients with a BMI 30 kg/m2, 0.55% (7/1271) for those with a BMI 35 kg/m2, and 0.94% (14/1491) for those with a BMI 40 kg/m2. Analyzing the 1573 THAs using Cox regression analysis, it was found that female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P ¼ .0271) was again associated with a higher risk of undergoing superficial I&D (Table 3). Survivorship from superficial I&D at 1, 2, and 5 years postoperatively was 97.7% ± 0.6% at all time points for females vs 99.5 ± 0.3% at all time points for males (Fig. 2). There was no association with BMI, height, age, or operative time (hazard ratio 0.75-3.08, 95% confidence interval includes 1.0, P ¼ .1975-.5953).
Table 3 Hazard Ratios for Superficial I&D in This Population. Variable
Hazard Ratio
95% Confidence Interval
P-Value
Female gender Weight Height BMI BMI >30 kg/m2 BMI >35 kg/m2 BMI >40 kg/m2 Age Operative time
5.5 0.75 1.39 2.34 1.74 3.08 1.97 0.99 1.01
1.20-32.34 0.54-1.00 0.99-2.04 0.99-6.19 0.22-15.10 0.56-19.74 0.29-10.66 0.95-1.04 0.99-1.02
.0271 N/A N/A N/A .5953 .1975 .4629 N/A N/A
(per kg) (per cm) (per unit BMI)
(per year) (per minute)
P value is only available for gender and three BMI cutoffs as those were the only dichotomous variables analyzed. No other variable was significant, though, as evidenced by the 95% confidence interval including 1.0. BMI, body mass index; I&D, irrigation and debridement; N/A, not applicable.
(P ¼ .4921), BMI >30 kg/m2 (P ¼ .4190), >35 kg/m2 (P ¼ .1750), or >40 kg/m2 (P ¼ 1.0), and re-reoperation following initial I&D.
Clinical Outcomes Survivorship Analysis After Superficial I&D A summary of patients and results after superficial I&D can be found in Table 4. At an average follow-up of 2.2 (range 0.2-5.5) years, 0 of the 18 patients who underwent superficial I&D developed PJI, making the 1-, 2-, and 5-year survivorship from PJI 100% at all time points. There was only 1 re-reoperation, which was a femoral component revision for a painful fibrously ingrown femoral component at 1.25 years postoperatively with normal preoperative erythrocyte sedimentation rate and C-reactive protein and three negative intraoperative cultures, making the 1-, 2-, and 5-year survivorship from revision and re-reoperation 100% ± 0%, 90% ± 9%, and 90% ± 9%, respectively (Fig. 3). Statistical analysis using Cox regression analysis could not be carried out as there was only 1 patient failure. However, using Fisher’s exact test, there was no association between female gender
Besides the aforementioned revision, there were two other complications. One was a pulmonary embolus that occurred 10 days after superficial I&D in a man with sickle cell disease, which was treated effectively with several months of anticoagulation. The other was a patient with a history of interstitial lung disease who died from acute hypoxemic respiratory failure 22 days after superficial I&D. Harris Hip Scores were available in 12 of 18 (67%) patients. The average score was 86.8 (range 57-99). Of these 12 patients, 11 noted that they were “much better now” as compared to before surgery and 1 noted that she was “worse.” The one patient who was worse was the patient who underwent a revision for a painful fibrously ingrown femoral component. Using Fisher’s exact test, there was no correlation between female gender or BMI and Harris Hip Score or the patient rating their hip as “much better now” after surgery (P ¼ .8333-1.0).
Fig. 1. Kaplan-Meier implant survival curve demonstrating survivorship from superficial I&D of 98.6% ± 0.3% at 1, 2, and 5 years postoperatively.
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Fig. 2. Kaplan-Meier implant survival curve demonstrating survivorship from superficial I&D of 97.7% ± 0.6% at all time points for females and 99.5% ± 0.3% at all time points for males (P ¼ .0271).
