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Lin KC, Huang FT, Chen CY, Tarng YW. Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study. Life (Basel) 2024; 14:753. [PMID: 38929737 PMCID: PMC11204462 DOI: 10.3390/life14060753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs. PATIENTS AND METHODS A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM. RESULTS The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001). CONCLUSIONS In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.
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Affiliation(s)
- Kai-Cheng Lin
- Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan; (C.-Y.C.); (Y.-W.T.)
| | - Fu-Ting Huang
- Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan; (C.-Y.C.); (Y.-W.T.)
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Ashkenazi I, Sobba WD, Morton JS, Bieganowski T, Shichman I, Schwarzkopf R. Knotless suture in revision total joint arthroplasty: a prospective randomized controlled trial. Arch Orthop Trauma Surg 2024; 144:2207-2212. [PMID: 38520550 DOI: 10.1007/s00402-024-05283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/10/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting. METHODS A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups. RESULTS The use of barbed sutures decreased closure time by 6 min (30.1 vs. 36.1 min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5 mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up. CONCLUSION Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, NewYork, NY, USA
- Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Walter D Sobba
- Department of Orthopaedic Surgery, NYU Langone Health, NewYork, NY, USA
| | - Jessica S Morton
- Department of Orthopaedic Surgery, NYU Langone Health, NewYork, NY, USA
| | | | - Ittai Shichman
- Department of Orthopaedic Surgery, NYU Langone Health, NewYork, NY, USA
- Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NewYork, NY, USA.
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Morgan T, Page T. The effectiveness of prophylactic closed incision negative pressure wound therapy compared to conventional dressings in the prevention of periprosthetic joint infection post hip and knee revision arthroplasty surgery: A systematic review. Int J Orthop Trauma Nurs 2024; 53:101048. [PMID: 37845090 DOI: 10.1016/j.ijotn.2023.101048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of prophylactic closed incision negative pressure wound therapy (ciNPWT) compared to conventional dressings in the prevention of periprosthetic joint infection (PJI) post hip and knee revision arthroplasty surgery. METHOD Five databases (MEDLINE, Embase., Emcare, CINAHL and Scopus) were searched with no date or language limits. Two independent reviewers assessed articles against the inclusion criteria and methodological quality of the 3 included studies. Data was extracted using a customised data tool and included the intervention, study methods and outcomes of interest. A meta-analysis was performed, and results presented in narrative form with forest plots. FINDINGS The three studies, one randomized control trial and two quasi-experimental studies, included 136 intervention and 228 control participants (Sample 364). The PJI rate decreased in the ciNPWT cohort compared to the conservative dressing cohort (2 [1.47%] vs 27 [11.84%]). The reoperation rate was lower in the ciNPWT cohort versus the conventional cohort (4 [2.94%] vs 35 [15.35%]). The rate of wound complications was significantly decreased in the ciNPWT cohort compared to the conventional dressing cohort (14 [10.29%] v 85 [37.28), p=<0.001). CONCLUSION Prophylactic application of ciNPWT may be effective in reducing wound complications, PJI and reoperation post hip and knee revision arthroplasty surgery. The added cost of ciNPWT may be justified in the reduction of wound complications, PJI and reoperation. Ongoing trials determining if the prophylactic application of ciNPWT post hip and knee revision arthroplasty surgery is beneficial in preventing PJI particularly in high risk patients with additional comorbidities are warranted.
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Affiliation(s)
- Tracy Morgan
- The University of Adelaide, Adelaide, South Australia, Australia; Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia.
| | - Tamara Page
- Adelaide Nursing School, Faculty of Health & Medical Science, The University of Adelaide, Adelaide, South Australia, Australia.
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Baird HBG, Heffron WM, Pullen WM, Slone HS. Distinct risk profiles for short-term surgical complications and venous thromboembolism exist among extensor mechanism repair procedures. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38651565 DOI: 10.1002/ksa.12198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Extensor mechanism injuries, which comprise patella fractures, patella tendon tears and quadriceps tendon tears, are severely debilitating injuries and a common cause of traumatic knee pathology that requires surgical intervention. Risk factors for short-term surgical complications and venous thromboembolism (VTE) in this population have not been well characterised. The aim of this study was to identify perioperative risk factors associated with these short-term complications. METHODS The National Surgical Quality Improvement Program database was used to identify patients who underwent an isolated, primary extensor mechanism repair from 2015 to 2020. Patients were stratified by injury type. Demographic data were collected and compared. A multivariate logistic regression was used to control for demographic and comorbid factors while assessing risk factors for developing short-term complications. RESULTS A total of 8355 patients were identified for inclusion in this study. Overall, 3% of patients sustained short-term surgical complications and 1% were diagnosed with VTE within 30 days of surgery. Patella fracture fixation had a nearly twofold higher risk for surgical complications compared to quadriceps tendon repair (p = 0.004). Patella tendon repair had a twofold higher risk for VTE (p = 0.045), specifically deep vein thrombosis (p = 0.020), compared to patella fracture fixation. Increasing age, smoking and American Society of Anesthesiologists Classifications 3 and 4 were also found to be risk factors for surgical complications (p = 0.012, p = 0.004, p = 0.011 and p = 0.032, respectively). CONCLUSION This study used a nationally representative, widely validated, peer-reviewed database to provide valuable insights into risk factors for short-term postoperative complications associated with extensor mechanism repair procedures, revealing notable differences in risk profiles among distinct surgical procedures. The results of this study will inform surgeons and patients in enhancing risk assessment, guiding procedure-specific decision-making, optimising preoperative care, improving postoperative monitoring and contributing to future research of extensor mechanism injuries. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Henry B G Baird
- College of Medicine, Clinical Science Building, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Walker M Heffron
- Department of Orthopaedic Surgery and Physical Medicine, Clinical Sciences Building, Medical University of South Carolina, Charleston, South Carolina, USA
| | - W Michael Pullen
- Department of Orthopaedic Surgery and Physical Medicine, Clinical Sciences Building, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Harris S Slone
- Department of Orthopaedic Surgery and Physical Medicine, Clinical Sciences Building, Medical University of South Carolina, Charleston, South Carolina, USA
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Vasireddi N, Neitzke CC, Chandi SK, Cororaton AD, Driscoll DA, Sculco PK, Chalmers BP, Gausden EB. Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation. J Arthroplasty 2024; 39:1083-1087.e1. [PMID: 37871864 DOI: 10.1016/j.arth.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/06/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.
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Affiliation(s)
- Nikhil Vasireddi
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Colin C Neitzke
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sonia K Chandi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Agnes D Cororaton
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Daniel A Driscoll
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Elizabeth B Gausden
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Johnson TR, Oquendo YA, Seltzer R, Van Rysselberghe NL, Bishop JA, Gardner MJ. Incisional negative pressure wound therapy may not protect against post-operative surgical site complications in bicondylar tibial plateau fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1173-1181. [PMID: 37989870 DOI: 10.1007/s00590-023-03782-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To determine if incisional negative pressure wound therapy is protective against post-operative surgical site complications following definitive fixation of bicondylar tibial plateau fractures. METHODS A retrospective analysis of patients diagnosed with an acute bicondylar tibial plateau fracture (AO/OTA 41-C) undergoing ORIF from 2010 to 2020 was performed. Patients received either a standard sterile dressing (SD) or incisional negative pressure wound therapy (iNPWT). Primary outcomes included surgical site infection, osteomyelitis, and wound dehiscence. Secondary outcomes included non-union and return to the operating room. Multivariate logistic regression analyses were performed. RESULTS 180 patients were included and 22% received iNPWT (n = 40) and 78% received standard dressings (n = 140). iNPWT was more common in active smokers (24.7% vs. 19.3%, p = 0.002) and the SD group was more likely to be lost to follow up (3.6% vs. 0%, p = 0.025). iNPWT was not protective against infection or surgical site complications, and in fact, was associated with higher odds of post-operative infection (OR: 8.96, p = 0.005) and surgical site complications (OR:4.874, p = 0.009) overall. Alcohol abuse (OR: 19, p = 0.005), tobacco use (OR: 4.67, p = 0.009), and time to definitive surgery (OR = 1.21, p = 0.033) were all independent risk factors for post-operative infection. CONCLUSION In this series of operatively treated bicondylar tibial plateau fractures, iNPWT did not protect against post-operative surgical site complications compared to conventional dressings. Tobacco use, alcohol abuse, and time to definitive surgery, were independent risk factors for post-operative infection. Further studies are needed to determine if iNPWT offers a protective benefit in exclusively high-risk patients with relevant medical and social history.
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Affiliation(s)
- Taylor R Johnson
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA.
| | - Yousi A Oquendo
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Ryan Seltzer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | | | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway, Redwood City, CA, 94063, USA
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7
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Duncan ST, Schwarzkopf R, Seyler TM, Landy DC. The Practice Patterns of American Association of Hip and Knee Surgeons for the Management of Chronic Periprosthetic Joint Infection After Total Knee Arthroplasty. J Arthroplasty 2023; 38:2441-2446. [PMID: 37142069 DOI: 10.1016/j.arth.2023.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND The management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) has considerable variation. In order to better capture current preferences for the management of PJI, this study sought to poll the current members of American Association of Hip and Knee Surgeons (AAHKS) first to characterize the distribution of practice patterns. METHODS There were 32 questions in an online survey distributed to members of AAHKS. The questions were multiple choice regarding the management of PJI for TKA. There were 844 out of 2,752 members who completed the survey (response rate of 31%). RESULTS Most of the members were in private practice (50%) compared to 28% being in an academic setting. On average, members were performing between 6 to 20 PJI cases per year. Two-stage exchange arthroplasty was performed in over 75% of the cases with either a cruciate retaining (CR) or posterior stabilized (PS) primary femoral component used in over 50% of the cases and 62% using an all-polyethylene tibial implant. Most of the members were using vancomycin and tobramycin. Typically, 2 to 3 grams of antibiotics were added per bag of cement regardless of the cement type. When indicated, amphotericin was the most often-used antifungal. Post-operative management had major variability with range of motion, brace use, and weight-bearing restrictions. CONCLUSION There was variability in the responses from the members of AAHKS, but there was a preference toward performing a two-stage exchange arthroplasty with an articulating spacer using a metal femoral component and an all-polyethylene liner.
