From OT Europe

Expert interview: Wound closure and infections in orthopaedic surgery

EFORT

Mike Reed, MD, FRCS, is a full-time hip and knee replacement surgeon with trauma commitments in a busy trauma unit, as well as the clinical director at Northumbria Healthcare NHS Foundation Trust in the United Kingdom, leading a high-performing team and supported by a group of committed and talented colleagues. His research, supported by industry, charity and government funding, focuses on clinical outcomes and on his specialist interest in infection prevention, diagnosis and management. With Northumbria Healthcare, he is leading large national collaboratives on hip fracture care and enhanced recovery. In addition, Reed supervises basic science research at Newcastle University, which focuses on vitamin D and infection, and particularly biofilm modification with an extracellular DNase. He is also chief investigator for clinical trials on clinical outcomes and infection prevention at the Universities of York and Oxford.

This article is part of an ongoing series to raise awareness of a broad set of topics impacting orthopaedic practice to broaden the collaborative discussion around improving patient surgical outcomes, especially postoperative pain management (POPM) and with developing solutions that improve practices across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue. To further discuss the opinions expressed in this article, engage on Twitter, Facebook and LinkedIn at #painmanagement, #changepain and #POPM.

Focus on infection

Reed’s passion for the topic of reducing infection was jump-started years ago while performing an industry-sponsored clinical trial on triclosan sutures involving more than 2,000 patients having hip and knee replacements. The literature from industry suggested these sutures reduced the rate of postoperative infection, but the trial results did not show the sutures provided a significant advantage. This research changed the way surgical teams viewed recommendations of antibacterial sutures. Today, many on the Northumbria team have changed practice based upon avoiding dressing changes and standardizing on a triple closure method. The more frequently the dressing requires changing, the more opportunities there are for the wound to be exposed to bacteria.

“The issue is leaking wounds,” Reed said. “For some time now, I’ve been working to avoid wounds leaking at all after surgery.”

With about 2,700 primary procedures being performed each year for hip and knee replacements and revision, Northumbria Healthcare – the large NHS hospital group where Reed is clinical director – is a leader in multicenter research trials in several areas of orthopaedic surgery. The team lead the Arthroplasty Research Collaborative where research organized under one NHS umbrella is performed across a group of 25 United Kingdom hospitals. This provides a wealth of data from randomized patient trials leading to standardized best practices that continue to improve patients’ postoperative outcomes.

Reduced infections, postoperative pain

Reed is clear to point out that there is not a direct link between the actions a surgeon takes to reduce infection and those to reduce postoperative pain. Both practices, however, work together toward the common goal to get patients ready and comfortable to go home, often on the same day as their procedure. By performing regular local audits and improving communication between all members of the surgical team, they can measure the effects of change on an entire range of potential complications and outcomes. While the risk of important complications such as heart attacks, infection, and acute or chronic pain will vary from patient to patient, we find that standardized practices from a unified team improves outcomes. The team shares results, and individuals are willing to make changes.

For example, based on what Reed cites as the distinguished work of Drs. Henrik Kehlet and Henrik Husted in Denmark, the NHS Trust has adopted many of its processes to establish fast-track surgery programs with standardized functional criteria to reduce length of stay following hip and knee procedures. These best practices include having good perioperative pain control and predictive preoperative screenings to ensure patients are in the best possible state before they have surgery. Patient education, protocols and coordination of multimodal postoperative pain management to reduce the use of opiates all play a role in quickly returning patients to full mobility. By enacting programs with close ties to those put into place in Denmark, Northumbria Healthcare has reduced its mean length of stay to 2.2 days, the shortest length of stay nationally.

Reed said, “Surgical theaters are clean. Patients’ homes are much less clean in terms of bacterial load generally and so as much as possible, you need to avoid having a dressing changed in areas with more risk.”

The aim, therefore, is to have patients keep a dressing on for 14 days. To do so, Reed and his team looked closely at the number of dressing changes patients required on average by surgeon through local audits, and then surgeons moved to emulate the best results. Among those procedures adopted was the standardization of the triple closure method, which seeks to reduce chances of wound leakage providing two subcutaneous layers, a dermal layer, then clips and glue on top. This method looks to give absolute certainty that there are no leaks as the wound heals.