Discussion Superficial wound dehiscence is a known complication after THA performed through the DAA [1e5]. When this occurs, superficial I&D and wound closure is a reasonable treatment option. To our knowledge, there are no data in the literature fully detailing the outcomes of patients who receive a superficial I&D and wound closure after sustaining a superficial wound dehiscence after DAA THA. This study sought to elucidate those outcomes. In the present study, we had a 1.1% rate of superficial I&D, which is comparable to the rate found in other studies. In 2011, Jewett and Collis [2] studied complications associated with THA performed using the DAA and found a 1.6% rate of superficial I&D. In 2014, Christensen et al [3] found a 1.4% rate of wound complication requiring reoperation. In 2015, Watts et al [4] found a 1.3% rate of superficial I&D for wound complications. In 2016, Purcell et al [5] found a rate of 1.0%. In 2016, Jahng et al [7] found a 1.9% rate of reoperation for wound complications. In 2018, Purcell et al [8] found a rate of 0.5% reoperation for wound complications. Thus, superficial wound dehiscence requiring superficial I&D occurs in about 1%-2% of patients undergoing DAA THA. This is useful prognostic information for surgeons to know and share with patients during treatment counseling. The present study also found that female gender (P ¼ .0037), BMI >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037) were significant risk factors for undergoing a superficial I&D after DAA THA using Fisher’s exact test. The same findings for female gender (P ¼ .016), BMI 30 kg/m2 (P ¼ .006), and BMI 40 kg/m2 (P < .0001) were seen in the study by Watts et al. [4] Jahng et al [7] also found increased risk of reoperation for wound complication with BMI >40 kg/m2 (P < .0005). Conversely, Purcell et al [5,8] and Antoniadis et al [6] did not find that higher BMI was a significant risk factor for superficial wound problems or I&D (P > .05). With regards to female gender, it is possible that skin in the operative site is thinner and more susceptible to trauma during the DAA in women than in men, decreasing the healing potential of these wounds and increasing the risk of wound dehiscence [11].
With regards to BMI, this likely caused increased risk of impaired wound healing and need for superficial I&D in our study for several reasons. First, it is likely that the increased depth of the skin fold over the incision in patients with higher BMIs causes increased shear forces. Second, the moist environment in the skin fold likely leads to seeding of the incision with infectious organisms. Third, obese patients have a thicker layer of relatively poorly vascularized adipose tissue. Fourth, obese patients are known to often be paradoxically malnourished [12]. We additionally found that no patient undergoing superficial I&D developed subsequent PJI, regardless of cultured organisms or postoperative antibiotic regimen. Similarly, there were no cases of PJI after superficial I&D in studies performed by Jewett and Collis [2] or Watts et al [4]. This is encouraging information and shows that if the fascia is intact during superficial I&D, there is likely no need to expose the joint and risk contamination. We continue to collaborate with our infectious disease colleagues to determine the optimal postoperative antibiotic regimen for these cases. This decision is based on a combination of culture results, host comorbidities, and other concomitant infections. However, for a healthy patient requiring a superficial I&D, we recommend taking 4-5 tissue cultures at the time of I&D, giving the patient 24 hours of perioperative intravenous antibiotics, and continuing on appropriate oral prophylaxis for 2 weeks until cultures are negative. Our choice is 24 hours of weight-based intravenous cefazolin followed by either 14 days of cephalexin or 14 days of cefadroxil. If cultures turn positive, antibiotics should be tailored to treat specific organisms growing from the culture, the duration of which may vary depending on organism. To prevent these wound problems from occurring, we recommend using meticulous surgical technique, respecting the skin and soft tissues, performing careful wound closures, and protecting the incision from shear forces and skin folds during the first several weeks postoperatively. Incisions should be placed as far away from skin folds as possible in the area of the healthiest skin available to still safely carry out the surgery. In patients in whom the DAA cannot be carried out without placing the incision in a tenuous area, we would recommend utilizing an alternative approach for THA in which the incision is placed over
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Table 4 Summary of Patients Undergoing Superficial I&D After THA Using the DAA. Gender
Age (y)
BMI (kg/m2)
Time to I&D (d)
# Of Cultures
Culture Results
Antibiotics
Time to Last Follow-Up (y)
HHS
Response
1 2 3 4 5
F F F F F
47 61 51 67 80
40 38 39 45 27
12 35 32 16 83
4 3 1 1 1
MRSA (4) MSSA (2) Enterococcus faecalis (1) No growth No growth
IV/PO IV/POa IV PO IV/PO
5.5 5.2 5.0 5.4 0.3
90.5 97.5 73 79.8 N/A
Much Much Much Much N/A
6 7 8 9
M F F F
52 51 60 74
25 39 41 37
20 30 28 44
0 0 1 1
Periop PO PO PO
2.0 4.3 2.3 0.2
N/A 80.4 97.8 87.8
N/A Much better Much better Much better
10
M
63
37
19
3
PO
2.7
99
Much better
11
F
57
35
27
2
N/A N/A MSSA (1) MSSA (1), Fusobacterium periodonticum (1), Corynebacterium amycolatum (1), Streptococcus anginosus (1) MSSA (3), Morganella Morganii (3), Corynebacterium (1) Prevotella disiens (2)
PO
1.3
57
Worse
12 13 14 15 16 17 18
F F F F M F F
62 57 59 76 74 53 61
36 28 33 29 33 41 34
57 22 50 50 56 26 65
1 3 1 0 0 0 2
Finegoldia magna (1) MSSA (3), Escherichia coli (1) No growth N/A N/A N/A MSSA (2)
PO IV/POa PO PO PO PO PO
1.2 2.1 0.3 0.7 0.4 0.2 0.5
89 92.5 97.8 N/A N/A N/A N/A
Much better Much better Much better N/A N/A N/A N/A
Complications
better better better better Death from respiratory failure 22 d s/p I&D Pulmonary embolus
Femoral revision for painful, fibrously ingrown stem
Culture results reported as “Organism” (# of cultures positive for that organism). Periop ¼ 24 h of perioperative intravenous antibiotics. IV ¼ greater than 24 h of intravenous antibiotics without subsequent oral antibiotics. IV/ PO ¼ greater than 24 h of intravenous antibiotics with subsequent oral antibiotics. PO ¼ 24 h of perioperative intravenous antibiotics followed by oral antibiotics. Note that patient 2 was placed on lifelong suppression due to a separate acute prosthetic joint infection in a total knee arthroplasty. BMI, body mass index; d, days; F, female; HHS, Harris Hip Score; M, male; MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; N/A, not applicable. a Lifelong oral antibiotic suppression.