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Affiliation(s)
- Stephen T Duncan
- Department of Orthopedic Surgery, University of Kentucky, Lexington, Kentucky
| | | | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - David C Landy
- Department of Orthopedic Surgery, University of Kentucky, Lexington, Kentucky
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Magnuson JA, Griffin SA, Sutton RM, Blaber O, Ciesielka KA, Courtney PM, Krueger CA. Revision Total Hip Arthroplasty in Octogenarians Compared with Septuagenarians: Is There a Real Difference? J Bone Joint Surg Am 2023; 105:1246-1251. [PMID: 37200458 DOI: 10.2106/jbjs.22.00440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND The increasing frequency of total hip arthroplasty (THA) as well as an aging population indicate that the need for revision THA will continue to grow, especially in older and potentially medically complex patients. The purpose of this study was to compare THA revision indications, perioperative complications, and readmissions between octogenarian and septuagenarian patients. We hypothesized that patients aged 80 to 89 years would have similar outcomes to patients aged 70 to 79 years undergoing revision THA. METHODS Between 2008 and 2019, 572 revision THAs were performed at a single tertiary care hospital. Patients were stratified by age group: 70 to 79 years (n = 407) and 80 to 89 years (n = 165). Indication for revision, perioperative medical complications, and 90-day readmission were identified for each patient. Chi-square tests and t-tests were used to compare the groups. Logistic regression was used to assess medical complications and readmissions. RESULTS Aseptic loosening was a more common indication for revision in patients aged 70 to 79 years (33.4% versus 26.7%; p < 0.001), while periprosthetic fracture was a more common indication for revision in those aged 80 to 89 years (30.9% versus 13.0%). Perioperative medical complications occurred more often in octogenarians (10.9% versus 3.0%; p = 0.001), with arrythmia being the most common type. Patients aged 80 to 89 years were at increased risk for medical complications (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.5 to 7.3; p = 0.004) and readmission (OR, 3.2; 95% CI, 1.7 to 6.3; p < 0.001) when adjusting for body mass index (BMI) and indication for revision. Octogenarians had a higher rate of reoperation following first-time revision than septuagenarians (10.3% versus 4.2%, p = 0.009). CONCLUSIONS Octogenarians more commonly underwent revision THA for periprosthetic fracture and had higher rates of perioperative medical complications, 90-day readmissions, and reoperations than septuagenarians. Such findings should be considered when counseling patients on both primary and revision THAs. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Justin A Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sean A Griffin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
- Florida Atlantic University College of Medicine, Boca Raton, Florida
| | - Ryan M Sutton
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Olivia Blaber
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kerri-Anne Ciesielka
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Groenen H, Jalalzadeh H, Buis DR, Dreissen YE, Goosen JH, Griekspoor M, Harmsen WJ, IJpma FF, van der Laan MJ, Schaad RR, Segers P, van der Zwet WC, de Jonge SW, Orsini RG, Eskes AM, Wolfhagen N, Boermeester MA. Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis. EClinicalMedicine 2023; 62:102105. [PMID: 37538540 PMCID: PMC10393772 DOI: 10.1016/j.eclinm.2023.102105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023] Open
Abstract
Background The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA). Methods PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995. Findings We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis. Interpretation In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence. Funding Dutch Association for Quality Funds Medical Specialists.
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Affiliation(s)
- Hannah Groenen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Hasti Jalalzadeh
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Dennis R. Buis
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Yasmine E.M. Dreissen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Jon H.M. Goosen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Orthopedic Surgery, Sint Maartenskliniek, Ubbergen, Netherlands
| | - Mitchel Griekspoor
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Dutch Association of Medical Specialists, Utrecht, Netherlands
| | - Wouter J. Harmsen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Dutch Association of Medical Specialists, Utrecht, Netherlands
| | - Frank F.A. IJpma
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Division of Trauma Surgery, Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Maarten J. van der Laan
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Roald R. Schaad
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, Netherlands
- Dutch Association of Anesthesiology (NVA), Netherlands
| | - Patrique Segers
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wil C. van der Zwet
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Medical Microbiology, Infectious Diseases and Infection Prevention, Maastricht University Medical Center, Maastricht, Netherlands
| | - Stijn W. de Jonge
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Ricardo G. Orsini
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Anne M. Eskes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Gold Coast, Australia
| | - Niels Wolfhagen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
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10
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Hou Y, Collinsworth A, Hasa F, Griffin L. Incidence and impact of surgical site complications on length of stay and cost of care for patients undergoing open procedures. Surg Open Sci 2023; 14:31-45. [PMID: 37599673 PMCID: PMC10436177 DOI: 10.1016/j.sopen.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/25/2023] [Accepted: 05/10/2023] [Indexed: 08/22/2023] Open
Abstract
Background Surgical site complications (SSCs) can have serious and life-threatening consequences for patients; however, their frequency and impact on healthcare utilization across surgical procedures, particularly for non-infectious SSCs, are unknown. This study examined incidence of overall SSCs and non-infectious SSCs in patients undergoing open surgical procedures in the United States and their effect on length of stay (LOS) and costs. Methods This retrospective study utilizing 2019-2020 data from Medicare and Premier Health Database identified patients with SSCs during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSCs. Mean LOS and costs attributable to SSCs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSC on LOS and costs across healthcare settings. Results Overall and non-infectious SSC rates were 7.3 % and 5.3 % respectively for 2,696,986 Medicare and 6.7 % and 5.0 % for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSC were 7.8 days and $15,339 for Medicare patients and 6.2 days and $17,196 for Premier patients. Incremental LOS and cost attributable to non-infectious SSCs were 6.5 days and $12,703 and 5.2 days and $14,477 for Medicare and Premier patients respectively. Conclusions This study utilizing two large national databases provides strong evidence that SSCs, particularly non-infectious SSCs, are not uncommon in open surgeries and result in increased healthcare utilization and costs. These findings demonstrate the need for increased adoption of evidence-based interventions that can reduce SSC rates.
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11
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Yuan S, Zhang T, Zhang D, He Q, Du M, Zeng F. Impact of negative pressure wound treatment on incidence of surgical site infection in varied orthopedic surgeries: A systematic review and meta-analysis. Int Wound J 2023; 20:2334-2345. [PMID: 36524330 PMCID: PMC10333009 DOI: 10.1111/iwj.14043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 07/20/2023] Open
Abstract
Negative pressure wound therapy (NPWT) is a popular treatment to heal infected wounds. This meta-analysis aimed to determine if NPWT was more effective than conventional wound dressings for surgical site infections (SSI) in varied orthopaedic surgeries. Literature was retrieved from seven electronic databases (Medline, Web of Science, PubMed, Embase, Google Scholar, Cochrane Library, and CNKI). Randomised control trials (RCT) and retrospective cohort studies (RS) involving arthroplasty, fracture, and spinal surgery were extracted. SSI was our primary outcome, while total complications and length of hospital stay were secondary outcomes. We carried out the risk of bias assessment and meta-analysis using the Cochrane Risk of Bias 2.0 tool and Stata 17.0. Among the 798 studies retrieved, 18 of them met our inclusion criteria. We identified 13 RCTs and 5 RSs. The results of meta-analysis showed that the incidence of SSI in the NPWT group was significantly lower relative to the control group (OR = 0.60, 95% CI 0.47 to 0.77, P < 0.001). Subgroup analyses revealed that the incidences of SSI involving arthroplasty, fracture, and spinal surgery in the NPWT group accounted for 46%, 69%, and 37% relative to the control group, respectively. The incidence of SSI in RS (OR = 0.27, 95% CI 0.13 to 0.56) was significantly lower than that in RCT (OR = 0.69, 95% CI 0.54 to 0.90) (P = 0.02). Moreover, patients in the NPWT group had a lower total complication rate (OR = 0.51, 95% CI 0.34 to 0.76) and shorter hospital stays (SMD = -0.42, 95% CI -0.83 to -0.02), although high heterogeneity existed. NPWT may be an efficient alternative to help prevent the incidence of SSI and total complications as well as achieved shorten hospital stay in varied orthopaedic surgeries. The rational use of NPWT should be based on the presence of patients' clinical conditions and relevant risk factors.
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Affiliation(s)
- Song Yuan
- Department of OrthopaedicsDazhou Central HospitalDazhouChina
| | - Tingjiu Zhang
- Department of OrthopaedicsDazhou Central HospitalDazhouChina
| | - Dong Zhang
- Department of OrthopaedicsDazhou Central HospitalDazhouChina
| | - Qin He
- Department of OrthopaedicsDazhou Central HospitalDazhouChina
| | - Meiting Du
- Department of OrthopaedicsDazhou Central HospitalDazhouChina
| | - Fanwei Zeng
- Department of SpineSichuan Provincial Orthopedics HospitalChengduChina
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12
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Cooper HJ, Griffin LP, Bongards C, Silverman R. Outcomes of Two Different Negative Pressure Therapy Systems for Closed Incision Management in Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e40691. [PMID: 37485106 PMCID: PMC10358600 DOI: 10.7759/cureus.40691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Closed incision negative pressure therapy (ciNPT) has been adopted into practices of diverse surgical specialties to help reduce postsurgical complication risks. There are two primary commercially available systems that deliver ciNPT through different mechanisms. The purpose of this meta-analysis is to compare the potential effects of two different ciNPT systems on clinical outcomes following hip and knee arthroplasty. A systematic literature search was conducted to identify hip and knee arthroplasty studies comparing the incidence of surgical site infections (SSIs) and surgical site complications (SSCs) versus standard of care (SOC) following the use of two different ciNPT systems. Four meta-analyses were performed by calculating risk ratios (RR) to assess the effect of (1) ciNPT with foam dressing (ciNPT-F) versus SOC and (2) ciNPT with multilayer absorbent dressing (ciNPT-MLA) versus SOC. Comprehensive Meta-Analysis Version 3.0 (Biostat Inc., Englewood, NJ) software was used to perform the analyses. Twelve studies comparing ciNPT-F to SOC and six studies comparing ciNPT-MLAto SOC were analyzed. SSI rates were reported in seven of 12 studies involving ciNPT-F. In those, ciNPT-F significantly reduced the incidence of SSI (RR = .401, 95% confidence interval (CI) = .190, .844; p = .016). Across four of six studies that reported SSI rates, there was no significant difference in SSI rates between ciNPT-MLAvs SOC (RR = .580, 95% CI = .222, 1.513; p = .265). SSC rates were evaluated in eight of 12 ciNPT-F studies that reported SSC rates. This meta-analysis of the eight ciNPT-F studies showed significantly reduced SSC rates with ciNPT-F vs SOC (RR = .332, 95% CI = .236, .467; p < 0.001). For ciNPT-MLA, five of six studies reported SSC rates. In those, there was no significant difference in SSC rates between ciNPT-MLA vs SOC (RR = .798, 95% CI = .458, 1.398; p = .425). These meta-analyses results showed a significant reduction in SSI and SSC rates in the ciNPT-F group vs SOC and no difference in SSI and SSC rates in the ciNPT-MLA group vs SOC. The reasons for these observed differences were not evaluated as part of this study. Future controlled clinical studies comparing outcomes between different ciNPT systems over closed orthopedic incisions would help to validate these study results.
