144 CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL

MANAGEMENT FACTORIALS IN TOTAL KNEE REPLACEMENT

Wound healing in total joint replacement

R. E. Jones,R. D. Russell,M. H. Huo

From University of Texas, Southwestern Medical Center, Dallas, Texas, United States

R. E. Jones, MD, Professor, Department of Orthopaedic Surgery R. D. Russell, MD, Resident, Department of Orthopaedic Surgery M. H. Huo, MD, Professor, Department of Orthopaedic SurgeryUniversity of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, Texas, 75390, USA.

Correspondence should be sent to Dr M. H. Huo; e-mail: Michael.huo@utsouthwestern.edu

©2013 The British Editorial Society of Bone & Joint Surgerydoi:10.1302/0301-620X.95B11. 32836 $2.00

Bone Joint J2013;95-B, Supple A:144–7.Received 7 September 2013; Accepted after revision 8 September 2013

Satisfactory primary wound healing following total joint replacement is essential. Wound healing problems can have devastating consequences for patients. Assessment of their healing capacity is useful in predicting complications. Local factors that influence wound healing include multiple previous incisions, extensive scarring, lymphoedema, and poor vascular perfusion. Systemic factors include diabetes mellitus, inflammatory arthropathy, renal or liver disease, immune compromise, corticosteroid therapy, smoking, and poor nutrition. Modifications in the surgical technique are necessary in selected cases to minimise potential wound complications. Prompt and systematic intervention is necessary to address any wound healing problems to reduce the risks of infection and other potential complications.

Cite this article: Bone Joint J 2013;95-B, Supple A:144–7.

Achieving and maintaining primary woundhealing in total joint replacement is essentialfor a satisfactory outcome. Wound healingproblems can result in devastating conse-quences. This review will focus on the optimi-sation of patient factors in order to reducewound healing complications, the diagnosis ofwound healing complications, and the treat-ment options to recover the situation in thesepatients

Peri-operative patient managementRisk factors for wound complications can beclassified as those that are intrinsic to thepatient or extrinsic within the environment.These factors can be further differentiated intomodifiable or non-modifiable risks. It is criticalto reduce medically associated risks forpatients where possible prior to surgery, andduring the peri-operative period.

Achieving optimum pre-operative nutritionof patients and controlling as much as possibleany medical comorbidities, decreases post-operative wound complications. Low totallymphocyte counts, transferrin, albumin, andpre-albumin are associated with poor healing.1

Nutritional supplementation should aim toachieve a total lymphocyte count > 1500 cells/μl,albumin level > 3.5 g/dl, zinc level > 5 μl/dl,and transferrin > 200 mg/dl.2,3

Cierny, Mader and Pennick classified thepatient healing response into three categories;4

type A: no healing compromise, type B: local,systemic, or combined compromising factors,

and type C: significant compromising factors,high morbidity, and poor prognosis. Local fac-tors particular to patients include extensivescarring, lymphoedema, poor vascular perfu-sion, and excessive adipose tissue. Systemic co-morbidities include diabetes mellitus, rheuma-toid diseases, renal or liver disease, cortico-steroid medication, poor nutrition, immunecompromise states such as human immunodefi-ciency virus (HIV) infection, and smoking.Smoking causes vascular constriction andmakes the patient a type B healing risk.5 Since ahistory of smoking is associated with a statisti-cally significant increased risk of periprostheticjoint infection, many centres use formal smok-ing cessation programs to assist patients in giv-ing up, preferably before surgery.

Patel et al6 conducted a retrospective studyto determine the risk factors associated withprolonged wound drainage after primary totalhip (THR) and total knee replacements (TKR).Risk factors included: a BMI > 40 kg/m2, theuse of low molecular weight heparin (LMWH)prophylaxis, and a high drain output afterTHRs. High drain output was the only riskfactor associated with prolonged wound drain-age after TKRs.6 HIV infection is also a risk forpost-operative wound complications andinfection. These patients should have a CD4count > 400 cells/mm3 prior to surgery.7 Obe-sity is a risk factor associated with prolongedoperation times, and a higher rate of earlypost-operative complications including exces-sive wound drainage and infection.8 Diabetes

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Mellitus has been identified as an independent risk factor.9

However, optimal peri-operative glucose control is animportant factor in decreasing wound complications for allpatients, including those without diabetes. Mraovic et al10

demonstrated that non-diabetic patients were three timesmore likely to develop periprosthetic joint infection if thefasting blood glucose was > 140 mg/dl on the first post-operative day. Although haemoglobin A1C levels have notbeen consistently associated with an increased risk ofperiprosthetic joint infection, many centres delay surgeryuntil levels are < 7%.

Proper selection, dosing, and timing of prophylactic anti-biotics are critical. This is a quality measure used by theCentres for Medicare and Medicaid Services (CMS). Mostcommonly, a first-generation cephalosporin is administeredwithin one hour prior to the skin incision. In patients withallergies to penicillin or cephalosporins, clindamycin is anacceptable alternative. For patients with methicillin-resist-ant Staphylococcus aureus (MRSA) or coagulase-negativestaphylococcus colonisation, vancomycin is used. Timingof vancomycin infusion requires additional attention tomeet the compliance requirement (up to 120 minutes priorto skin incision).

