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Chinoy MA, Ahmed N, Zahid Selod I, Khan T, Waseem Memon M, Javed S. Anthropometry of Proximal Tibia in Patients Undergoing Total Knee Replacement at a Tertiary Care Hospital. Cureus 2024; 16:e58758. [PMID: 38784370 PMCID: PMC11112439 DOI: 10.7759/cureus.58758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Total knee arthroplasty is the standard of care treatment for advanced knee osteoarthritis. However, patients frequently continue to have pain and disability after surgery, with one of the most common reasons being a bone-implant mismatch. Notably, there is a significant difference reported in proximal tibia morphometry between Asian and Caucasian populations, and the currently available implants do not account for the anthropometric variations observed across ethnicities. We aimed to evaluate the proximal tibia anthropometry in a Pakistani population. Materials and methods A study was conducted at The Indus Hospital, Karachi Campus, from August 2019 to July 2020. All consecutive patients fulfilling the eligibility criteria and undergoing knee replacement surgery were included in the study. Baseline characteristics and anthropometry of proximal tibia were recorded on a pre-designed proforma. Statistical analysis was done using SPSS version 24. Results A total of 30 patients were enrolled in this study, which included 17 females (56.7%) and 13 males (43.3%). The mean age was 61.6± 7.9 years and the BMI was 33±5.7 kg/m2. There was a significant difference found in the anteroposterior and mediolateral dimensions in both genders. A significant association was noted with body mass index (p-value 0.01) and occupation (p-value=0.02). Conclusion The results indicated that the anatomical profile of the proximal tibia in the Pakistani population is distinct, thus stressing the fact that it requires developing prostheses specifically tailored to this population's sizing requirements.
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Affiliation(s)
| | - Naeem Ahmed
- Orthopaedics, The Indus Hospital, Karachi, PAK
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Jeong SH, Baik SH, Namgoong S, Dhong ES, Han SK. An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis. Front Surg 2023; 10:982669. [PMID: 36814861 PMCID: PMC9939455 DOI: 10.3389/fsurg.2023.982669] [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] [Received: 06/30/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023] Open
Abstract
Background Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy. Methods According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed. Results The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful. Conclusion During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.
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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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4
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Lazarides AL, Saltzman EB, Visgauss JD, Mithani SK, Eward WC, Brigman BE. Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection. J Orthop Res 2022; 40:2382-2390. [PMID: 35005805 DOI: 10.1002/jor.25270] [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: 10/03/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive series of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteen patients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.
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Affiliation(s)
- Alexander L Lazarides
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eliana B Saltzman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Julia D Visgauss
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Suhail K Mithani
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian E Brigman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Yeganeh A, Moghtadaei M, Ghaznavi A, Tavakoli N, Soleimani M, Cheraghiloohesara S, Taheri N. The distance between new and previous incisions does not affect skin necrosis in total knee arthroplasty: a parallel-randomized controlled clinical trial. BMC Surg 2022; 22:350. [PMID: 36163060 PMCID: PMC9513953 DOI: 10.1186/s12893-022-01791-w] [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: 03/02/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background To avoid skin necrosis, an 8 cm distance between the new and previous incision is recommended in patients undergoing total knee arthroplasty (TKA). It was hypothesized that making a new incision less than 8 cm of the prior scar does not increase the risk of skin complications, and the new incision can be made anywhere, regardless of the distance from the previous scar. This study investigated how making a new incision, irrespective of the previous scars, affects skin necrosis. Methods In this parallel, randomized clinical trial, by simple randomization method using a random number table, 50 patients with single longitudinal knee scars were randomly assigned to two groups with a 1:1 ratio and 25 participants in each group. Patients with a minimum age of 60 and a single longitudinal previous scar on the knee were included. The exclusion criteria were diabetes mellitus, hypertension, morbid obesity, smoking, vascular disorders, cardiopulmonary disorders, immune deficiencies, dementia, and taking steroids and angiogenesis inhibitors. TKA was performed through an anterior midline incision, regardless of the location of the previous scar in the intervention group. TKA was performed with a new incision at least 8 cm distant from the old incision in the control group. Skin necrosis and scar-related complications were evaluated on the first and second days and first, second, and fourth weeks after the surgery. Knee function was assessed using the Knee Society Score (KSS) six months after the surgery. Results The baseline characteristics of the groups did not differ significantly. The average distance from the previous scar was 4.1 ± 3.2 cm in the intervention group and 10.2 ± 2.1 cm in the control group. Only one patient in the control group developed skin necrosis (P-value = 0.31). Other wound-related complications were not observed in both groups. The mean KSS was 83.2 ± 10.2 and 82.9 ± 11.1 in the intervention and control groups, respectively (P-value = 0.33). Conclusions It is possible that in TKA patients, the new incision near a previous scar does not increase the risk of skin necrosis and other complications.
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Affiliation(s)
- Ali Yeganeh
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Moghtadaei
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Ghaznavi
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran
| | - Mohammad Soleimani
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Sahand Cheraghiloohesara
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran
| | - Nima Taheri
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran.
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Magan AA, Dunseath O, Armonis P, Fontalis A, Kayani B, Haddad FS. Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials. J Exp Orthop 2022; 9:62. [PMID: 35776268 PMCID: PMC9249956 DOI: 10.1186/s40634-022-00485-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/12/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose The intra-operative use of tourniquets during Total Knee Arthroplasty (TKA) is common practice. The advantages of tourniquet use include decreased operating time and the creation of a bloodless visualisation field. However, tourniquet use has recently been linked with increased post-operative pain, reduced range of motion, and slower functional recovery. Importantly, there is limited evidence of the effect of tourniquet use on infection risk. The purpose of this systematic review and meta-analysis is to fill this gap in the literature by synthesising data pertaining to the association between tourniquet use and infection risk in TKA. Methods A systematic literature search was performed on Pubmed, Embase, Cochrane and clinicaltrials.gov up to May 2021. Randomized control trials were included, comparing TKA outcomes with and without tourniquet use. The primary outcome was overall infection rate. Secondary outcomes included superficial and deep infection, skin necrosis, skin blistering, DVT rate, and transfusion rate. Results 14 RCTs with 1329 patients were included. The pooled incidence of infection in the tourniquet group (4.0%, 95% CI = 2.7–5.4) was significantly higher compared to the non-tourniquet group (2.0%, 95% CI = 1.1–3.1) with an OR of 1.9 (95% CI = 1.1–3.76, p = 0.03). The length of hospital stay, haemoglobin drop (0.33 95% CI =0.12–0.54), P = 0.002) and transfusion rates (OR of 2.7, 95%CI = 1.4–5.3, P = < 0.01) were higher in the tourniquet group than the non-tourniquet group. The difference in the length of inhospital stay was 0.24 days favouring the non-tourniquet group (95% CI = 0.10–0.38, P = < 0.01). The incidence of skin blistering (OR 2.6, 95% CI = 0.7–9.9, p = 0.17), skin necrosis (OR 3.0, 95% CI = 0.50–19.3, p = 0.25), and DVT rates (OR 1.5, 95% CI = 0.60–3.60, p = 0.36) did not differ between the two groups. Conclusion Quantitative synthesis of the data suggested tourniquet use was associated with an increased overall risk of infection, intraoperative blood loss, need for blood transfusion and longer hospital stay. Findings of this meta-analysis do not support the routine use of tourniquet in TKA and arthroplasty surgeons should consider any potential additional risks associated with its use. Level of evidence meta-analysis, Level II.
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Affiliation(s)
- A A Magan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK. .,Department of Orthopaedic Surgery, The Princess Grace Hospital, 42-52 Nottingham Pl, Marylebone, London, W1U 5NY, UK.
| | - O Dunseath
- University College London, Gower St, London, WC1E 6BT, UK
| | - P Armonis
- University College London, Gower St, London, WC1E 6BT, UK
| | - A Fontalis
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - B Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - F S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, 42-52 Nottingham Pl, Marylebone, London, W1U 5NY, UK.,University College London, Gower St, London, WC1E 6BT, UK.,Institute of Sports, Health and Exercise, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
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7
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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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8
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Benner RW, Behrens JP. A Novel Skin Closure Device for Total Knee Arthroplasty: Randomized Controlled Trial versus Staples. J Knee Surg 2020; 33:1116-1120. [PMID: 31288266 DOI: 10.1055/s-0039-1692628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Twenty-five patients undergoing simultaneous, bilateral total knee arthroplasty (TKA) were randomized to receive skin closure with Zip device on one knee and staples on the other. Patients' pain and scar appearance were rated from 0 (best) to 10 (worst). Knee arc of motion was measured by a physical therapist. At 2 weeks postoperatively, pain scores were significantly better with the Zip device during device wear (p = 0.03) and during device removal (p = 0.003); arc of motion was significantly better with the Zip device (p = 0.002). At 8 weeks of follow-up, scar appearance was significantly better in the Zip device knee as rated by the patients (1.3 vs. 2.6, p = 0.04), the surgeon (1.9 vs. 3.3, p = 0.0006), and three independent plastic surgeons (3.7 vs. 4.8, p < 0.001). Results of this randomized controlled trial show that skin closure with the Zip device resulted in less pain and better scar appearance and knee arc of motion than with staples.