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Affiliation(s)
- H John Cooper
- Orthopedics, Columbia University Irving Medical Center, New York, USA
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13
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Cooper HJ, Silverman RP, Collinsworth A, Bongards C, Griffin L. Closed Incision Negative Pressure Therapy vs Standard of Care Over Closed Knee and Hip Arthroplasty Surgical Incisions in the Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis of Comparative Studies. Arthroplast Today 2023; 21:101120. [PMID: 37096179 PMCID: PMC10121636 DOI: 10.1016/j.artd.2023.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/03/2023] [Accepted: 01/29/2023] [Indexed: 04/26/2023] Open
Abstract
Background Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common surgical procedures but carry a risk of harmful and costly surgical site complications (SSCs). This systematic review and meta-analysis examined the impact of closed incision negative pressure therapy (ciNPT) on the risk of SSCs following THA and TKA. Methods A systematic literature review identified studies published between January 2005 and July 2021 comparing ciNPT (Prevena Incision Management System) to traditional standard-of-care dressings for patients undergoing THA and TKA. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national database. Results Twelve studies met the inclusion criteria. Eight studies evaluated SSCs, where a significant difference was seen in favor of ciNPT (relative risk [RR]: 0.332, P < .001). Significant benefits in favor of ciNPT were also observed for surgical site infection (RR: 0.401, P = .016), seroma (RR: 0.473, P = .008), dehiscence (RR: 0.380, P = .014), prolonged incisional drainage (RR: 0.399, P = .003), and rate of return to the operating room (RR: 0.418, P = .001). The estimated cost savings attributed to ciNPT use was $932 per patient. Conclusions The use of ciNPT after TKA and THA was associated with a significant reduction in the risk of SSCs, including surgical site infections, seroma, dehiscence, and prolonged incisional drainage. The risk of reoperation was reduced as were the costs of care in the modeled cost analysis, suggesting a potential for both economic and clinical advantages for ciNPT over standard-of-care dressings, particularly in high-risk patients.
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Affiliation(s)
- H. John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Ronald P. Silverman
- 3M Company, Saint Paul, MN, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashley Collinsworth
- 3M Company, Saint Paul, MN, USA
- Corresponding author. Medical Solutions Division, 3M Company, 12930 W Interstate 10, San Antonio, TX 78249, USA. Tel.: +1 469 990 6578.
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14
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Chau WW, Lo KCH, Lau LCM, Ong MTY, Ho KKW. Single use Negative Pressure Wound Therapy (NPWT) system in the management of knee arthroplasty. BMC Musculoskelet Disord 2023; 24:351. [PMID: 37147702 PMCID: PMC10161500 DOI: 10.1186/s12891-023-06470-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 04/27/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Wound complication, skin blister formation in particular, causes devastating consequences after total knee arthroplasty (TKA). Negative Pressure Wound Therapy (NPWT) tries to improve wound management leading to decrease length of hospital stay and better clinical outcomes. Low body mass index (BMI) could play a part in wound recovery management although lacking evidence. This study compared length of hospital stay and clinical outcomes between NPWT and Conventional groups, and factors affected and how BMI affected. METHODS This was a retrospective clinical record review of 255 (160 NPWT and 95 Conventional) patients between 2018 and 2022. Patient demographics including body mass index (BMI), surgical details (unilateral or bilateral), length of hospital stay, clinical outcomes including skin blisters occurrence, and major wound complications were investigated. RESULTS Mean age of patients at surgery was 69.95 (66.3% were female). Patients treated with NPWT stayed significantly longer in the hospital after joint replacement (5.18 days vs. 4.55 days; p = 0.01). Significantly fewer patients treated with NPWT found to have blisters (No blisters: 95.0% vs. 87.4%; p = 0.05). In patients with BMI < 30, percentage of patients requiring dressing change was significantly lower when treated with NPWT than conventional (0.8% vs. 33.3%). CONCLUSION Percentage of blisters occurrence in patients who underwent joint replacement surgery is significantly lower using NPWT. Patients using NPWT stayed significantly longer in the hospital after surgery because significant proportion received bilateral surgery. NPWT patients with BMI < 30 were significantly less likely to change wound dressing.
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Affiliation(s)
- Wai-Wang Chau
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Kelvin Chin-Hei Lo
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong SAR
| | - Lawrence Chun-Man Lau
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Michael Tim-Yun Ong
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Kevin Ki-Wai Ho
- Department of Orthopaedics and Traumatology, Chinese University of Hong Kong Medical Centre, Shatin, Hong Kong SAR.
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15
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Saini A, Dbeis A, Bascom N, Sanderson B, Golden T. A Radiographic Abdominal Pannus Sign is Associated With Postoperative Complications in Anterior THA. Clin Orthop Relat Res 2023; 481:1014-1021. [PMID: 36218821 PMCID: PMC10097585 DOI: 10.1097/corr.0000000000002447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 09/15/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Numerous studies have shown that elevated BMI is associated with adverse outcomes in THA; however, BMI alone does not adequately represent a patient's adipose and soft tissue distribution, especially when the direct-anterior approach is evaluated. Local soft tissue and adipose, especially in the peri-incisional region, has an unknown impact on patient outcomes after direct-anterior THA. Moreover, there is currently no known evaluation method to estimate the quantity of local soft tissue and adipose tissue. The current study introduced a new radiographic parameter that is measurable on supine AP radiographs: the abdominal pannus sign. QUESTION/PURPOSE Are patients who have an abdominal pannus extending below the upper (cephalad) border of the symphysis pubis more likely to experience problems after anterior-approach THA that are plausibly associated with that finding, including infections resulting in readmission, wound complications resulting in readmission, fractures, or longer surgical time, than patients who do not demonstrate this radiographic sign? METHODS Between 2015 and 2020, five surgeons performed 727 primary direct-anterior THAs. After exclusion criteria were applied, 596 procedures were included. Of those, we obtained postoperative radiographs in the postanesthesia care unit in 100% of procedures (596 of 596), and 100% of radiographs (596) were adequate for review in this retrospective study. The level of the pannus in relation to the pubic symphysis was assessed on immediate supine postoperative AP radiographs of the pelvis: above (pannus sign 1), between the upper and lower borders (pannus sign 2), or below the level of the pubic symphysis (pannus sign 3). In this study, we combined pannus signs 2 and 3 into a single group for analysis not only because there was a limited number of patients in each group, but also because there was no statistically significant difference between the two groups. Pannus sign 1 was identified in 82% of procedures (486 of 596), and pannus sign ≥ 2 was identified in 18% (110). We compared the groups (pannus sign 1 versus pannus sign ≥ 2) in terms of the percentage of patients who experienced problems within 90 days of THA that might be associated with that physical finding, including infections resulting in readmission including subcutaneous, subfascial, and prosthetic joint infections; wound complications resulting in readmission, defined as dehiscence or delayed healing; and all fractures, and we compared the groups in terms of surgical time-that is, the cut-to-close time. RESULTS Patients with a pannus sign of ≥ 2 were more likely than those with a pannus sign of 1 to have a postoperative infection (6.4% [seven of 110 procedures] versus 0.6% [three of 486], odds ratio 10.96 [95% confidence interval (CI) 2.83 to 42.38]; p < 0.01), wound complications (0.9% [one of 110] versus 0% [0 of 486] with an infinite odds ratio [95% CI indeterminate]; p = 0.18), and fractures (4.5% [five of 110] versus 0% [0 of 486], with an infinite odds ratio [95% CI indeterminate]; p < 0.01). The mean surgical time was longer in patients with a pannus sign of ≥ 2 than it was in those with a pannus sign of 1 (128 ± 25.3 minutes versus 118 ± 27.5 minutes, mean difference 10 minutes; p < 0.01). CONCLUSION Based on these findings, patients who have an abdominal pannus that extends below the upper (cephalad) edge of the pubic symphysis are at an increased risk of experiencing serious surgical complications. If THA is planned in these patients, an approach other than the direct-anterior approach should be considered. Surgeons performing THA who do not obtain supine radiographs preoperatively should use a physical examination to evaluate for this finding, and if it is present, they should use an approach other than the direct-anterior approach to minimize the risk of these complications. Future studies might compare the abdominal pannus sign using standing radiographs, which are used more often, with other well-documented associated risk factors such as elevated BMI or higher American Society of Anesthesiologists classification. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Atul Saini
- Department of Orthopedic Surgery, Community Memorial Health System, Ventura, CA, USA
| | - Ammer Dbeis
- Department of Orthopedic Surgery, Community Memorial Health System, Ventura, CA, USA
| | - Nathan Bascom
- Department of Orthopedic Surgery, Community Memorial Health System, Ventura, CA, USA
| | - Brent Sanderson
- Department of Orthopedic Surgery, Community Memorial Health System, Ventura, CA, USA
| | - Thomas Golden
- Department of Orthopedic Surgery, Community Memorial Health System, Ventura, CA, USA
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16
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Koressel J, Perez BA, Minutillo GT, Granruth CB, Mastrangelo S, Lee GC. Wound complications following revision total knee arthroplasty: Prevalence and outcomes. Knee 2023; 42:44-50. [PMID: 36878112 DOI: 10.1016/j.knee.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/22/2023] [Accepted: 02/10/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Wound complications following revision TKA can be catastrophic and can compromise joint and even limb. The purpose of this study was to determine the prevalence of superficial wound complications requiring return to the OR in revision TKA, rates of subsequent deep infection, factors that increase the risk of superficial wound complications, and the outcomes of revision TKA following development of superficial wound complications. METHODS We retrospectively reviewed 585 consecutive TKA revisions with at least two years follow-up, including 399 aseptic revisions and 186 reimplantations. Superficial wound complications without deep infection requiring return to the OR within 120 days were compared to controls. RESULTS Fourteen patients following revision TKA (2.4%) required return to the OR for a wound complication, including 7 of 399 (1.8%) patients who underwent aseptic revision TKA and 7 of 186 (3.8%) patients undergoing reimplantation TKA (p = 0.139). Aseptic revisions with wound complications were more likely to develop subsequent deep infection (HR 10.04, CI 2.24-45.03, p = 0.003), but this did not hold true for reimplantations (HR 1.17, CI 0.28-4.91, p = 0.829). Risk factors for wound complication included atrial fibrillation when all patients were combined (RR 3.98, CI 1.15-13.72, p = 0.029), connective tissue disease in the aseptic revision group (RR 7.1, CI 1.1-44.7, p = 0.037), and a history of depression in the re-implantation group (RR 5.8, CI 1.1-31.5, p = 0.042).