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Patient
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Fig. 3. Kaplan-Meier patient survival curve demonstrating 1-, 2-, and 5-year survivorship from revision and re-reoperation of 100% ± 0%, 90% ± 9%, and 90% ± 9%, respectively.
healthy, intact skin. This is especially true in female patients and in patients with high BMIs. This study should be interpreted in the face of its limitations. First, we did not analyze all patients with superficial wound dehiscence, rather, we only looked at those undergoing superficial I&D. This prevents us from recommending indications for superficial I&D over local wound care. Nonetheless, it does seem that superficial I&D is a reasonable option to successfully treat patients with superficial wound dehiscence with a low rate of subsequent PJI. Second, there was a relatively small number of patients who underwent superficial I&D, limiting the power to find statistical correlations and to find an association with PJI, which is rare itself. Third, this study was a retrospective review fraught with potential recall and treatment bias. Higher level studies analyzing a larger number of patients with a greater variety of treatments would be useful to fully elucidate the appropriate treatment and clinical outcomes of patients with superficial wound problems.
Conclusions Superficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%-2% of patients and is more common in female patients and those with higher BMIs. Superficial I&D is an effective treatment option for wound dehiscence with a low risk for subsequent PJI. Patients can be expected to be satisfied with their THA with high clinical outcomes scores. In high-risk patients undergoing DAA THA, extra care should be taken to respect the soft tissues, and when appropriate, a different approach should be utilized to avoid this complication.
References [1] Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am 2003;85-A(Suppl 4):39e48. [2] Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469:503e7. [3] Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. J Arthroplasty 2014;29:1839e41. [4] Watts CD, Houdek MT, Wagner ER, Sculco PK, Chalmers BP, Taunton MJ. High risk of wound complications following direct anterior total hip arthroplasty in obese patients. J Arthroplasty 2015;30:2296e8. [5] Purcell RL, Parks NL, Gargiulo JM, Hamilton WG. Severely obese patients have a higher risk of infection after direct anterior approach total hip arthroplasty. J Arthroplasty 2016;31(9 Suppl):162e5. [6] Antoniadis A, Dimitriou D, Flury A, Wiedmer G, Hasler J, Helmy N. Is direct anterior approach a credible option for severely obese patients undergoing total hip arthroplasty? A matched-control, retrospective, clinical study. J Arthroplasty 2018;33:2535e40. [7] Jahng KH, Bas MA, Rodriguez JA, Cooper HJ. Risk factors for wound complications after direct anterior approach hip arthroplasty. J Arthroplasty 2016;31:2583e7. [8] Purcell RL, Parks NL, Cody JP, Hamilton WG. Comparison of wound complications and deep infections with direct anterior and posterior approaches in obese hip arthroplasty patients. J Arthroplasty 2018;33:220e3. [9] Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res 2015;473: 623e31. [10] Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 2011;469: 2992e4. [11] Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol 1975;93:639e43. [12] Fu MC, D'Ambrosia C, McLawhorn AS, Schairer WW, Padgett DE, Cross MB. Malnutrition increases with obesity and is a stronger independent risk factor for postoperative complications: a propensity-adjusted analysis of total hip arthroplasty patients. J Arthroplasty 2016;31:2415e21.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Complications - Other
Outcome of Direct Anterior Total Hip Arthroplasty Complicated by Superficial Wound Dehiscence Requiring Irrigation and Debridement Joseph M. Statz, MD, Nicholas C. Duethman, MD, Robert T. Trousdale, MD, Michael J. Taunton, MD * Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 January 2019 Received in revised form 21 February 2019 Accepted 6 March 2019 Available online 12 March 2019
Background: Superficial wound dehiscence after total hip arthroplasty (THA) performed through the direct anterior approach (DAA) can be treated with superficial irrigation and debridement (I&D). The incidence and treatment of this complication has been described, but there are little data on the outcomes after a superficial I&D have not been described. The purpose of this paper was to examine the clinical outcomes of DAA THAs requiring postoperative superficial I&D. Methods: A retrospective review of 1573 THAs performed using the DAA were identified utilizing a prospectively collected, single-institution joint registry. Of these 1573 cases, 18 THAs in 18 patients (1.1%) underwent a superficial I&D for superficial wound dehiscence. Outcomes studied included prosthetic joint infection (PJI) after superficial I&D, revisions, re-reoperations, complications, and clinical outcome scores. Results: Survivorship from superficial I&D at 1, 2, and 5 years postoperatively was 98.6% at all time points. In the 18 patients who underwent superficial I&D, this was performed an