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Affiliation(s)
- Rodney W Benner
- Shelbourne Knee Center, Shelbourne Knee Center at Community East Hospital, Indianapolis, Indiana
| | - Jonathan P Behrens
- Department of Orthopaedics, St. Louis University Hospital, St. Louis, Missouri
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9
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Feng S, Zhang Y, Zhang F, Yang Z, Chen XY, Zha GC. Are There Lower Complication Rates with Bidirectional Barbed Suture in Total Knee Arthroplasty Incision Closure? A Randomized Clinical Trial. Med Sci Monit 2020; 26:e922783. [PMID: 32753571 PMCID: PMC7431387 DOI: 10.12659/msm.922783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The use of barbed suture in total knee arthroplasty (TKA) remains controversial. We performed a prospective study to investigate the clinical outcomes of bidirectional barbed suture for incision closure in TKA. Material/Methods We conducted a single-center, randomized controlled trial to determine the efficiency and safety of barbed suture in TKA at our institution between December 2017 and April 2019. Eligible patients were randomly assigned to different suture methods for skin closure. Randomization was conducted via computerized randomization list. Our primary endpoint was the incidence of wound complications within 3 months of surgery. This trial was registered at ClinicalTrials.gov, number ChiCTR-IPR-17013677. Results A total of 582 patients were enrolled, consisting of 193 who received full-layer barbed suture (group A), 195 who received barbed suturing of the joint capsule (group B), and 194 who received suturing of the joint capsule by traditional absorbable suture (group C). The incidence of incision complications in group A (19.7%) was significantly higher than that in group B (7.2%) and C (9.3%) (P<0.0125). The incidence rate for incision complications in group B was similar to that in group C (P>0.0125). The time for incision closure in groups A (13.5±2.0 min) and B (16.1±1.9 min) was significantly shorter than that in group C (25.0±2.0 min) (P<0.001). Conclusions The use of full-thickness bidirectional barbed suture for incision closure after TKA may increase postoperative incision complications, and therefore is not recommended. However, the use of barbed suture for the joint capsule has shown effectiveness, reducing suture time with no increase in incision complications.
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Affiliation(s)
- Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Ye Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Feng Zhang
- Postgraduate Department, Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Zhi Yang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
| | - Guo-Chun Zha
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China (mainland)
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10
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Knapper TD, Dahill M, Eastaugh-Waring S, Baker RP, Webb JC, Blom AW, Whitehouse MR. Barbed sutures versus staples for closure in total hip arthroplasty using wound ooze as a primary outcome measure: A prospective study. J Orthop Surg (Hong Kong) 2020; 27:2309499019857166. [PMID: 31221004 DOI: 10.1177/2309499019857166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prosthetic joint infection is a rare, but devastating complication of primary total hip arthroplasty (THA). Postoperative wound discharge and deep infection are related. We examined whether barbed sutures were associated with a decrease in the incidence of postoperative wound discharge when compared with skin closure using metal staples. METHODS Prospective nonrandomized comparison between two groups (35 barbed suture closures vs. 49 staple closures). Wounds were assessed daily for postoperative wound discharge until dry. Hemoglobin and hematocrit were recorded at the preoperative assessment and on day 3 postoperative. RESULTS There were no significant differences between the groups with regard to age, body mass index, gender, preoperative hemoglobin, preoperative hematocrit, or estimated blood volume. The number of days elapsed until the wound was dry was significantly lower in the barbed suture group than the staples group (p < 0.0001). In the staples cohort, ongoing wound ooze resulted in delayed hospital discharge in three (6%) patients, six bed days total. CONCLUSION Barbed sutures reliably reduce the period of postoperative wound ooze following primary THA compared to staple closure. The use of barbed sutures may prevent delayed patient discharge from hospital, decreasing the bed burden.
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Affiliation(s)
- Thomas D Knapper
- 1 Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol Trust, Bristol, UK.,2 Department of Trauma and Orthopaedics, Gloucestershire Royal Hospital, Gloucester, UK
| | - Mark Dahill
- 1 Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Stephen Eastaugh-Waring
- 1 Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Richard P Baker
- 1 Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Jason Cj Webb
- 2 Department of Trauma and Orthopaedics, Gloucestershire Royal Hospital, Gloucester, UK
| | - Ashley W Blom
- 3 Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK.,4 National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- 3 Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK.,4 National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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11
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Yang G, Zhu Y, Zhang Y. Prognostic risk factors of surgical site infection after primary joint arthroplasty: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e19283. [PMID: 32080142 PMCID: PMC7034688 DOI: 10.1097/md.0000000000019283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Surgical site infection (SSI) can be a devastating complication in joint arthroplasty. Objective of this study was to identify potential risk factors associated with SSI following primary joint arthroplasty.This retrospective cohort study was performed from January 2016 to October 2017. A total of 986 patients were enrolled. We extracted the patients' baseline information, treatment-related variables and indexes of laboratory examination during their hospitalization. Receiver operating characteristic (ROC) analysis was performed to find the optimum cut-off value for serum albumin. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.Nine hundred eighty-six patients with complete data were included in the final analysis. There were 314 male and 672 females in this study with a mean age of 64.6 years, and twenty patients developed SSI. The overall incidence of SSI was 2.03%, with 0.20% for deep infection and 1.83% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were ALB < 36.7 g/L (odds ratio = 3.42; 95% CI = 1.24-9.48; P = .018), BMI ≥28 (odds ratio = 5.08; 95%CI = 1.52-17.01; P = .008) and ASA class 3 or higher (odds ratio = 3.36; 95% CI = 1.22-9.30; P = .019). Drain use was demonstrated as a protective factor of postoperative wound healing.The incidence of SSI following primary joint arthroplasty was 2.03%. ASA ≥3, BMI ≥28 and ALB < 36.7 g/L were demonstrated as risk factors of postoperative wound infection. Supplementary nutrition support is necessary to reduce the risk of infection in patients who underwent artificial joint arthroplasty.
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Affiliation(s)
- Guang Yang
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, PR China
| | - Yanbin Zhu
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, PR China
| | - Yingze Zhang
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, PR China
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12
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Wang XS, Zhou YX, Shao HY, Yang DJ, Huang Y, Duan FF. Total Knee Arthroplasty in Patients with Prior Femoral and Tibial Fractures: Outcomes and Risk Factors for Surgical Site Complications and Reoperations. Orthop Surg 2020; 12:210-217. [PMID: 31958890 PMCID: PMC7031548 DOI: 10.1111/os.12610] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/15/2019] [Accepted: 12/20/2019] [Indexed: 01/17/2023] Open
Abstract
Objective To investigate the outcomes of total knee arthroplasty (TKA) in patients with a prior femoral or tibial fracture, and identify the risk factors for surgical site complications and reoperations. Methods Seventy‐one TKAs performed in 71 patients with a prior tibial or femoral fracture between January 2005 and December 2016 were reviewed retrospectively. Forty males (40 knees) and 31 females (31 knees) were included. The mean age at the time of TKA was 59.2 (range, 29–83) years. Outcomes were assessed using the Knee Society score before surgery and at the final follow‐up visit. The patients' satisfaction rates were evaluated. Complications and reoperations were recorded by clinical and radiographic assessment. Logistic regression analysis was used to identify the risk factors for surgical site complications and reoperations. Results The median follow‐up period was 4.7 (range, 3.2–7.1) years. The median knee range of motion increased from 90° preoperatively to 110° at the latest follow‐up. The Knee Society knee score and function score improved from 35 (30, 40) and 40 (30, 50) to 90 (82, 93) and 90 (65, 100), respectively. The degree of overall satisfaction after TKA surgery was very satisfied in 41 patients, satisfied in 20 patients, neutral in four patients, dissatisfied in four patients, and very dissatisfied in two patients. The overall satisfaction (very satisfied and satisfied) rate was 85.9% (61 knees). Twelve knees (16.9%) had 19 surgical site complications. Six knees (8.3%) underwent reoperations, including one revision due to periprosthetic joint infection, one debridement and implant retention for superficial infection, two debridements for delayed wound healing, one open reduction and internal fixation for supracondylar fracture, and one re‐fixation and bone grafting for hardware failure after a combined femoral shaft osteotomy and TKA. Preoperative patella baja was diagnosed in 12 knees, and was identified as a risk factor for surgical site complications and reoperations. Conclusions TKA for post‐fracture osteoarthritis significantly relieved pain and improved function, but the incidence of surgical site complications and reoperations was high. Preoperative patella baja was a risk factor for surgical site complications and reoperations.
