Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

Review Article Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

Abstract Matthew J. Simons, MD Normal wound healing with avoidance of early wound complications is Nirav H. Amin, MD critical to the success of total knee arthroplasty. The severity of acute complications includes less morbid problems, such as quickly Giles R. Scuderi, MD resolved drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft-tissue coverage. To achieve proper healing, surgeons must respond to persistent drainage by addressing modifiable patient risk factors, using meticulous surgical technique, and implementing an From Sierra Pacific Orthopedics, algorithmic approach to treatment. Fresno, CA (Dr. Simons), the Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA (Dr. Amin), and Northwell Health Orthopaedic Institute, he incidence of wound compli- requiring surgery (P = 0.046). Com- Lenox Hill Hospital, New York, NY cations after total knee arthro- paratively, uncomplicated wounds (Dr. Scuderi). T plasty (TKA) that requires further following TKA required additional Dr. Scuderi or an immediate family surgery is low, with 0.33% of major surgery or had a deep infection member has received royalties from .17,000 TKAs in a Mayo Clinic at a rate of 0.6% and 0.8%, respec- Zimmer Biomet; is a member of a 1 speakers’ bureau or has made paid Total Joint Registry study needing tively, within 2 years. These results presentations on behalf of ConvaTec, surgical intervention within 30 days highlight the importance of obtaining Medtronic, Pacira Pharmaceuticals, after the TKA.1 Compared with the primary wound healing after TKA. and Zimmer Biomet; serves as a paid tissue encapsulation about the hip, Persistent drainage is an important consultant to or is an employee of ConvaTec, Medtronic, Merz the soft-tissue envelope surrounding sign that a surgical wound may Pharmaceuticals, Pacira the knee tolerates far less compro- become problematic. Postoperative Pharmaceuticals, and Zimmer mise before progressing to a com- incisional drainage occurs in 1% to Biomet; has received research or plicated wound. For TKA patients 10% of patients undergoing primary institutional support from Pacira 3-5 Pharmaceuticals; and serves as a who required acute returns to sur- TKA. After the skin heals, how- board member, owner, officer, or gery to manage wound complica- ever, drainage should diminish or committee member of the tions, the rate of deep infection at cease. Persistent wound drainage International Congress for Joint 2-year follow-up was 6.0%, and the after TKA is defined as continued Reconstruction and Operation Walk USA. Neither of the following authors rate for subsequent major surgery drainage from the surgical incision nor any immediate family member has (ie, component resection, muscle flap for .72 hours; this standard allows received anything of value from or has coverage, amputation) was 5.3%.1 for earlier intervention and may stock or stock options held in a In a related case-control study, Galat therefore limit adverse consequences.6 commercial company or institution 2 related directly or indirectly to the et al found that acute returns to Drainage that continues beyond 1 subject of this article: Dr. Simons and surgery within 30 days to specifically week, whether light persistent drain- Dr. Amin. evacuate hematomas following TKA age or massive acute effluence, is J Am Acad Orthop Surg 2017;25: correlated with a 12.3% probability particularly concerning and typically 547-555 of needing additional major surgery requires surgical intervention. A dis- DOI: 10.5435/JAAOS-D-15-00402 within2yearsanda10.5%proba- ciplined approach is essential to dis- bility of a deep infection. A history of criminate among arthroplasties with Copyright 2017 by the American Academy of Orthopaedic Surgeons. a bleeding disorder was significantly slow healing but noninfected wounds, associated with hematoma formation superficial site infections, and deep

