Obtaining primary wound healing in total joint arthroplasty is essential to a good result. Wound healing problems can occur and the consequences can be devastating. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as type A, no healing compromises; and type B, systemic or local healing compromising factors present. Local factors include traumatic arthritis, multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor nutrition. In high-risk patients, the surgeon should encourage positive choices such as smoking cessation and nutritional supplementation to elevate the total lymphocyte count and total albumin.
Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thus, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We perform all potentially complicated total knee arthroplasties without tourniquet to enhance blood flow and tissue viability. The use of perioperative anticoagulation will increase wound problems.
If wound drainage or healing problems occur, immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count (>2000), differential (>50% polys), and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound.
Obtaining and maintaining primary wound healing in total joint arthroplasty is essential to a satisfactory outcome. Since prospective management and prevention of wound healing disturbances is primary, each patient must be individually assessed for potential problems.
Prospective Approach to Patient Management
A number of methods have been documented to prevent wound healing disturbances and include:
- Alteration to enhance host healing capacity,
- Appropriate timing and administration of prophylactic antibiotics,
- Personnel isolation devices,
- Antibiotic impregnated cement,
- Limitation of operating room traffic,
- Appropriate selection of incision using previous incision whenever possible, and
- Meticulous surgical techniques.
Patients who are debilitated or with poor nutrition should be identified prior to elective total joint surgery. Those with low total lymphocyte counts and low total albumin exhibit a poor host healing response.1 Administration of nutritional supplementation, either oral or parenteral, will improve the counts and the host healing capacity. We supplementally nourish all patients entered into our infected implant protocol.
Cierney and Mader classified the host healing response of patients as type A, no healing comprises; type B, local, systemic, or combined compromising factors; or type C, significant compromising factors, high morbidity for treatment, and poor prognosis.2 Local factors include extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose.
Systemic factors include diabetes, rheumatic diseases, renal or liver disease, steroids, poor nutrition, immune compromises; eg, human immunodeficiency virus positive status, and finally, tobacco use. Smoking causes vascular constriction and makes the patient a type B healing host. We do not accept patients who continue to smoke into our infected implant management protoccol.3
Antibiotics administered for prophylaxis should be given prior to the surgical incision and are a part of the “time out” process. Personnel isolation devices and limitation of operating room traffic have been shown to have a small, but measurable decrease in infection rates. Antibiotic impregnated cement is also documented to decrease infection. Antibiotic impregnated cement obtained from the manufacturer is expensive to use on every total joint. For the past 10 years we have used an inexpensive homemade antibiotic impregnated cement with no complications: 1.5 g of cefuroxime powder mixed under vacuum with 2 packs of cement powder before the monomer is added.4
While previous incisions present a risk for proper wound healing, selection of the appropriate incision can diminish that risk. The blood supply to the skin is fasciocutaneous and always better in the medial flap.5 When there are multiple previous incisions select the most lateral one to re-enter the knee. This may require a tubercle osteotomy to best expose the joint. The previous incision should always be excised to obtain primary healing.
Cutaneous hypoxia may result from high tourniquet pressures and from aggressive early flexion. Our protocol for dealing with the knee with multiple previous incisions emphasizes performing the arthroplasty with no tourniquet. Also, we delay initiation of flexion for 24 hours to assure adequate healing.
The use of perioperative anticoagulation measure will increase wound healing problems.6,7 Selection of foot pumps and aspirin as deep vein thrombosis prophylaxis8 is recommended over chemical methods when dealing with patients who present with compromising wound problems.
In patients with extensive scarring or adherence to underlying tissue, preoperative use of tissue expanders9 or muscle flaps10 may provide a more satisfactory healing environment.
Finally meticulous handling of soft tissue is essential to proper wound healing. Undermining skin should be minimized, especially in the lateral flap. Full thickness fasciocutaneous flaps best preserve the skin blood supply.
Diagnosis and Management of Wound Complications
Wound healing disturbances can present a spectrum of findings from superficial incisional, to deep incisional (outside the joint space) to involving the joint space. Gaine et al11 reported a 10% incidence of superficial wound problems in primary total knee arthroplasty (TKA). Patel et al12 reported that each day of prolonged wound drainage increased the risk of deep wound infection by 29% following TKA.
