Aims. Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs. Methods. Six techniques were tested to determine which one resulted in the quickest drying time for 2-octyle cyanoacrylate (Dermabond) skin adhesive. These were nothing (control), fanning with a hand (Fanning), covering with a hand (Covering), bringing operating room lights close (OR Lights), ultraviolet lights (UV Light), or prewarming the TA applicator in a hot water bath (Hot Water Bath). Equal amounts of TA were applied to a reproducible plexiglass surface and allowed to dry while undergoing one of the six techniques. The time to complete dryness was recorded for ten specimens for each of the six techniques. Results. Use of the Covering, OR Lights, and Hot Water Bath techniques were associated with a 25- (p = 0.042), 27- (p = 0.023), and 30-second (p = 0.009) reduction in drying time, respectively, when compared to controls. The UV Light (p = 0.404) and Fanning (p = 1.000) methods had no effect on drying time. Conclusion. Use of the Covering, OR Lights, and Hot Water Bath techniques present a means for reducing overall operating time for surgeons using TA for closure augmentation, which can increase intraoperative efficiency. Further studies are needed to validate this in vivo. Cite this article: Bone Jt Open 2022;3(8):607–610

Background. The duration and extent of postoperative wound leakage after joint arthroplasty in patients with or without a complicated course, like a prosthetic joint infection (PJI), is currently unknown. Adequate differentiation between normal postoperative wound leakage and wound leakage due to a postoperative PJI is important and prevents unnecessary surgical procedures. We investigated the association between postoperative wound leakage and development of PJI in patients who used a previously developed mobile wound care app. Methods. A multicenter, prospective cohort study with patients aged 18 years or older after primary implantation or revision of a total joint arthroplasty. During 30 post-operative days after arthroplasty, patients recorded their wound status in the woundcare app. An algorithm calculated a daily score from imputed data. If the daily score exceeded a predefined threshold, the patients received an alert that advised them to contact their physician. Results. Of 1020 included patients from 11 centers, 14 patients developed a PJI. Of 1006 patients without PJI, any form of postoperative wound leakage occurred in 51%, 12%, 7% and 3% during the 1. st. , 2. nd. , 3. rd. and 4. th. postoperative week, respectively. Median duration of wound leakage was eight days (IQR 3.5–12.5) for patients with PJI and two days (IQR 0–4) for patients without PJI (p <0.001). In total, 498 (49%) patients received 2589 alerts. Receiving an alert was not predictive for the development of a PJI. The odds ratio for a PJI was higher in patients with wound leakage compared to patients without wound leakage: OR 1.76 (0.59–5.29), OR 45.42 (10.04–205.53), OR 16.76 (3.68–76.28) and OR 18.09 (1.59–205.66) in the 1. st. , 2. nd. , 3. rd. and 4. th. postoperative week, respectively. Conclusion. In patients who received a knee or hip arthroplasty, the odds ratios for PJI were significantly increased in patients with postoperative wound leakage. However, the high absolute number of patients with wound leakage and no PJI showed that wound leakage alone is not a sensitive, i.e. discriminative, indicator to guide the decision whether to reoperate patients for a suspected PJI. The abstract was submitted on behalf of the Woundcare app study group: H.M.J. van der Linden, Leiden University Medical Centre; D. Broekhuis, Leiden University Medical Centre; M. de Jong, Leiden University Medical Centre; M.R. Benard, Alrijne Hospital; A.P. Wassenaar, Alrijne hospital; A.S.B. Mol, Alrijne Hospital; M. Rutgers, Reinier Haga Orthopedic Center; J.Pasma, Reinier Haga Orthopedic Center; R. Bazuin, Reinier Haga Orthopedic Center; N. Mathijssen, Reinier Haga Orthopedic Center; C.E. Van Der Wijngaart, Onze Lieve Vrouwe Gasthuis; N.W. Willigenburg, Onze Lieve Vrouwe Gasthuis; M.E. Van Der Hoorn, Onze Lieve Vrouwe Gasthuis; B. Dijkstra, Medical Center Leeuwarden; L.D. De Jong, Rijnstate Hospital; H. Haan, University Medical Centre Groningen; M. Stevens, University Medical Centre Groningen; M. Reijman, Erasmus Medical Centre Rotterdam; H. Hoogeboom, Nijsmellinghe Medical Centre; C. Meijer, Park Medical Centre + all authors listed above this article

