Fig. 4.1
The persistent drainage was seen in the operative wound 4 days after total hip arthroplasty
Introduction
Despite the implementation of numerous measures, wound-related complications after total joint arthroplasty (TJA) continue to be a concerning problem. Wound-related complications are associated with increased morbidity, and can elevate the cost of episode of care substantially. Carroll et al. [1] reported that superficial wound complications occurred at a rate of 9% in total hip arthroplasty (THA) and of these 30% required readmission to hospital for management. Wound complications after THA can occur in the form of persistent drainage, hematoma formation, blistering, wound dehiscence, and skin necrosis. Among the latter, wound drainage is not an infrequent complication that is usually self-limiting and stops within a few days after surgery. Drainage continuing beyond 48 h after hip arthroplasty, especially at high volume, is considered as persistent wound drainage that usually requires intervention. The incidence of serosanguineous drainage after primary THA, which persists beyond 48 h, is 1.3–3% [2, 3].
Significance of Wound Complications
Wound complications require prompt attention as they either arise as a result of deep periprosthetic infection (PJI) or pose a serious risk to cause such event if left untreated. Superficial wound complications, such as surgical site infection (SSI) and prolonged wound drainage, have been consistently implicated in the development of periprosthetic joint infection and may increase the risk of subsequent deep infection by up to 35-fold [4, 5]. Most infections present within the first year following surgery and may be associated with contamination at the time of surgery or in the early postoperative period [6]. Each day of persistent wound drainage increases the risk of infection by 42% in THA [7]. In addition, superficial wound complications, without deep infection, are associated with patient morbidity and cost to the healthcare system, including prolonged hospital stay, readmission, ongoing treatments, and reduced patient satisfaction [4, 5, 8, 9].
Risk Factors for Wound Complications
Identification and modification of risk factors that lead to wound complications can reduce the incidence of subsequent serious problems such as deep PJI. As previously mentioned, prolonged wound drainage is associated with a higher rate of infection following THA [4, 7]. Risk factors for persistent wound drainage include malnutrition [2], obesity [6, 7, 10, 11], use of aggressive prophylactic anticoagulation such as low-molecular-weight heparin or an elevated INR as a result of administration of Coumadin [7], and use of a surgical drain [7]. There are also reports of some skin preparation agents predisposing patients to the development of skin blisters and other wound-related problems. One such agent that has been implicated is 0.5% chlorhexidine in 70% alcohol [1].
Types of Wound Complications
Skin Blistering
Blisters can be attributed to the movement between the skin and the wound dressing over time. The dressing type and the technique of dressing application, as well as the degree of swelling of the skin or allergic response to the adhesive material in the dressing, can influence the incidence of blistering [12, 13].
The Delphi Panel [14] suggested that an ideal wound dressing that could minimize blister formation should conform well to the wound, be easy to apply and remove, and allow for soft-tissue swelling.
Exudate from blisters is sterile but rapidly becomes contaminated with bacteria from the skin flora after rupture until re-epithelialization. Blistering results in breakdown of the epithelia barrier in the skin and can potentially lead to infections.
The best method for treatment of skin blistering is to burst and drain the blister fluid. The roof should, however, be left intact to act as a barrier during the process of epithelialization. There is no evidence to support the use of antibiotics in patients with skin blisters after THA.
Prolonged Wound Drainage
The definition of persistent wound drainage varies. The International Consensus Meeting (ICM) on Periprosthetic Joint Infection defined it as drainage covering an area greater than 2 × 2 cm of gauze persisting beyond 72 h after total joint arthroplasty (TJA) (Fig. 4.1). The ICM recommends that persistent wound drainage after TJA should be managed aggressively. The first line of treatment involves application of compressive dressing, negative-pressure wound dressing (VAC), and observation. If the wound drainage persists beyond 5–7 days, especially if copious, surgical intervention is recommended [15].
Administration of antibiotics for persistent wound drainage is discouraged as this may mask an underlying infection .
Swab culture of a draining wound should not be performed as it does not provide any information except isolation of organisms resident on the skin [16].
Skin Necrosis
Skin necrosis following THA may be less critical than total knee arthroplasty because of the relative good coverage of soft tissues around the hip. Necrosis of skin around the hip does however require thorough debridement and revision closure of the wound if adequate soft tissue exists. Less than 3 cm of superficial necrosis can also be treated with local care or delayed closure. However, skin necrosis more than 3 cm often requires treatment with soft-tissue coverage and split-thickness skin grafts (STSGs) or fasciocutaneous flaps. Full-thickness skin necrosis exposing the prosthesis leads to colonization of the prosthesis, and necessitates resection arthroplasty and later reconstruction that should include soft-tissue flaps.