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

Table 1 mellitus, rheumatoid arthritis, smoking, obesity, and malnutrition all Preoperative Medical Condition or Risk Factor and Optimization Strategy in Patients Undergoing Total Knee Arthroplasty negatively affect wound healing and are associated with increased soft- Condition or Risk Factor Optimization tissue complications after TKA.10 Diabetes mellitus Tight glycemic control Current evidence also implicates Rheumatoid arthritis Medication review: hold 1 to 2 wk anemia as a contributing factor for preoperative; restart 2 wk postoperative complications of wound healing.11,12 Smoking Cessation at least 6–8 wk before total In addition to impaired blood and knee arthroplasty oxygen delivery, delayed collagen Obesity Weight loss from calorie reduction and/or synthesis and decreased wound bariatric surgery strength are also related to hypergly- Malnutrition Nutritional screening, education, and/or cemia associated with diabetes mel- supplementation litus.13,14 Galat et al1 found a significant association between a history of diabetes mellitus and the infections. It is critical to recognize After 48 to 96 hours from incision, development of early wound com- modifiable and nonmodifiable risk macrophages accumulate and facili- plications requiring surgical inter- factors, as well as technique variables tate angiogenesis and fibroplasia vention, with an odds ratio of 5.0 that may obstruct proper wound necessary for transition into the pro- (95% confidence interval, 1.4 to healing. To prevent complications liferation phase.8 The proliferation 17.3; P = 0.01). Although limited and lessen the potential for infection, phase occurs from day 4 to 14 and research has been carried out on surgeons must address patient pre- involves epithelialization, angiogen- precise perioperative blood glucose operative medical optimization, use esis, granulation tissue formation, values to prevent wound complica- 1,13,14 meticulous surgical technique, and and collagen deposition. Some skin tions, early preoperative med- recognize a problem wound early to edge hyperemia is expected at the ical assessment should be arranged implement proper and expeditious proliferation phase and should be to develop a perioperative diabetes wound management.7 differentiated from surgical site management strategy and to identify 15 infection and reactive skin problems, and optimize other comorbidities. such as a psoriatic skin plaque. The Rheumatoid arthritis is managed Biology of Wound Healing maturation phase, and associated with complex drug regimens includ- remodeling, occurs from day 8 ing NSAIDs, methotrexate, cortico- A healed wound serves as a protective through 1 year and mainly consists steroids, and biologics, all of which barrier to a TKA prosthesis from of collagen synthesis and organiza- may affect wound healing and the retrograde bacterial contamination tion. At 1 week postoperatively, a potential for infection. In addition, from the skin. Knowledge of the three healing incision exhibits 3% of its the pathology of rheumatoid phases of normal healing (ie, inflam- final strength; at 3 weeks, 30%; and arthritisisassociatedwitha2to3 mation, proliferation, maturation) is at 3 months, 80%. Wound strength times greater risk of a surgical site critical during the clinical assessment never achieves that of normal tissue infectionthanthatofosteoarthri- 10 of acute postoperative drainage. The (even after 1 year) because of less tis. Newer disease-modifying anti- inflammation phase begins at the organized collagen.8,9 Disease and rheumatic drugs may require a longer initial incision and continues through malnutrition have a substantial effect period of discontinuance before sur- 8 days 4 to 6. At the time of incision, on wound strength because of gery, and consultation with the ’ exposure of collagen begins the adverse effects on matrix deposition. patient s rheumatologist is recom- inflammatory process by activating mended to balance medical necessity the clotting cascade. The initial with optimal wound healing. fibrin clot serves to attract cells and Preoperative Medical Smoking is another modifiable risk concentrate cytokines and growth Optimization factor that is associated with factors. Neutrophils migrate via increased short-term complications chemotaxis from mediators such as Knowledge of modifiable risk factors after TKA because nicotine and the interleukin-1, tumor necrosis fac- (as well as potential preoperative byproducts of smoking cause vaso- tor-a, transforming growth factor- interventions) that affect wound heal- constriction via diminished oxygen b, and platelet factor 4.8 ing is imperative10 (Table 1). Diabetes transport and metabolism at the