Aim. Wound leakage has been shown to increase the risk of prostetic joint infections (PJIs) in primary total hip (THA) and knee arthroplasty (unicondylar and total knee arthroplasty; KA). The aim of this study is to determine whether the addition of a continuous subcuticular bonding stitch to a conventional 3-layer closure method reduces the incidence of prolonged wound leakage and PJIs after THA and KA. Method. This retrospective cohort study included all patients receiving a THA or KA. Patients in the control group with a 3-layer closure method had surgery between November 1. st. 2015 and 2016, and were compared to the study group with a 4-layer closure method that had surgery between January 1. st. 2017 and 2018. The primary outcome was incidence of prolonged wound leakage longer than 72 hours. Differences were evaluated using logistic regression. Incidence of PJIs was the secondary outcome. Results. A total of 439 THA and 339 KA in the control group and 460 THA and 350 KA in the study group were included. In the control group 11.7% of the patients had a prolonged leaking wound compared to 1.9% in the study group (p<0.001). The modified wound closure method showed a protective effect for obtaining prolonged wound leakage; odds ratios were 0.09 (95%CI 0.04–0.22; p<0.001) for THA and 0.21 (95%CI 0.10–0.43; p<0.001) for KA. PJIs decreased from 1.54% to 0.37% (p=0.019). Conclusions. The addition of a continuous subcuticular bonding stitch reduces the incidence of prolonged wound leakage and PJIs after THA and KA compared to a conventional 3-layer wound closure method. The large reduction of incidence in wound leakage and PJIs in this study, combined with relatively negligible cost and effort of the modified wound closure method, would advocate for implementing this wound closure method in arthroplasty

Aim. This was a multicenter, randomized, clinical trial to compare the 90-day 1) incidence of surgical site complications (SSC); 2) health care utilization (the number of dressing changes, readmission, and reoperation); and 3) the patient-reported outcomes (PRO) in high-risk patients undergoing revision total knee arthroplasty (rTKA) with postoperative closed incision negative pressure wound therapy (ciNPT) versus a standard of care (SOC) silver-impregnated occlusive dressing. Method. A total of 294 rTKA patients (15 centers) at high-risk for wound complications were prospectively randomized to receive either SOC or ciNPT (n = 147 each). The ciNPT system was adjusted at 125 mmHg of suction. Investigated outcomes were assessed weekly up to 90 days after surgery. A preset interim analysis was conducted at 50% of the intended sample size, with planned discontinuation for clear efficacy/harm if a significance of p < 0.005 was attained. Results. A total of 242 patients completed the required follow-up (ciNPT: n = 124 (84.4%); SOC: n = 118 (80.3%)). Demographics, baseline comorbidities, causes of revision (prosthetic joint infection, aseptic loosening, implant-related, and periprosthetic fractures), and duration of treatment were similar in both cohorts (p > 0.05). Intention to treat analysis demonstrated lower rates of SSC with ciNPT (3.4%) compared to SOC (14.3%) (p = 0.0013) (Table 1 – not included in the proceeding). Similar outcomes were obtained with the modified intention to treat analysis (p = 0.0013). The ciNPT cohort exhibited lower readmission rates (p = 0.0208), and number of dressing changes (p = 0.0003). Conversely, differences in the 90-day incidence of SSI and measured patient-reported outcomes did not reach statistical significance (p > 0.05). Conclusions. ciNPT mitigates the risk of SSC and readmission among high-risk rTKA patients. The lower frequency of dressing changes within the ciNPT cohort may provide added value for healthcare utilization without compromising pain and function. For the table, please contact authors directly

Aim. There are no studies in literature that analyze the effectiveness of closed-incisional negative pressure wound therapy (ciNPWT) in the treatment of bone and joint infections (BJI). The aim of the study was to evaluate the efficacy and the safety of the application of ciNPWT in the postsurgical wound management of patients with osteoarticular infections. Method. We conducted a perspective single-center study on patients with BJI treated between 01/2022 and 10/2022 with ciNPWT dressing application at the end of the surgical procedure. All patients were treated by a multidisciplinary team (MDT) approach and operated by the same surgical equipe. Inclusion criteria were: presence of periprosthetic joint infection (PJI), fracture-related infection (FRI), osteomyelitis (OM), septic arthritis (SA) surgically treated, after which ciNPTW was applied over the closed surgical wound. 30 patients (19M, 11F) have been analyzed with mean age of 56,10±17,11 years old; BJIs were all localized in the lower limb (16 PJI, 12 FRI, 1 SA, 1 OM). Results. We considered the following clinical local pre-operative parameters: presence of fistula (10 patients, 33,33%), presence of erythema (18 patients, 60%), presence of previous flap in the incisional site (7 patients, 23,33%). In 11 cases (36,67%) more than 3 previous surgical procedures were performed in the surgical site. The following surgical procedures were performed: 8 debridement and implants removal, 7 DAIR, 3 one-stage exchange, 6 two-stage exchange, 3 spacer exchange, 3 resection arthroplasty. Nineteen patients (63,34%) showed no occurrence of any local post-operative complication (erythema, hematoma, wound breakdown, wound blister, necrosis). Seven (23,33%) patients showed the presence of one or more postoperative complications that didn't require additional surgery. We observed four (13,33%) failures, defined as the need for further surgical procedures following the onset of a local complication: two patients had a wound breakdown before wound closure and two had a recurrence of infection after an uneventfully wound closure. All failures were within the group of joint infection (PJI+SA) and were affected by a multi drug resistant pathogen. Conclusions. In our series four patients required further surgery, but only two cases were related to incisional wound problems, that is consistent with aseptic joint revision surgeries data that are available in literature (3.4%-6.9%)[1-2]. Patients affected by BJI are a group with significant high risk of failure and therefore the use of ciNPWT should be considered. However, randomized clinical trials are needed to establish the superiority of the ciNPWT dressing over the standard one