Hematoma
Hematoma formation around a surgical incision impairs soft-tissue healing by increasing the wound tension and reducing tissue perfusion. The latter may then lead to soft-tissue ischemia/necrosis. Hematomas can also act as a favorable culture medium for pathogens, prevent antibiotic access, and lead to infection [4, 17].
There are multiple reasons for the development of a hematoma after THA. Mortazavi et al. [18] reported that the high blood loss, administration of fresh frozen plasma (FFP) or vitamin K, and administration of perioperative therapeutic anticoagulation for a preexisting condition and hormonal therapy were independent risk factors for hematoma formation.
Hematoma formation is associated with a subsequent PJI [19].
Administration of less aggressive, yet effective, form of venous thromboembolism (VTE) prophylaxis , such as aspirin, minimizes hematoma formation and reduces the incidence of subsequent PJI [20].
Cellulitis
Cellulitis refers to a superficial infection that occurs in the skin presenting as a patch of red, warm, tender skin over the surgical site. Cellulitis is not usually a serious problem and typically resolves with appropriate treatment.
However, the presence of erythema, swelling, and tenderness around the surgical site can also be a manifestation of a deep PJI that requires further investigation, namely aspiration of the joint to confirm or refute the diagnosis of deep PJI [21].
Most cases of cellulitis are treated with elevation, antibiotics, warm compression, and marking out the involved area for close observation.
Rodriguez et al. [22] reported 16 cases of erythematous eruption on the skin within the flaps of the surgical incision after primary THA over an 8-year period. All the patients had a similar onset and appearance of the skin eruption, which began at the posterior skin flap and spread radially. All were treated with antibiotics with complete resolution of the eruption within 1–6 days. There were no cases of PJI or other sequelae.
The cause of cellulitis is unclear. Mainetti et al. [23] have reported cellulitis after internal fixation using a dynamic hip screw. They suggest that the compromise of the venous and lymphatic circulation around the skin flaps may have been responsible .
Wound Dehiscence
Dehiscence involves breakdown and opening of the surgical incision. A wound may break down and open up for several reasons, including infection, poor healing, or tension and pressure from within the incision due to collection of blood or fluid. Superficial dehiscence is usually not serious, but does merit close observation. The wound usually fills from within by granulation tissue, over a period of weeks. Sometimes superficial dehiscence may require packing, or application of negative-pressure dressing until it heals.
Differential Diagnosis of Superficial vs. Deep-Wound Complications
Differentiation between superficial infection and deep PJI may be difficult. Local inflammation around the sutures in a wound that heals within 3 weeks is likely to be a superficial infection. On the other hand, an erythematous, indurated wound with persistent and copious drainage is more suggestive of a deep infection.
As distinction between superficial and deep infection is difficult, it is recommended that aspiration of the joint be carried out in patients presenting with wound-related problems. Areas of cellulitis should be avoided when completing an aspiration .
Wound Management
Wound management is often a neglected area in joint arthroplasty because of the common belief that complications such as blistering, drainage, and SSI are rare.
In recent years, and with economic emphasis on minimizing readmission and reoperation, there has been increasing interest in implementing strategies that can minimize wound-related complications.
Wound healing is affected by various factors related to the host, surgery, and postoperative wound care. Wound management will be discussed by dividing it into local and general managements.
General Managements
Malnutrition
Preoperative malnutrition has been associated with delayed wound healing, longer length of hospital stay, and higher incidence of subsequent infection [24]. The definition of malnutrition varies but is determined by measuring the serum level of transferrin, total lymphocytes, total albumin, and prealbumin. Gherini et al. [25] reported that only preoperative serum transferrin level was strongly associated with delayed wound healing .
Anticoagulant
Well-designed studies evaluating the effects of anticoagulation on wound complication and hematoma formation in patients who have undergone reoperation for wound-related problems are lacking. Parvizi et al. [26] reported that a mean INR of greater than 1.5 was found to be more prevalent in patients who developed postoperative wound complications and subsequent PJI. Another retrospective observational study found that patients who received low-molecular-weight heparin for VTE prophylaxis had a longer time until the postoperative wound was dry than those treated with aspirin and mechanical foot compression or those who received Coumadin (warfarin) for the persistent wound drainage [7].
Anemia
Preoperative anemia prior to TJA has been associated with a prolonged length of hospital stay, greater 90-day readmission rates, and need for higher allogeneic blood transfusion [27, 28]. Therefore, all possible means must be undertaken to improve hemoglobin levels prior to TJA. Both preoperative anemia and need for allogeneic blood transfusions have been associated with higher rates of PJI [27]. Hence, blood conservation protocols were devised to decrease the need for postoperative transfusions in anemic patients. Patients should have an evaluation to determine the cause of the anemia such as colon cancer or other causes of a GI bleed can be identified and addressed preoperatively.