average of 37 (range 1283) days after their THA. Female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P ¼ .0271) was associated with a higher risk of undergoing superficial I&D as was body mass index >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037). At average follow-up of 2.2 (range 0.2-5.5) years, 0 patients developed PJI. Complications included femoral revision for a painful fibrously ingrown femoral component (1), pulmonary embolus (1), and death from respiratory failure (1). Postoperative Harris Hip Scores averaged score was 86.8 (range 57-99). Conclusions: Superficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%2% of patients with low risk of subsequent PJI. © 2019 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty direct anterior approach superficial wound dehiscence irrigation and debridement prosthetic joint infection
Superficial wound dehiscence is a known complication associated with total hip arthroplasty (THA) performed through the direct anterior approach (DAA) with a rate of about 1%-2% [1e8].
Investigation was performed at the Mayo Clinic, Rochester, MN. One or more of the authors of this paper have 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.2019.03.020. Sources of Funding: No external sources of funding were utilized for this study. * Reprint requests: Michael J. Taunton, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905. https://doi.org/10.1016/j.arth.2019.03.020 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Authors have attributed this complication to a combination of skin quality and incision location. The skin quality around the anterior hip is thin, making closure more difficult and less stout than in the lateral or posterior skin. The incision is also near to, or sometimes overlapping, the inguinal and waist creases. This can lead to the incision being exposed to infectious organisms that reside within the moist environment of these folds which are also difficult for patients to clean, especially if the patient is obese. Furthermore, the incision can experience a large amount of shear force with hip movement due to these folds. All of this together can lead to separation of the skin edges and failure of the wound to heal. Although superficial wound dehiscence can sometimes heal nonoperatively with a combination of local wound care and antibiotics, performing a superficial irrigation and debridement (I&D) is a reasonable option to close the skin, treat accompanying
J.M. Statz et al. / The Journal of Arthroplasty 34 (2019) 1492e1497
superficial infection, and protect the underlying THA prosthesis [4]. Although the incidence and treatment of this complication have been described, the data on outcomes of THAs after a superficial I&D for wound dehiscence are limited. The purpose of this article was to examine the clinical outcomes of THAs performed through the DAA that required postoperative superficial I&D. Patients and Methods After approval from our institutional review board, we performed a retrospective review of a prospectively collected singleinstitution total joint registry. This registry follows up all patients after joint arthroplasties at time points of 1 year, 2 years, 5 years, and then every 5 years thereafter. If patients are unable to return, they are asked to complete a validated outcomes questionnaire and send radiographs. Patient Selection and Demographics We identified 1573 THAs performed using the DAA between August 26, 2010 and July 11, 2018. Each surgery was performed by one of the two fellowship-trained hip and knee arthroplasty surgeons. Of these 1573 cases, there were 18 THAs in 18 patients (1.1%) who underwent a superficial I&D, all for superficial wound dehiscence. The demographic information is shown in Table 1. Operative Technique THA using the DAA was performed for all 1573 patients as previously described [4,9]. This technique uses a traction table and intraoperative fluoroscopy. The incision was placed over the tensor fascia lata (TFL) muscle belly and the hip was approached through the TFL investing fascia. After implants were placed, thorough irrigation of the joint and superficial tissues was performed followed by closure of the joint capsule with absorbable suture. The TFL investing fascia was then closed with absorbable suture followed by closure of the subcutaneous fat and skin with absorbable sutures. Either Steri-Strips (3M, St. Paul, MN,) with an overlying layer of Dermabond (Ethicon, Somerville, New Jersey) or Dermabond Prineo (Ethicon, Somerville, New Jersey) was placed on the skin surface. Mean operating time from incision to closure was 96 (range 54-222) minutes. The 18 patients who underwent a superficial I&D all had the affected areas of their incisions excised with an elliptical incision. A
Table 1 Demographic Information of the Total Hip Arthroplasties Performed in This Study. Demographic Variable All patients Total number Age at surgery (y) Laterality (left/right) BMI (kg/m2) Weight (kg) Height (cm) Male/female Patients undergoing superficial I&D Total number Age at surgery (y) Laterality (left/right) BMI (kg/m2) Weight (kg) Height (cm) Male/female Data are presented as mean (range) or n (%). BMI, body mass index; I&D, irrigation and debridement.