548 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Matthew J. Simons, MD, et al cellular level.7,16 In a recent study of managed on an individual basis The techniques of soft-tissue expan- 78,191 patients, Duchman et al16 before elective orthopaedic proce- sion, as well as additional pro- found that current smokers are at an dures.23,24 A serum albumin level phylactic and salvage soft-tissue increased risk of wound complica- ,3.5 g/dL, total lymphocyte count transfers about the knee, are beyond tions after TKA and total hip ar- ,1,500/mm3, or transferrin level the scope of this article.26,28 throplasty (THA; 1.8%) compared ,200 mg/dL is associated with with former smokers and non- increased incidence of wound com- smokers (1.3% and 1.1%, respec- plications.3,25 Malnutrition in sev- Intraoperative Factors tively; P , 0.001). Compared with eral forms, including the paradoxical former smokers and nonsmokers, malnutrition sometimes seen in The blood supply to the anterior skin current smokers had approximately obese patients, has been linked to about the knee arises from deep per- twice the rate of deep infection and prolonged wound drainage and pros- forators predominantly found along increased rates of superficial wound thetic joint infections,25 and thus, the medial side of the joint. These infection and wound dehiscence. The patients in whom laboratory values perforating vessels traverse through authors’ multivariate analysis found fall below these lower limits should the anterior thigh muscles and current smokers to be at increased consult a nutritionist preoperatively.24 between the intermuscular septa. risk of wound complications (odds Arterioles then arborize in the plane ratio, 1.47; 95% confidence interval, directly superficial to the deep fascia of 1.21 to 1.78; P = 0.001) compared Prophylactic Soft-Tissue the subcutaneous layer, requiring skin with nonsmokers. Although no Assessment flap dissection to be deep to this layer concrete evidence exists regarding to preserve the perforating arteriolar smoking cessation before TKA, Preoperative surgical consultation network29,30 (Figure 1). The blood Møller et al17 evaluated the effects of with an expert in flap coverage and supply to the patella is separated from smoking intervention, including microvascular techniques for soft- the skin by the patellar bursa, arising counseling and nicotine replacement, tissue management should be consid- from terminal branches of the peri- 6 to 8 weeks before TKA or THA ered if difficulties with closure or patellar anastomoses, with arterial compared with no intervention and wound healing are anticipated,26 contributions from the supreme demonstrated a significantly decreased especially in patients with previous geniculate artery, the medial and overall complication rate in the incisions, severe varus or rotational lateral superior geniculate arteries, smoking cessation group (18% versus deformity, and prior trauma with the anterior tibial recurrent artery, 52%; P = 0.0003). contracted and immobile skin. Prior and a branch of the profunda femoris Counseling obese patients about soft-tissue flaps about the knee should artery30,31 (Figure 2). weight loss, including bariatric sur- also prompt evaluation by a surgeon The area should be meticulously gery, before TKA is advisable,18 and with microvascular expertise to obtain evaluated for evidence of prior inci- it must be emphasized to the patient detail on the tissue quality and the sions. More medial incisions inter- that complication rates are high vascular pedicle. A vascular surgeon rupt the blood supply closer to the regardless of the timing of bariatric should be consulted as well when source, potentially compromising surgery, whether before or after concern for general circulatory com- wound healing along the lateral skin TKA.19 Light et al20 studied the promise exists, because poor venous edge. Therefore, in patients with metabolic changes to the skin in obese return may result in wound edge multiple old scars, it is safer to use the patients after bariatric surgery and ischemia and necrosis from venous most lateral, vertical incision, even if found poorly organized collagen, engorgement. this necessitates a lateral arthrotomy elastin degradation, and scar forma- Prophylactic or revision soft-tissue (such as in a severe, fixed valgus tion intermixed within normal tissue. procedures are indicated for knees at deformity).7,32 Transverse incisions Accordingly, the risk of postoperative high risk for wound problems from should be crossed at 90.33 A short complications after TKA is higher in multiple prior incisions or poorly oblique incision may be incorpo- obese patients.21,22 In one study, placed flaps.26 In many patients, a rated into a new vertical incision obese patients had a 6.7 times greater planned medial gastrocnemius flap provided the prior incision is near risk of infection than nonobese with skin grafting at the time of the midline. Ideal spacing between patients undergoing TKA.22 joint arthroplasty may be required. multiple vertical incisions includes a Proper wound healing and immune Alternatively, the preoperative use of 7-cm skin bridge, because parallel function is dependent on optimized soft-tissue expanders may address incisions that are close together may nutrition, and malnutrition should be skin that is severely adherent.27,28 compromise the epidermal blood