Incisional drainage 1 to 3 days postoperatively should be managed by immobilization in extension and direct application of a foam compressive bandage over the incision. The dressing we use is demonstrated in the Figure. This same dressing is applied immediately postoperatively and has proved useful. Use of immobilization and observation should not exceed 3 days, lest deep infection ensue.13
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|Figure: Velfoam wrap with foam pads to provide direct compression to incision (A). Wrap applied (B). |
If there is suspicion of deep infection on clinical or laboratory grounds, intra-articular aspirations from a site away from any cellulitis must be performed with culture and sensitivities, white blood cell count, and differential. Deep infection can be ruled out with negative cultures and white blood cell count <2000 with <50% polymorphonuclear cells.14 Intra-articular sepsis requires immediate surgical intervention. Such operative management is outside the scope of this paper, but our protocol has been reported.3
A single punctate site of persistent drainage may occasionally present a diagnostic challenge. We have found intra-articular injection of 10 cc hydrogen peroxide plus 0.5 cc of methylene blue will produce a “blue fountain” at the punctate site if there is communication with the joint space. This should be done in the operating room since a positive finding requires operative intervention.
Necrotic skin edges should always be excised and all wound hematomas evacuated. Proper debridement with total synovectomy and removal of all necrotic tissue should be performed. This yields a viable wound and promotes further appropriate management.15
- Wilde AH, Greene IA, Stulberg BN. Preoperative nutritional status of total joint patients relationship to postoperative wound complications. J Arthroplasty. 1991; 6(4):321-325.
- Cierny G III, Mader JT, Pennick JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003; (414):7-24.
- Jones RE, Huo MH. The infected knee: all my troubles now. J Arthroplasty. 2006; 21(4 Suppl 1):50-53.
- Chiu FY, Chen CM, Lin CF, Lo WH. Cefuroxime-impregnated cement in primary total knee arthroplasty. J Bone Joint Surg Am. 2002; 84(5):759-762.
- Johnson DP, Eastwood DM, Bader DL. Biomechanical factors in wound healing following knee arthroplasty. J Med Eng Technol. 1991; 15(1):8-14.
- Burnett RS, Clohisy JC, Wright RW, et al. Failure of the American College of Chest Physicians-1A protocol for Lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplasty. 2007; 22(3):317-324.
- Sachs RA. Does anticoagulation do more harm than good?: A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty. 2003; 18(4):389-395.
- Warwick D, Harrison J, Glew D, Mitchelmore A, Peters TJ, Donovan J. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial. J Bone Joint Surg Am. 1998; 80(8):1158-1166.
- Manifold SG, Cushner FD, Craig-Scott S, Scott WN. Long term results of total knee arthroplasty after the use of tissue expanders. Clin Orthop Relat Res 2000; (380):133-139.
- Markovich GD, Dorr LD, Klein NE, McPherson EJ, Vince KG. Muscle flaps in total knee arthroplasty. Clin Orthop Relat Res. 1995; (321):122-130.
- Gaine WJ, Ramamohan NA, Hussein NA, Hullin MG, McCreath SW. Wound infection in hip and knee arthroplasty. J Bone Joint Surg Br. 2000; 82(4):561-565.
- Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007; 89(1):33-38.
- Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement. J Orthop Res. 2002; 20(3):506-515.
- Mason JB, Fehring TK, Odum SM, Griffin WL, Nussman DS. The value of white blood cell counts before revision total knee arthroplasty. J Arthroplasty. 2003; 18(8):1038-1043.
- Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following TKA. J Bone Joint Surg Am. 2009; 91(1):48-54.
Dr Jones is from the Department Orthopedic Surgery, UT Southwestern Medical Center, and Orthopedic Specialists, Dallas, Texas.
Dr Jones has no relevant financial relationships to disclose.
Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.
Correspondence should be addressed to: Richard E. Jones, MD, UT Southwestern Medical Center, 5920 Forest Park Rd #600, Dallas, TX 75235 (firstname.lastname@example.org).