Value 1573 64 716 30 83.9 170 799
(100%) (19-97) (46%)/857 (54%) (14-60)
18 61 12 35 96 165 3
(1.1%) (47-80) (67%)/6 (33%) (25-45) (66-122) (154-191) (17%)/15 (83%)
(138-200) (51%)/774 (49%)
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thorough inspection of the TFL investing fascial closure was performed. If the fascia had no defects in it, the joint was not entered, and the I&D remained superficial to the fascia. The skin was then closed with absorbable monofilament sutures in the dermal layer and nonabsorbable sutures in the skin. This was covered with a negative-pressure dressing. If the fascia was violated and there was a path to the joint, a deep I&D with head-liner exchanged was performed, and these patients were not included in this cohort. Cultures were taken from the superficial tissues in 13 of 18 (72%) cases. An average of 1.3 cultures were taken (range 0-4), and the cultures grew a variety of organisms (Table 2). Postoperative antibiotic regimen also varied and was determined by the operative surgeon and infectious disease specialists. All patients received 24 hours of perioperative intravenous antibiotics. Additional intravenous antibiotics were administered to 5 (28%) patients. Of these 5 patients, 4 (22%) received additional oral antibiotics. Of these 4 patients, 2 (11%) were placed on lifelong oral antibiotic suppression, 1 of which was for acute prosthetic joint infection (PJI) of a separate total knee arthroplasty. There were 12 (67%) patients who received 24 hours of perioperative intravenous antibiotics then only oral antibiotics for no longer than 3 weeks postoperatively. There was 1 (6%) patient who received only 24 hours of perioperative intravenous antibiotics. Outcomes Assessment The primary outcome of interest was survivorship from PJI after superficial I&D, which we defined according to the criteria set forth by the Musculoskeletal Infection Society [10]. Secondary outcomes studied included revisions, re-reoperations, complications, and clinical outcomes scores. Statistical Methods Statistical analysis was carried out using JMP version 13.0 (SAS Institute, Inc, Cary, NC). Kaplan-Meier survivorship analysis was utilized. Cox regression analysis, Fisher’s exact test, and the Wilcoxon rank-sum test were used to compare differences in outcomes based on variables of interest. An alpha level of 0.05 was used to determine statistical significance. Results Survivorship From Superficial I&D Superficial I&D occurred in 18 of 1573 (1.1%) THAs performed through a DAA. All these occurred within 83 days of THA implantation at an average of 37 (range 12-83) days postoperatively. Kaplan-Meier survivorship analysis showed a survivorship from
Table 2 Patient Hip Cultures in the Present Study. Infectious Organism
N ¼ 18
MSSA MRSA Enterococcus faecalis Finegoldia magna Prevotella disiens Polymicrobial No growth No cultures taken
3 1 1 1 1 3 3 5
(17%) (6%) (6%) (6%) (6%) (17%) (17%) (28%)
Data are presented as n (%). MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus.
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superficial I&D at 1-, 2-, and 5-years postoperatively of 98.6% ± 0.3% at all time points (Fig. 1). Using Fisher’s exact test, female gender was associated with higher risk of undergoing superficial I&D (P ¼ .0037) as was body mass index (BMI) >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037). The rate of superficial I&D was 2.16% (14/649) for patients with a BMI >30 kg/m2, 4.06% (11/271) for those with a BMI >35 kg/m2, and 6.90% (4/58) for those with a BMI >40 kg/m2. In comparison, the rate of superficial I&D was 0.44% (4/ 900) for patients with a BMI 30 kg/m2, 0.55% (7/1271) for those with a BMI 35 kg/m2, and 0.94% (14/1491) for those with a BMI 40 kg/m2. Analyzing the 1573 THAs using Cox regression analysis, it was found that female gender (hazard ratio 5.5, 95% confidence interval 1.20-32.34, P ¼ .0271) was again associated with a higher risk of undergoing superficial I&D (Table 3). Survivorship from superficial I&D at 1, 2, and 5 years postoperatively was 97.7% ± 0.6% at all time points for females vs 99.5 ± 0.3% at all time points for males (Fig. 2). There was no association with BMI, height, age, or operative time (hazard ratio 0.75-3.08, 95% confidence interval includes 1.0, P ¼ .1975-.5953).