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Affiliation(s)
- Xing-Shan Wang
- Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Yi-Xin Zhou
- Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Hong-Yi Shao
- Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - De-Jin Yang
- Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Yong Huang
- Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
| | - Fang-Fang Duan
- Clinical Epidemiology Research Center, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China
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Biomechanical Properties and Biocompatibility of a Non-Absorbable Elastic Thread. J Funct Biomater 2019; 10:jfb10040051. [PMID: 31744160 PMCID: PMC6963933 DOI: 10.3390/jfb10040051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/05/2019] [Accepted: 11/09/2019] [Indexed: 12/11/2022] Open
Abstract
To date, extensive studies have been conducted to assess diverse types of sutures. But there is a paucity of data regarding biomechanical properties of commonly used suture materials. In the current experiment, we compared biomechanical properties and biocompatibility, such as tensile strength and elongation, the degree of bovine serum albumin (BSA) release, in vitro cytotoxicity and ex vivo frictional properties, between a non-absorbable elastic thread (NAT; HansBiomed Co. Ltd., Seoul, Korea) (NAT-R: NAT with a rough surface, NAT-S: NAT with a smooth surface) and the Elasticum® (Korpo SRL, Genova, Italy). The degree of tensile strength and elongation of Si threads was significantly higher in both the NAT-R and -S as compared with the Elasticum® (p < 0.05). Moreover, the degree of tensile strength and elongation of PET threads was significantly lower in both NAT-R and -S as compared with the Elasticum® (p < 0.05). Furthermore, the degree of tensile strength and elongation of braided Si/PET threads was significantly lower in NAT-S as compared with NAT-R and Elasticum® (p < 0.05). The degree of BSA release was significantly higher in the NAT-R as compared with Elasticum® and NAT-S throughout a 2-h period in the descending order (p < 0.05). The degree of cell viability was significantly higher in both NAT-R and -S as compared with Elasticum® (p < 0.05). The degree of coefficient of friction as well as the frictional force and strength was significantly higher in NAT-R as compared with NAT-S and Elasticum® (p < 0.05). NAT had a higher degree of biomechanical properties and biocompatibility as compared with Elasticum®. But further experimental and clinical studies are warranted to compare the efficacy, safety, and potential role as a carrier for drug delivery between NAT and Elasticum®.
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Soft Tissue Issues and Considerations in Total Knee Arthroplasty. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Regier PJ, Smeak DD, McGilvray KC. Ex vivo comparison of intradermal closures with conventional monofilament suture vs unidirectional barbed suture in dogs. Vet Surg 2019; 48:1399-1405. [PMID: 31271237 DOI: 10.1111/vsu.13271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 06/26/2018] [Accepted: 08/31/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the mechanical properties, strength, and quality of seal provided by continuous intradermal suture lines closed with barbed suture vs monofilament suture. STUDY DESIGN Experimental study. SAMPLE POPULATION Forty-eight full-thickness wounds in canine cadavers. METHODS Four-centimeter-long parasagittal cutaneous wounds were created in canine cadavers. Each intradermal closure was closed with smooth monofilament suture and terminated with a 2 + 1 Aberdeen knot (n = 24) or a unidirectional barbed suture terminated with a single end pass (n = 24). Wounds (n = 12/group) were harvested, and a servohydraulic machine applied tensile load perpendicular to the long axis of the suture line. A load-displacement curve was generated; maximum load, displacement, stiffness, and mode of construct failure were recorded. Harvested wounds were placed in a watertight construct to measure the volume of fluid leaking over 3 minutes at 1.0 ± 0.1 psi. RESULTS Stiffness did not differ between constructs (P > .05). Incisions closed with monofilament sutures sustained higher maximum load (311.21 N ± 87.40) and displacement at failure (21.19 mm ± 4.51) compared with those with barbed sutures (116.38 N ± 42.82 and 15.03 mm ± 2.32, respectively, P < .05). Closures with monofilament sutures leaked more (4.38 mL ± 7.90) compared with those with barbed sutures (0.15 mL ± 0.43, P < .05). CONCLUSION Monofilament sutures resulted in stronger constructs, whereas barbed suture constructs provided a better watertight seal. CLINICAL SIGNIFICANCE While unidirectional barbed sutures may improve watertight skin closure, surgeons should consider using conventional monofilament sutures when mechanical strength of the closure is of primary concern.
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Affiliation(s)
- Penny J Regier
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
| | - Daniel D Smeak
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
| | - Kirk C McGilvray
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
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Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference? Musculoskelet Surg 2019; 104:163-169. [PMID: 31055725 DOI: 10.1007/s12306-019-00605-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically. OBJECTIVE The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction. METHODS A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted. RESULTS A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary. CONCLUSION The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.
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Amin NH, Speirs JN, Simmons MJ, Lermen OZ, Cushner FD, Scuderi GR. Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options. J Arthroplasty 2019; 34:735-742. [PMID: 30665832 DOI: 10.1016/j.arth.2018.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wound complications associated with soft tissue defects following total knee arthroplasty present challenges for the orthopedic surgeon. The scale of early complications include less morbid problems, such as quickly resolving drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft tissue coverage. METHODS This review outlines current wound management strategies and provides an algorithm to help guide treatment and clinical decision-making. CONCLUSION A surgeon's understanding of soft tissue coverage options is essential in protecting the knee prosthesis from a deep infection and to obtain an optimal functional outcome.
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Affiliation(s)
- Nirav H Amin
- Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA
| | - Joshua N Speirs
- Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA
| | - Matthew J Simmons
- Department of Orthopedic Surgery, Sierra Pacific Orthopedic Center, Fresno, CA
| | - Oren Z Lermen
- Department of Plastic Surgery, Lenox Hill Hospital, New York, NY
| | - Fred D Cushner
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Giles R Scuderi
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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Agarwala S, Vijayvargiya M. Concealed cosmetic closure in total knee replacement surgery - A prospective audit assessing appearance and patient satisfaction. J Clin Orthop Trauma 2019; 10:111-116. [PMID: 30705543 PMCID: PMC6349645 DOI: 10.1016/j.jcot.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/24/2017] [Accepted: 11/10/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE With the trend towards accelerated rehabilitation, the method of skin closure has become increasingly important in orthopedic surgery. It is imperative to evaluate a technique that provides superior clinical and cosmetic results specifically for TKA, due to relatively thin skin anterior to the knee making poor wound healing an issue of concern. We conducted a prospective, single-arm audit evaluating the patient assessments of incision cosmesis for a novel technique in TKA wound closure called Concealed Cosmetic Closure (CCC). METHODS 570 knees were included in the study whose wound was closed with concealed cosmetic subcuticular interrupted sutures (CCCIS) between January 2014 and May 2016. A validated, ordinal questionnaire, Stony Brooks Scar Evaluation Scale (SBSES) designed to elicit a score evaluating scar satisfaction was interviewed by the investigators to patients 6 months to 3 years postoperatively. RESULTS CCC is a simple and relatively rapid single-operator technique that takes about 7-10 min to close 11-17 cm knee incision. In our study, the mean score for Stony Brook Scar Evaluation Scale (SBSES) was 4.4 (SD of 0.73) (range 3-5). The scar was rated highly in terms of cosmesis, patient satisfaction and appearance of the wound. CONCLUSION CCC is an effective modality for skin closure in total knee arthroplasty providing superior cosmetic healing with minimal complications leading to improved long term patient satisfaction.
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Affiliation(s)
- Sanjay Agarwala
- P.D Hinduja Hospital and Medical Research Centre, Mumbai, India
- Corresponding author at: P.D. Hinduja National Hospital,Mumbai, India Veer Savarkar Marg, Mahim (W), Mumbai-16, India.
| | - Mayank Vijayvargiya
- Department of Orthopedics, P.D Hinduja Hospital and Medical Research Centre, Mumbai, India
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Cunningham D, Karas V, DeOrio J, Nunley J, Easley M, Adams S. Patient Risk Factors Do Not Impact 90-Day Readmission and Emergency Department Visitation After Total Ankle Arthroplasty: Implications for the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Plan. J Bone Joint Surg Am 2018; 100:1289-1297. [PMID: 30063591 PMCID: PMC6661249 DOI: 10.2106/jbjs.17.01149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital care and care within 90 days following discharge for Medicare beneficiaries undergoing lower-extremity joint replacement involving the hip, knee, or ankle (total hip arthroplasty, total knee arthroplasty, or total ankle arthroplasty [TAA]). The study hypothesis was that patient comorbidities are associated with readmissions, emergency department (ED) utilization, and subspecialist wound-healing consultation, which are examples of costly contributors to postoperative health-care spending. METHODS The medical records for 1,024 patients undergoing TAAs between June 2007 and December 2016 at a single academic center in the southeastern United States were reviewed for the outcomes of readmissions, ED visitations, and subspecialist wound-healing consultation within the 90-day post-discharge period. All patients undergoing TAA (n = 1,365) were eligible. Of the 1,037 patients who consented to participation in the study and underwent TAA, 1,024 (98.7%) completed the study. Medical comorbidities according to the Elixhauser and Charlson-Deyo comorbidity indices that were present prior to TAA were recorded. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. RESULTS Four hundred and ninety-six (48.4%) of the 1,024 patients were female, and 964 (94.1%) were white/Caucasian, with an average age (and standard deviation) of 63 ± 10.5 years. Hypertension, obesity, solid tumor, depression, rheumatic disease, cardiac arrhythmia, hypothyroidism, diabetes mellitus, and chronic pulmonary disease had a prevalence of >10%. Fifty-three (5.2%) of the 1,024 patients were readmitted for any cause. Thirty-six (3.5%) of the 1,024 returned to the ED but were not admitted to the hospital. Readmission or ED visitation was most commonly for a wound complication, followed by deep venous thrombosis (DVT) and pulmonary embolism (PE) evaluation, while urgent medical evaluations composed the majority of non-TAA-related ED visitations. No patient comorbidities were significantly associated with 90-day readmission, ED visitation, or wound complications in multivariable models. CONCLUSIONS Patient comorbidities were not associated with 90-day hospital readmissions or ED visitation for patients undergoing TAA. Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. These data suggest that there may be considerable differences between TAA and total hip arthroplasty or total knee arthroplasty that cause surgeons to question the inclusion of TAA in CJR bundled payment models. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Cunningham
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Vasili Karas
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - James DeOrio
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - James Nunley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Mark Easley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Samuel Adams
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Temporal Change of Interleukin-6, C-Reactive Protein, and Skin Temperature after Total Knee Arthroplasty Using Triclosan-Coated Sutures. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9136208. [PMID: 29568771 PMCID: PMC5820568 DOI: 10.1155/2018/9136208] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/20/2017] [Accepted: 11/29/2017] [Indexed: 12/22/2022]
Abstract
The risk of surgical site infections (SSIs) after total knee arthroplasty (TKA) can never be eliminated. Antimicrobial sutures containing triclosan have been used to decrease SSIs, but whether triclosan-coated sutures are effective with TKA is unclear. Between 2011 and 2012, 102 patients randomly assigned to a triclosan or a control group were prospectively assessed. The incidence of SSI within 3 months of surgery, length of hospital stay, pain scale, functional scores, wound condition, and serum inflammatory markers during hospitalization and within 3 months postoperatively were compared. At the final follow-up, there were 2 patients with superficial infections (3.9%) in the control group but none in the triclosan group. Lower serum IL-6 was detected in the triclosan group at 4 weeks and 3 months. The local skin temperature of the knees—recorded at 3 months using infrared thermography—was lower in the triclosan group than in the control group. More precise analytical measurements are needed to investigate local and systemic complications, especially in the early subclinical stage. This prospective, randomized, open-label clinical trial is in the public registry: ClinicalTrials.gov (NCT02533492).
