Thiago Vivacqua1*, Rodrigo Resende2, Idemar M. da Palma2, José Leonardo Rocha de Faria3, Douglas Pavão3, Rodrigo Albuquerque2,3
1Clinical Fellow, Fowler Kennedy Sports Medicine Clinic, Western University.
2Rios D`Or Hospital.
3National Institute of Traumatology and Orthopaedics of Brazil
*Corresponding Author: Thiago Vivacqua, Clinical Fellow, Fowler Kennedy Sports Medicine Clinic, Western University.
Received date: December 31, 2021
Accepted date: January 13, 2022
Published date: January 18, 2022
Citation: Thiago Vivacqua, Idemar M. da Palma, José Leonardo Rocha, Douglas Pavão, Rodrigo Albuquerque. “Early Surgical Wound Complications Following Total Knee Arthroplasty– Risk Factors and Management’’. J Orthopaedic Research and Surgery, 1(3); DOI: http;//doi.org/03.2022/1.1027.
Copyright: © 2021 Thiago Vivacqua. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Surgical wound complications after a total knee replacement may lead to disastrous consequences if not recognized and properly managed at its earliest stage. The objective of this manuscript is to describe patient risk factors and surgical approaches to manage potential early postoperative wound complications following total knee arthroplasty. Furthermore, this manuscript aims to report alternatives therapeutic options for each one of the described complications providing surgeons a set of treatment guidelines depending on each of those potentials early post-operative side effects.
Surgical wound complications represent an impediment to a successful total knee arthroplasty (TKA) in up to 0.33% of patients1. Such complications may occur in the early postoperative period what can and include: superficial skin necrosis, deep necrosis, persistent drainage and wound blisters2. The development of these complications can lead to deep wound infections and consequent acute periprosthetic infection2. Post- operative surgical wound complications are associated with a prolonged hospital length of stay increasing patient morbidity and health care costs.
The objective of this manuscript is to describe patient risk factors and technical issues related to early wound complications following total knee arthroplasty. Furthermore, a set of guidelines in order to assist surgeons when facing such oftentimes hazardous situations following TKA.
There two main categories of patient risk factors: modifiable and non-modifiable. They are presented and discussed below.
1A. Modifiable risk factors
Modifiable patient risk factors such as anemia, diabetes mellitus, obesity, smoking, rheumatoid arthritis, and nutritional disorders, are associated with healing problems and surgical wound complications after a TKA4. Inflammatory joint diseases have an increased risk for surgical wound complications when compared to primary osteoarthritis5. Drugs like oral corticosteroids, modifying rheumatic disease drugs and/or non-steroidal anti-inflammatory drugs, may interfere with surgical wound healing response. Disease- modifying biological agents should typically be discontinued two weeks prior to surgery5.
Patients with preoperative chronic anemia with or without inflammatory joint disease have an increased risk for wound complications following TKA6. Nicotine abuse leads to vasoconstriction of the microcirculation with decreased tissue oxygen supply and increased risk of wound complications in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA)7. Quit smoking or using nicotine substitutes between six to eight weeks before THA or TKA significantly decreases the risk of wound complications when compared to patients without any intervention at all8.
Obesity is related to decreased venous flow leading to increased interstitial pressure and may be related to the risk of wound blisters after TKA9. Preoperative nutritional assessment can be evaluated by serum albumin levels, white blood cell count and transferrin level. Wound complications are correlated to albumin < 3.5 g/dl, serum transferrin < 200 mg/dl and white blood cell count <1500/mm 10.
Diabetic patients have an increased risk of wound complications due to changes in collagen synthesis and a lower oxygen supply to connective tissues. Diabetes medications and glucose level must be carefully reviewed and optimized preoperatively11. Finally, patients previously medicated with heparin are associated with the development of hemorrhagic blisters following lower limb orthopedic open approaches. This association must be known preoperatively, and medication should be interrupted depending on additional risk factors12.