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

Introduction. Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment. Materials & Methods. Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity. Results. Results: There were forty patients treated with pin site infections. Swab results showed S. aureus in 60% (N=24), other organisms in 15% (N=6) and no growth or mixed skin organisms in 10% (N=10). Flucloxacillin was prescribed to 77.5% (n=31) of patients with the remaining 22.5% (n=9) of patients receiving clindamycin (due to allergy) or rifampicin and ciprofloxacin (due to a previous MRSA diagnosis). Antibiotic management was subsequently changed in only 5% (n=2) of patients due to one patient with a new MRSA diagnosis and one patient growing Enterobacter in three pin sites tested. Conclusions. Conclusion: This study has shown that routine swab testing of pin sites does not usually change antibiotic management but should still be used in multiple, severe or unresolving pin site infections

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

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating; they may result in multiple subsequent surgeries and significant patient morbidity. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in resections of irradiated soft tissue sarcoma of the extremities. A consecutive series of patients 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, Kalamazoo MI) at the time of closure. Three fellowship trained Orthopaedic Oncologic Surgeons were asked to prospectively predict likelihood of wound complications based on fluorescence. 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. An a priori power analysis demonstrated that 5 patients were necessary to achieve statistical significance. Univariate and multivariate statistical analyses were performed to identify predictors of wound complications. 14 patients were consecutively imaged. The diagnosis was undifferentiated pleomorphic sarcoma in 9 (64.3%) of patients; 11 (78.6%) tumors were high grade. There were 6 patients with wound complications classified as “aseptic” in 5 cases and secondary to hematoma in 1 case. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. In the area of wound complication, the mean % of maximal signal for wound complications was 49% during the inflow phase and 48% during the peak phase. The mean % maximal signal for peri-incisional tissue without wound complications was 77% during the inflow phase and 83% during the peak phase (p=0.003 and p<0.001). 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 area under the curve (AUC=0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity 100%. Intraoperative use of indocyanine green fluorescent angiography may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis. Future studies are necessary to validate this technology in a prospective manner and to determine if interventions can be instituted to prevent predicted wound complications

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

Aim. Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery [1]. The role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI [2]. Currently, as scientific evidence is lacking, most recommendations for NPWT with respect to the treatment of FRI are based on expert opinion [3]. The aim of this study was to assess the influence of NPWT and its duration on recurrence of infection in operatively treated FRI patients. Methods. This is a retrospective cohort study based on the FRI database of three Level 1 Trauma Centres. To be included, patients had to be at least 16 years of age and needed to be surgically treated for FRI between January 1. st. 2015 and September 1. st. 2020. Included patients were subdivided in either the NPWT group, or in the control group, when no NPWT had been applied. To avoid confounding, patients were excluded if they (also) underwent NPWT prior to the FRI diagnosis. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. Results. 99 patients were included in the NPWT group with a mean age of 51.4 ± 17.0 years. Most patients were male (n = 66). Tibia/fibula was the most common FRI location (n = 68). The median duration of NPWT was 18.0 (IQR 15.8) days. Overall, 28 patients (28.3%) developed a recurrent FRI. In the control group (n = 164), 19 patients (11.6%) developed a recurrent FRI (p = 0.001, 95% CI [0.174 – 0.635]). There were no significant differences in baseline characteristics between the recurrence and non-recurrence category in NPWT group. The duration of NPWT was associated with a higher risk of re-infections (p = 0.013, OR 1.036, 95% CI [1.008 – 1.066]). Conclusion. The application of NPWT is associated with a two-and-a-half-fold increased risk of recurrence in patients with soft tissue defects due to FRI. Also, the duration of NWPT is an independent risk factor for recurrence. Therefore, NPWT should be used with caution in the treatment of orthopedic trauma patients with FRI. It is advised to consider its use only as a short-term necessity to bridge the period until definitive wound closure can be established and to keep this interval as short as possible