Table 3 Hazard Ratios for Superficial I&D in This Population. Variable
Hazard Ratio
95% Confidence Interval
P-Value
Female gender Weight Height BMI BMI >30 kg/m2 BMI >35 kg/m2 BMI >40 kg/m2 Age Operative time
5.5 0.75 1.39 2.34 1.74 3.08 1.97 0.99 1.01
1.20-32.34 0.54-1.00 0.99-2.04 0.99-6.19 0.22-15.10 0.56-19.74 0.29-10.66 0.95-1.04 0.99-1.02
.0271 N/A N/A N/A .5953 .1975 .4629 N/A N/A
(per kg) (per cm) (per unit BMI)
(per year) (per minute)
P value is only available for gender and three BMI cutoffs as those were the only dichotomous variables analyzed. No other variable was significant, though, as evidenced by the 95% confidence interval including 1.0. BMI, body mass index; I&D, irrigation and debridement; N/A, not applicable.
(P ¼ .4921), BMI >30 kg/m2 (P ¼ .4190), >35 kg/m2 (P ¼ .1750), or >40 kg/m2 (P ¼ 1.0), and re-reoperation following initial I&D.
Clinical Outcomes Survivorship Analysis After Superficial I&D A summary of patients and results after superficial I&D can be found in Table 4. At an average follow-up of 2.2 (range 0.2-5.5) years, 0 of the 18 patients who underwent superficial I&D developed PJI, making the 1-, 2-, and 5-year survivorship from PJI 100% at all time points. There was only 1 re-reoperation, which was a femoral component revision for a painful fibrously ingrown femoral component at 1.25 years postoperatively with normal preoperative erythrocyte sedimentation rate and C-reactive protein and three negative intraoperative cultures, making the 1-, 2-, and 5-year survivorship from revision and re-reoperation 100% ± 0%, 90% ± 9%, and 90% ± 9%, respectively (Fig. 3). Statistical analysis using Cox regression analysis could not be carried out as there was only 1 patient failure. However, using Fisher’s exact test, there was no association between female gender
Besides the aforementioned revision, there were two other complications. One was a pulmonary embolus that occurred 10 days after superficial I&D in a man with sickle cell disease, which was treated effectively with several months of anticoagulation. The other was a patient with a history of interstitial lung disease who died from acute hypoxemic respiratory failure 22 days after superficial I&D. Harris Hip Scores were available in 12 of 18 (67%) patients. The average score was 86.8 (range 57-99). Of these 12 patients, 11 noted that they were “much better now” as compared to before surgery and 1 noted that she was “worse.” The one patient who was worse was the patient who underwent a revision for a painful fibrously ingrown femoral component. Using Fisher’s exact test, there was no correlation between female gender or BMI and Harris Hip Score or the patient rating their hip as “much better now” after surgery (P ¼ .8333-1.0).
Fig. 1. Kaplan-Meier implant survival curve demonstrating survivorship from superficial I&D of 98.6% ± 0.3% at 1, 2, and 5 years postoperatively.
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Fig. 2. Kaplan-Meier implant survival curve demonstrating survivorship from superficial I&D of 97.7% ± 0.6% at all time points for females and 99.5% ± 0.3% at all time points for males (P ¼ .0271).
Discussion Superficial wound dehiscence is a known complication after THA performed through the DAA [1e5]. When this occurs, superficial I&D and wound closure is a reasonable treatment option. To our knowledge, there are no data in the literature fully detailing the outcomes of patients who receive a superficial I&D and wound closure after sustaining a superficial wound dehiscence after DAA THA. This study sought to elucidate those outcomes. In the present study, we had a 1.1% rate of superficial I&D, which is comparable to the rate found in other studies. In 2011, Jewett and Collis [2] studied complications associated with THA performed using the DAA and found a 1.6% rate of superficial I&D. In 2014, Christensen et al [3] found a 1.4% rate of wound complication requiring reoperation. In 2015, Watts et al [4] found a 1.3% rate of superficial I&D for wound complications. In 2016, Purcell et al [5] found a rate of 1.0%. In 2016, Jahng et al [7] found a 1.9% rate of reoperation for wound complications. In 2018, Purcell et al [8] found a rate of 0.5% reoperation for wound complications. Thus, superficial wound dehiscence requiring superficial I&D occurs in about 1%-2% of patients undergoing DAA THA. This is useful prognostic information for surgeons to know and share with patients during treatment counseling. The present study also found that female gender (P ¼ .0037), BMI >30 kg/m2 (P ¼ .0028), >35 kg/m2 (P < .0001), and >40 kg/m2 (P ¼ .0037) were significant risk factors for undergoing a superficial I&D after DAA THA using Fisher’s exact test. The same findings for female gender (P ¼ .016), BMI 30 kg/m2 (P ¼ .006), and BMI 40 kg/m2 (P < .0001) were seen in the study by Watts et al. [4] Jahng et al [7] also found increased risk of reoperation for wound complication with BMI >40 kg/m2 (P < .0005). Conversely, Purcell et al [5,8] and Antoniadis et al [6] did not find that higher BMI was a significant risk factor for superficial wound problems or I&D (P > .05). With regards to female gender, it is possible that skin in the operative site is thinner and more susceptible to trauma during the DAA in women than in men, decreasing the healing potential of these wounds and increasing the risk of wound dehiscence [11].
