Journal of Arthroplasty Best Practices for TJA Wound Closure

Two new studies published in The Journal of Arthroplasty provide best practice approaches and insights for wound closure and dressing management in total knee arthroplasty (TKA) and total hip arthroplasty (THA).

“The biggest problem that we have in terms of revisions or morbidity following total knee and total hip arthroplasty is infection, and approximately half of the infections are attributable to wound healing problems,” said Michael A. Mont, M.D., Rubin Institute for Advanced Orthopedics and study co-author. “With the consensus reached by the participating orthopedic surgeons, we now have a guide that may help reduce the variability between surgeons and centers, promote standardization, and improve outcomes for patients after knee and hip replacements.”

TKA Study

Dr. Mont told OTW, “The most devastating complication of TKA is a deep infection, which still occurs 1 to 2% of the time for primary procedures and is much higher for revisions. Issues with the wound can account for approximately 50% of these infections, so the importance of this topic cannot be overestimated.”

“Unfortunately, there are countless approaches to wound healing techniques for TKA, which are confounded by the fact that there are no true standards of care in this field. These standards have been mostly derived without Level 1 evidence and few systematic reviews. Therefore, a scientific, evidence-based approach is really needed.”

“In addition, different aspects of wound healing with TKA are not well-defined. For example, I typically divide the procedure closure into four parts: the deep fascia, the more superficial layer, then the skin and subcutaneous layer, followed by the dressing.”

“All of these are differently described in many studies; investigators have combined some of these different layers, and it is hard to further differentiate best practices for each layer. There is also a large diversity of patients who we treat; for example, obese patients, ones who smoke, ones that have many comorbidities, as well as patients who need a revision knee arthroplasty, which are more complicated.”

The researchers used a Delphi process to prioritize best practices. Mont explained, “For important and relevant medical issues, it is mandated that evidence-based approaches be used to make care decisions, especially in this era of healthcare reform with an increasing downward-pressure on reimbursement.”

“Consensus conferences, according to Delphi methods, have been increasingly utilized to get ‘answers’ to clinically important questions throughout medicine. These types of consensus efforts can also identify important gaps in the existing evidence that require further research, which are parts of two future publications as well.”

“The Delphi method is an iterative process that collects opinions from a panel of experts to achieve consensus in a given subject area. The method involves a series of structured consensus-building rounds in which responses are collected through anonymous polling. The results of each round are quantitatively and/or qualitatively summarized and shared with the panelists. This process is then repeated until consensus is reached.”

“In this case, 75% of the 20 panel members from a group of orthopedic experts from the United States, Europe, and Canada reached agreement after three rounds on 40 questions pertinent to total hip and knee arthroplasty.”

Dr. Mont told OTW that the most actionable findings from the TKA study were:

• “Barbed sutures were superior to non-barbed sutures based on lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings.
• Mesh-adhesives were superior to other skin closure methods due to lower wound complications, higher patient satisfaction scores, and lower rates of readmission.
• Silver-impregnated dressings were superior to standard dressings because of lower wound complications, decreased infections, and fewer dressing changes.
• Negative pressure wound therapy was superior to other dressings for high-risk patients due to lower wound complications, decreased reoperations, and fewer dressing changes.”

THA Study

“Similar to the knee arthroplasty study, there was a paucity of data to recommend on many different aspects of wound care after total hip arthroplasties,” Dr. Mont told OTW. “In fact, there is much less data than TKA in terms of the published literature on many of the different questions. This means there are multiple evidence gaps prevalent for this procedure.”

“Fortunately, many of the take-home messages that were obtained from the TKA Delphi process could be applied to THA. This is in the same manner that many take-home messages from other specialties can be applied to total hip and total knee arthroplasty.”

“For example, the use of sutures that have an antimicrobial-impregnated agent, namely triclosan, has been shown to reduce infections in many other surgical specialties. Therefore, the panelists do not necessarily believe that specific studies dealing with triclosan need to be repeated for total knee and total hip arthroplasty because of the success of these sutures in the other specialties.”

“Likewise, with much data on many topics about barbed sutures and mesh adhesives after total knee arthroplasty, for example, much of the conclusions for the knee can be applied to the hip.”

“There were a number of nuanced issues that dealt with wound healing for both total knee and total hip arthroplasty. For example, for total knee arthroplasty, the group opined on the advantages of closing in semi-flexion over extension to lead to superior range of motion. They also found that aspirin for venous thromboembolism prophylaxis reduces wound complications.”

“For THA, some of the more specific topics included the best approaches (anterior versus posterior), drain use, and the best method of DVT [deep vein thrombosis] prophylaxis.”

Dr. Mont noted that the most important and actionable findings from the Delphi panel for THA included the following:

• “Barbed sutures were superior to non-barbed sutures in terms of shorter closing times and overall cost savings.
• Subcuticular sutures were superior to skin staples based on lower risk of superficial infections and higher patient preferences, though there were longer closing times.
• Mesh adhesives were superior to silver-impregnated dressings with a lower rate of wound complications.
• For at-risk patients, the use of negative pressure wound therapy was superior to other dressings because of lower wound complications and reoperations, as well as fewer dressing changes.”

“The panel of experts identified key interventions in both TKA and THA that are most focused on patient safety and improved outcomes, including the use of barbed sutures over non-barbed sutures; the use of triclosan-coated sutures over non-antimicrobial-coated sutures; and the application of mesh adhesives over other skin closure methods. As discussed in the review by the panel, these interventions were preferred as they have been associated with lower rates of wound complications, lower risk of surgical site infections, and lower rates of readmission.”