“The important thing is that once the patient leaves, the wound is not leaking at all, so the dressing does not need to be changed in the patient’s home where the risk of contamination is greater,” Reed said.

Processes to reduce swelling as part of preparation for wound closure also can contribute to overall better outcomes for the patient’s postoperative experience. Reed noted some practitioners might be concerned that using IV high-dose steroids to reduce pain and nausea and to improve the patient’s overall feeling of well-being could increase the infection rate, but there has been no indication of this in the large studies performed. In reducing the risk of infection, Reed reiterated that the goal of his team and supporting practitioners is to ensure that once patients have left the hospital, they are not readmitted on account of infection. Working together with partners focused on pain management as a team (including the patient as part of that team), addressing complications and other risk factors, such as infection, ensures positive overall patient outcomes so the possibility of postoperative complications is reduced.

“Where a patient does get an infection, joint replacements can be very painful,” Reed said. “It is not necessarily the acute pain we deal with for postoperative pain management, but a patient who gets an infection will often have a poor outcome from surgery.”

In another study from 2018, the collaborative looked at more than 2,300 randomized patients from about 25 centers across the United Kingdom to understand the potential to reduce swelling and hence improve function after knee replacement by using compression bandages. This could not only reduce pain but could also help increase function in the joint. Results of this study will be forthcoming in 2020 once 1-year follow-ups with patients can be conducted.

Current initiatives

One key area where Reed’s team has been working is preventing methicillin-sensitive Staphylococcus aureus (MSSA) infection rather than focusing solely on MRSA, which has become rarer due a successful national drive. About 20% of patients carry the MSSA bug. Northumbria is running a trial across the NHS that looks to decolonize MSSA carriers. This is an area where Reed believes the United Kingdom is ahead of the curve, with WHO guidance on MSSA coming out only in late 2016.

Another area where the Northumbria team has found positive indications is in a pilot study investigating whether high-dose dual antibiotic cement can reduce infections in patients having a hemiarthroplasty. A large full trial is now underway with 5,000 patients being randomized across 25 centers throughout the United Kingdom during a period of 2 years. The basic concept is that with a high dose of antibiotic in the cement holding the bone, there is then antibiotic prophylaxis at the site of the suture, as well as internally. Early outcomes have shown great promise, and the emerging results might prove to be practice-changing.

As routine practice, the Northumbria team performs povidone-iodine lavage on all joint replacement wounds to reduce the risk of surgical site infection. The latest results from the United States are promising according to Reed. By taking care of many of the risks pre-closure, Reed and his team aim to standardize the best practices they have found to keep patients from suffering undue complications following wound closure.

Path to the future

Aside from the studies underway, Reed said exciting developments happening throughout global orthopaedics and traumatology hold out the promise for continuously better patient outcomes as they become further studied and refined. One such area is in the area of robotics in surgery. While Reed does not have direct experience in the area, he explained the evidence coming out of robotic knee replacement initially show less postoperative pain and earlier recovery, which is probably due to less perioperative trauma on account of the high accuracy of the robot. This accuracy would also likely lower additional risks of post-surgical trauma and perhaps infection. The prospects of this emerging technology are exciting and likely to improve upon many current practices throughout the profession.

Closer to home, Reed explained that within the NHS they are working on artificial intelligence (AI) to try and ascertain whether a patient is more or less likely to have a complication or not. To do so involves looking at the patient’s past medical history, observations within the hospital and the patient’s current blood results and feeding it to the AI, which will predict complications and outcomes based on large volumes of data. If we can predict with relative certainty a patient will have a myocardial infarction around the time of surgery, preventative measures can be taken, and the patient can be transferred to a higher-level hospital.

“One advantage to the NHS,” Reed said, “is that because we are all operating in one big organization, we can collect the same information and we can begin to use very large data sets to try and figure out the patterns and red flags in one patient from the thousands of patients that came before.”

Among his proudest accomplishments is the Arthroplasty Research Collaborative that, since 2015, unites a group of 25 hospitals across the United Kingdom that are randomizing patients into clinical trials to find the best standardized practices for surgical teams to achieve the best results for their patients.

Reed said, “The more standardized the practice, the more predictable the outcome. As orthopaedic surgeons and our supporting teams, we all have slightly different techniques, but we are trying to become more standardized in our processes.”