With regards to BMI, this likely caused increased risk of impaired wound healing and need for superficial I&D in our study for several reasons. First, it is likely that the increased depth of the skin fold over the incision in patients with higher BMIs causes increased shear forces. Second, the moist environment in the skin fold likely leads to seeding of the incision with infectious organisms. Third, obese patients have a thicker layer of relatively poorly vascularized adipose tissue. Fourth, obese patients are known to often be paradoxically malnourished [12]. We additionally found that no patient undergoing superficial I&D developed subsequent PJI, regardless of cultured organisms or postoperative antibiotic regimen. Similarly, there were no cases of PJI after superficial I&D in studies performed by Jewett and Collis [2] or Watts et al [4]. This is encouraging information and shows that if the fascia is intact during superficial I&D, there is likely no need to expose the joint and risk contamination. We continue to collaborate with our infectious disease colleagues to determine the optimal postoperative antibiotic regimen for these cases. This decision is based on a combination of culture results, host comorbidities, and other concomitant infections. However, for a healthy patient requiring a superficial I&D, we recommend taking 4-5 tissue cultures at the time of I&D, giving the patient 24 hours of perioperative intravenous antibiotics, and continuing on appropriate oral prophylaxis for 2 weeks until cultures are negative. Our choice is 24 hours of weight-based intravenous cefazolin followed by either 14 days of cephalexin or 14 days of cefadroxil. If cultures turn positive, antibiotics should be tailored to treat specific organisms growing from the culture, the duration of which may vary depending on organism. To prevent these wound problems from occurring, we recommend using meticulous surgical technique, respecting the skin and soft tissues, performing careful wound closures, and protecting the incision from shear forces and skin folds during the first several weeks postoperatively. Incisions should be placed as far away from skin folds as possible in the area of the healthiest skin available to still safely carry out the surgery. In patients in whom the DAA cannot be carried out without placing the incision in a tenuous area, we would recommend utilizing an alternative approach for THA in which the incision is placed over
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Table 4 Summary of Patients Undergoing Superficial I&D After THA Using the DAA. Gender
Age (y)
BMI (kg/m2)
Time to I&D (d)
# Of Cultures
Culture Results
Antibiotics
Time to Last Follow-Up (y)
HHS
Response
1 2 3 4 5
F F F F F
47 61 51 67 80
40 38 39 45 27
12 35 32 16 83
4 3 1 1 1
MRSA (4) MSSA (2) Enterococcus faecalis (1) No growth No growth
IV/PO IV/POa IV PO IV/PO
5.5 5.2 5.0 5.4 0.3
90.5 97.5 73 79.8 N/A
Much Much Much Much N/A
6 7 8 9
M F F F
52 51 60 74
25 39 41 37
20 30 28 44
0 0 1 1
Periop PO PO PO
2.0 4.3 2.3 0.2
N/A 80.4 97.8 87.8
N/A Much better Much better Much better
10
M
63
37
19
3
PO
2.7
99
Much better
11
F
57
35
27
2
N/A N/A MSSA (1) MSSA (1), Fusobacterium periodonticum (1), Corynebacterium amycolatum (1), Streptococcus anginosus (1) MSSA (3), Morganella Morganii (3), Corynebacterium (1) Prevotella disiens (2)
PO
1.3
57
Worse
12 13 14 15 16 17 18
F F F F M F F
62 57 59 76 74 53 61
36 28 33 29 33 41 34
57 22 50 50 56 26 65
1 3 1 0 0 0 2
Finegoldia magna (1) MSSA (3), Escherichia coli (1) No growth N/A N/A N/A MSSA (2)
PO IV/POa PO PO PO PO PO
1.2 2.1 0.3 0.7 0.4 0.2 0.5
89 92.5 97.8 N/A N/A N/A N/A
Much better Much better Much better N/A N/A N/A N/A
Complications
better better better better Death from respiratory failure 22 d s/p I&D Pulmonary embolus
Femoral revision for painful, fibrously ingrown stem
Culture results reported as “Organism” (# of cultures positive for that organism). Periop ¼ 24 h of perioperative intravenous antibiotics. IV ¼ greater than 24 h of intravenous antibiotics without subsequent oral antibiotics. IV/ PO ¼ greater than 24 h of intravenous antibiotics with subsequent oral antibiotics. PO ¼ 24 h of perioperative intravenous antibiotics followed by oral antibiotics. Note that patient 2 was placed on lifelong suppression due to a separate acute prosthetic joint infection in a total knee arthroplasty. BMI, body mass index; d, days; F, female; HHS, Harris Hip Score; M, male; MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; N/A, not applicable. a Lifelong oral antibiotic suppression.