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Affiliation(s)
- Joseph Koressel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Brian A Perez
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Gregory T Minutillo
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Caroline B Granruth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Sand Mastrangelo
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, United States.
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17
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Cooper HJ, Singh DP, Gabriel A, Mantyh C, Silverman R, Griffin L. Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4722. [PMID: 36936465 PMCID: PMC10019176 DOI: 10.1097/gox.0000000000004722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/26/2022] [Indexed: 03/18/2023]
Abstract
Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes. Methods A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments. Results The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05). Discussion For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.
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Affiliation(s)
- H. John Cooper
- From the Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, N.Y
| | - Devinder P. Singh
- Department of Plastic Surgery, University of Miami Health System and Miller School of Medicine, Miami, Fla
| | | | | | - Ronald Silverman
- Department of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Md
- Medical Solutions Division, 3M, St Paul, Minn
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18
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Naylor BH, Tarazi JM, Salem HS, Harwin SF, Mont MA. Wound Management following Total Knee Arthroplasty: An Updated Review. J Knee Surg 2023; 36:274-283. [PMID: 34261158 DOI: 10.1055/s-0041-1731740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Optimal wound closure techniques following total knee arthroplasty (TKA) have focused on enhancing healing potential, preventing infection, yielding satisfactory cosmesis, and allowing early ambulation and functionality. An appropriate layered closure and management of the TKA typically involves addressing the (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) final application of a specific aseptic dressing, each of which are covered here in detail. This focused critical review of the literature discusses traditional techniques used in all layers of wound closure following TKA while introducing several emerging popular techniques. For example, absorbable barbed skin sutures and occlusive dressings have the potential to reduce operative time, limit the need for early postoperative visits, obviate the need for suture or staple removal, and safely promote patient communication via telemedicine. As novel wound closure techniques continue to emerge and traditional approaches are improved upon, future comparative studies will assist in elucidating the key advantages of various options. In an extremely important field that has tremendous variability, these efforts may enable the reaching of a classically elusive standard of care for these techniques.
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Affiliation(s)
- Brandon H Naylor
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York City, New York
| | - John M Tarazi
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York City, New York
| | - Hytham S Salem
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York City, New York
| | - Steven F Harwin
- Department of Orthopaedic Surgery, Mount Sinai West Hospital, New York City, New York
| | - Michael A Mont
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York City, New York
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19
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Hou Y, Collinsworth A, Hasa F, Griffin L. Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. Surg Open Sci 2023; 11:1-18. [PMID: 36425301 PMCID: PMC9679670 DOI: 10.1016/j.sopen.2022.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background Surgical site infections (SSIs) are associated with increased morbidity and mortality; however, current SSI rates across open procedures and their effect on healthcare delivery are unknown. The objective of this study was to examine incidence of SSIs for open surgical procedures in the United States and impact on length of stay (LOS) and costs. Methods This retrospective study utilizing 2019-2020 data from Medicare and Premier identified patients with SSIs occurring during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSIs. Mean LOS and costs attributable to SSIs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSI on LOS and costs across healthcare settings. Results SSI rates were 2.0% for 2,696,986 Medicare and 1.8% for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSI, including index admission, readmissions, and outpatient visits were 9.3 days and $18,626 for Medicare patients and 7.8 days and $20,979 for Premier patients. SSI rates were higher for urgent/emergency surgeries compared to overall SSI rates. Although less common that superficial SSIs, deep SSIs resulted in higher incremental LOS and index costs for the index admission and for SSI-related readmissions. Conclusions This study of SSIs utilizing two large national databases provides robust data and analytics reinforcing and bolstering current evidence that SSIs occur infrequently but are detrimental to patients in terms of increased LOS and care costs.
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Affiliation(s)
- Yuefeng Hou
- 3M, Medical Solutions Division, 12930 W Interstate 10, San Antonio, TX 78249
| | - Ashley Collinsworth
- 3M, Medical Solutions Division, 12930 W Interstate 10, San Antonio, TX 78249
| | - Flutura Hasa
- 3M, Medical Solutions Division, 12930 W Interstate 10, San Antonio, TX 78249
| | - Leah Griffin
- 3M, Medical Solutions Division, 12930 W Interstate 10, San Antonio, TX 78249
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20
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McMillan H, Vo UG, Moss JL, Barry IP, Bosanquet DC, Richards T. Controlling the controls: what is negative pressure wound therapy compared to in clinical trials? Colorectal Dis 2022; 25:794-805. [PMID: 36579358 DOI: 10.1111/codi.16465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022]
Abstract
AIM Surgical site infections (SSIs) are common following colorectal operations. Clinical trials suggest that closed incision negative pressure wound therapy (ciNPWT) may reduce SSIs compared to a 'standard of care' group. However, wound management in the standard of care group may vary. The aim of this review was to assess the control arms in trials of ciNPWT for potential confounding variables that could influence the rates of SSI and therefore the trial outcomes. METHODS A mapping review of the PubMed database was undertaken in the English language for randomized controlled trials that assessed, in closed surgical wounds, the use of ciNPWT compared to standard of care with SSI as an outcome. Data regarding wound care to assess potential confounding factors that may influence SSI rates were compared between the ciNPWT and standard of care groups. Included were the method of wound closure, control dressing type, frequency of dressing changes and postoperative wound care (washing). RESULTS Twenty-seven trials were included in the mapping review. There was heterogeneity in ciNPWT duration. There was little control in the comparator standard of care groups with a variety of wound closure techniques and different control dressings used. Overall standard of care dressings were changed more frequently than the ciNPWT dressing and there was no control over wound care or washing. No standard for 'standard of care' was apparent. CONCLUSION In randomized trials assessing the intervention of ciNPWT compared to standard of care there was considerable heterogeneity in the comparator groups and no standard of care was apparent. Heterogeneity in dressing protocols for standard of care groups could introduce potential confounders impacting SSI rates. There is a need to standardize care in ciNPWT trials to assess potential meaningful differences in SSI prevention.
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Affiliation(s)
- Hayley McMillan
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia
| | - Uyen G Vo
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jana-Lee Moss
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ian P Barry
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - David C Bosanquet
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK
| | - Toby Richards
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia
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One and a Half-Stage Revision With Prosthetic Articulating Spacer for Definitive Management of Knee Periprosthetic Joint Infection. Arthroplast Today 2022; 19:100993. [PMID: 36507285 PMCID: PMC9727150 DOI: 10.1016/j.artd.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 12/12/2022] Open
Abstract
This paper is a comprehensive review that describes indications, contraindications, clinical outcomes, and pearls and pitfalls of 1.5-stage revision total knee arthroplasty (TKA) utilizing a primary TKA femoral component, all-polyethylene tibial component, and hand-crafted antibiotic cement for the management of chronic periprosthetic joint infection. The 1.5-stage exchange TKA details placement of an articulating spacer for an indefinite period, prolonging revision until reinfection, deterioration of functional status, or construct failure. A 1.5-stage revision TKA technique is a viable option for treatment of chronic periprosthetic knee infections. The inherent advantages of decreased health-care costs, decreased morbidity and mortality, and improved emotional ease from having a single procedure is attractive, especially if reinfection rates are determined to be equivocal to 2-stage revision.
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22
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Chen Z, Bains SS, Sax OC, Sodhi N, Mont MA. Dressing Management during Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Knee Surg 2022; 35:1524-1532. [PMID: 36538940 DOI: 10.1055/s-0042-1758674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Dressings for total knee arthroplasty (TKA) typically focus on promoting optimal healing, while preventing infection, allowing for functionality and immediate ambulation, while providing for excellent cosmesis. We have previously described four aspects of closure after TKA involving the: (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) a specific aseptic dressing. In this meta-analysis and systematic review of the literature, we will focus on the dressing. Specifically, we assessed: (1) infection risk of different techniques; (2) re-operation or readmission risk; and (3) length of time until dressing change needed. There were 16 reports on infection risk, re-operation risk, and length of time until change needed. A meta-analysis focused on the qualifying wound complication risk reports was also performed. The meta-analysis including four studies (732 patients) demonstrated overall lower wound complication risk with the use of adhesives and mesh dressings (odds ratio 0.67) versus traditional closures. Additionally, studies demonstrated fewer re-operations and readmissions with the use of adhesives and mesh dressings. Furthermore, one report demonstrated mesh dressings persist longer than silver dressings. Therefore, multiple recent reports suggest superior outcomes when using adhesive and mesh dressings for TKAs.