EFORT

Mike Reed, MD, FRCS, is a full-time hip and knee replacement surgeon with trauma commitments in a busy trauma unit, as well as the clinical director at Northumbria Healthcare NHS Foundation Trust in the United Kingdom, leading a high-performing team and supported by a group of committed and talented colleagues. His research, supported by industry, charity and government funding, focuses on clinical outcomes and on his specialist interest in infection prevention, diagnosis and management. With Northumbria Healthcare, he is leading large national collaboratives on hip fracture care and enhanced recovery. In addition, Reed supervises basic science research at Newcastle University, which focuses on vitamin D and infection, and particularly biofilm modification with an extracellular DNase. He is also chief investigator for clinical trials on clinical outcomes and infection prevention at the Universities of York and Oxford.

This article is part of an ongoing series to raise awareness of a broad set of topics impacting orthopaedic practice to broaden the collaborative discussion around improving patient surgical outcomes, especially postoperative pain management (POPM) and with developing solutions that improve practices across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue. To further discuss the opinions expressed in this article, engage on Twitter, Facebook and LinkedIn at #painmanagement, #changepain and #POPM.

Focus on infection

Reed’s passion for the topic of reducing infection was jump-started years ago while performing an industry-sponsored clinical trial on triclosan sutures involving more than 2,000 patients having hip and knee replacements. The literature from industry suggested these sutures reduced the rate of postoperative infection, but the trial results did not show the sutures provided a significant advantage. This research changed the way surgical teams viewed recommendations of antibacterial sutures. Today, many on the Northumbria team have changed practice based upon avoiding dressing changes and standardizing on a triple closure method. The more frequently the dressing requires changing, the more opportunities there are for the wound to be exposed to bacteria.

“The issue is leaking wounds,” Reed said. “For some time now, I’ve been working to avoid wounds leaking at all after surgery.”

With about 2,700 primary procedures being performed each year for hip and knee replacements and revision, Northumbria Healthcare – the large NHS hospital group where Reed is clinical director – is a leader in multicenter research trials in several areas of orthopaedic surgery. The team lead the Arthroplasty Research Collaborative where research organized under one NHS umbrella is performed across a group of 25 United Kingdom hospitals. This provides a wealth of data from randomized patient trials leading to standardized best practices that continue to improve patients’ postoperative outcomes.

PAGE BREAK

Reduced infections, postoperative pain

Reed is clear to point out that there is not a direct link between the actions a surgeon takes to reduce infection and those to reduce postoperative pain. Both practices, however, work together toward the common goal to get patients ready and comfortable to go home, often on the same day as their procedure. By performing regular local audits and improving communication between all members of the surgical team, they can measure the effects of change on an entire range of potential complications and outcomes. While the risk of important complications such as heart attacks, infection, and acute or chronic pain will vary from patient to patient, we find that standardized practices from a unified team improves outcomes. The team shares results, and individuals are willing to make changes.

For example, based on what Reed cites as the distinguished work of Drs. Henrik Kehlet and Henrik Husted in Denmark, the NHS Trust has adopted many of its processes to establish fast-track surgery programs with standardized functional criteria to reduce length of stay following hip and knee procedures. These best practices include having good perioperative pain control and predictive preoperative screenings to ensure patients are in the best possible state before they have surgery. Patient education, protocols and coordination of multimodal postoperative pain management to reduce the use of opiates all play a role in quickly returning patients to full mobility. By enacting programs with close ties to those put into place in Denmark, Northumbria Healthcare has reduced its mean length of stay to 2.2 days, the shortest length of stay nationally.

Reed said, “Surgical theaters are clean. Patients’ homes are much less clean in terms of bacterial load generally and so as much as possible, you need to avoid having a dressing changed in areas with more risk.”

The aim, therefore, is to have patients keep a dressing on for 14 days. To do so, Reed and his team looked closely at the number of dressing changes patients required on average by surgeon through local audits, and then surgeons moved to emulate the best results. Among those procedures adopted was the standardization of the triple closure method, which seeks to reduce chances of wound leakage providing two subcutaneous layers, a dermal layer, then clips and glue on top. This method looks to give absolute certainty that there are no leaks as the wound heals.

“The important thing is that once the patient leaves, the wound is not leaking at all, so the dressing does not need to be changed in the patient’s home where the risk of contamination is greater,” Reed said.