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Patient
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Fig. 3. Kaplan-Meier patient survival curve demonstrating 1-, 2-, and 5-year survivorship from revision and re-reoperation of 100% ± 0%, 90% ± 9%, and 90% ± 9%, respectively.
healthy, intact skin. This is especially true in female patients and in patients with high BMIs. This study should be interpreted in the face of its limitations. First, we did not analyze all patients with superficial wound dehiscence, rather, we only looked at those undergoing superficial I&D. This prevents us from recommending indications for superficial I&D over local wound care. Nonetheless, it does seem that superficial I&D is a reasonable option to successfully treat patients with superficial wound dehiscence with a low rate of subsequent PJI. Second, there was a relatively small number of patients who underwent superficial I&D, limiting the power to find statistical correlations and to find an association with PJI, which is rare itself. Third, this study was a retrospective review fraught with potential recall and treatment bias. Higher level studies analyzing a larger number of patients with a greater variety of treatments would be useful to fully elucidate the appropriate treatment and clinical outcomes of patients with superficial wound problems.
Conclusions Superficial wound dehiscence requiring superficial I&D after DAA THA occurs in about 1%-2% of patients and is more common in female patients and those with higher BMIs. Superficial I&D is an effective treatment option for wound dehiscence with a low risk for subsequent PJI. Patients can be expected to be satisfied with their THA with high clinical outcomes scores. In high-risk patients undergoing DAA THA, extra care should be taken to respect the soft tissues, and when appropriate, a different approach should be utilized to avoid this complication.
References [1] Kennon RE, Keggi JM, Wetmore RS, Zatorski LE, Huo MH, Keggi KJ. Total hip arthroplasty through a minimally invasive anterior surgical approach. J Bone Joint Surg Am 2003;85-A(Suppl 4):39e48. [2] Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469:503e7. [3] Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications requiring reoperation with direct anterior approach total hip arthroplasty. J Arthroplasty 2014;29:1839e41. [4] Watts CD, Houdek MT, Wagner ER, Sculco PK, Chalmers BP, Taunton MJ. High risk of wound complications following direct anterior total hip arthroplasty in obese patients. J Arthroplasty 2015;30:2296e8. [5] Purcell RL, Parks NL, Gargiulo JM, Hamilton WG. Severely obese patients have a higher risk of infection after direct anterior approach total hip arthroplasty. J Arthroplasty 2016;31(9 Suppl):162e5. [6] Antoniadis A, Dimitriou D, Flury A, Wiedmer G, Hasler J, Helmy N. Is direct anterior approach a credible option for severely obese patients undergoing total hip arthroplasty? A matched-control, retrospective, clinical study. J Arthroplasty 2018;33:2535e40. [7] Jahng KH, Bas MA, Rodriguez JA, Cooper HJ. Risk factors for wound complications after direct anterior approach hip arthroplasty. J Arthroplasty 2016;31:2583e7. [8] Purcell RL, Parks NL, Cody JP, Hamilton WG. Comparison of wound complications and deep infections with direct anterior and posterior approaches in obese hip arthroplasty patients. J Arthroplasty 2018;33:220e3. [9] Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res 2015;473: 623e31. [10] Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the workgroup of the musculoskeletal infection society. Clin Orthop Relat Res 2011;469: 2992e4. [11] Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol 1975;93:639e43. [12] Fu MC, D'Ambrosia C, McLawhorn AS, Schairer WW, Padgett DE, Cross MB. Malnutrition increases with obesity and is a stronger independent risk factor for postoperative complications: a propensity-adjusted analysis of total hip arthroplasty patients. J Arthroplasty 2016;31:2415e21.