Intra-operative patient managementSelection of the most appropriate incision can diminish therisk associated with multiple prior incisions at the surgicalsite. The blood supply to the skin over the knee joint is fas-ciocutaneous and is more robust on the medial side.11

When there are multiple previous incisions, select the mostlateral one to approach the knee joint. This may require atubercle osteotomy to best expose the joint. Meticuloushandling of the soft tissues is essential. Undermining of theskin flaps should be minimised, especially in the lateral flap.Full thickness fasciocutaneous flaps best preserve the bloodsupply. In patients with extensive scarring or adherence to

the underlying tissue, pre-operative use of tissue expandersor muscle flaps during surgery may provide a more satisfac-tory healing environment.12,13

In the authors’ experience, personal isolation suits formany and laminar flow operating rooms for most are rou-tinely used for THRs and TKRs. However, Hooper et al14

analysed over 51 000 primary THRs and over 36 000primary TKRs. The data failed to demonstrate any decreasein the rate of infection using these methods.

Post-operative patient managementPost-operatively, the method of thromboembolism prophy-laxis has an effect on wound complications. Potent chemo-prophylaxis has been associated with higher rates of wounddrainage and complications.15,16 Parvizi et al15 demon-strated a clear association with anticoagulants to peripros-thetic joint infection after THR and TKR. Patients withinfections had a higher mean international normalisedratios (INR) > 1.5 compared with those patients that didnot develop an infection.15 Others have recommendedusing a combination of mechanical prophylaxis and lesspotent chemoprophylaxis in those patients at high risk ofwound complications.17

Diagnosis and management of wound complicationsWound healing problems can range from superficial inci-sional, to deep incisional (outside the joint space), toinvolving the joint space (Fig. 1). Gaine et al18 reported a10% incidence of superficial wound problems in primaryTKRs. Patel et al6 found that each day of prolonged wounddrainage increased the risk of deep wound infection by29% following TKRs.

Drainage from the incision one to three days after sur-gery should be managed by immobilisation in extension,and application of a foam or rolled gauze compressive

Fig. 1a

Photographs showing (a) wound breakdown after total knee replacement with exposure of the prosthesis after debridement of overlying eschar and(b) the wound healing successfully after aggressive surgical debridement and negative pressure wound dressings.

Fig. 1b

146 R. E. JONES, R. D. RUSSELL, M. H. HUO

CCJR SUPPLEMENT TO THE BONE & JOINT JOURNAL

bandage over the incision. Use of immobilization andobservation should not exceed three days. Wound drainagethat persists greater than three days is considered abnormaland should be treated surgically to decrease the chance ofsubsequent periprosthetic joint infection.6,16,19,20

Aspiration of the joint is necessary if there is a high levelof suspicion. The synovial fluid should be analysed forwhite blood cell (WBC) count and differential. Culturesshould also be obtained. There is some consensus withregard to the cell count. In patients with TKRs, a synovialWBC count > 1700 cells/μl or a polymorphonuclearneutrophil (PMN) percentage > 65% is the recommendedthreshold for the diagnosis of infection.21-23 In THRs, therecommended thresholds are a synovial WBC count of> 4200 cells/μl or PMN percentage > 80%.24 During theacute post-operative period, within six weeks of surgery,the thresholds are higher, with a synovial WBC count> 10 000 cells/μl, and PMN > 89%.25

A single punctate site of persistent drainage may occasion-ally present a diagnostic challenge. We have found that intra-articular injection of a mixture of 10 ml hydrogen peroxideplus 0.5 ml of methylene blue will produce a ‘blue fountain’at the punctate site if there is communication with the jointspace.26 This should be carried out in the operating roomsince a positive finding requires operative intervention.

When surgery is undertaken, necrotic skin edges shouldalways be excised and the wound haematoma evacuated.Proper debridement with total synovectomy and removalof all the contaminated tissues should be the goal. This islikely to produce a viable wound and facilitates furthermanagement.27 In cases with inadequate soft-tissue cover-age a negative pressure wound dressing may help preventfurther tissue necrosis and promote healing throughreduction of oedema and elimination of shear. Soft-tissuecoverage may also be achieved through the use of muscleflaps (Fig. 2).

Fig. 2a

Photographs showing a) rotational muscle flap used for coverage of a compromised total knee replacement (TKR) wound, b) a skin graft used to coverthe muscle flap, c) pre-operative and d) post-operative TKR procedure.

Fig. 2bFig. 2b

Fig. 2c Fig. 2d

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ConclusionWound healing is essential in achieving a satisfactory out-come after joint replacement surgery. Wound healing prob-lems can be minimised using a proactive approach toenhance the patient’s healing capacity. Once a problematicwound is recognised, prompt management of the woundincluding evacuating haematomas, debriding necrotic tis-sue, eliminating dead space, and obtaining adequate soft tis-sue coverage all contribute to satisfactory wound healing.

No benefits in any form have been received or will be received from a commer-cial party related directly or indirectly to the subject of this article.

This paper is based on a study which was presented at the 29th Annual Winter2012 Current Concepts in Joint Replacement® meeting held in Orlando, Florida,12th – 15th December.

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