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Management of soft tissues may prevent wound complications after TJR

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With careful management of the soft tissues and assessment of wound drainage, surgeons can avoid wound complications after total joint replacement, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting,

“The best way to manage wound problems is to avoid them. Try to perform meticulous wound closure,” Jay R. Lieberman, MD, Professor and Chairman of the Department of Orthopaedic Surgery at the Keck School of Medicine of USC, said in his presentation. “If there are problems with the wound: rest the leg, but do not start antibiotics. A [C-reactive protein] CRP followed by joint aspiration may be useful to diagnose an infection. If drainage is persistent, you need surgical intervention, and the most important message is do not sit on a continuously draining wound.”

Jay R. Lieberman

Wound management

Lieberman discussed the best ways to avoid wound complications in total joint replacement (TJR), one of which is to carefully manage the soft tissues.

“You need a meticulous closure of the fascia. It needs to be water tight,” Lieberman said. “You can do that with either interrupted sutures or with a running barbed suture.”

Subcutaneous tissue must be handled carefully, with any large, dead spaces closed in layers, he noted.

Interrupted absorbable sutures or running barbed or absorbable sutures can be used to close subcuticular tissue, according to Lieberman.

Evaluate aspiration, drainage

In published studies that evaluated joint aspirations performed within 6 weeks of TJR, “CRP greater than 100, an aspiration of the joint with a white blood cell count greater than 10,000 and 80% to 90% [polymorphonuclear cells] ‘polys’ were parameters consistent with infection, Lieberman noted.

He noted surgeons should be concerned about persistent wound drainage because it may be a sign of an infection. Wounds with persistent drainage, which Lieberman defined as longer than 72 hours, should not be cultured and patients should not receive oral antibiotics. He mentioned a study of 2,400 TJR patients that showed morbid obesity in total hip arthroplasty (THA) patients and the use of low molecular heparin was associated with prolonged wound drainage.

“Prolonged wound drainage was associated with increased length of stay, and for each day [of the extended stay] a prolonged wound drainage was at increased risk of infection: 42% for total hips and 29% for total knee replacement,” Lieberman said.

Wound VAC

There has been recent interest in using wound vacuum-assisted closure (VAC) or negative pressure wound therapy in patients with wound drainage. According to Lieberman, one retrospective study of 109 THA patients with persistent wound drainage who underwent wound VAC treatment for two days starting on postoperative day 3 or day 4, showed that 83 patients required no further surgery. Eleven patients underwent superficial irrigation and debridement, 12 patients required deep irrigation and debridement and three patients had components removed. Lieberman noted that predictors of which of these patients may require a subsequent operative intervention include patients with an international normalized ratio greater than 2.0, more than one prior hip surgery or those who had a device application for more than 48 hours because of continued drainage.

“At the [International Consensus Meeting on Periprosthetic Joint Infection] their consensus statement was a wound that has been persistently draining for greater than 5 to 7 days [should undergo surgery],” he said. “Available literature provides little guidance regarding the specifics of the surgical procedure.” – by Casey Tingle

Lieberman JR, et al. Paper #95. Presented at: Current Concepts in Joint Replacement Winter Meeting. Dec. 13-16, 2016; Orlando, Fla.

Patel VP, et al. J Bone Joint Surg Am. 2007; doi:10.2106/JBJS.F.00163.

Jay R. Lieberman, MD, can be reached at Keck Medical Center of USC, 1520 San Pablo St. #2000, Los Angeles, CA 90033; email: jrlieber@usc.edu.

Disclosure: Lieberman reports he receives royalties from DePuy Synthes.