Wound closure

Open-label randomized controlled trial to compare wound dressings for patients undergoing hip and knee arthroplasty: study protocol for a randomized controlled trial

Background

Surgical wounds are covered to prevent bleeding, absorb the exudates, and provide a barrier against external contamination. Currently, in our hospital, after orthopedic surgery, traditional occlusive dressing of sterile gauze and non-woven hypoallergenic adhesive tape is placed. Some of the newest dressings have been shown to reduce the incidence of blisters compared with traditional dressing or colloid adhesive dressings. However, there are no comparative evaluations between the different types of dressings and their contribution to the overall results of the healing process.

Methods/design

This is a randomized, controlled, open-label trial to compare five types of dressings used in total knee and hip arthroplasty surgical wounds. A total of 550 patients will be randomly allocated to one of the following dressings: (1) traditional occlusive dressing, (2) Aquacel Surgical^®, (3) Mepilex^® Border Post-Op, (4) OpSite Post-Op Visible, or (5) UrgoTul^® Absorb Border. The dressing assigned is placed right after surgery. Patients will be followed up to 14 days after surgery when the dressing is definitively removed and will be tracked up to 3 months to record any late complications. During the immediate postoperative period and patient hospitalization and at the ambulatory visits after discharge, every time that the dressing is changed, nurses perform the study assessments. The main study outcome will be the percentage of patients with skin integrity at all times when the dressing has been changed. Skin integrity is a composite of the absence of blisters, erosion, erythema, maceration, swelling, wound dehiscence, and purulent exudates. Secondary outcomes include time to first change of dressing; percentage of patients with presence/absence of blisters, erosion, erythema, maceration, swelling, wound dehiscence, and purulent exudates; number of dressing changes needed; days of hospital stay; and nurse and patient satisfaction.

Differences in the main variable between each treatment group and group 1 will be tested by means of a chi-squared test or Fisher’s exact test. Subgroup analyses of diabetic and non-diabetic patients, patients with a body mass index of more than 30 or not more than 30, and type of surgery (hip or knee) are planned.

Discussion

The results of this study will be useful for clinical decision making by giving information on the contribution of the dressings studied to the outcome of the wound and may also show which dressing offers better results depending on the characteristics of patients.

Trial registration

This trial has been registered at ClinicalTrials.gov (NCT03190447). Retrospectively registered on 16 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2755-8) contains supplementary material, which is available to authorized users.

The effect of tourniquet and knee position during wound closure after total knee arthroplasty on early recovery of range of motion: a prospective, randomized study

INTRODUCTION

There is no consensus on the position of the knee joint while performing wound closure after total knee arthroplasty (TKA). Further, there are no studies focusing on the association between early functional outcomes and different wound closure strategies. Therefore, we investigated the effects of tourniquet and knee position during wound closure on early recovery of range of motion (ROM) after primary TKA. To our knowledge, this is the first study to evaluate the influence of both tourniquet and knee position during wound closure in primary TKA.

METHODS

One hundred-twenty eligible patients were consecutively enrolled in this study and randomly divided into four groups according to wound closure strategy. Wound closure was either performed with the knee in flexion at 90° or in full extension, with the combination of an inflated or deflated tourniquet. Visual analogue score (VAS), knee ROM, ROM recovery, knee society score (KSS), and wound complications were evaluated in the early postoperative period.

RESULTS

After the first postoperative week, ROM recovery in the group with knee in extension and inflated tourniquet was significantly lesser than the two groups with deflated tourniquets. Between the first and fourth postoperative weeks, ROM recovery in the group with knee inflection and deflated tourniquet was significantly higher than the two groups with knee in extension. After the first postoperative week, the visual analog score (VAS) for pain in the group with knee inflection and deflated tourniquet was significantly lesser than the two groups with inflated tourniquets. The differences in the outcomes between the four groups were not significant after the fourth postoperative week. The incidence of wound complications and KSS were not significantly different between the four groups.

CONCLUSION

Following TKA, wound closure with the knee in flexion and after deflating the tourniquet significantly decreased postoperative pain and promoted the recovery of ROM in the early postoperative period.

Influence of skin incision position on physiological and biochemical changes in tissue after primary total knee replacement - a prospective randomised controlled trial

Background

Influence of skin incision position on physiological and biochemical changes in tissue after primary total knee replacement. A prospective randomised controlled trial.

The blood supply to the skin covering the anterior knee has been shown to arise predominantly from blood vessels on the medial side of the knee. Skin incisions for primary Total Knee Replacement (TKR) positioned medially therefore risk creating a large lateral skin flap that may be poorly perfused. Poorly perfused skin is likely to result in hypoxia at the wound edges and consequently may lead to delayed wound healing and complications.

Methods

We have carried out a randomised controlled trial (n = 20) to compare blood flow on both the medial and lateral sides of two commonly used skin incisions in TKR (midline and paramedian). We have also assessed interstitial biochemistry (glucose, pyruvate and lactate levels) in the presumed at risk lateral skin flap of both incision types.

Results

In both incision types tissue hyper-perfusion occurs post-operatively and is maintained for at least 3 days. We found no significant difference between blood flow between the two incision types on the medial side of the incision at either day 1 (p = 0.885) or day 3 post-op (p = 0.269), or, on the lateral side of the incision (p = 0.885 at day 1, p = 0.532 at day 3). Glucose levels are maintained post-operatively in the at risk lateral flap with only minimal changes. Lactate levels rise post-operatively and remain elevated for at least 24 hours. However, the levels did not reach levels suggestive of critical ischaemia in either incision group and no significant difference was observed between incision types.

Conclusion

We conclude that the use of a paramedian incision results in only minimal biochemical changes, which are unlikely to alter wound healing.

Trial registrations

ISRCTN06592799.