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

Figure 1

Illustrations showing the microvascular anatomy of the skin of the thigh (A) and the areas supplied by the deep vessels (B). The solid circles in panel B indicate the approximate position of deep perforating vessels and the vascular anatomy of the skin about the knee. P = deep perforators. (Reproduced from Younger AS, Duncan CP, Masri BA: Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg 1998;6[1]:55-64.)

27,29 , Figure 2 supply. Skin bridges 2.5to5cm excessive tension. Should the V flat- between existing and new incisions ten out to become a U (U sign), the should be avoided. However, in skin is under excessive tension, and some cases, when considerable time the incision should be extended to has passed since a prior incision was prevent tearing and iatrogenic injury formed and revascularization is (Figure 3). Using full-thickness skin considered adequate, a surgeon may flaps to avoid undermining the skin opt for a skin bridge slightly less than and to avoid a lateral retinacular the 7-cm ideal. In a midline incision, release will help preserve lateral skin the distal aspect is the most common oxygenation34 and reduce the risk of area for wound complications and, skin necrosis. accordingly, an incision directly Meticulous hemostasis is imperative medial to the tibial tubercle as it is to prevent postoperative hematoma carried distally optimizes soft-tissue and persistent drainage. Any vessels and patellar tendon coverage.27 exposed during the dissection should The skin incision should be long be cauterized because a wound enough to prevent excessive tension hematoma is frequently the initiating on the wound edges. Avoiding event to wound breakdown. Mini- excessive retraction of the skin edges mizing the infrapatellar fat pad resec- by forceps and self-retaining retraction likewise diminishes the rate of a Illustration showing the vascular tors will help maintain the subfascial subcutaneous hematoma and poten- anatomy of the patella. (Reproduced arteriolar supply. Particular attention tial drainage. Hemostasis may be from Younger AS, Duncan CP, Masri BA: Surgical exposures in should be paid to the superior and done with any combination of elec- revision total knee arthroplasty. inferior apices of the skin incision. trocautery devices,35,36 pharmaco- J Am Acad Orthop Surg 1998;6 The apex should form a V (V sign), logic and intravenous hemostatic [1]:55-64.) indicating that the skin is not under agents,37 and recently, with advances

550 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Matthew J. Simons, MD, et al of systemic and local application of Figure 3 tranexamic acid.38,39 Atension-free closure with correct wound-edge alignment is paramount to prevent skin necrosis and potential drainage. Proper closure of the wound at the distal aspect of the incision near thepatellartendonisespecially important because most patients who later develop infection start with early postoperative serous drainage at this site.33 The routine use of primary wound closure over a drain remains controversial. Intraoperative photographs showing the V sign (A), which indicates proper skin traction, and the U sign (B), which indicates that skin is under excessive tension.

