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Draining wounds: No time to procrastinate
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The association between persistent wound drainage and periprosthetic joint infection is proven beyond doubt in numerous studies. The question that deserves investigation is what to do to minimize wound problems and, when the problem does arise, what strategy should one employ.
First, one needs to look at the patient factors that impact wound healing in total joint arthroplasty (TJA). Obesity, diabetes — particularly when uncontrolled — immunosuppressed state, irradiated skin, poor vascular perfusion, renal disease, congestive cardiac disease, liver disease, lymphodema, malnutrition and heavy smoking have all been shown to adversely affect wound healing and increase risk of periprosthetic joint infection (PJI). Although this list is not exhaustive, it contains most conditions that could potentially be optimized prior to subjecting the patient to an elective procedure.
Medical optimization
To begin, all patients with the aforementioned conditions, particularly when uncontrolled, should be subjected to medical optimization prior to TJA. Strict glucose control should be implemented, the patient should be counseled to stop smoking, surgery should be deferred for at least a year following a recent irradiation, congestive cardiac failure should be treated aggressively and so on. At our institution, we have implemented nutritional screening as a fair number of our patients, particularly those with obesity (paradoxical malnutrition) were found to be malnourished. We need to recall that, after all, joint arthroplasty is an elective procedure and patients can wait until these issues are addressed.
With the cloud of health care reform looming over our heads and talk of reimbursement being linked to quality of care, one thing we can be certain about is the fact that readmission and reoperation will be part of quality metrics by the government and, of course, payers. Based on studies at our institution and numerous others, most readmissions following TJA are wound related.
Steps to limit problems
There is plenty that the surgeon can also do to minimize wound-related problems. Intraoperative factors that can assist in wound healing include careful planning of incisions in patients with multiple incisions from previous surgeries. Not only is meticulous handling of soft tissues highly encouraged, but it is equally important to avoid undermining the skin during exposure. Abstaining from using tourniquets for knee arthroplasty in patients at risk of infection is potentially advantageous for preventing postoperative wound complications.
Wound closure, a task often relegated to the most junior of surgeons, is one of the most important aspects of surgery. Proper handling of the tissues and skin during closure, and obtaining a water-tight, but not strangulated, wound is critical for proper healing.
Although there have been claims about some sutures being superior to others, at this point there is little level 1 evidence to support the use of one suture over another. A recent randomized study evaluated the efficacy and patient satisfaction of resorbable subcuticular staples vs. traditional stainless steel stables, often used as a mainstay for skin closure in TJA. The authors concluded that skin irritation and wound drainage were more common with the use of stainless steel staples, and that patient satisfaction was greater with resorbable subcuticular sutures. More studies are needed to confirm these findings prior to widespread acceptance, but evidence is mounting to suggest that staples increase wound-related problems and surgical site infection.
Postoperative care
During the postoperative period, surgical wounds in high risk patients should be scrutinized daily for wound drainage. In this patient population, continuous passive motion use should be avoided. Several studies have demonstrated that low-molecular-weight heparin and aggressive anticoagulation are associated with hematoma formation and/or prolonged drainage in patients following joint replacement.
Postoperative hematomas are considered benign by some, but in fact, they may herald an underlying periprosthetic infection. In one study from our institution, patients developing PJI were 13 times more likely to also have a hematoma and 17 times more likely to have persistent wound drainage. While postoperative anticoagulation is an evolving science and optimal treatment continues to be debated, wound complications from excessive anticoagulation should not be regarded as a benign complication. In an effort to protect our patients from thromboembolic disease, we should not make our patients vulnerable to other complications that can be associated with even more deleterious consequences.
Optimal timing and type of treatment for wound drainage in the postoperative period remains ill-defined. Studies have shown that drainage persisting beyond 7 days is unlikely to resolve spontaneously. In one study, single debridement resulted in complete resolution of drainage in 76% of patients, while the rest needed additional treatment. Time from index surgery to debridement was a significant risk factor for treatment failure and aggressive early surgical debridement was encouraged. A recent study evaluating the use of antimicrobial therapy and postoperative wound drainage found an increased association with negative cultures in patients who had PJI. The study concluded that persistent wound drainage should be critically evaluated for infection prior to the administration of antibiotic therapy. There is currently no evidence to demonstrate that administration of antibiotics enhances the healing potential of a draining wound or reduces the incidence of surgical site infection.
Monitor the patient
The best strategy that is supported by some evidence is to closely monitor a patient with a draining wound. Most patients undergoing TJA are usually discharged 3 to 4 days following index surgery. A patient with a draining wound on day three may be kept in hospital for close monitoring. A bulky, compressive dressing or wrap may be applied and maintained for 24 to 48 hours. In the meantime, anticoagulation status and nutritional status (pre-albumin, transferring and lymphocyte counts) of the patient are checked and corrected.
At our institution, patients with a draining wound who have normal nutritional or anticoagulation parameters on postoperative day seven are returned to the operating room for wash out. The wound is examined carefully and deeper tissues are spared unless hematoma formation extends into deeper tissues or there is evidence of gross infection. If deeper tissues are involved, then modular parts and uncemented total hip arthroplasty components are exchanged, and aggressive debridement of deeper tissues are performed. Culture samples from deeper tissues are obtained and, based on the result of cultures, the patient is treated with intravenous antibiotics for 6 weeks. For superficial wound problems, we do not administer antibiotics unless a pathogen is isolated in more than one solid medium. Culture of the skin at anytime should be avoided. Data obtained by this practice is usually confusing, as usually multiple organisms are isolated from non-sterile skin and the significance of these organisms is not known.
Vacuum-assisted closure devices have recently been employed with some success in the treatment of open wounds in trauma patients and in hand surgery. There are also promising results, namely reduced incidence of wound-related problems, with the use of microfiber silver-impregnated dressings.
Currently, a paucity of literature exists on the efficacy of any particular product or treatment for wound drainage in the arthroplasty patient population. Akin to other areas of orthopedics, a search for evidence in this arena is also desperately needed. One fact, however, is that persistent wound drainage after joint replacement should be a call to action for the surgeon. Although the best strategy for each patient may differ, procrastination is the least successful of strategies.
References:
- Galat DD, McGovern SC, Larson DR, et al. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am. 2009;91:48-54.
- Jaberi FM, Parvizi J, Haytmanek CT, et al. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res. 2008;466:1368-1371.
- Parvizi J, Ghanem E, Joshi A, et al. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22(6Suppl2):24-28.
- Patel VP, Walsh M, Sehgal B, et al. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89:33-38.
- Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res. 2006;452:88-90.
- Javad Parvizi, MD, FRCS, editor of Infection Watch, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
- Disclosures: Parvizi is a consultant to Stryker. Porat has no relevant financial disclosures.