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Affiliation(s)
- Zhongming Chen
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Oliver C Sax
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, North Shore University Hospital Northwell Health, New York, New York
| | - Michael A Mont
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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23
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Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Kavolus JJ. The Cost-Effectiveness of Closed Incisional Negative Pressure Wound Therapy for Infection Prevention after Revision Total Knee Arthroplasty. J Knee Surg 2022; 35:1301-1305. [PMID: 33511588 DOI: 10.1055/s-0041-1724137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses.
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Affiliation(s)
- Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | | | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Joseph J Kavolus
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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24
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How Can Negative Pressure Wound Therapy Pay for Itself?-Reducing Complications Is Important. J Orthop Trauma 2022; 36:S31-S35. [PMID: 35994307 DOI: 10.1097/bot.0000000000002427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Orthopaedic trauma demonstrates a relatively high rate of surgical site infections (SSI) as compared with other surgical specialties. SSIs provide significant clinical challenges and create significant health care costs. Incisional negative pressure wound therapy (iNPWT) has reduced the risk of SSI in orthopaedic surgery and other surgical specialties. PURPOSE The purpose of this study is to investigate potential cost savings with the use of iNPWT (3M Prevena Therapy, 3M, St. Paul, MN) in high-risk orthopaedic trauma patients with closed OTA/AO 41C and 43C fractures. METHODS This is a retrospective cohort study performed at a single, level-1 trauma center using data from a lower extremity fracture registry. Using the results from the registry and baseline infection rates derived from the literature, a health economic model was developed to evaluate the potential cost savings. RESULTS A total of 79 patients included in the registry underwent open reduction and internal fixation of OTA/AO 41C and 43C fractures. A total of 10.1% developed a SSI. For those who received iNPWT, the rate of SSI was 7.4%. A health economic model suggests that the use of iNPWT may reduce the costs per patient by approximately $1381 to $4436 per patient. CONCLUSIONS This health economic assessment and model suggests that judicious use of iNPWT may reduce health care costs in patients undergoing open reduction and internal fixation of OTA/AO 41C and 43C fractures. LEVEL OF EVIDENCE Economic Level IV.
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25
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Cooper HJ, Santos WM, Neuwirth AL, Geller JA, Rodriguez JA, Rodriguez-Elizalde S, Shah RP. Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty. J Arthroplasty 2022; 37:S931-S936. [PMID: 35304299 DOI: 10.1016/j.arth.2022.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA. METHODS This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m2, diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications. RESULTS One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ2 = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ2 = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI. CONCLUSION Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.
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Affiliation(s)
- H John Cooper
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Walkania M Santos
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jose A Rodriguez
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | | | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Cooper HJ, Bongards C, Silverman RP. Cost-Effectiveness of Closed Incision Negative Pressure Therapy for Surgical Site Management After Revision Total Knee Arthroplasty: Secondary Analysis of a Randomized Clinical Trial. J Arthroplasty 2022; 37:S790-S795. [PMID: 35288248 DOI: 10.1016/j.arth.2022.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 03/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The PROMISES (Post-market, Randomized, Open-Label, Multicenter, Study to Evaluate the Effectiveness of Closed Incision Negative Pressure Therapy Versus Standard of Care Dressings in Reducing Surgical Site Complications in Subjects With Revision of a Failed Total Knee Arthroplasty) randomized controlled trial compared closed incision negative pressure therapy (ciNPT) to standard of care (SOC) after revision total knee arthroplasty in high-risk patients. We assessed the costs associated with 90-day surgical site complications (SSCs) to determine the cost-benefit of ciNPT. METHODS A health economic model was used to determine mean per-patient costs to manage the surgical site, including the costs of postoperative dressings, surgical and non-surgical interventions, and readmission. A subanalysis was performed to examine cost-benefit in "lower risk" (Charlson Comorbidity Index < 2) and "higher risk" (Charlson Comorbidity Index ≥ 2) patients. RESULTS Patients with ciNPT experienced fewer SSCs (3.4% vs 14.3%; P = .0013) and required fewer surgical (0.7% vs 4.8%; P = .0666) and non-surgical (2.7% vs 12.9%; P = .0017) interventions compared to those with SOC. Readmission rates were significantly higher when patients experienced SSC (31% vs 4%; P = .0001). Using the economic model, respective per-patient costs for the ciNPT and SOC groups were $666 and $52 for postoperative dressings, $135 and $994 for surgical interventions, $231 and $970 for readmissions, and $15 and $70 for non-surgical interventions. Total per-patient costs for surgical site management were $1,047 for ciNPT and $2,036 for SOC. Among the lower risk population, mean per-patient cost was $1,066 for ciNPT and $1,474 for SOC. Among the higher risk population, mean per-patient cost was $676 for ciNPT and $3,212 for SOC. CONCLUSION Despite higher upfront costs for postoperative dressings, ciNPT was cost-effective in this health economic model, decreasing the costs of surgical site management after revision total knee arthroplasty by 49% in this study population and 79% in higher risk subgroup.
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Affiliation(s)
- Herbert J Cooper
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY
| | | | - Ronald P Silverman
- 3M Company, St. Paul, MN; University of Maryland School of Medicine, Baltimore, MD
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Lygrisse KA, Teo G, Singh V, Muthusamy N, Schwarzkopf R, William L. Comparison of silver-embedded occlusive dressings and negative pressure wound therapy following total joint arthroplasty in high BMI patients: a randomized controlled trial. Arch Orthop Trauma Surg 2022; 143:2989-2995. [PMID: 35779102 DOI: 10.1007/s00402-022-04530-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION High body mass index (BMI) and wound drainage following total joint arthroplasty (TJA) can lead to wound healing complications and periprosthetic joint infection. Silver-embedded occlusive dressings and negative pressure wound therapy (NPWT) have been shown to reduce these complications. The purpose of this prospective trial was to compare the effect of silver-embedded dressings and NPWT on wound complications in patients with BMI ≥ 35 m/kg2 undergoing TJA. METHODS We conducted a randomized control trial of patients who had a BMI > 35 m/kg2 and were undergoing primary TJA between October 2017 and February 2020. Patients who underwent revision surgery, or those with an active infection, previous scar, history of wound healing complications, post-traumatic degenerative joint disease with hardware, or inflammatory arthritis were excluded. Patients were randomized to receive either a silver-embedded occlusive dressing (control) or NPWT. Frequency distributions, means, and standard deviations were used to describe patient demographics, postoperative complications, 90-day readmissions, and reoperations. T-test and chi-squared tests were used to test for significant differences between continuous and categorical variables, respectively. RESULTS Two hundred-thirty patients with 3-month follow-up were included. One-hundred-fifteen patients received the control and 115 patients received NPWT. There were six patients (5.2%) in the control group with wound complications (drainage: n = 5, non-healing wound: n = 1) and two patients (1.7%) in the NPWT with complications (drainage: n = 2). There were no 90-day readmissions in the control group versus two (1.8%) 90-day readmissions in the NPWT group. Finally, three patients (2.6%) in the control group underwent reoperations (irrigation and debridement [I&D], I&D with modular implant exchange, and implant revision), while none in the NPWT group had undergone reoperation. The two groups showed insignificant differences in wound complications (p = 0.28), 90-day readmissions (p = 0.50), and reoperations (p = 0.25). CONCLUSION Patients with BMI ≥ 35 m/kg2 undergoing TJA have no statistical difference in early wound complications, readmissions, or reoperations when treated with either silver-embedded dressings or NPWT.
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Affiliation(s)
- Katherine A Lygrisse
- Department of Orthopedic Surgery, Huntington Hospital, Zucker School of Medicine Hofstra/Northwell, 270 Park Ave, Huntington, NY, 11743, USA
| | - Greg Teo
- Department of Orthopedic Surgery, Hospital for Special Surgeries, 541 East 71st St, 7th Fl, New York, NY, 10021, USA
| | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Health, 301, East 17th Street, New York, NY, 10003, USA.
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Long William
- Department of Orthopedic Surgery, Hospital for Special Surgeries, 541 East 71st St, 7th Fl, New York, NY, 10021, USA
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Polymicrobial Colonization of Prosthetic Joint Infections Treated With Open Wound Management. J Arthroplasty 2022; 37:S653-S656. [PMID: 35283231 DOI: 10.1016/j.arth.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Open wound management in prosthetic joint infection (PJI) patients has been used in problematic dehisced wounds hoping to stimulate granulation tissue and closure. However, infections that start as a monomicrobial PJI can become polymicrobial with resultant worse outcomes following open wound management. This study assessed the relationship between open wound management and the development of polymicrobial periprosthetic joint infections. METHODS We reviewed patients referred with a synovial cutaneous fistula. Patients with an open wound measuring less than 2 cm and less than two weeks of open wound management were excluded. Variables included original organisms cultured, type and length of open wound management, and organisms cultured at the time of revision infection surgery. RESULTS Of the 65 patients with a previous monomicrobial infection treated with open wound management, 22/65 (34%) progressed to a polymicrobial infection. Thirty (46%) wounds were packed open with gauze, 20 (31%) were managed with negative pressure wound therapy, and 15 (23%) had surface dressings only. Of the 22 patients who converted to a polymicrobial infection, only 10 (45%) were infection free at follow-up. In contrast, 30 of 43 patients (70%) whose infections remained monomicrobial were infection free at follow-up. CONCLUSION Open wound management can lead to conversion from a monomicrobial to a polymicrobial PJI, a rate of 34% in this series. Open prosthetic wound management should be discontinued for a fear of converting a monomicrobial infection to a difficult to treat polymicrobial infection. Surgeons must be prudent in the use of open wound management. LEVEL OF EVIDENCE Level IV, Retrospective Case Series.
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Salem HS, Sherman AE, Chen Z, Scuderi GR, Mont MA. The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review. J Knee Surg 2022; 35:1023-1043. [PMID: 34875715 DOI: 10.1055/s-0041-1740394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.