Acute Postoperative Drainage represent edema, blood products, Physical therapy, specifically knee and fat ischemia but may also con- range of motion, should be tempo- Serosanguinous drainage after TKA stitute fluid from a capsular defect rarily limited for 24 to 48 hours. is common. Drainage affects 1% to that should be surgically repaired. Continuous passive motion should be 10% of patients undergoing primary After 72 hours, drainage is no longer avoided, or at least limited, because total joint arthroplasty.3-5 Persistent benign and may be considered poten- flexion .40 after TKA is known to incisional drainage after TKA is tially infectious.6 In patients with pri- reduce transcutaneous oxygen satu- defined as continued drainage from mary wound complications, aggressive ration about the incision.41 Anti- the surgical wound for .72 hours, treatment of the problem is essential to coagulation status should be and substantial drainage (.2 · 2–cm diminish the risk of a secondary deep reviewed, and short-term cessation of area of gauze) beyond this time periprosthetic infection. anticoagulation should be considered. period is abnormal.6 Although Patients treated with low-molecular- drainage requires close monitoring, weight heparin for prophylaxis most cases spontaneously resolve Management against deep vein thrombosis have without a need for surgical débride- shown longer times to achieve a dry ment.40 Small areas of marginal Nonsurgical surgical wound, compared with wound necrosis measuring a few It is difficult to define absolute patients treated with aspirin and millimeters wide and up to 4 cm long parameters when nonsurgical man- mechanical compression or warfa- or locally débrided eschar in a de- agement of a persistently draining rin.40 In light of these findings, it is layed manner may be observed. wound is appropriate. Postoperative prudent to temporarily stop anti- Nonsurgical care may be the drainage .48 hours has been iden- coagulation with low-molecular- appropriate treatment in certain tified as a contributing factor to weight heparin, or other chemical cases; however, profuse and persis- periprosthetic infection. Patel et al40 anticoagulation, but continue me- tent drainage (for .5 to 7 days) is found that each day of prolonged chanical venous thromboembolism unlikely to stop, and surgical inter- incisional drainage after TKA prophylaxis. vention is typically required.32 increased the risk of wound infection An emerging area of interest for a The surgeon must determine the by 29%. Patients with a draining variety of indications is the use of inci- source of early postoperative drain- wound on postoperative days 2 or 3 sional negative pressure wound ther- age; the drainage may arise from a should remain in the hospital for apy (NPWT), whereby nonadherent, superficial or a deep source, and it close clinical monitoring and may semipermeable dressings are used may involve a benign or infectious initially be treated with compressive along with polyurethane foam and process.6 Immediate postoperative dry dressings. Such dressings may be tubing systems over closed incisions. drainage within the first 72 hours sufficient for most wounds, espe- Randomized controlled trial evidence is typically serosanguinous and cially when drainage acutely dimin- exists that incisional NPWT reduces involves the superficial tissue layers. ishes. Wounds should be frequently dehiscence and infection in orthopae- Persistent drainage .72 hours may inspected until dry. dic trauma patients and has a positive