Age represents a non-modifiable risk factor associated with the development of blisters after TKA. Wound blisters can be classified as hemorrhagic or serous (Figure 1). Hemorrhagic blisters (HB) typically have a longer re-epithelialization time and are associated with severe trauma to skin cells. HB is associated with a sub dermic blood accumulation creating a cleavage plane between the epidermis and dermis. Differently, serous blisters (SB) are characteristically present with serous exudate accumulates in the epidermis layer, so these often have a shorter re-epithelialization time9,13. SB have an average epithelialization time of 12 days, while HB require 16 days9. Aging is associated with loss of collagen and elastin in connective tissue, as well as vascular atrophy, compromising the competence of the dermis in cases of increased interstitial pressure. Thus, elderly patients undergoing TKA surgery have an increased risk of developing blisters following the procedure13.
2. Risk factors related to the surgical procedure
Tourniquet deflation at the end of the TKA is a critical moment for the development of postoperative blisters. In cases where the dressing is performed before releasing the tourniquet, blood flow return associated with dressing mechanical pressure might increase shear forces between the dermis and epidermis increasing the risk for postoperative wound blisters. Tourniquet release before applying the dressing was associated with a lower incidence of blisters after TKA14,15. Antimicrobial adhesive (Ioban, 3M®) is used to reduce the risk of infection after arthroplasty, but this benefit has as yet not been validated in the literature16. Improper removal of antimicrobial adhesive at the end of the surgical procedure can result in shear forces between the dermis and epidermis, which in turn may favor the development of post-operative wound blisters 17.
When planning the location of the surgical incision for TKA, surgeons must be aware that the anterior vascular supply of the knee runs from medial to lateral. A more lateral incision tends to preserve a better arterial blood flow to the anterior knee subdermal tissue, decreasing the risk of post-operative wound necrosis 11. Subcutaneous dissection above the fascia preserves the subdermal vascularization of the anterior region of the knee, thus reducing the risk of superficial wound necrosis (Figure 2)11. In patients with previous incisions of the knee, a distance of 5 to 7cm between them must be respected to avoid vascular compromise of the epidermis. Oblique incisions can be included in a vertical incision18. Surgical incision vertices should be V-shaped (V sign). In the case of incisions with the U-shaped vertices (U sign), the incision must be elongated avoiding excessive skin tension19. An appropriated preoperative plan of surgical incision can reduce the risk of superficial and deep surgical wound necrosis.
3. Management of acute wound complications
The presence of serosanguineous drainage 72 hours after the TKA is defined as a persistent wound drainage20. In this scenario, the patient must not be discharged, and some additional postoperative actions should be taken. Restricted range of motion, compressive dressing, suspension of anticoagulation medication and negative pressure therapy (NPT) are alternatives in order to control persistent wound drainage. If drainage persists between 5-7 days postoperatively acute infection should be considered. Therefore, the patient must return to the operating room for irrigation, debridement, and procurement of samples for culture and biopsy 21. The presence of purulent discharge from the knee capsule or any communication with superficial layers implies the necessity for deep joint debridement and exchange of modular components. In this scenario the patient should not be discharged and associated intravenous antimicrobial therapy is mandatory until results of samples culture and biopsy are available21.
The management of a postoperative blister adjacent to a surgical wound remains controversial. When intact, the blister fluid is considered sterile. However, following rupture a local polymicrobial contamination was described during the epithelialization period9,22. After blister rupture, an intravenous antimicrobial prophylaxis can prevent superficial surgical wound infection. The use of systemic antibiotics with topic silver sulfadiazine is suggested associated to a low-compressive dressing23.
The treatment of patients with soft tissue necrosis adjacent to the surgical wound depends on the size of tissue damaged and any possible sign of local infection. Patients with superficial necrosis of the surgical wound must be immobilized and their range of motion restricted in order to reduce wound tension. Edges debridement with necrotic tissue removal must be performed using an aseptic technique. After this step, re- epithelialization can occur by secondary intention or surgical tension-free suture can be perfomed24. NPT represents an adjuvant option to remove recurrent fluid, stimulating microcirculation and improving a local oxygen flow. Therefore, NPT is a useful additional option in patients who a complete wound suture was not achieved25.
Local skin grafts are another reasonable surgical means for patients where tension-free suture was not feasible. To perform this technique, it is necessary to have an intact fascia and a soft tissue infection must be excluded24. The ipsilateral superolateral thigh is a common source for harvesting a skin graft often providing one with an appropriate graft length. The donor site usually heals by second intention without
side effects. NPT can be used as an adjuvant method improving local granulation and reducing fluid accumulation24.