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Affiliation(s)
- Hytham S Salem
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Alain E Sherman
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
| | - Zhongming Chen
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Giles R Scuderi
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
| | - Michael A Mont
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Sheridan GA, Lennox PA, Masri BA. Soft Tissue Procedures in the Multiply Operated on Knee Replacement Patient. Orthop Clin North Am 2022; 53:267-276. [PMID: 35725035 DOI: 10.1016/j.ocl.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the multiply operated on knee replacement, no one soft tissue procedure is vastly superior to another. The most extensive literature available is in relation to muscle flaps, which will continue to be the workhorse technique for orthopedic and plastic reconstructive surgeons for the foreseeable future. Closed incision negative pressure wound therapy may prove to be a superior method in time but further large-scale studies are required to expand our understanding of this technique. The continued use of a combination of these techniques, tailored to the specific patient, is likely to be the best approach to the multiply operated on knee into the future.
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Affiliation(s)
- Gerard A Sheridan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Peter A Lennox
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Yilmaz M, Thorn A, Sørensen MS, Jensen CL, Petersen MM. Effect of negative pressure wound therapy after surgical removal of deep-seated high-malignant soft tissue sarcomas of the extremities and trunk wall-study protocol for a randomized controlled trial. Trials 2022; 23:507. [PMID: 35717239 PMCID: PMC9206250 DOI: 10.1186/s13063-022-06468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 06/09/2022] [Indexed: 11/22/2022] Open
Abstract
Background Sarcomas are a heterogeneous group of rare malignant tumors of mesenchymal origin in the musculoskeletal system. The main treatment is surgery often supplemented with pre-or postoperative radiotherapy. A retrospective study by Bedi et al. indicated that negative pressure wound therapy (NPWT) reduced the risk of postoperative wound complications in patients treated with preoperative radiation followed by surgical tumor removal of lower extremity soft tissue sarcomas (STS), and the use of NPWT was not associated with an increased risk of local recurrence. Previous studies have shown that NPWT can reduce postoperative complications. STS surgeries are a high-risk procedure concerning wound complications. Methods Non-blinded single-center randomized controlled trial comparing NPWT versus conventional wound dressing and postoperative wound complications after surgical removal of deep-seated high-malignant STS of the extremities or trunk wall Sample-size calculation: 154 STS patients (80% risk of avoiding type II error, 5% risk of type I error, and an 80% wound complication risk) Block randomization of 8 into: Group A: Conventional wound dressing Group B: NPWT (PREVENA PLUS™ Incision Management System) Inclusion criteria: Surgery for a deep-seated STS of an extremity or the trunk wall Exclusion criteria: Age < 18 years, plastic surgery, low malignant/borderline STS, chemotherapy, preoperative radiotherapy, allergic/hypersensitive to acrylic adhesives or silver, unwilling/unable to provide informed consent, metastatic disease, and ischemic surgeries Primary study endpoints were set as major wound complications defined by O’Sullivan et al. as a secondary surgery under anesthesia for wound repairs and wound management without secondary surgery within 4 months postoperatively. Secondary study endpoints among others are Musculoskeletal Tumor Society Score (MSTS), Toronto Extremity Salvage Score (TESS), and European Quality of Life - 5 Dimensions (EQ-5D). Approval from the Scientific Ethical Committee and the Data Protection Agency has been obtained, and the study is registered at clinicaltrial.gov. This study did not apply for external funding. Discussion Many new medical devices and technical solutions are currently being introduced, and even though some documentation regarding the use of NPWT, e.g., in joint replacement surgery exist, it is also important to seek documentation for this treatment principle in STS surgery. Trial registration Registered at ClinicalTrials.gov NCT04960332 and approved on 11 July 2021
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Affiliation(s)
- Müjgan Yilmaz
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Andrea Thorn
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Michala Skovlund Sørensen
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Claus Lindkær Jensen
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Michael Mørk Petersen
- Department of Orthopedic Surgery, University Hospital of Copenhagen, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
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Norman G, Shi C, Goh EL, Murphy EM, Reid A, Chiverton L, Stankiewicz M, Dumville JC. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2022; 4:CD009261. [PMID: 35471497 PMCID: PMC9040710 DOI: 10.1002/14651858.cd009261.pub7] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain. OBJECTIVES To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure. SEARCH METHODS In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting. SELECTION CRITERIA We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence. MAIN RESULTS In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I2 = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I2 = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I2 = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I2 = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I2 = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I2 = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I2 = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I2 = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed. AUTHORS' CONCLUSIONS People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Elizabeth Ma Murphy
- Ward 64, St. Mary's Hospital, Manchester Foundation NHS Trust, Manchester, UK
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Mortazavi SMJ, Razzaghof M, Ghasemi MA. Parsonage-Turner Syndrome and Closed-Incision Negative-Pressure Wound Therapy After Total Hip Arthroplasty in a Case of Marfan Syndrome. Arthroplast Today 2022; 14:1-5. [PMID: 35097175 PMCID: PMC8783111 DOI: 10.1016/j.artd.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022] Open
Abstract
Negative pressure wound therapy (NPWT) is a postoperative wound care method, which has recently become an ongoing field of research in hip and knee arthroplasty. We report the successful management of wound dehiscence and infection after THA in a case of Marfan syndrome by closed-incision negative-pressure wound therapy (ciNPWT). Our patient also developed a rare postoperative neurologic complication, that is, Parsonage-Turner syndrome (PTS). To our knowledge, this is the first report of PTS and ciNPWT use for SSI after THA in a Marfan patient. As wound dehiscence and infection can occur after THA in Marfan patients, we propose ciNPWT as an option to treat or even prevent (prophylactic use) such complications in this rare group of patients.
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Affiliation(s)
- Seyed Mohammad Javad Mortazavi
- Corresponding author. Imam Khomeini Hospital Complex, North Chamran Highway, East Baqerkhan Street, Tehran 1419733141, IR Iran. Tel.:+98 21 66581586.
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Elcock KL, Carter TH, Yapp LZ, MacDonald DJ, Howie CR, Stoddart A, Berg G, Clement ND, Scott CEH. Total knee arthroplasty in patients with severe obesity provides value for money despite increased complications. Bone Joint J 2022; 104-B:452-463. [PMID: 35360945 DOI: 10.1302/0301-620x.104b4.bjj-2021-0353.r3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m2). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m2 to examine whether this is supported. METHODS This single-centre study compared 169 consecutive patients with severe obesity (BMI ≥ 40 kg/m2) (mean age 65.2 years (40 to 87); mean BMI 44.2 kg/m2 (40 to 66); 129/169 female) undergoing unilateral TKA to a propensity score matched (age, sex, preoperative Oxford Knee Score (OKS)) cohort with a BMI < 40 kg/m2 in a 1:1 ratio. Demographic data, comorbidities, and complications to one year were recorded. Preoperative and one-year patient-reported outcome measures (PROMs) were completed: EuroQol five-dimension three-level questionnaire (EQ-5D-3L), OKS, pain, and satisfaction. Using national life expectancy data with obesity correction and the 2020 NHS National Tariff, QALYs (discounted at 3.5%), and direct medical costs accrued over a patient's lifetime, were calculated. Probabilistic sensitivity analysis (PSA) was used to model variation in cost/QALY for each cohort across 1,000 simulations. RESULTS All PROMs improved significantly (p < 0.05) in both groups without differences between groups. Early complications were higher in BMI ≥ 40 kg/m2: 34/169 versus 52/169 (p = 0.050). A total of 16 (9.5%) patients with a BMI ≥ 40 kg/m2 were readmitted within one year with six reoperations (3.6%) including three (1.2%) revisions for infection. Assuming reduced life expectancy in severe obesity and revision costs, TKA in patients with a BMI ≥ 40 kg/m2 costs a mean of £1,013/QALY (95% confidence interval £678 to 1,409) more over a lifetime than TKA in patients with BMI < 40 kg/m2. In PSA replicates, the maximum cost/QALY was £3,921 in patients with a BMI < 40 kg/m2 and £5,275 in patients with a BMI ≥ 40 kg/m2. CONCLUSION Higher complication rates following TKA in severely obese patients result in a lifetime cost/QALY that is £1,013 greater than that for patients with BMI < 40 kg/m2, suggesting that TKA remains a cost-effective use of healthcare resources in severely obese patients where the surgeon considers it appropriate. Cite this article: Bone Joint J 2022;104-B(4):452-463.
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Affiliation(s)
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Liam Z Yapp
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Colin R Howie
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
| | - Andrew Stoddart
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Guy Berg
- Healthcare Improvement Scotland, Edinburgh, UK
| | - Nick D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Orthopaedics, University of Edinburgh, Edinburgh, UK
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Shen TS, Gu A, Bovonratwet P, Ondeck NT, Sculco PK, Su EP. Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study. Clin Orthop Relat Res 2022; 480:495-503. [PMID: 34543238 PMCID: PMC8846341 DOI: 10.1097/corr.0000000000001985] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 09/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described. QUESTIONS/PURPOSES (1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA? METHODS Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups. RESULTS Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04). CONCLUSION Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Tony S. Shen
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Alex Gu
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Patawut Bovonratwet
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Nathaniel T. Ondeck
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Peter K. Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
| | - Edwin P. Su
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA
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36
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Elhage KG, Awad ME, Irfan FB, Lumbley J, Mostafa G, Saleh KJ. Closed‐incision
negative pressure therapy at −125
mmHg
significantly reduces surgical site complications following total hip and knee arthroplasties: A stratified meta‐analysis of randomized controlled trials. Health Sci Rep 2022; 5:e425. [PMID: 35229037 PMCID: PMC8865069 DOI: 10.1002/hsr2.425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022] Open
Abstract
Background Closed‐incision negative pressure wound therapy (ciNPT) has shown promising effects for managing infected wounds. This meta‐analysis explores the current state of knowledge on ciNPT in orthopedics and addresses whether ciNPT at −125 mmHg or −80 mmHg or conventional dressing reduces the incidence of surgical site complications in hip and knee arthroplasty. Methods This meta‐analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta‐analysis (PRISMA) guidelines and Cochrane Handbook. Prospective randomized controlled trials (RCTs) with ciNPT use compared to conventional dressings following hip and knee surgeries were considered for inclusion. Non‐stratified and stratified meta‐analyses of six RCTs were conducted to test for confounding and biases. A P value less than .05 was considered statistically significant. Results The included six RCTs have 611 patients. Total hip and knee arthroplasties were performed for 51.7% and 48.2% of the included population, respectively. Of 611 patients, conventional dressings were applied in 315 patients and 296 patients received ciNPT. Two ciNPT systems have been used across the six RCTs; PREVENA Incision Management System (−125 mmHg) (63.1%) and PICO dressing (−80 mmHg) (36.8%). The non‐stratified analysis showed that the ciNPT system had a statistically significant, lower risk of persistent wound drainage as compared to conventional dressing following total hip and knee arthroplasties (OR = 0.28; P = .002). There was no difference between ciNPT and conventional dressings in terms of wound hematoma, blistering, seroma, and dehiscence. The stratified meta‐analysis indicated that patients undergoing treatment with high‐pressure ciNPT (120 mmHg) displayed significantly fewer overall complications and persistent wound drainage (P = .00001 and P = .002, respectively) when compared to low‐pressure ciNPT (80 mmHg) and conventional dressings. In addition, ciNPT is associated with shorter hospital stays. (P = .005). Conclusion When compared to conventional wound dressing and −80 mmHg ciNPT, the use of −125 mmHg ciNPT is recommended in patients undergoing total joint arthroplasty.
