Orthopedic patients are susceptible to wound complications for several reasons. Surgery may involve wide undermining from the soft tissues. Postoperative edema may be significant since joints have relatively poor lymphatic drainage, further compromised by surgery, resulting in undue tension of your skin and incision.
Prostheses may be positioned directly underneath the skin incision in an area that is poorly vascularized. Finally, many patients have experienced prior surgery, the scarring that plays a role in decreased tissue pliability and blood circulation. In sum, the altered blood flow, increased edema and wound tension result in decreased oxygen delivery towards the healing incision.
Persistent drainage or problematic wound healing has been described in as much as 20% of total knee arthroplasty (TKA) patients, by having an infection rate of 1-12%. The total incidence of infection following total hip arthroplasty (THA) has a smaller footprint: about 1%. When looking for such problems, it is advisable to distinguish wound infection from wound failure, since the treatment algorithms will vary. Wound infection could cause wound failure.
Wound failure, meanwhile, may cause implant contamination and subsequent infection. The most typical symptoms and signs and symptoms of infection following TKA and THA are pain, erythema and purulent wound drainage. Additional laboratory tests like a CBC, ESR, C-reactive protein and joint aspiration may also help to establish the diagnosis.
It is also vital that you think about the patient's comorbidities. Factors that predispose to failure of implant salvage include: previous surgeries, diabetes, adjuvant radiotherapy, ligament disease, peripheral vascular disease, tobacco use, prior steroid treatments and rheumatic disease. Factors that predict successful implant salvage in the setting of infection include: <2 week duration of symptoms; susceptible gram positive organism (especially Streptococcus); lack of radiologic evidence of infection or loosening of the prosthesis; and absence of a sinus tract.
In the absence of infection, prostheses underlying open wounds are often salvageable, even when exposed. Immediate closure may be considered, provided that there are no signs of infection and well-vascularized tissue exists. Primary closure may be especially difficult due to the lack of mobile soft tissue adjacent to the wound.
Wounds that do not involve exposed tendon, bone or joint may be treated with local wound care, negative pressure wound therapy followed by skin grafts, or fasciocutaneous flaps-depending on the size of the defect. Wounds in which the tendon, bone or joint are exposed should be treated with debridement, irrigation and flap reconstruction.
The keys to initial management of wound infections are: identification of the anatomic extent of infection, aggressive debridement of devascularized tissue, thorough irrigation, and culture-specific systemic antibiotic therapy. Thereafter, superficial infections may be managed with local wound care, skin grafts or fasciocutaneous flaps.
Medium-depth infections, which extend to the joint capsule without involving the bone or joint structures, may be treated with skin grafts, fasciocutaneous flaps or muscle flaps depending on the size of the defect and, in the case of the knee, whether tendon is involved.
Deep infections that involve the bone or joint structures require more aggressive management. Acutely infected wounds should be thoroughly debrided, irrigated and treated with broad spectrum, anti-staphylococcal antibiotics. Definitive surgical closure of the wound, often with muscle flaps, may be undertaken when signs of infection have abated, preferably within 7 days. Chronic infections (greater than 4 weeks) often require implant removal and placement of an antibiotic-impregnated spacer, followed by second-stage reimplantation after long-term IV antibiotic therapy.
Patients who require implant removal are at increased risk of wound failure following prosthesis reimplantation due to inadequate local tissues and patient compromise. As such, a low threshold should be used for muscle flap coverage at the second stage.
Successful salvage of a threatened or exposed implant requires a good working relationship with the orthopedic surgeon and prompt evaluation and treatment of the patient. Serial debridements may be needed until the site is clean and all tissues are deemed viable. Final closure should proceed in an expeditious manner when the wound is deemed ready.
The major pitfalls to success lie in both delaying treatment and conversely, rushing closure. If one adopts the "wait and see" attitude, a worsening picture may develop due to bacterial contamination and subsequent infection. Hurrying the closure before the wound is clean may result in the subsequent development of osteomyelitis.
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