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Carli AV, Spiro S, Barlow BT, Haas SB. Using a non-invasive secure skin closure following total knee arthroplasty leads to fewer wound complications and no patient home care visits compared to surgical staples. Knee 2017; 24:1221-1226. [PMID: 28797879 DOI: 10.1016/j.knee.2017.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/18/2017] [Accepted: 07/16/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Superficial wound complications occur in up to 10% of total knee arthroplasty (TKA) procedures and have been associated with periprosthetic joint infection. The ideal material for TKA closure should offer: 1) fast intraoperative application, 2) minimal wound complications and 3) removable by patients without assistance. We evaluated a novel, non-invasive, removable skin closure system for TKA to determine its effect on wound complications. METHODS We prospectively evaluated 221 consecutive TKA patients who received skin closure using a non-invasive zipper-like system ('Zip'; Zip 16 Surgical Skin Closure System; Zipline Medical). All procedures were performed by a single surgeon using the mini-midvastus approach. Patients received two weeks of rivaroxaban postoperatively. Demographics, comorbidities, in-hospital complications and six-week wound evaluation were recorded. Data was compared to a cohort of 1001 patients from the same surgeon who received staples for closure and coumadin for thromboprophylaxis. RESULTS Zip patients had a significantly higher BMI (p=0.001), incidence of diabetes (p=0.035) and smoking (p=0.005). Zip patients removed dressings themselves and did not report problems with dressing care. Rate of readmission for wound-related complications was significantly lower in the Zip closure group (p=0.045). Overall readmission rates were similar between groups. CONCLUSIONS In our experience, the Zip 16 Surgical Skin Closure System is easy to apply, avoids home care and has produced fewer wound complications compared to staples. Results have been positive despite the study cohort having a higher number of diabetic patients and using an anticoagulant associated with a higher risk of wound complications.
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Affiliation(s)
| | - Sara Spiro
- Hospital for Special Surgery, New York, USA
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Liu PL, Li DQ, Zhang YK, Lu QS, Ma L, Bao XZ, Zhang M. Effects of Unilateral Tourniquet Used in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty. Orthop Surg 2017; 9:180-185. [PMID: 28598560 DOI: 10.1111/os.12329] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/01/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the benefits of use of a tourniquet in one limb in patients undergoing simultaneous bilateral total knee arthroplasty (TKA). METHODS A prospective randomized trial was designed to evaluate the outcomes of unilateral tourniquet use during simultaneous bilateral TKA. A total of 52 (36 women and 16 men) patients with osteoarthritis who underwent simultaneous bilateral primary TKA between January 2010 and January 2015 were assigned randomly to tourniquet (TG) or non-tourniquet (NG) groups prior to surgery. Operating time, pain score, range of motion, first active straight-leg raise time, swelling, wound healing, deep vein thrombosis, and Knee Society score were observed. RESULTS Mean operating time in the TG group was shorter than that in the NG group (P < 0.05). Postoperative pain was measured by a visual analog scale (VAS) and straight-leg raise time, which was lower and shorter in limbs operated without the use of a tourniquet (P < 0.05). In addition, this group had less postoperative swelling and lower incidence of wound complications in the early postoperative period (P < 0.05). There was no significant difference in the range of motion (ROM), deep venous thrombosis incidence, and Knee Society scores between the two groups. CONCLUSIONS Tourniquet use in bilateral TKA can reduce intraoperative time but was associated with a higher incidence of wound complications and larger postoperative knee swelling.
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Affiliation(s)
- Pei-Lai Liu
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - De-Qiang Li
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - Yuan-Kai Zhang
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - Qun-Shan Lu
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - Liang Ma
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - Xue-Zhi Bao
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
| | - Meng Zhang
- Department of Orthopaedics, Qilu Hospital, Shandong University, Jinan, China
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Garnavos C. Intramedullary Nailing with a Suprapatellar Approach and Condylar Bolts for the Treatment of Bicondylar Fractures of the Tibial Plateau. JB JS Open Access 2017; 2:e0017. [PMID: 30229216 PMCID: PMC6132469 DOI: 10.2106/jbjs.oa.16.00017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background Bicondylar tibial plateau fractures have been treated with either plating or external fixation techniques, with conflicting results. A recently introduced technique involving the combined use of intramedullary nailing via a suprapatellar approach and condylar bolts could represent a new pathway toward better treatment of this severe injury. Methods The present report describes a retrospective and prospective study of all 17 patients (age range, 25 to 75 years) who were admitted under the author's care for the treatment of a closed, bicondylar tibial plateau fracture between 2013 and 2015. All patients consented to undergo fixation of the fracture with intramedullary nailing through a suprapatellar approach and with use of condylar bolts. The reconstructed articular surface was supported with freeze-dried allograft that had been previously soaked in concentrated bone marrow. The patients were followed at regular intervals, and the results were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS). Results All patients were followed for at least 1 year (average and standard deviation, 25.23 ± 8.95 months; range, 12 to 46 months). All fractures united clinically and radiographically between 10 and 22 weeks (average, 15.1 ± 2.91 weeks), with no instances of neurovascular complication, infection, or implant failure. One patient underwent early revision of the fixation because of unsatisfactory reduction of the articular surface, and 1 patient had secondary fracture displacement. One condylar bolt was removed after fracture healing because of irritation at the insertion site. However, all patients regained knee motion without physiotherapy and all were fully weight-bearing by the fifth postoperative month. Conclusions The short and intermediate-term results associated with the use of the proposed technique appear to be satisfactory. However, the effectiveness of the technique should be reassessed with long-term studies as well as comparative studies involving other fixation techniques. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christos Garnavos
- Orthopaedic Department, "Evangelismos" General Hospital, Athens, Greece
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Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty. Arch Plast Surg 2017; 44:124-135. [PMID: 28352601 PMCID: PMC5366519 DOI: 10.5999/aps.2017.44.2.124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 01/14/2023] Open
Abstract
Background In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. Methods A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. Results A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. Conclusions Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.
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Role of Joshi's external stabilization system with percutaneous screw fixation in high-energy tibial condylar fractures associated with severe soft tissue injuries. Chin J Traumatol 2016; 18:326-31. [PMID: 26917022 DOI: 10.1016/j.cjtee.2015.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The treatment of high-energy tibial condylar fractures which are associated with severe soft tissue injuries remains contentious and challenging. In this study, we assessed the results of Joshi's external stabilization system (JESS) by using the principle of ligamentotaxis and percutaneous screw fixation for managing high-energy tibial condylar fractures associated with severe soft tissue injuries. METHODS Between June 2008 and June 2010, 25 consecutive patients who were 17e71 years (mean, 39.7), underwent the JESS fixation for high-energy tibial condylar fractures associated with severe soft tissue injuries. Out of 25 patients, 2 were lost during follow-up and in 1 case early removal of frame was done, leaving 22 cases for final follow-up. Among them, 11 had poor skin condition with abrasions and blisters and 2 were open injuries (Gustilo-Anderson grade I&II). The injury mechanisms were motor vehicle accidents (n=19), fall from a height (n=2) and assault (n=1). The fractures were classified according to Schatzker classification system. RESULTS There were 7 type-V, 14 type-VI and 1 type-lV Schatzker's tibial plateau fractures. The average interval between the injury and surgery was 6.8 days (range 2-13). The average hospital stay was 13 days (range, 7-22). The average interval between the surgery and full weight bearing was 13.6 weeks (range 11-20). The average range of knee flexion was 121°(range 105°-135°). The normal extension of the knee was observed in 20 patients, and an extensor lag of 5°-8° was noted in 2 patients. The complications included superficial pin tract infections (n=4) with no knee stiffness. CONCLUSION JESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation, at the same time as allowing the ease of access to the soft tissue for wound checks, pin care, dressing changes, measurement of compartment pressure, and the monitoring of the neurovascular status. In a nutshell, JESS along with screw fixation offers a promising alternative treatment for high- energy tibial condylar fractures associated with severe soft tissue injuries.
