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Diabetes the only major risk factor for early wound problems after primary TKA
Database of nearly 18,000 cases over 23 years shows low incidence, but certain groups at risk.
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SAN DIEGO — A large database review has found that having diabetes ranks among the top risk factors for superficial wound problems following primary total knee arthroplasty.
“Superficial wound healing problems, although uncommon, can be potentially serious,” Daniel D. Galat, MD, said. “Patients with diabetes should be advised of their specific risks and followed closely. Overall, it is important to strive for primary wound healing following primary total knee arthroplasty (TKA).”
Galat presented data culled from 17,790 primary TKA surgeries performed at the Mayo Clinic from 1981 to 2004 and collected in the Mayo Total Joint Registry. From that cohort, Galat and his co-investigators formed two groups. Group I included patients who had early superficial wound healing complications significant enough to require surgical intervention within 30 days of the index TKA. Group II included all those patients who did not have that complication.
Low incidence
“We defined wound healing complications as dehiscence, skin-edge necrosis, superficial infection, delayed healing or persistent drainage,” Galat said. “Surgical treatment was defined as: debridement, skin-edge excision with primary closure, or general wound revision.” The mean time from TKA to surgical treatment of the complications was 18 days, he told Orthopedics Today.
Overall, the investigators identified only 67 knees in 66 patients (0.38%) as having superficial wound complications that required surgical treatment. “We found no differences in terms of mean age, gender or length of follow-up,” Galat said. His comments came during the American Academy of Orthopaedic Surgeons 74th Annual Meeting.
Senior author Henry D. Clarke, MD, told Orthopedics Today that the low incidence of wound complications did not surprise the investigators.
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Images: Galat DD |
“This actually represents the patients with the worst soft tissue complications that required surgical intervention,” he said. “Immediate postoperative problems requiring repeat surgery after TKA are rare. Therefore, soft tissue problems really represent a large proportion of these early surgical problems.”
Based on the investigation’s results, however, orthopedic surgeons should take all reasonable steps perioperatively to minimize potential complications, including optimizing medical conditions such as diabetes and smoking cessation, Clarke said.
“Also, patients with poor soft tissues or multiple prior incisions should be considered for prophylactic soft tissue techniques, including tissue expanders or soft tissue flaps,” he said. “Finally, intraoperative tissue handling should be optimized, especially avoiding creating large, laterally based skin flaps.”
Two-part study
The investigators divided the study into two parts. The first part compared the patients in Group I to a specific endpoint — either a subsequent surgery or a deep infection — to determine the cumulative probabilities for the endpoints. The second part included a matched-case controlled study wherein the patients who had a superficial wound healing problem were matched by age and gender to evaluate risk factors for developing these superficial complications.
“Of the 67 knees in Group I, six went on to have a major reoperation, three eventually had resection arthroplasty and three had either a muscle flap or skin graft. There were no knees that went on to amputation,” Galat said.
Six patients also developed deep infections. “There was some overlap between these two groups, such that three knees with infection also had resection, so in reality there were a total of nine patients who met either or both of these two end points,” he said.
In the matched-case control, the investigators found that only diabetes had a statistically significant association, with an odds ratio of 3.0.
“We found a suggestive but not statically significant association with prior open knee surgery, peripheral vascular disease and body mass index greater than 30,” Galat said.
According to the investigators, in patients with knees that underwent early surgical treatment for wound complications, the 2-year cumulative probability for undergoing major subsequent surgery was 9.3%, and for developing a deep infection, 8.6%. For patients with knees which did not undergo early surgical intervention for wound complications, the probabilities were 0.6% and 0.8%, respectively (P<.001 for both).
“Prior reports have identified risk factors for postoperative wound healing problems from patient-specific to intraoperative to postoperative factors. In our study, with the numbers involved, we were only able to identify diabetes as a significant risk factor,” Galat said.
Clarke said the take-home message from the investigation is patients who develop wound complications after TKA that are serious enough to warrant surgical intervention are at high risk of developing major complications that limit the success of the arthroplasty.
“Therefore, all reasonable measures should be taken perioperatively to optimize wound healing,” he said.
For more information:
- Henry D. Clarke, MD, can be reached at Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85259; 480-301-8276; e-mail: clarke.henry@mayo.edu.
- Daniel D. Galat, MD, a graduate medical student, can be reached at Mayo Graduate School of Medicine, 200 First St. SW, Rochester, MN 55905; 507-284-2884; e-mail: galat.daniel@mayo.edu. Both indicated that they have no financial disclosures.
Reference:
- Galat DD, McGovern Sc, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. Paper #91. Presented at the American Academy of Orthopaedic Surgeons 74th Annual Meeting. Feb. 14-18, 2007. San Diego.