PAGE BREAK

Processes to reduce swelling as part of preparation for wound closure also can contribute to overall better outcomes for the patient’s postoperative experience. Reed noted some practitioners might be concerned that using IV high-dose steroids to reduce pain and nausea and to improve the patient’s overall feeling of well-being could increase the infection rate, but there has been no indication of this in the large studies performed. In reducing the risk of infection, Reed reiterated that the goal of his team and supporting practitioners is to ensure that once patients have left the hospital, they are not readmitted on account of infection. Working together with partners focused on pain management as a team (including the patient as part of that team), addressing complications and other risk factors, such as infection, ensures positive overall patient outcomes so the possibility of postoperative complications is reduced.

“Where a patient does get an infection, joint replacements can be very painful,” Reed said. “It is not necessarily the acute pain we deal with for postoperative pain management, but a patient who gets an infection will often have a poor outcome from surgery.”

In another study from 2018, the collaborative looked at more than 2,300 randomized patients from about 25 centers across the United Kingdom to understand the potential to reduce swelling and hence improve function after knee replacement by using compression bandages. This could not only reduce pain but could also help increase function in the joint. Results of this study will be forthcoming in 2020 once 1-year follow-ups with patients can be conducted.

Current initiatives

One key area where Reed’s team has been working is preventing methicillin-sensitive Staphylococcus aureus (MSSA) infection rather than focusing solely on MRSA, which has become rarer due a successful national drive. About 20% of patients carry the MSSA bug. Northumbria is running a trial across the NHS that looks to decolonize MSSA carriers. This is an area where Reed believes the United Kingdom is ahead of the curve, with WHO guidance on MSSA coming out only in late 2016.

Another area where the Northumbria team has found positive indications is in a pilot study investigating whether high-dose dual antibiotic cement can reduce infections in patients having a hemiarthroplasty. A large full trial is now underway with 5,000 patients being randomized across 25 centers throughout the United Kingdom during a period of 2 years. The basic concept is that with a high dose of antibiotic in the cement holding the bone, there is then antibiotic prophylaxis at the site of the suture, as well as internally. Early outcomes have shown great promise, and the emerging results might prove to be practice-changing.

PAGE BREAK

As routine practice, the Northumbria team performs povidone-iodine lavage on all joint replacement wounds to reduce the risk of surgical site infection. The latest results from the United States are promising according to Reed. By taking care of many of the risks pre-closure, Reed and his team aim to standardize the best practices they have found to keep patients from suffering undue complications following wound closure.

Path to the future

Aside from the studies underway, Reed said exciting developments happening throughout global orthopaedics and traumatology hold out the promise for continuously better patient outcomes as they become further studied and refined. One such area is in the area of robotics in surgery. While Reed does not have direct experience in the area, he explained the evidence coming out of robotic knee replacement initially show less postoperative pain and earlier recovery, which is probably due to less perioperative trauma on account of the high accuracy of the robot. This accuracy would also likely lower additional risks of post-surgical trauma and perhaps infection. The prospects of this emerging technology are exciting and likely to improve upon many current practices throughout the profession.

Closer to home, Reed explained that within the NHS they are working on artificial intelligence (AI) to try and ascertain whether a patient is more or less likely to have a complication or not. To do so involves looking at the patient’s past medical history, observations within the hospital and the patient’s current blood results and feeding it to the AI, which will predict complications and outcomes based on large volumes of data. If we can predict with relative certainty a patient will have a myocardial infarction around the time of surgery, preventative measures can be taken, and the patient can be transferred to a higher-level hospital.

“One advantage to the NHS,” Reed said, “is that because we are all operating in one big organization, we can collect the same information and we can begin to use very large data sets to try and figure out the patterns and red flags in one patient from the thousands of patients that came before.”

Among his proudest accomplishments is the Arthroplasty Research Collaborative that, since 2015, unites a group of 25 hospitals across the United Kingdom that are randomizing patients into clinical trials to find the best standardized practices for surgical teams to achieve the best results for their patients.

Reed said, “The more standardized the practice, the more predictable the outcome. As orthopaedic surgeons and our supporting teams, we all have slightly different techniques, but we are trying to become more standardized in our processes.”

PAGE BREAK