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Primary total knee arthroplasty for elderly complex tibial plateau fractures. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:702-705. [PMID: 27889405 PMCID: PMC6197325 DOI: 10.1016/j.aott.2015.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/28/2015] [Indexed: 02/05/2023]
Abstract
Objective The aim of this study is to evaluate the clinical and radiologic results of primary Total Knee Arthroplasty (TKA) for elderly complex tibial plateau fractures. Materials and methods Between November 2010 and February 2012, six cases of elderly complex tibial plateau fractures were treated with primary TKA using the standard medial parapatellar approach. All six patients were available at follow up with mean duration of 32.3 months (range 25–41 months). There were 3 women and 3 men with an average age of 69.5 years (58–78 years) at the time of the arthroplasty. Results The mean Hospital for Special Surgery (HSS) knee score was 89.8 (range 85–94): 6/6 excellent. The mean knee flexion was 119.2° (105–130°). No significant postoperative complications were noted. None of these patients had significant postoperative knee pain required revision surgery, or had radiographic loosening of the components at the latest follow-up. Conclusions TKA is a suitable solution for the treatment of elderly patients with complex tibial plateau fractures. Level of Evidence Level IV, Therapeutic study
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Abstract
Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.
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Cerciello S, Morris BJ, Lustig S, Corona K, Visonà E, Maccauro G, Neyret P. The role of wound closure in total knee arthroplasty: a systematic review on knee position. Knee Surg Sports Traumatol Arthrosc 2016; 24:3306-3312. [PMID: 27026031 DOI: 10.1007/s00167-016-4088-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 03/14/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Post-operative range of motion (ROM) is one of the most important parameters to assess, following total knee arthroplasty (TKA). The aims of the present systematic review were to analyse the available literature and determine if closing the knee in flexion or extension influences post-operative ROM, clinical outcomes, and complications following TKA. METHODS A systematic review was performed using the keywords "total knee arthroplasty", "total knee replacement", and "wound closure" or "joint closure" or "extension" or "flexion" with no limit regarding the year of publication. The review was limited to the English-language articles, and each article was evaluated with a modified Coleman Methodology Score (mCMS). RESULTS Six articles met inclusion criteria. The initial cohort included 202 TKAs in the flexion group and 201 in the extension group. Three hundred and ninety-seven TKAs were evaluated with an average follow-up of 8 months. There was no statistical difference (n.s.) between the two groups in terms of the average post-operative flexion. There were no statistical differences between the two groups regarding post-operative functional scores and VAS scores (n.s.). The average mCMS was 70.9, indicating good methodological quality in the included studies. CONCLUSIONS The findings of the present review did not show any statistically significant differences in terms of post-operative flexion ROM, functional scores, or complications related to the position of the knee at the time of joint and wound closure during TKA. There is no clear advantage to either closure method based on the currently available evidence, and therefore, this choice should be based on surgeon preference.
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Affiliation(s)
| | - Brent Joseph Morris
- The Shoulder Center of Kentucky, Lexington Clinic Orthopedics - Sports Medicine Center, Lexington, KY, USA
| | - Sébastien Lustig
- Albert Trillat Center, Lyon North University Hospital, Lyon, France
| | - Katia Corona
- Università degli Studi del Molise, Campobasso, Italy
| | - Enrico Visonà
- Ospedali Riuniti Padova Sud, ULSS 17, via Albere 30, 35043, Monselice, PD, Italy.
| | | | - Philippe Neyret
- Albert Trillat Center, Lyon North University Hospital, Lyon, France
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Yuenyongviwat V, Iamthanaporn K, Hongnaparak T, Tangtrakulwanich B. A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples. Bone Joint Res 2016; 5:185-90. [PMID: 27190132 PMCID: PMC4921055 DOI: 10.1302/2046-3758.55.2000629] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/09/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Nylon sutures and skin staples are used commonly in total knee arthroplasty (TKA) surgical wound closure. However, there is no study that compares the wound healing efficacy and patient satisfaction scores of both techniques in the same knee. METHODS We randomised 70 patients who underwent primary TKA into two groups. In one group of 34 patients, the skin at the upper half of the wound was closed with skin staples and the lower half of the wound was closed with simple interrupted nylon sutures. In the other group of 36 patients, the skin at the upper half of the wound was closed with nylon stitches and the lower half of the wound was closed with skin staples. We recorded the wound closure time, pain score at the time of stitch removal, wound complication rate, patient satisfaction score, and the Hollander wound evaluation score at the post-operative periods of five days, 14 days, six weeks, three months, and six months. Each half wound was analysed separately. RESULTS The mean patient body mass index was 26.8 kg/m(2) (standard deviation 6.3). A total of 70 nylon stitched wounds and 70 skin stapled wounds were analysed. There were no significant differences in wound complication rates, patient satisfaction score, and the Hollander wound evaluation score between both types of wounds (p > 0.05). The wound closure time for skin stapled wounds was significantly lower than the nylon stitched wounds (p < 0.001). However, the skin stapled wounds had a significantly higher pain score at the time of stitch removal (p < 0.001). CONCLUSION Skin staples and nylon stitches had comparable results with respect to wound healing and patient satisfaction in TKA wound closure in non-obese patients. The benefit of skin staples over nylon stitches was a decrease in operative time, but was more painful upon removal.Cite this article: V. Yuenyongviwat. A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples. Bone Joint Res 2016;5:185-190. DOI: 10.1302/2046-3758.55.2000629.
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Affiliation(s)
- V Yuenyongviwat
- Department of Orthopaedic Surgery and Physical Medicine, Prince of Songkla University, Faculty of Medicine, Songkhla 90110, Thailand
| | - K Iamthanaporn
- Department of Orthopaedic Surgery and Physical Medicine, Prince of Songkla University, Faculty of Medicine, Songkhla 90110, Thailand
| | - T Hongnaparak
- Department of Orthopaedic Surgery and Physical Medicine, Prince of Songkla University, Faculty of Medicine, Songkhla 90110, Thailand
| | - B Tangtrakulwanich
- Department of Orthopaedic Surgery and Physical Medicine, Prince of Songkla University, Faculty of Medicine, Songkhla 90110, Thailand
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Long-Term Outcomes of Total Knee Arthroplasty following Soft-Tissue Defect Reconstruction with Muscle and Fasciocutaneous Flaps. Plast Reconstr Surg 2016; 137:177e-186e. [PMID: 26710050 DOI: 10.1097/prs.0000000000001929] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. METHODS A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive débridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. RESULTS Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). CONCLUSIONS Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Wyles CC, Jacobson SR, Houdek MT, Larson DR, Taunton MJ, Sim FH, Sierra RJ, Trousdale RT. The Chitranjan Ranawat Award: Running Subcuticular Closure Enables the Most Robust Perfusion After TKA: A Randomized Clinical Trial. Clin Orthop Relat Res 2016; 474:47-56. [PMID: 25733009 PMCID: PMC4686502 DOI: 10.1007/s11999-015-4209-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Maintaining robust perfusion is an important physiologic parameter in wound healing. The effect of different closure techniques on wound perfusion after total knee arthroplasty (TKA) has not been established previously and may have implications for wound healing. QUESTIONS/PURPOSES We asked whether a running subcuticular, vertical mattress, or skin staple closure technique enables the most robust wound perfusion after TKA as measured by laser-assisted indocyanine green angiography (LA-ICGA) in patients without specific risk factors for wound healing complications. METHODS Forty-five patients undergoing primary TKA without comorbidities known to impact wound healing and perfusion were prospectively randomized to receive superficial skin closure with one of the following techniques: (1) running subcuticular (3-0 monofilament); (2) vertical mattress (2-0 nylon); or (3) skin staples. Twenty procedures were performed by RTT, 15 by RJS, and 10 by FHS. All surgeons used an anterior skin incision over the medial third of the patella in combination with a median parapatellar arthrotomy. Perfusion was assessed with a LA-ICGA device and software system immediately after closure to quantify fluorescence. Twenty-seven points were assessed immediately after closure in the operating room in each patient (nine along the incision and nine pairs medial and lateral to the incision). Mean incision perfusion was determined from the nine points along the incision with higher values indicating greater blood flow. Mean perfusion impairment was determined by calculating the difference between the nine pairs of surrounding skin and the nine points along the incision with smaller values indicating less perfusion impairment. These parameters were compared with analysis of variance (ANOVA) and subsequent pairwise comparisons with an unadjusted analysis as well as a multivariate analysis that adjusted for age, sex, and body mass index. Patients were followed for a mean of 7 months after surgery (range, 3-12 months) for possible incision-related complications. No patents were lost to followup. RESULTS Running subcuticular closure demonstrated the best overall perfusion. Mean incision perfusion in fluorescent units with SD was as follows: running subcuticular, 64 (16); vertical mattress, 32 (18); and staples, 19 (7) (ANOVA p < 0.001). The running subcuticular closure demonstrated the least impairment of perfusion among the closures compared. Mean perfusion impairment was as follows: running subcuticular, 21 (12); vertical mattress, 37 (24); and staples, 69 (27) (ANOVA p < 0.001). All Tukey-adjusted pairwise comparisons from both metrics likewise favored the subcuticular closure (p < 0.001) both before and after adjusting for age, sex, and body mass index. One patient in the vertical mattress cohort experienced a surgical site infection; no other wound-related complications were observed in this study. CONCLUSIONS The method of closure can influence skin and soft tissue perfusion after TKA. Running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing. However, the clinical importance of these findings remains uncertain, because patients in this study were selected because they lacked risk factors for wound healing complications. Studies with this modality in specific patient populations at higher risk for wound complications will be necessary to quantify the clinical advantage of using running subcuticular closure. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
| | - Steven R. Jacobson
- Mayo Clinic Department of Plastic and Reconstructive Surgery, Rochester, MN USA
| | - Matthew T. Houdek
- Mayo Clinic Department of Orthopedic Surgery, 200 1st Street SW, Rochester, MN 55905 USA
| | - Dirk R. Larson
- Mayo Clinic Department of Biomedical Statistics and Informatics, Rochester, MN USA
| | - Michael J. Taunton
- Mayo Clinic Department of Orthopedic Surgery, 200 1st Street SW, Rochester, MN 55905 USA
| | - Franklin H. Sim
- Mayo Clinic Department of Orthopedic Surgery, 200 1st Street SW, Rochester, MN 55905 USA
| | - Rafael J. Sierra
- Mayo Clinic Department of Orthopedic Surgery, 200 1st Street SW, Rochester, MN 55905 USA
| | - Robert T. Trousdale
- Mayo Clinic Department of Orthopedic Surgery, 200 1st Street SW, Rochester, MN 55905 USA
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Baldini A, Castellani L, Traverso F, Balatri A, Balato G, Franceschini V. The difficult primary total knee arthroplasty: a review. Bone Joint J 2015; 97-B:30-9. [PMID: 26430084 DOI: 10.1302/0301-620x.97b10.36920] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.