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management effect on wound healing and compli- P = 0.021).45 Animal models confirm Although concern exists that early cation rates in arthroplasty patients. that incisional NPWT accelerates surgical intervention may increase Stannard et al42 published a random- wound healing more quickly than the risk of periprosthetic infection by ized study of incisional NPWT applied simple dressings at normal or hyper- potentially contaminating a sterile to patients with high-energy fractures, baric oxygen pressures,46 likely by joint, studies to date suggest the a population known to be at higher diminishing postoperative edema opposite; that prompt intervention risk for wound complications than through effects on lymph drainage. likely reduces the risk of wound arthroplasty patients. A total of 263 breakdown and deep infection by lower extremity fractures were evalu- limiting retrograde skin contamina- ated, with 122 managed with standard Surgical tion. Weiss and Krackow5 found that dry dressings and 141 with incisional The 2013 Proceedings of the Inter- of 8 of 597 TKA patients who NPWT for a mean of 2.5 days. Use of national Consensus on Peri- underwent early surgical interven- NPWT rather than standard dry prosthetic Joint Infection had a tion for prolonged drainage at an dressings resulted in a significant strong consensus that a persistently average of 12.5 days after index reduction in the rate of deep infection draining wound for .5 to 7 days surgery, no patient developed a deep (10.0% and 19.0%, respectively; P = should expeditiously undergo revi- periprosthetic infection with this 0.049) and dehiscence (8.6% and sion surgery to prevent a deep peri- strategy. Jaberi et al3 studied 10,325 16.5%, respectively; P =0.044). prosthetic joint infection.6 The patients undergoing THA or TKA in Reddix et al43 retrospectively studied workgroup noted that it is reason- which 300 patients postoperatively 235 patients undergoing acetabular able to wait until postoperative day 5 developed drainage beyond 48 hours fracture stabilization using incisional because this interval to a dry wound (2.9%). Drainage stopped in 217 NPWTforupto3daysontheclosed may be affected by anticoagulation. patients at 2 to 4 days with local incision. The incidence of infection Beyond this time point, it is impor- wound care with no adverse out- and dehiscence reduced approximately tant to exclude and prevent a deep comes, and of the remaining 83 sixfold from 6% to 1% and from 3% infection, and aspiration of the knee patients, 63 (76%) had successful to 0.5%, respectively, compared with joint should be performed either treatment with a single débridement. incidences in 66 consecutive patients preoperatively or intraoperatively. Patients who underwent débride- before the institutional use of inci- Joint aspiration helps determine ment at a mean of 5 days after the sional NPWT. whether drainage arises from a onset of drainage were more likely to Incisions that drain serous fluid structural defect of the arthrotomy be infection free at 1 year compared after the second postoperative day or an acute deep infection. Although with patients who underwent de- are indicated for NPWT. Webb4 cell count data from fluid aspiration layed débridement at a mean of 10 reported that 10% of elective hip in the acute postoperative period days.3 Because drainage .5to7 and knee surgeries have serous may have confounding variables, days is unlikely to stop, surgical drainage at or beyond postoperative Bedair et al47 found that infection intervention is now advocated.5,6,32 day 2 that is correctable with may be presumed for white blood Drainage or hematoma that com- incisional NPWT. In such situations, cell count values .28,000 cells/mL promises the skin or causes skin the pressure setting is lowered to and 89% polymorphonuclear cells. ischemia, substantially increases 250 mm Hg to reduce skin irrita- No evidence currently exists to pain, or fails to diminish must be tion. In most patients, dry wounds demonstrate that reflexive adminis- aggressively managed.3,5 After a can be expected with this treatment tration of antibiotics improves the problem wound has been estab- within 24 hours after one applica- outcome of a draining wound or lished, interventions at minimum tion.4 In THA patients with persis- reduces the occurrence of a surgical must include a superficial incisional tent draining wounds, Hansen et al44 site infection, and the 2013 Proceed- exploration, excising necrotic skin found resolution in 76% of patients ings of the International Consensus edges, and evacuating any hema- treated with incisional NPWT. A on Periprosthetic Joint Infection toma. If the joint capsule is com- significantly lower volume of seroma strongly recommends against such promised, treatment must include was confirmed with ultrasonography treatment.6 In their rationale, the opening the fascia, performing a in THA patients treated with a workgroup cites the known adverse thorough irrigation and débride- single-use incisional NPWT for 5 systemic effects of antibiotics, emerg- ment, with synovectomy and days versus a standard dry dressing, ing bacterial antibiotic resistance, and removal of all contaminated tissue. (1.97 mL with NPWT and 5.08 mL the obfuscation of diagnosing a deep The use of low-pressure pulsatile with standard dressing, respectively; infection. lavage has a success rate similar to

552 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Matthew J. Simons, MD, et al