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Affiliation(s)
- Kareem G. Elhage
- FAJR Scientific Northville Michigan 48167 USA
- Wayne State University, School of Medicine Detroit Michigan USA
| | - Mohamed E. Awad
- FAJR Scientific Northville Michigan 48167 USA
- NorthStar Anesthesia‐Detroit Medical center Detroit Michigan USA
- Michigan State University, College of Osteopathic Medicine Detroit Michigan USA
| | - Furqan B. Irfan
- Michigan State University, College of Osteopathic Medicine Detroit Michigan USA
| | - Joshua Lumbley
- NorthStar Anesthesia‐Detroit Medical center Detroit Michigan USA
| | - Gamal Mostafa
- Wayne State University, School of Medicine Detroit Michigan USA
- Surgical Outcomes Research Institute, John D. Dingell VA Medical Center Detroit Michigan USA
| | - Khaled J. Saleh
- FAJR Scientific Northville Michigan 48167 USA
- Michigan State University, College of Osteopathic Medicine Detroit Michigan USA
- Surgical Outcomes Research Institute, John D. Dingell VA Medical Center Detroit Michigan USA
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37
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Dowling S, Alton TB. A Modified Technique for Applying Closed Incision Negative Pressure Therapy Dressing Following Total Joint Arthroplasty. Cureus 2021; 13:e20539. [PMID: 35103124 PMCID: PMC8769074 DOI: 10.7759/cureus.20539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 12/03/2022] Open
Abstract
Postoperative incisional management subsequent to total joint replacement arthroplasty is of importance to the orthopedic surgical team. The application of closed incision negative pressure therapy (ciNPT) to surgical incisions following replacement arthroplasty has demonstrated positive outcomes in orthopedics. This paper describes a technique involving the postoperative application of ciNPT over closed incisions originating from joint arthroplasty to facilitate a reduction in the incidence of surgical site complications (SSCs). To address any potential challenges that may be associated with ciNPT application and removal, the ciNPT dressing was applied to the knee incision with approximately 15 degrees of flexion utilizing the total knee bump to allow the knee to rest with flexion at that angle. For posterior hip replacements or revisions, the readily adjustable ciNPT dressing was enlisted for use to cover curvilinear incisions. The adhesive drape over the foam ciNPT dressing would be blocked to ensure that drain placement, if used, would not be incorporated with the hydrocolloid portion of the dressing. In order to properly apply the dressing, it was imperative that the hydrocolloid portion was not subject to any buckling. The dressing was walked over the foam ciNPT dressing to ensure that there was an absence of tension on the dressing. The manufacturer's instructions support dressing use for a maximum of seven days with continuous subatmospheric pressure (-125 mmHg) applied to the closed incision. Applying the adhesive ciNPT drape over the ciNPT foam dressing with a minimal amount of tension is integral to attaining positive outcomes using ciNPT. Employing ciNPT may reduce the risk of delayed incisional healing and SSCs, which may alleviate providers from extra postoperative global visits.
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Affiliation(s)
- Shane Dowling
- Adult Reconstruction, Proliance Orthopedic Associates, Renton, USA
- Orthopaedics, Valley Medical Center, Renton, USA
| | - Timothy B Alton
- Adult Reconstruction, Proliance Orthopedic Associates, Renton, USA
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Analysis of Failed Two-Stage Procedures with Resection Arthroplasty as the First Stage in Periprosthetic Hip Joint Infections. J Clin Med 2021; 10:jcm10215180. [PMID: 34768700 PMCID: PMC8584448 DOI: 10.3390/jcm10215180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 01/18/2023] Open
Abstract
Resection arthroplasty can be performed as the first stage of a two-stage procedure in some patients with severe periprosthetic hip joint infections with poor bone stock. This retrospective study aimed to evaluate factors associated with the subsequent failure or success of these patients. Between 2011 and 2020; in 61 (26.4%) of 231 patients who underwent a two-stage protocol of periprosthetic hip joint infections; no spacer was used in the first stage. The minimum follow-up period was 12 months. Patient's demographics and various infection risk factors were analyzed. In total, 37/61 (60.7%) patients underwent a successful reimplantation, and four patients died within the follow-up period. Patients within the failure group had a significantly higher Charlson comorbidity index (p = 0.002); number of operations prior to resection arthroplasty (p = 0.022) and were older (p = 0.018). Failure was also associated with the presence of a positive culture in the first- and second-stage procedures (p = 0.012). Additional risk factors were persistent high postoperative CRP values and the requirement of a negative-pressure wound therapy (p ≤ 0.05). In conclusion, multiple factors need to be evaluated when trying to predict the outcome of patients undergoing resection arthroplasty as the first stage of a two-stage procedure in patients with challenging periprosthetic hip joint infections.
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39
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Chan PK, Fung WC, Lam KH, Chan W, Chan VWK, Fu H, Cheung A, Cheung MH, Yan CH, Chiu KY. The application of close incisional negative pressure wound therapy in revision arthroplasty among asian patients: a comparative study. ARTHROPLASTY 2021; 3:38. [PMID: 35236484 PMCID: PMC8796595 DOI: 10.1186/s42836-021-00094-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/16/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Peri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order to reduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT) has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of ciNPWT in revision arthroplasty. METHODS This was a single-centre retrospective comparative study approved by the Institutional Review Board. Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author's institution from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients, who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts. RESULTS There was a statistically significant difference in the rate of superficial surgical site infection (SSI) between control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statistically significance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504). CONCLUSIONS The application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties. TRIAL REGISTRATION UW19-706.
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Affiliation(s)
- Ping Keung Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China.
| | - Wing Chiu Fung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Kar Hei Lam
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Winnie Chan
- Department of Nursing, Queen Mary Hospital, Operation Theatre Services, Hong Kong SAR, China
| | - Vincent Wai Kwan Chan
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Henry Fu
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Amy Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Man Hong Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Chun Hoi Yan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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40
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Luzzi AJ, Anatone AJ, Lauthen D, Shah RP, Geller JA, Cooper HJ. How much does a surgical site complication cost after Medicare total joint arthroplasty? J Wound Care 2021; 30:880-883. [PMID: 34747218 DOI: 10.12968/jowc.2021.30.11.880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew J Luzzi
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, US
| | | | - David Lauthen
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, US
| | - Roshan P Shah
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, US
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, US
| | - H John Cooper
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, US
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41
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Doman DM, Young AM, Buller LT, Deckard ER, Meneghini RM. Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study. J Arthroplasty 2021; 36:3437-3442. [PMID: 34140207 DOI: 10.1016/j.arth.2021.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing. METHODS One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m2, autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation. RESULTS Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications. CONCLUSION Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.
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Affiliation(s)
- David M Doman
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA
| | | | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Evan R Deckard
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Rothfusz CA, Emara AK, McLaughlin JP, Molloy RM, Krebs VE, Piuzzi NS. Wound Dressings for Hip and Knee Total Joint Arthroplasty: A Narrative Review. JBJS Rev 2021; 9:01874474-202107000-00011. [PMID: 34270476 DOI: 10.2106/jbjs.rvw.20.00301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Dressing choice following lower-extremity total joint arthroplasty has substantial ramifications for postoperative outcomes and should be carefully made to prevent complications such as periprosthetic joint infection. » Patient risk factors are essential components in the selection of wound dressings in total joint arthroplasty. » Traditional dressings are inexpensive per unit; nevertheless, the associated higher complication profile in patients at a high risk for poor wound healing and sequelae-associated costs may outweigh the up-front savings. » Modern dressings have the potential to yield better safety outcomes and increased patient satisfaction; however, there is a paucity of evidence regarding the ideal interactive dressing. » Active dressings, such as silver-ion dressings and closed-incisional negative-pressure wound therapy, have shown promising results to reduce surgical site and periprosthetic joint infection, especially in patients at a high risk for poor wound healing following hip and knee total joint arthroplasty.
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Ailaney N, Johns WL, Golladay GJ, Strong B, Kalore NV. Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2021; 36:2402-2411. [PMID: 33358608 DOI: 10.1016/j.arth.2020.11.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/15/2020] [Accepted: 11/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed. RESULTS SSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01). CONCLUSION ciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.