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Affiliation(s)
- A Baldini
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - L Castellani
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - F Traverso
- Humanitas Clinical and Research Center, via Manzoni 56 Rozzano, Milan, Italy
| | - A Balatri
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - G Balato
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - V Franceschini
- "Sapienza" University of Rome, via F. Faggiana 1668 Latina, Italy
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Intraoperative angiography provides objective assessment of skin perfusion in complex knee reconstruction. Clin Orthop Relat Res 2015; 473:82-9. [PMID: 25005480 PMCID: PMC4390910 DOI: 10.1007/s11999-014-3612-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Wound necrosis is a potentially devastating complication of complex knee reconstruction. Laser-assisted indocyanine green angiography (LA-ICGA) is a technology that has been described in the plastic surgery literature to provide an objective assessment of skin perfusion in the operating room. This novel technology uses a plasma protein bound dye (ICG) and a camera unit that is calibrated to view the frequency emitted by the dye. The intention of this technology is to offer real-time visualization of blood flow to skin and soft tissue in a way that might help surgeons make decisions about closure or coverage of a surgical site based on blood flow, potentially avoiding soft tissue reconstruction while preventing skin necrosis or wound breakdown after primary closures, but its efficacy is untested in the setting of complex TKA. QUESTIONS/PURPOSES The purpose of this study was to evaluate perfusion borders and tension ischemia in a series of complex knee reconstructions to guide optimal wound management. METHODS Beginning in mid-2011, an LA-ICGA system was used to evaluate soft tissue viability in knee reconstruction procedures that were considered high risk for wound complications. Seven patients undergoing complex primary or revision TKA from 2011 to 2013 were included. These patients were chosen as a convenience sample of knee reconstruction procedures for which we obtained consultation with the plastic surgery service. The perfusion of skin and soft tissue coverage was evaluated intraoperatively for all patients with the LA-ICGA system, and the information was used to guide wound management. Followup was at a mean of 9 months (range, 6-17 months), no patients were lost to followup, and the main study endpoint was uneventful healing of the surgical incision. RESULTS All seven closures went on to heal without necrosis. One patient, however, was subsequently revised for a deep periprosthetic infection 4 months after their knee reconstruction and underwent flap coverage at the time of that revision. CONCLUSIONS Implementation of LA-ICGA provides an objective intraoperative assessment of soft tissue perfusion. This technology may help guide the surgeon's decisions about wound closure in real-time to accommodate the perfusion challenges unique to each patient. Specifically, patients with medical risk factors for poor perfusion or wound healing (such as diabetes, peripheral vascular disease, tobacco use, corticosteroid therapy, infection) or anatomical/surgical risk factors (ie, previous surgery about the reconstruction site, trauma wounds, or reconstruction of severe deformity) may benefit from objective intraoperative information regarding perfusion of the wound site. Furthermore, LA-ICGA could be used to prospectively evaluate the physiologic impact of different wound closure techniques. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Kadimcherla P, Lovy AJ, Sambaziotis C, Blum Y, Hirsh DM, Kim SJ. Knee arthrotomy closure with barbed suture in flexion versus extension: a porcine study. J Arthroplasty 2014; 29:2211-3. [PMID: 25134741 DOI: 10.1016/j.arth.2014.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/06/2014] [Accepted: 07/19/2014] [Indexed: 02/01/2023] Open
Abstract
The purpose of this biomechanical study was to evaluate knee arthrotomy closure with a barbed suture in flexion versus extension. 48 porcine knees were randomized into three groups: full extension, 30° flexion, and 60° flexion. Each knee was then flexed to 90° and then 120°, with failures recorded. Arthrotomy closure in extension had significantly higher failure rates (6/16) upon flexion to 90° compared to arthrotomy closure in either 30° or 60° flexion (0/32) (P = 0.032). Upon ranging from 0° to 120°, arthrotomy failure occurred in 50% (8/16) of arthrotomies in the extension group, 6.25% (1/16) in the 30° flexion group and 18.75% (3/16) in the 60° flexion group (P = 0.022). Knee arthrotomy closure in extension compared to flexion had significantly higher rates of failure.
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Affiliation(s)
- Praveen Kadimcherla
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Andrew J Lovy
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, New York
| | - Chris Sambaziotis
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York; Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Yossef Blum
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York; Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - David M Hirsh
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York; Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
| | - Sun J Kim
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York; Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, New York
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Helito CP, Junqueira JJM, Gobbi RG, Angelini FJ, Rezende MU, Tírico LEP, Demange MK, Mota e Albuquerque RFD, Pécora JR, Camanho GL. Effect of postoperative use of nasal oxygen catheter supplementation in wound healing following total knee arthroplasty. Clinics (Sao Paulo) 2014; 69:735-9. [PMID: 25518030 PMCID: PMC4255075 DOI: 10.6061/clinics/2014(11)05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/12/2014] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Healing is an event that is fundamental to the success of total knee arthroplasty. The aims of the present study were to compare the rates of complications related to wound healing between two groups of volunteers submitted to total knee arthroplasty and to evaluate the effects of postoperative oxygen supplementation by means of a nasal catheter. METHOD A total of 109 patients who underwent total knee arthroplasty were randomized into two groups, namely, groups that did and did not receive postoperative oxygen supplementation via a nasal catheter. The surgical wound was monitored every day during the hospital stay and on the 7th, 14th, 21st, 30th and 42nd postoperative days. Characteristics related to healing were observed, including hyperemia, dehiscence, necrosis, phlyctenules and deep and superficial infection. RESULTS There were no cases of deep infection. Hyperemia was statistically correlated with the total number of complications in the groups, with oxygen demonstrated to be a protective factor against hyperemia. Approximately 30% of the patients who exhibited hyperemia had other complications, independent of oxygen supplementation. CONCLUSION Oxygen supplementation following total knee arthroplasty was shown to be effective in diminishing hyperemia around the operative wound. The development of hyperemia was a precursor to other complications, irrespective of whether oxygen supplementation was used.
