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Surgeon reviews how to predict, prevent and treat wound problems after TKA
Suggestion: If aspiration is negative for infection, use open debridement and change polyethylene.
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Surgeons can prevent wound problems after total knee arthroplasty, but they should be aware of certain factors which can influence a patient's likelihood to develop those problems, according to Kelly G. Vince, MD.
When wound problems occur, "We have to know if there is an infection underneath that draining wound and treat it aggressively and appropriately," Vince said.
Old incisions problematic
Vince suggested a few ways to prevent wound problems: Use existing longitudinal incisions, ignore prior transverse incisions and when there are multiple scars, use the most recently healed or most lateral. Soft tissue expanders or gastrocnemius flaps are also beneficial.
“Old incisions pose significant problems and we would recommend that in the presence of old transverse incisions to simply cross them,� Vince said at a recent Current Concepts in Joint Replacement meeting.
Among multiple factors, some disorders can influence the occurrence of wound problems after total knee arthroplasty (TKA), as demonstrated in a 1991 study by Wilde and Stulberg in the Journal of Arthroplasty.
Their findings showed that rheumatoid arthritis patients are three times more at risk for wound problems after TKA; patients with low lymphocyte counts are five times more at risk; and patients with low albumin have a seven times greater risk, Vince said.
The investigators also found that lower lymphocyte counts and lower albumin levels were associated with more serious wound problems.
Tourniquet use
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The literature has also shown that tourniquet use is associated with wound hypoxia, Vince said.
A 2001 study demonstrated that the patients with the least wound hypoxia at 1 week postoperative were those who underwent surgery without a tourniquet.
He said when low pressure tourniquets were used there was a lower occurrence of wound hypoxia. “And when high pressures, about 350 mm, were used, there was the greatest wound hypoxia.�
Furthermore, increased tourniquet times and, therefore, increased surgical times have been associated with increased infection rates.
Prevention factors
Oxygen therapy is beneficial in preventing wound problems, Vince said, when applied with a nasal cannula during postop.
“This increases the skin oxygen tension and is clearly good for wound healing,� he said.
Drains, which are currently controversial among orthopedists, are also related to a lower rate of wound drainage.
A 1997 study by Ovadia and colleagues in the Journal of Arthroplasty found a 38% incidence of wound drainage from the incision when patients did not have drains placed, and a 12.5% wound drainage incidence when drains were used during surgery, Vince said.
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Images: Vince KG |
Determining infection
He recommended that surgeons manage wounds based on whether or not aspirations are negative.
In the early postoperative period, data on synovial fluid, erythrocyte sedimentation rates and white blood cell counts can be unreliable for predicting infection, Vince said.
“If the aspiration is negative for infection, an open debridement with polyethelene exchange is highly appropriate and should be done aggressively,� he said. “If the cultures are negative, the patient can simply resume rehabilitation.
“If the cultures are positive, a probable recommendation for 6 weeks of intravenous antibiotic therapy is appropriate.
Remember, the antibiotics should only be given at this point — after the knee has been aspirated, so that we know we are not dealing with an infected arthroplasty.â€�
Chronic infections
Vince said it should also be noted that open debridement with polyethylene exchange is indicated for acute postoperative and acute late hematogenous infection.
Chronic infections are better treated with a two-stage revision protocol.
In cases of recurrent drainage, a small amount may be covering a larger defect in the arthrotomy, which requires tissue transfer.
“Be very careful with wounds on the lateral side of the knee,� Vince said. “The retinaculum is thin, and scars there have drainage that rapidly turns into infection.�
Also of concern: drainage from the distal-most aspect of a knee arthroplasty wound.
“This may indicate a hole in the arthrotomy that will not close without operative intervention. Finally, drainage that lasts more than 5 days has been shown to greatly increase the risk of infection.�
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For more information:
- Kelly G. Vince, MD, can be reached at University of Southern California Orthopedic Surgery Associates, 1520 San Pablo St., Suite 2000, Los Angeles, CA 90033; 323-442-6936; e-mail: vince@usc.edu. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
References:
- Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty. 1991;6(4):321-325.
- Ovadia D, Luger E, Bickels J, et al. Efficacy of closed wound drainage after total joint arthroplasty. A prospective randomized study. J Arthroplasty. 1997;12(3):317-321.
- Vince KG. Wound healing problems in TKA: Sapere aude. #91. Presented at the 23rd Annual Current Concepts in Joint Replacement Winter 2006 Meeting. Dec. 13-16, 2006. Orlando, Fla.