Tranexamic acid (TXA) is a synthetic derivative of the amino acid lysine with antifibrinolytic properties. A meta-analysis performed by Sukeik et al. [21] showed that the administration of TXA in THA significantly diminished blood loss and need for allogeneic blood transfusion. However, it did not show any increased risk of thromboembolic events, infection, or other complications.
A systematic approach to optimizing hemoglobin levels preoperatively that implements oral and possibly intravenous iron, folic acid supplements, and erythropoietin while minimizing blood loss intraoperatively by the use of tranexamic acid, cell salvage, and induced hypotension has been shown to diminish the need for allogeneic transfusion [28].
Diabetes Mellitus
Diabetes mellitus has been implicated in causing higher rate of early wound complication after TJA [29] and PJI [30] with the capacity to double the risk of wound complications in patients with uncontrolled diabetes [31]. The exact definition of uncontrolled diabetes is not clear. The pending surgical site infection (SSI) prevention recommendations by the Center for Disease Control have chosen fasting glucose levels >200 mg/dL as being indicative of uncontrolled diabetes that requires optimization prior to elective arthroplasty. The threshold for hemoglobin A1c that is indicative of uncontrolled diabetes remains unknown and its value in predicting risk for subsequent infection after TJA is also unknown [32]. Jamsen et al. [31] reported that in patients without a diagnosis of diabetes at the time of the surgery, there was a trend toward a higher infection rate in association with a preoperative glucose level of >6.9 mmol/L (124 mg/dL) compared with <6.9 mmol/L. A recent study [24] showed that patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty .
Smoking
Approximately 20% of the adults in the United States smoke [33]. Smoking is a modifiable patient factor that has been previously shown to increase postoperative complications. Nicotine-mediated vasoconstriction is considered to be the primary etiology of these effects [34–36]. Nicotine results in decreased blood flow, local tissue hypoxia, decreased collagen production, and increased platelet aggregation ultimately affecting wound healing as well as fracture healing [37–40].
Duchman et al. [41] reported that current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty.
Several studies have noted that smoking cessation may reverse the risk for all-time complications as long as it is implemented far in advance (4 weeks) of elective arthroplasty [42–46]. Moller et al. [46] performed a randomized clinical trial that demonstrated that smoking cessation program implemented 6–8 weeks before surgery reduced the incidence of postoperative complications, in particular wound-related problems.
Local Managements
Wound Closure
The goals of wound closure are to maximize blood flow while minimizing bacterial contamination and dead space around the incision.
We believe that the use of monofilament suture for wound closure in patients undergoing THA is likely to reduce issues related to wound healing by minimizing tissue ischemia and by providing a better watertight closure and potential for ingress of bacteria into the deeper tissues [15].
A prior meta-analysis has shown that the risk of developing a wound infection was four times greater when staples were used for wound closure compared to suture closure [9, 47]. However, there was no significant difference between the development of inflammation, wound discharge, wound dehiscence, skin necrosis, and allergic reaction when suture versus staples were used.
Dressing
Wound dressing is probably one of the most important aspects of local wound care. An ideal wound dressing is one that is:
Permeable: Keeping the wound environment appropriately moist while preventing skin maceration, and blister formation [48].
Barrier: That prevents ingress of microbes into the deeper tissues. In addition it is a barrier for entry of water into the incision, thus allowing the patients to shower [49].
Occlusive: Resulting in creation of a sealed hypoxic environment that accelerates angiogenesis, mitotic cell division, and leukocyte activity, all being critical for wound healing. Each dressing change disrupts the fibroblast activity around the wound for a period of 3–4 h for this activity to resume.
Dressing change: Frequent dressing changes expose the wound to exogenous bacteria and increase the risk for SSI, especially when performed in contaminated environment such as the hospitals, rehabilitation facilities, and skilled nursing facilities with abundant pathogens. Reducing dressing changes not only minimizes the cost and pain associated with the dressing changes, but it also reduces the risk of blistering and skin injury [12].
The introduction of recent occlusive dressing allows for minimizing dressing changes. The first dressing change can occur at 7 days during which the critical part of wound healing has taken place.
More regular dressing changes may be needed in patients with drainage when the dressing is saturated.
A few studies have shown that wound management following TJA with the use of an occlusive dressing with alginated hydrofiber and silver leads to a reduction in the incidence of all-time complications including PJI [13, 48, 50–52]. However, the role of silver in reducing wound infection and PJI still remains unclear [53–55].Related posts:
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