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Affiliation(s)
- Camilo Partezani Helito
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jader Joel Machado Junqueira
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Gomes Gobbi
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Fábio Janson Angelini
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcia Uchoa Rezende
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luis Eduardo Passarelli Tírico
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - José Ricardo Pécora
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Knee Surgery Department, Orthopaedic and Traumatology Institute, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Wang S, Xia J, Wei Y, Wu J, Huang G. Effect of the knee position during wound closure after total knee arthroplasty on early knee function recovery. J Orthop Surg Res 2014; 9:79. [PMID: 25149657 PMCID: PMC4237872 DOI: 10.1186/s13018-014-0079-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022] Open
Abstract
Objective This study investigated the effect of the knee position during wound closure on early knee function recovery after total knee arthroplasty (TKA). Methods This study included 80 primary total knee arthroplasties due to osteoarthritis. The patients were randomized according to the type of wound closure: extension group for full extension and flexion group for 90° flexion. The incision of articular capsule was marked for precise wound alignment. In the flexion group, the knee was kept in high flexion for 1 to 2 min after wound closure. The two groups were treated with the same postoperative rehabilitation exercises. The range of motion (ROM), visual analogue scale (VAS) score of anterior knee pain, Knee Society Score (KSS) and postoperative complications were assessed at 6 weeks, 3 months and 6 months, postoperatively. Results At 6 weeks and 3 months postoperatively, the ROM in flexion group was 98.95 ± 10.33° and 110.05 ± 4.93° respectively, with 87.62 ± 8.92° and 95.62 ± 6.51° in extension group, respectively; The VAS score of anterior knee pain in flexion group was 2.02 ± 1.38 and 2.21 ± 0.87, respectively, with 2.57 ± 1.07 and 2.87 ± 0.83 in extension group, respectively. The ROM and VAS pain score of the two groups were significantly different at these two time points, with no significant difference at 6 months postoperatively. The two groups were not significantly different in KSS, and no apparent complication was observed at three time points. Conclusion Marking the articular capsule incision, wound closure in flexion and high flexion after wound closure can effectively decrease anterior knee pain after TKA and promote the early recovery of ROM.
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Cerciello S, Vasso M, Maffulli N, Neyret P, Corona K, Panni AS. Total knee arthroplasty after high tibial osteotomy. Orthopedics 2014; 37:191-8. [PMID: 24762146 DOI: 10.3928/01477447-20140225-08] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 09/30/2013] [Indexed: 02/03/2023]
Abstract
High tibial osteotomy may be indicated in the treatment of varus knee in young, active patients. The preservation of proprioception and native joint and biomechanics is crucial for functional recovery in these patients. However, deterioration of initial good results can occur with time. In such cases, revision with total knee arthroplasty is indicated. However, this is a more surgically demanding option compared with a primary prosthesis. Accurate preoperative planning is mandatory to decrease the risk of intraoperative complications. A precise surgical technique, which is crucial to improving functional outcomes, includes hardware removal, joint exposition, tibial deformities due to previous osteotomy, and managing soft tissue mismatches. Possible technical challenges and surgical solutions exist for each of these aspects. However, several studies report lower functional results compared with primary implants. Thus, patients should be informed before high tibial osteotomy about its failure rate, the difficult surgical aspects of an additional prosthesis, and less satisfactory clinical results.
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Corten K, Struelens B, Evans B, Graham E, Bourne RB, MacDonald SJ. Gastrocnemius flap reconstruction of soft-tissue defects following infected total knee replacement. Bone Joint J 2013; 95-B:1217-21. [DOI: 10.1302/0301-620x.95b9.31476] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult technical problem that can be treated with a gastrocnemius flap, which is rotated over the defect during the first-stage of a revision procedure. This facilitates wound healing and the safe introduction of a prosthesis at the second stage. We describe the outcome at a mean follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12 score also improved significantly (p < 0.001). This form of treatment can be used reliably and safely to treat many of these complex cases where control of infection, retention of the components and acceptable functional recovery are the primary goals. Cite this article: Bone Joint J 2013;95-B:1217–21.
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Affiliation(s)
- K. Corten
- Ziekenhuis Oost-Limburg Genk, Schiepse
Bos 6, 3600 Genk, Belgium
| | - B. Struelens
- University Hospital Pellenberg, Weligerveld
1, 3212 Pellenberg, Belgium
| | - B. Evans
- London Health Sciences Centre, University
Campus, 339 Windermere Road, London, Ontario
N6A 5A5, Canada
| | - E. Graham
- London Health Sciences Centre, University
Campus, 339 Windermere Road, London, Ontario
N6A 5A5, Canada
| | - R. B. Bourne
- London Health Sciences Centre, University
Campus, 339 Windermere Road, London, Ontario
N6A 5A5, Canada
| | - S. J. MacDonald
- London Health Sciences Centre, University
Campus, 339 Windermere Road, London, Ontario
N6A 5A5, Canada
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Pozzobon LR, Helito CP, Guimarães TM, Gobbi RG, Pécora JR, Camanho GL. Rotation flaps for coverage after total knee arthroplasty. ACTA ORTOPEDICA BRASILEIRA 2013; 21:219-22. [PMID: 24453672 PMCID: PMC3862006 DOI: 10.1590/s1413-78522013000400007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 06/07/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE: To evaluate the results obtained using local myocutaneous rotation flaps in cases of wound dehiscence after total knee arthroplasty. METHODS: Patients undergoing these surgical procedures were selected in the 2000-2012 period. The nine selected cases during this period were subjected to flap coverage due to skin dehiscence associated with infection. In eight cases we used rotation flaps of the medial gastrocnemius, and in one case we used advancing skin. RESULTS: Eighty nine percent of the cases were successful in the coverage of the prosthesis and the viability of the flaps. In four cases it was possible to maintain or review the prosthesis. Four other cases progressed to amputation due to failure on treatment of infections, and one case remained without the prosthesis. The functional evaluation showed an unsatisfactory outcome in 89% of cases. CONCLUSION: Coverage flaps are a good option for the treatment of cases of dehiscence with exposure of the prosthesis and the functional failure was associated with the inability to control the infection and the damage it caused. Level of Evidence IV, Case Series.
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Abstract
In this paper, we consider wound healing after total knee arthroplasty.
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Affiliation(s)
- K. G. Vince
- Whangarei Hospital, Northland
District Health Board, 118 Crane Road, RD1, Kamo 0185, New
Zealand
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Aso K, Ikeuchi M, Izumi M, Kato T, Tani T. Transcutaneous oxygen tension in the anterior skin of the knee after minimal incision total knee arthroplasty. Knee 2012; 19:576-9. [PMID: 22079808 DOI: 10.1016/j.knee.2011.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 09/22/2011] [Accepted: 10/16/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Delayed wound healing after total knee arthroplasty (TKA) can lead to devastating complications. The lateral flap is reported to be more hypoxic than the medial flap in conventional TKA. However, the surgical approach significantly affects the cutaneous blood supply. Our hypothesis was that postoperative oxygenation of the skin over the anterior knee would be different in minimal incision TKA. METHODS This prospective observation study included 21 patients who underwent minimal incision TKA. Transcutaneous oxygen tension (TcPO2) was measured perioperatively at four sites around the midline incision: superio-medial, superio-lateral, inferio-medial, and inferio-lateral. The ratio of the regional TcPO2 to the reference TcPO2 was calculated as the regional perfusion index (RPI). We compared the RPI among four sites and evaluated the association between the RPI and wound healing. RESULTS At all measurement sites, the RPI significantly decreased after surgery (days 1 and 7; p<0.01). On day 7, the RPI at inferio-medial and inferio-lateral sites were significantly lower than superio-medial and superio-lateral sites, respectively (p<0.05). No significant difference between the medial and lateral sites was observed. In three patients, delayed healing was noted at the inferio-lateral wound edge, where the RPI significantly decreased on day 1. CONCLUSION The distal part of the wound was significantly more hypoxic than the proximal part in minimal incision TKA. Atraumatic wound edge retraction should be carried out especially in the distal part. Although further investigation is necessary, delayed wound healing is potentially associated with regional skin hypoxia on day 1.
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Affiliation(s)
- Koji Aso
- Department of Orthopaedic Surgery Kochi Medical School, Kochi University, 185-1 Oko-cho Kohasu, Nankoku 783-8505, Japan
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Panni AS, Vasso M, Cerciello S, Salgarello M. Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis? Knee Surg Sports Traumatol Arthrosc 2011; 19:1060-8. [PMID: 21161178 DOI: 10.1007/s00167-010-1328-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 11/08/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of our review paper is to present a possible algorithm of treatment of knee periprosthetic soft tissue defects, relative to their extent and depth. Different management of exposed total joints is also proposed, depending on the presence or loss of deep infection and on the timing of infection itself. METHODS In accordance with literature and the experience of senior knee surgeon, the incidence and risk factors, and possible treatment options of wound complications following total knee arthroplasty have been throughly analyzed. RESULTS There is much controversy regarding the optimal management of wound necrosis around a total knee. Local wound care, debridement, and fasciocutaneous, muscle and perforator flaps have been differently used. Muscle coverage remains the standard to which all other flaps should be compared, especially in infected wounds. Perforator flaps have recently represented a true revolution in the soft tissue reconstruction around the knee, with peculiar advantages due to their low donor morbidity and long pedicles. CONCLUSION When wound complications occur, prompt management is mandatory. An algorithm for treatment of wound defects is presented, available for both primary and revision knee replacement.
