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Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

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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 August 2017, Vol 25, No 8 547 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, smok- ing, 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
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