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Affiliation(s)
- Nikhil Ailaney
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - William L Johns
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
| | - Benjamin Strong
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
| | - Niraj V Kalore
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health, Richmond, VA
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Periprosthetic Femur Fractures After Total Hip Arthroplasty: Does the Mode of Failure Correlate With Classification? J Arthroplasty 2021; 36:2597-2602. [PMID: 33714632 DOI: 10.1016/j.arth.2021.02.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/09/2021] [Accepted: 02/16/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic femur fracture is one of the most common indications for reoperation after total hip arthroplasty. Our objectives were to evaluate the incidence of reoperation after the surgical treatment of periprosthetic femur fractures and to compare the mechanisms of failure between fractures around a stable femoral component and those with an unstable femoral component. METHODS We identified a consecutive series of 196 surgically treated periprosthetic fractures after total hip arthroplasty between 2008 and 2017. Mean age was 72 years (range, 29-96 years), and 108 (55%) were women. The femoral component was unstable in 127 cases (65%) and stable in the remaining 69 cases (35%). Mean follow-up was 2 years. RESULTS The 2-year cumulative probability of any reoperation was 19%. The most common indication for reoperation among the cases with a stable femoral component was nonunion, and the most common indication for reoperation among the cases with an unstable femoral component was infection. Fractures that originated at the distal aspect of the femoral component were associated with a high risk of nonunion (6 of 28 cases, P < .01) and reoperation (9 of 28 cases, P = .03). CONCLUSION Surgeons should take measures to mitigate the failure modes that are distinct based on fracture type. The high infection rate after surgical management of B2 fracture suggests that additional antiseptic precautions may be warranted. For B1 fractures, particularly those originating near the distal aspect of the femoral component, augmenting fixation with orthogonal plating, spanning the entire femur, or revising the stem in cases of poor proximal bone should be considered.
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Higuera-Rueda CA, Emara AK, Nieves-Malloure Y, Klika AK, Cooper HJ, Cross MB, Guild GN, Nam D, Nett MP, Scuderi GR, Cushner FD, Piuzzi NS, Silverman RP. The Effectiveness of Closed-Incision Negative-Pressure Therapy Versus Silver-Impregnated Dressings in Mitigating Surgical Site Complications in High-Risk Patients After Revision Knee Arthroplasty: The PROMISES Randomized Controlled Trial. J Arthroplasty 2021; 36:S295-S302.e14. [PMID: 33781638 DOI: 10.1016/j.arth.2021.02.076] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/12/2021] [Accepted: 02/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up. METHODS This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs. RESULTS Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05). CONCLUSION ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses.
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Affiliation(s)
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Herbert J Cooper
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY
| | - Michael B Cross
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - George N Guild
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | - Denis Nam
- Midwest Orthopaedics, Rush University Medical Center, Chicago, IL
| | - Michael P Nett
- Northwell Health Physician Partners Orthopaedic Institute at Babylon, Babylon, NY
| | - Giles R Scuderi
- Northwell Health Physician Partners Orthopaedic Institute at MEETH, New York, NY
| | - Fred D Cushner
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
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Ekhtiari S, Gazendam AM, Nucci NW, Kruse CC, Bhandari M. The Fragility of Statistically Significant Findings From Randomized Controlled Trials in Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:2211-2218.e1. [PMID: 33390336 DOI: 10.1016/j.arth.2020.12.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The Fragility Index (FI) is a method for evaluating the robustness of statistically significant findings from randomized controlled trials (RCTs) beyond the P value in trials with dichotomous outcomes. The FI is defined as the number of patients in one arm of a trial that would have to have a different outcome to change the results of the trial from statistically significant to nonsignificant. This review assessed the FI in arthroplasty RCTs. METHODS A systematic search was conducted in MEDLINE, Embase, and Web of Science for RCTs related to primary total joint arthroplasty (TJA) from 2010 to 2020. Trials with a statistically significant dichotomous primary outcome were included. The FI was calculated using Fisher's exact test to determine how many events would need to be reversed to change a study from statistically significant to nonsignificant. RESULTS A total of 34 RCTs were included. The median sample size was 103 patients (range 24-791). The median FI was 1 (range 0-45), meaning that reversing the outcome of just one patient in either treatment group of each trial would change it from a significant to a nonsignificant result. CONCLUSION Hip and knee arthroplasty RCTs with statistically significant dichotomous outcomes in TJA are fragile. The median FI in TJA is lower than the FI in any of the other previously reported orthopedic subspecialties. Fragility is another reason to be cautious when conducting or interpreting small trials, and to continue to strive toward large trials to answer important questions in TJA. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Seper Ekhtiari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aaron M Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas W Nucci
- Northern Ontario School of Medicine, Department of Medicine, Lakehead University, Thunder Bay, Ontario, Canada
| | - Colin C Kruse
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Gabor S, de Lima Favaro M, Pimentel Pedroso RF, Duarte BHF, Novo R, Iamarino AP, Ribeiro MAF. Pilonidal Cyst Excision: Primary Midline Closure with versus without Closed Incision Negative Pressure Therapy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3473. [PMID: 33907657 PMCID: PMC8062152 DOI: 10.1097/gox.0000000000003473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
Background Pilonidal cysts are a painful condition that primarily affect young adult men. In the literature, numerous operative techniques for resolving pilonidal cysts are described, with variable outcomes. The objective of this study was to compare primarily closed midline incisions managed with or without the use of closed incision negative pressure therapy after pilonidal cyst excision. Methods Twenty-one patients underwent excision and midline primary closure. Postoperative care composed of closed incisional negative pressure therapy (study group; n = 10) or gauze dressings (control group; n = 11). In both groups, the sutures were partially removed on day 14 and completely removed on day 21. Compared outcomes included the duration of hospitalization, pain on the day of surgical procedure, and on postoperative day 7, and time-to-healing. Results The median hospital stay was about 9 hours and 23 hours in the study and control groups, respectively (P < 0.05). The median pain scores on the day of operation were 1.20/10 in the study group and 3.36/10 in the control group (P < 0.05). On day 7, study group showed median pain score 0.9/10 and control group showed 2.63/10 (P < 0.05). The mean healing time was 23.8 and 57.9 days in the ciNPT group and gauze group, respectively (P < 0.05). Conclusion These outcomes supported the incorporation of closed incision negative pressure therapy into our surgical treatment protocol for pilonidal cysts.
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Affiliation(s)
- Silvio Gabor
- Clínica Silvio Gabor de Gastroenterologia, São Paulo, Brazil
| | | | | | | | - Rafaela Novo
- General Surgery Residency Program, Santo Amaro University, São Paulo, Brazil
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Siddiqi A, Alden KJ, Yerasimides JG, Kamath AF. Direct Anterior Approach for Revision Total Hip Arthroplasty: Anatomy and Surgical Technique. J Am Acad Orthop Surg 2021; 29:e217-e231. [PMID: 33351524 DOI: 10.5435/jaaos-d-20-00334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
There has been increased interest and literature on the efficacy of direct anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopaedic residency training, may augment the adoption of this approach among practicing orthopaedic surgeons. With the increasing number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft-tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intraoperative tips, clinical outcomes, and complications after DAA for revision THA.
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Affiliation(s)
- Ahmed Siddiqi
- From the Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, OH (Kamath and Siddiqi), the Hinsdale Orthopaedics, Hinsdale, IL (Alden), and the Norton Orthopedic Institute, Louisville, KY (Yerasimides)
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Long DR, Bryson-Cahn C, Pergamit R, Tavolaro C, Saigal R, Chan JD, Lynch JB. 2021 Young Investigator Award Winner: Anatomic Gradients in the Microbiology of Spinal Fusion Surgical Site Infection and Resistance to Surgical Antimicrobial Prophylaxis. Spine (Phila Pa 1976) 2021; 46:143-151. [PMID: 32796459 PMCID: PMC8299899 DOI: 10.1097/brs.0000000000003603] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective hospital-registry study. OBJECTIVE To characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis. SUMMARY OF BACKGROUND DATA SSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice. METHODS Spinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled. RESULTS Among 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P < 0.001). The majority (57.5%) of infections were resistant to the prophylaxis administered during the procedure. Cephalosporin-resistant gram-negative infection was common at lumbosacral levels and undetected methicillin-resistance was common at cervical levels. CONCLUSION Individualized infection prevention strategies tailored to operative level are needed in spine surgery. Endogenous wound contamination with enteric flora may be a common mechanism of infection in lumbosacral fusion. Novel approaches to prophylaxis and prevention should be prioritized in this population.Level of Evidence: 3.
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Affiliation(s)
- Dustin R. Long
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Chloe Bryson-Cahn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Ronald Pergamit
- Quality Improvement Program, Harborview Medical Center, Seattle, WA
| | - Celeste Tavolaro
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Rajiv Saigal
- Department of Neurosurgery, Harborview Medical Center, Seattle, WA
| | - Jeannie D. Chan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA
- Department of Pharmacy, Harborview Medical Center, School of Pharmacy, University of Washington, Seattle, WA
| | - John B. Lynch
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Yaghmour KM, Hossain FS, Konan S. Clinical and Health-Care Cost Analysis of Negative Pressure Dressing in Primary and RevisionTotal Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2020; Publish Ahead of Print:541-548. [PMID: 33369987 DOI: 10.2106/jbjs.20.01254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) has been used because of its perceived advantages in reducing surgical site infections, wound complications, and the need for further surgery. The purpose of this study was to assess the infection rates, wound complications, length of stay, and financial burden associated with NPWT use in primary and revision total knee arthroplasty (TKA). METHODS We performed a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) systematic review of the existing literature on using NPWT in primary and revision TKA. PubMed, Embase, Science Direct, and the Cochrane Library were utilized. The risk of bias was evaluated using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool, and the quality of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. RESULTS Twelve articles that evaluated 1,403 primary TKAs and 279 revision TKAs were reviewed. NPWT significantly reduced complication rates in revision TKA. However, there was no significant difference in infection rates between NPWT and regular dressings in primary or revision TKA. NPWT use in primary TKA significantly increased the risk of blistering, although no increase in reoperations was noted. The analysis showed a possible reduction in length of stay associated with NPWT use for both primary and revision TKA, with overall health-care cost savings. CONCLUSIONS Based on a meta-analysis of the existing literature, we do not recommend the routine use of NPWT. However, in high-risk revision TKA and selected primary TKA cases, NPWT reduced wound complications and may have health-care cost savings. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Khaled M Yaghmour
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Sujith Konan
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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