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Affiliation(s)
- Alfredo Schiavone Panni
- Department of Science for Health, University of Molise, Via Francesco De Sanctis, Campobasso, Italy
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Horstmann WG, Slappendel R, van Hellemondt GG, Wymenga AW, Jack N, Everts PAM. Autologous platelet gel in total knee arthroplasty: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2011; 19:115-21. [PMID: 20640848 DOI: 10.1007/s00167-010-1207-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 06/23/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Total knee arthroplasty (TKA) is often associated with major postoperative blood loss, postoperative pain, and impaired wound healing. The application of autologous platelet gel (APG), prepared from the buffy coat of a unit of autologous blood, has been advocated to improve haemostasis after surgery, to decrease perioperative blood loss, diminish postoperative pain and to enhance the wound healing process. This randomized controlled pilot study was developed to assess the effects of APG after total knee arthroplasty on blood loss, wound healing, pain, range of motion, and hospital stay. METHOD A prospective, randomized observer blind controlled trial was performed. Forty patients with only osteoarthritis of the knee were scheduled to have a TKA, and they were randomized into two groups. Patients in the treatment group were all treated with the application of autologous platelet gel after the prosthesis was implanted. Patients in the control group were treated with the same protocol but no APG was used. RESULTS Preoperative and postoperative Hb levels showed no significant difference and allogenic blood transfusions were not given in either group. Haematomas were significantly larger in the control group than in the platelet gel group (P = 0.03). The pain score at rest was higher in the control group on the 3rd day (P = 0.04). Wound healing disturbances were seen in four patients in the control group and in no patients in the APG group (n.s.). Range of motion of the knee was similar postoperatively. Hospital stay was 6.2 days in the APG and 7.5 days in the control group (n.s.). CONCLUSION In this prospective randomized pilot study on APG in total knee arthroplasty, differences in favour of the use of platelet gel were found, but these were subjective evaluations, marginal in effect, or did not reach statistical significance. The use of drains might have decreased the concentration of delivered platelets and may have diminished the effect. However, in this study, a statistically significant clinically important effect in favour of platelet gel application was not found. Further studies with larger numbers of patients, and without the use of drains, are warranted to investigate the possible benefits of autologous platelet gel in total knee arthroplasty.
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Affiliation(s)
- Wieger G Horstmann
- Department of Orthopedic Surgery, Kennemer Gasthuis, Location E.G., P.O. Box 417, 2000 AK Haarlem, The Netherlands.
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Papaioannou K, Lallos S, Mavrogenis A, Vasiliadis E, Savvidou O, Efstathopoulos N. Unilateral or bilateral V-Y fasciocutaneous flaps for the coverage of soft tissue defects following total knee arthroplasty. J Orthop Surg Res 2010; 5:82. [PMID: 21050437 PMCID: PMC2988015 DOI: 10.1186/1749-799x-5-82] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 11/04/2010] [Indexed: 12/04/2022] Open
Abstract
Background Soft tissue necrosis following total knee arthroplasty (TKA) may be the cause of the devastating complication of deep infection. It necessitates an immediate operative intervention because it could potentially jeopardise the arthroplasty or even the limb. Methods Sixteen consecutive patients with a mean age of 73,8 years (range 47 to76 years) over a 6-year period (January 2003 to December 2008) with wound dehiscence after TKA were enrolled in the present study. Unilateral or bilateral fasciocutaneous V-Y flaps that are differently oriented, depending on the local conditions of the tissues were used to reconstruct the soft tissues defects. Results In 15 of the 16 cases studied, the wound was successfully covered with the presented technique while in 1 patient a partial flap loss occurred, which was healed after surgical debridement and the application of vacuum system. No other complications occurred. Knee prosthesis was salvaged in all the patients with a good functional and esthetical outcome. Conclusions The presented reconstructive technique is a simple, quick, versatile and reliable solution for the coverage of soft tissue defects following TKA, more than 2 cm width and grade 1 and 2 according to Laing classification, provided the V-Y flaps are applied early in the postoperative period and no complex defects are involved.
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Affiliation(s)
- Konstantinos Papaioannou
- Orthopaedic Department, "Thriasio" General Hospital, G, Gennimata Av, 19600, Magoula, Athens, Greece.
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Butt U, Ahmad R, Aspros D, Bannister GC. Factors affecting wound ooze in total knee replacement. Ann R Coll Surg Engl 2010; 93:54-6. [PMID: 20836920 DOI: 10.1308/003588410x12771863937124] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Wound ooze is common following total knee arthroplasty (TKA) and persistent wound infection is a risk factor for infection, and increased length and cost of hospitalisation. PATIENTS AND METHODS We undertook a prospective study to assess the effect of tourniquet time, peri-articular local anaesthesia and surgical approach on wound oozing after TKA. RESULTS The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Peri-articular local anaesthesia (0.25% Bupivacaine with 1:1,000,000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 min (range, 38-125 min). We found a significant association between cessation of oozing and peri-articular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). CONCLUSIONS Peri-articular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.
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Affiliation(s)
- U Butt
- Yeovil District Hospital, Bristol, UK
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Tiengo C, Macchi V, Vigato E, Porzionato A, Stecco C, Azzena B, Morra A, De Caro R. Reversed gracilis pedicle flap for coverage of a total knee prosthesis. J Bone Joint Surg Am 2010; 92:1640-6. [PMID: 20595571 DOI: 10.2106/jbjs.i.00195] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Poor wound-healing and skin necrosis are potentially devastating complications after total knee arthroplasty. Primary soft-tissue coverage with a medial or lateral gastrocnemius transposition flap is typically the first choice for reconstruction. The aim of this study was to evaluate the use of a distally based secondary-pedicle flap of the gracilis muscle for reconstruction of a soft-tissue defect. METHODS The characteristics of the distally based (secondary) pedicles of the gracilis muscle were studied with use of dissection (ten cadavers) and computed tomographic angiograms (fifty patients). On the basis of the anatomical features, an extended reversed gracilis flap based on the secondary pedicles was used in three patients with severe soft-tissue complications of total knee arthroplasty. RESULTS The mean number of secondary pedicles was 1.8 (range, one to four). The pedicles originated from the superficial femoral or popliteal artery. The most proximal pedicle was often the largest (mean caliber, 2.0 mm), and its point of entry into the gracilis muscle was an average (and standard deviation) of 21 +/- 3.6 cm (range, 16 to 28 cm) from the ischiopubic branch. A significant positive association (p = 0.001; r(2) = 0.49) was found between the caliber of the proximal secondary pedicle and the number of other secondary pedicles. In all three patients, the adequate caliber of the secondary pedicles (as shown on preoperative computed tomographic angiograms) and good muscle vascularization confirmed the utility of the gracilis as a distally based pedicle flap. CONCLUSIONS For the treatment of large soft-tissue defects of the patella or the proximal part of the knee, or for soft-tissue reconstruction over an exposed total knee prosthesis, the reversed gracilis pedicle flap may be an alternative to, or may be integrated with, a lateral or medial gastrocnemius flap.
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Affiliation(s)
- C Tiengo
- Section of Anatomy, Department of Human Anatomy and Physiology, School of Medicine, University of Padova, Via A Gabelli 65, 35127 Padova, Italy.
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Ishihara G, Eto Y, Tukamoto M, Sato T, Kaneko A, Kida D, Sugishita H, Saito K, Tuji K, Kamei Y, Toriyama K. Omental free-tissue transfer following infected total knee arthroplasty with granuloma formation. J Orthop Sci 2010; 15:140-3. [PMID: 20151264 DOI: 10.1007/s00776-009-1413-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 05/08/2009] [Indexed: 11/24/2022]
Affiliation(s)
- Gintaro Ishihara
- Department of Orthopedics Surgery, Yoneda Hospital, Nishi-ku, Nagoya, Aichi, Japan
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Jepegnanam TS, Boopalan PRJVC, Nithyananth M, Titus VTK. Reconstruction of complete knee extensor mechanism loss with gastrocnemius flaps. Clin Orthop Relat Res 2009; 467:2662-7. [PMID: 19212795 PMCID: PMC2745445 DOI: 10.1007/s11999-009-0735-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2008] [Accepted: 01/26/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED We assessed the outcome after reconstruction of traumatic, complete, infected, extensor mechanism loss attributable to high-velocity open knee injuries in eight consecutive patients (all males) who presented to us between February 2005 and September 2007 at an average followup of 24 months. All were treated with gastrocnemius flaps. The loss in extensor mechanism was the patellar tendon in five patients, patella and patellar tendon in two patients, and combined patella, quadriceps, and patellar tendon in one patient. The size of the defect ranged from 8 x 5 cm to 15 x 15 cm. The patients were evaluated for functional outcome of the knee, resolution of infection, range of flexion of the knee, and return to work. Four patients had an excellent outcome whereas the others had a good outcome using the Hospital for Special Surgery knee rating scale. All flaps healed primarily with resolution of infection. The average knee flexion was 110 degrees. All patients except two returned to their original occupation. Three patients had an extensor lag of 5 degrees. The gastrocnemius flap is a good option for open knee injuries with extensor mechanism loss, giving consistent results across a wide spectrum of presentation. LEVEL OF EVIDENCE Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
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Musahl V, Tarkin I, Kobbe P, Tzioupis C, Siska PA, Pape HC. New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. ACTA ACUST UNITED AC 2009; 91:426-33. [PMID: 19336799 DOI: 10.1302/0301-620x.91b4.20966] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.
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Affiliation(s)
- V Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA
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Shetty VD, Shetty GM. Anterolateral incision in total knee arthroplasty: is there a role for a longer incision in this day-and-age of minimal invasive surgery? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2009. [DOI: 10.1007/s00590-009-0436-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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