Figure 4

Treatment algorithm for acute incisional knee drainage. I & D = incision and drainage, NPWT = negative pressure wound therapy, OR = operating room high-pressure lavage during the open ing acute periprosthetic joint infec- management of acute periprosthetic débridement of orthopaedic implants. tions with a two-stage approach. The total joint infections; however, fur- Thorough irrigation with 6 to 9 L of first step is a débridement with ther research is needed. solution is used, and retained com- retention of the prosthesis and To promote healing in patients with ponents are scrubbed with either placement of antibiotic-impregnated soft-tissue deficiency, NPWT may Dakin solution or dilute betadine cement beads followed by a second help prevent additional tissue necrosis (0.3%), made by mixing 17 mL of procedure within 1 week, at which by reducing edema and minimizing sterile 10% povidone-iodine to 500 time the beads are removed and new shear forces. In the setting of more mL saline in a basin. New gowns and modular components are inserted. severe soft-tissue defects, coverage gloves should be donned, suction tips Patients receive intravenous antibi- with muscle flaps or other advanced and tubing changed, and additional otics for 6 weeks, followed by oral soft-tissue reconstructive techniques sterile drapes used after completing antibiotics, depending on the sus- may be necessary. Should an infection the irrigation. The modular poly- ceptibility of the bacterial organism. be present, deep cultures should be ethylene component should be In a retrospective review of 20 taken at the time of revision surgery to exchanged and a meticulous fascial patients, the authors controlled provide antibiotic guidance (Figure 4). closure performed over a drain. infection in 18 patients with this The success of early aggressive Although the reports of single-stage technique, which compared favor- intervention without introducing débridement with component reten- ably with prior reports with com- infection and with no statistically sig- tion have not indicated over- ponent retention. With proper nificant morbidity comes from limited whelming success, Estes et al48 patient selection, this two-stage pro- data,1,3,5 anditislikelythatsome developed an approach for manag- cedure may be a viable option in the patients would never have developed

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management complications with nonsurgical man- contents. In this article, references surgical patients. Ann Surg 1991;214(5): agement. However, because of the 11, 17, 35, 36, 38, 39, 41, 42, and 45 605-613. strong association between prolonged are level I studies. References 16, 19, 12. Rohrich RJ: Current concepts in wound healing: Update 2011. Plast Reconstr Surg drainage and deep prosthetic infec- 21, 22, 34, and 47 are level II studies. 2011;127(suppl 1):1S-2S. tion, we think that early prophylactic References 1-3, 5, 10, 13, 14, 20, 25, 13. Zerr KJ, Furnary AP, Grunkemeier GL, irrigation and débridement is prefera- 26, 40, and 43 are level III studies. Bookin S, Kanhere V, Starr A: Glucose ble to delayed management or no References 7, 28, 30, 44, 46, and 48 control lowers the risk of wound infection management to mitigate or prevent the are level IV studies. References 4, 6, in diabetics after open heart operations. Ann Thorac Surg 1997;63(2):356-361. potentially devastating postoperative 8, 9, 12, 15, 18, 23, 34, 27, 29, 31- 14. England SP, Stern SH, Insall JN, Windsor RE: problems of wound breakdown lead- 33, and 37 are level V expert Total knee arthroplasty in diabetes mellitus. ingtoanestablishedinfection. opinion. Clin Orthop Relat Res 1990;260:130-134.