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL). Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT. Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05. After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87. 1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03). Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the health care system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with a 2-year cumulative risk of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown post-operatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastics surgery is associated with increased rates of prosthesis retention and limb salvage

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

Obtaining primary wound healing in total joint arthroplasty (TJA) is essential to a good result. Wound healing disturbances (WHD) 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 compromise factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphodema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor nutrition. Low serum albumin, total lymphocyte count, and low transferrin increase WHD. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to modify healing responses. Use of tourniquet in obese patients also increases WHD. 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. Thusly, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKA's 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 (less than 2500), differential (less than 60% polys), and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound

Wound complications are much more common following knee arthroplasty as compared to hip arthroplasty, due in part to the precarious blood supply to the knee, as well as the subcutaneous position of the joint. Many, if not most, infections are related to wound problems, and thus avoiding wound problems is a critical issue in knee replacement surgery. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. The important steps are to first identify patients at risk and optimally addressing these risk factors. Patient risk factors include: chronic corticosteroid use, diabetes, rheumatoid arthritis, malnutrition, obesity, and smoking. Soft tissue handling is a second major issue. Minimal incision surgery should be used with great caution for knee replacements since the skin is much less forgiving than in hip replacements. A midline skin incision should be utilised when possible. When multiple incisions are present it is usually advisable to use the lateral most incision through which it is feasible to perform a knee replacement. In rare cases, a soft tissue expander may be used preoperatively for thin, adherent skin. Perioperative steps that can be taken include delaying CPM in high risk wounds, and using a wound vac system in obese or other high risk wounds to minimise persistent drainage. Furthermore, anticoagulation should be used judiciously to avoid prolonged drainage. The final step in salvaging the problem wound is early recognition and aggressive management of wound healing problems. Prolonged, serous drainage is the most common clinical scenario. Drainage that is increasing beyond 5–7 days frequently requires evacuation, irrigation, debridement, and liner exchange. Early aspiration can decompress a hematoma and also rule out infection

Wound complications are much more common following knee arthroplasty as compared to hip arthroplasty, due in part to the precarious blood supply to the knee, as well as the subcutaneous position of the joint. Many, if not most, infections are related to wound problems, and thus avoiding wound problems is a critical issue in knee replacement surgery. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. The important steps are to first identify patients at risk and optimally addressing these risk factors. Patient risk factors include: chronic corticosteroid use, diabetes, rheumatoid arthritis, malnutrition, obesity, and smoking. Soft tissue handling is a second major issue. Minimal incision surgery should be used with great caution for knee replacements since the skin is much less forgiving than in hip replacements. A midline skin incision should be utilised when possible. When multiple incisions are present it is usually advisable to use the lateral most incision through which it is feasible to perform a knee replacement. In rare cases, a soft tissue expander may be used pre-operatively for thin, adherent skin. Peri-operative steps that can be taken include delaying CPM in high risk wounds, and using a wound vac system in obese or other high risk wounds to minimise persistent drainage. Furthermore, anticoagulation should be used judiciously to avoid prolonged drainage. The final step in salvaging the problem wound is early recognition and aggressive management of wound healing problems. Prolonged, serous drainage is the most common clinical scenario. Drainage that is increasing beyond 5–7 days frequently requires evacuation, irrigation, debridement, and liner exchange. Early aspiration can decompress a hematoma and also rule out infection

Wound complications are much more common following knee arthroplasty compared to hip arthroplasty. This is because of the precarious blood supply which contributes to the infection rate which is about twice as high. Many, if not most, infections are related to wound problems. Avoiding wound problems is a critical issue in joint replacement, more so in the knee than the hip. The volume of these procedures is growing rapidly. Infection continues to be a major complication. The incidence is not decreasing and infections are becoming more difficult to treat, because of resistant organisms. Also, the increasing number of procedures in patients with obesity and other risk factors makes wound management a major issue in knee replacement. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. Salvaging the problem wound is a major issue in total knee replacement currently in order to minimise infection, which remains a major issue and is frequently related to wound healing problems. The first step is identifying the patient at risk and either deferring surgery or optimising the patient to minimise the risk of wound healing problems and subsequent infection. Secondly, is appropriate soft tissue handling with careful attention to choosing the optimal skin incision. Third is taking steps to facilitate primary wound healing and absolutely minimising the risk of persistent drainage, particularly through the very judicious use of anticoagulants. Finally, the delayed wound healing and persistent drainage must be identified early and treated aggressively in order to minimise the risk of infection