Drainage from the knee wound after TKA is an obvious concern for the arthroplasty surgeon. One of the inherent problems with a total knee arthroplasty is there is a focus on obtaining maximum range of motion but at the same time the wound needs to heal in a timely fashion. Consistent knee drainage after a TKA is a source of concern. The quantity and quality of drainage needs to be assessed and there are certain questions that need to be answered including: 1) Is there bloody drainage which suggests fascial dehiscence?; 2) Is the patient too active?; 3) Is the drainage in some way related to DVT prophylaxis?; 4) Is the patient obese and could the drainage be secondary to fat necrosis or seroma? and 5) Is the drainage suggestive of an infection? The work-up can include C-reactive protein and sed rate, and possibly a knee aspiration. In general, C-reactive protein >100mg/L within the first six weeks after surgery suggests the presence of an infection. The sed rate is generally not useful in the early post-operative period. In the first six weeks after surgery if the number of white cells in the aspiration is >10,000 this suggests infection especially if there are 80–90% polymorphonuclear cells.

Each day of prolonged wound drainage is noted to increase the risk of infection by 29%. Morbid obesity has been shown to be an independent risk factor for infection. Some anticoagulants (i.e. low molecular weight heparin) have been associated with increased wound drainage. In a retrospective review of 11,785 total joint arthroplasties, 2.9% of joints developed wound drainage, and of these patients, 28% required further surgery. It was noted that patients that were malnourished had a 35% failure rate with respect to controlling the drainage and preventing infection versus 5% in patients that were healthy.

The International Consensus Conference on Infection concluded that a wound that has been persistently draining for greater than 5–7 days requires surgical intervention. The available literature provides little guidance regarding the specifics of this procedure. In general, if the wound is draining or is red, rest the leg for a day or two. In some instances a bulky Jones dressing can be helpful. If the drainage persists one could consider using a negative pressure dressing (wound vac) but there is little data on efficacy after TKA. If there is persistent drainage or cellulitis, then operative intervention is probably necessary. Evaluation of CRP and a knee joint aspiration can be helpful. The decision to return to the OR should be made within the first 7 days after the surgery. At the time of the procedure one will need to decide to perform either a superficial washout versus a washout and polyethylene exchange.

Drainage from the knee wound after TKA is an obvious concern for the arthroplasty surgeon. One of the inherent problems with a total knee arthroplasty is there is a focus on obtaining maximum range of motion but at the same time the wound needs to heal in a timely fashion. Consistent knee drainage after a TKA is a source of concern. The quantity and quality of drainage needs to be assessed and there are certain questions that need to be answered including: 1) Is there bloody drainage which suggests fascial dehiscence?; 2) Is the patient too active?; 3) Is the drainage in some way related to DVT prophylaxis?; 4) Is the patient obese and could the drainage be secondary to fat necrosis or seroma? and 5) Is the drainage suggestive of an infection? The work up can include C-reactive protein and sed rate, and possibly a knee aspiration. In general, C-reactive protein >100 mg/L within the first six weeks after surgery suggests the presence of an infection. The sed rate is generally not useful in the early post-operative period. In the first six weeks after surgery if the number of white cells in the aspiration is >10,000 this suggests infection especially if there are 80–90% polymorphonuclear cells.

Each day of prolonged wound drainage is noted to increase the risk of infection by 29%. Morbid obesity has been shown to be an independent risk factor for infection. Some anticoagulants (i.e. low molecular weight heparin) have been associated with increased wound drainage. In a retrospective review of 11,785 total joint arthroplasties, 2.9% of joints developed wound drainage, and of these patients, 28% required further surgery. It was noted that patients that were malnourished had a 35% failure rate with respect to controlling the drainage and preventing infection versus 5% in patients that were healthy.

The International Consensus Conference on Infection concluded that a wound that has been persistently draining for greater than 5–7 days requires surgical intervention. The available literature provides little guidance regarding the specifics of this procedure. In general, if the wound is draining or is red, rest the leg for a day or two. In some instances a bulky Jones dressing can be helpful. If there is persistent drainage or cellulitis, then operative intervention is probably necessary. Evaluation of CRP and a knee joint aspiration can be helpful. The decision to return to the OR should be made within the first 7 days after the surgery. At the time of the procedure one will need to decide to perform either a superficial washout versus a washout and polyethylene exchange.

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

Introduction

Wound condition after primary total knee arthroplasty (TKA) is important for prevention of periprosthetic infection. Any delay in wound healing will cause deep infection, which leads to the arthroplasty failure. Prevention of soft tissue problems is thus essential to achieve excellent clinical results. However, it is unknown as to the important surgical factors affecting the wound healing using detailed wound score after primary TKA so far.

It was hypothesized that operative technique would affect wound healing in primary TKA. The purpose of the present study was to investigate and to clarify the important surgical factors affecting wound score after primary TKA.

Our previous study has revealed that silver nanoparticles (AgNPs) have potential to promote wound healing by accelerated re-epithelization and enhanced differentiation of fibroblasts. However, the effect of AgNPs on the functionality of repaired skin is unknown. The aim of this study was to explore the tensile properties of healed skin after treatment with AgNPs. Immunohistochemical staining, quantitative assay and scanning electron microscopy (SEM) were used to detect and compare collagen deposition, and the morphology and distribution of collagen fibers. Our results showed that AgNPs improved tensile properties and led to better fibril alignments in repaired skin, with a close resemblance to normal skin.

Based on our findings, we concluded that AgNPs were predominantly responsible for regulating deposition of collagen and their use resulted in excellent alignment in the wound healing process. The exact signaling pathway by which AgNPs affect collagen regeneration is yet to be investigated.

Introduction

Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty.

Aim

Treatment of complicated wound healing after total joint arthroplasty is controversial. What exactly constitutes prolonged wound drainage is matter of debate and recommendations to manage it vary considerably. Nonoperative measures are often recommended. If drainage persists, surgery may be indicated. To further intricate decision-making, differentiating superficial from deep surgical site infection is also controversial and inherently complex. Specific cutoffs for synovial fluid leukocyte count and blood C-reactive protein (CRP) in the acute stage have been suggested as a way to superficial infection requiring superficial wound washout from deep infection requiring a formal debridement, antibiotics and implant retention (DAIR) procedure. The goal of this study is to analyze clinical and laboratory findings of an institutional protocol of “aggressively” proceeding with formal DAIR in all patients with complicated wound healing

Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immune compromise, steroids, smoking, and poor nutrition. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to elevate the total lymphocyte count and total albumin.

Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thus, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKAs without tourniquet to enhance blood flow and tissue viability. The use of perioperative anticoagulation will increase wound problems.

If wound drainage or healing problems do occur immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count, and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound. Options available for coverage of complex wound problems include myocutaneous flaps, pedicled skin flaps, and skin grafts. Wet, occlusive dressings and wound VACs encourage epithelisation of chronic wounds.