References printed in bold type are 15. Handelsman Y, Bloomgarden ZT, those published within the past 5 Grunberger G, et al: American Association Summary of Clinical Endocrinologists and American years. College of Endocrinology: Clinical practice Postoperative soft-tissue problems guidelines for developing a diabetes mellitus 1. Galat DD, McGovern SC, Larson DR, comprehensive care plan. 2015. Endocr about the knee can severely compro- Harrington JR, Hanssen AD, Clarke HD: Pract 2015;21(suppl 1):1-87. mise the generally excellent outcomes Surgical treatment of early wound complications following primary total knee 16. Duchman KR, Gao Y, Pugely AJ, Martin of TKA. Modifiable patient factors arthroplasty. J Bone Joint Surg Am 2009; CT, Noiseux NO, Callaghan JJ: The effect should be preoperatively addressed 91(1):48-54. of smoking on short-term complications following total hip and knee arthroplasty. J to optimize wound healing poten- 2. Galat DD, McGovern SC, Hanssen AD, Bone Joint Surg Am 2015;97(13): tial. Soft-tissue problems may still Larson DR, Harrington JR, Clarke HD: 1049-1058. Early return to surgery for evacuation of a occur, despite appropriate mea- postoperative hematoma after primary 17. Møller AM, Villebro N, Pedersen T, sures to minimize complications. total knee arthroplasty. J Bone Joint Surg Tønnesen H: Effect of preoperative When an acute wound problem Am 2008;90(11):2331-2336. smoking intervention on postoperative complications: A randomised clinical trial. occurs, the guiding principle is close 3. Jaberi FM, Parvizi J, Haytmanek CT, Joshi Lancet 2002;359(9301):114-117. A, Purtill J: Procrastination of wound monitoring and aggressive pro- drainage and malnutrition affect the 18. Workgroup of the American Association of phylactic intervention to resolve the outcome of joint arthroplasty. Clin Orthop Hip and Knee Surgeons Evidence Based wound complication before a second- Relat Res 2008;466(6):1368-1371. Committee: Obesity and total joint arthroplasty: A literature based review. J 4. Webb LX: New techniques in wound ary periprosthetic infection ensues. Arthroplasty 2013;28(5):714-721. Surgical intervention should take place management: Vacuum-assisted wound closure. J Am Acad Orthop Surg 2002;10 19. Severson EP, Singh JA, Browne JA, within5to7daysinthesettingof (5):303-311. Trousdale RT, Sarr MG, Lewallen DG: Total knee arthroplasty in morbidly obese persistent drainage or skin necrosis to 5. Weiss AP, Krackow KA: Persistent wound patients treated with bariatric surgery: A drainage after primary total knee prevent (or manage) a deep infection. comparative study. J Arthroplasty 2012;27 arthroplasty. J Arthroplasty 1993;8(3): The optimal definitive surgical treat- (9):1696-1700. 285-289. ment continues to be refined, and with 20. Light D, Arvanitis GM, Abramson D, 6. Parvizi J, Gehrke T, Chen AF: Proceedings the advent of new markers to diagnose Glasberg SB: Effect of weight loss after of the International Consensus on bariatric surgery on skin and the early deep periprosthetic infection, a Periprosthetic Joint Infection. Bone Joint J extracellular matrix. Plast Reconstr Surg 2013;95-B(11):1450-1452. more exact distinction between pri- 2010;125(1):343-351. mary aseptic wound healing problems 7. Vince K, Chivas D, Droll KP: Wound 21. McElroy MJ, Pivec R, Issa K, Harwin SF, complications after total knee arthroplasty. and secondary complications from a Mont MA: The effects of obesity and J Arthroplasty 2007;22(4 suppl 1):39-44. deep infection may emerge. The man- morbid obesity on outcomes in TKA. J agement of acute wound complications 8. Broughton G II, Janis JE, Attinger CE: The Knee Surg 2013;26(2):83-88. basic science of wound healing. Plast will also benefit from data on incisional Reconstr Surg 2006;117(7 suppl):12S-34S. 22. Namba RS, Paxton L, Fithian DC, Stone ML: Obesity and perioperative morbidity NPWT in TKA and from advances in 9. Broughton G II, Janis JE, Attinger CE: in total hip and total knee arthroplasty soft-tissue reconstruction techniques to Wound healing: An overview. Plast patients. J Arthroplasty 2005;20(7 suppl 3): cover larger and more complex peri- Reconstr Surg 2006;117(7 suppl):1e-S- 46-50. 32e-S. incisional defects. 23. Smith TK: Prevention of complications in 10. Moucha CS, Clyburn T, Evans RP, orthopedic surgery secondary to nutritional Prokuski L: Modifiable risk factors for depletion. Clin Orthop Relat Res 1987; surgical site infection. J Bone Joint Surg Am 222:91-97. References 2011;93(4):398-404. 24. Cross MB, Yi PH, Thomas CF, Garcia J, 11. Jonsson K, Jensen JA, Goodson WH III, Della Valle CJ: Evaluation of malnutrition Evidence-based Medicine: Levels of et al: Tissue oxygenation, anemia, and in orthopaedic surgery. J Am Acad Orthop evidence are described in the table of perfusion in relation to wound healing in Surg 2014;22(3):193-199.

554 Journal of the American Academy of Orthopaedic Surgeons

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