The use of a fasciocutaneous flaps represents an alternative with less morbidity than muscle flaps. Cases of superficial wound necrosis where there has not been sufficient granulation tissue can be addressed using fasciocutaneous flaps. Post- operative success depends on the blood flow remaining after superficial and deep tissue layers after fasciocutaneous graft transplants. Fasciocutaneous flap originates from the posterior calf are based on the popliteal artery descending cutaneous branch, which may cover an area greater than 8 x 17 cm. A Doppler preoperative assessment should be performed considering anatomical variations described in up to one third of patients27. Knee medial superficial necrosis can be addressed with the saphenous fasciocutaneous flap, supplied by the saphenous artery, a branch of the descending genicular artery. This technique can be performed to cover an area of approximately 6 x 10 x 15cm28.
Deep wound necrosis, bone or prosthetic implant exposure are often associated with local bacterial contamination. In this scenario, the gastrocnemius muscle flap as a well vascularized graft provides local antimicrobial input in lesions limited to the proximal third of the tibia29. The medial portion of the gastrocnemius muscle has an independent vascular supply (middle sural artery) and is longer and more mobile than the lateral portion. The rotational mobility of the medial gastrocnemius flap allows to cover wound necrosis located in the proximal third of the tibia, medial articular interline, medial tubercle and the patella, covering an area of up to 49 cm2. A free skin flap is then transferred after granulation tissue been achieved29,30.
The gracilis muscle flap is an option for reducing donor side morbidity and can be performed through the same surgical incision as the previous TKA, with an estimated length of 6 x 20 cm. Its vascularization comes from the medial branch of the medial femoral circumflex artery31. In cases of deep wound necrosis including the joint capsule, or extensor mechanism, muscle flaps from the medial vastus, lateral and gastrocnemius muscles can be considered. Musculocutaneous flaps to manage wound complications after TKA are described in Table 1.
|
Description |
Coverage |
Vascularization |
Fasciocutaneous flaps |
Saphenous |
6 x 10 x 15 cm |
branch of the descending genicular artery* |
|
Posterior calf |
8 x 17 cm |
popliteal artery descending cutaneous branch |
Musculocutaneous flaps |
Medial portion of the Gastrocnemius** |
Limit of 49cm2 |
middle sural artery |
|
Gracilis |
6 x 20 cm |
medial branch of the medial femoral circumflex artery |
Table 1. Musculocutaneous flaps options to manage wound complications after TKA. *Saphenous artery.
**Direct and independent vascularization.
Vascularized free flap transfer techniques are an option for cases where muscle or fasciocutaneous flaps are not appropriate or when other treatment techniques for surgical wound complications have previously failed. In this clinical scenario, the preoperative planning must consider skin thickness, size, contour of the region to be grafted, and the graft vascular supply33. The latissimus dorsi free flap provides excellent coverage for the anterior region of the knee and can be used for extensive skin necrosis. Its vascular pedicle originates from the thoracodorsal artery, a branch of the subscapular artery. Thus, the vascular pedicle longer than 12 cm must be anastomosed proximally to the descending genicular artery, a branch of the superficial femoral artery34.
The free miocutaneous rectus abdominals flap muscle is based on the pedicle of the deep inferior and superior epigastric arteries. Its flat shape represents a reasonable option based on the anterior knee anatomy. Possible donor side effects include abdominal muscle weakness or abdominal herniation.
For obese patients, other vascularized free flap options should be considered35,36. Finally, a free vascularized flap from the lateral proximal region of the thigh with vascular pedicle from the lateral femoral circumflex artery, can also be used.37 In cases with a small area to be addressed, the radial fasciocutaneous flap from the volar region of the forearm, vascularized by the radial artery, represents an additional option38.
Conclusion
Early surgical wound complications after TKA should have a multidisciplinary approach. A microsurgery or a plastic surgery team is helpful to assist in the decision- making process. Careful preoperative assessment and intraoperative management potentially decreased risks of postoperative wound and potential side effects. A prolonged hospital length of stay leads to patient psychological and social issues and increases complications public and private health system costs.
Conflict of interests
The authors declare no conflict of interest.
Our acknowledgements and tribute to the late Dr. Victor Favilla who was a member of our staff and had suggested this manuscript.