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    Managing Persistent Wound Drainage with Negative Pressure Wound Therapy

    Infection and wound complications are 2 of the most common reasons for readmission after total joint arthroplasty. [1] One of the causes of these issues is persistent wound drainage, with research showing that patients with wound drainage exceeding 5 days are at more than 12 times greater risk for a periprosthetic infection than patients without persistent drainage. [2]

    RELATED: Register for the 7th Annual ICJR South Hip & Knee Course

    Speaking at the recent ICJR East ISK Hip & Knee Course, David G. Nazarian, MD, from The Rothman Institute in Philadelphia, Pennsylvania, said that reducing wound complications requires a 3-pronged approach:

    • Surgery done appropriately
    • Patients optimized before surgery
    • Dressings that maximize wound potential and wound healing

    In most patients, occlusive dressings are sufficient for wicking away drainage, promoting healing, and reducing patient contact with the wound. Those with persistent drainage despite use of an occlusive dressing have traditionally needed a second surgical procedure, which retraumatizes the tissue and restarts the healing process.

    A newer alternative may be the use of negative pressure wound therapy, which was introduced into orthopaedics through fracture management to convert large, open wounds with severe soft tissue deficits to closed wounds. [3] Large open-cell foam sponges and occlusive dressings are placed over the wound. The sponges are attached to non-compressible tubing, which is attached to a vacuum pump that can be set to deliver intermittent or continuous pressure from -75 mm Hg to -125 mm Hg. The goal is to remove excess fluid, increase local blood flow, and enhance granulation tissue formation. [3]

    In total joint arthroplasty, negative pressure wound therapy could be used to diminish dead space in persistently draining wounds and decrease strain on the incision, Dr. Nazarian said. This treatment is indicated for:

    • High-risk patients
    • Patients with a closed incision
    • Patients with persistent drainage (more than 3 to 5 days)

    Research in Europe has shown some benefit of negative pressure wound therapy in hip replacement patients with periprosthetic joint infection, [4] but more studies are needed before it can be recommended for this application.

    Negative pressure wound therapy is contraindicated in the presence of:

    • Necrotic tissue
    • Fistulas
    • Exposed vasculature
    • Active osteomyelitis
    • Neoplasm

    Click the image above to hear more from Dr. Nazarian about negative pressure wound therapy and its role in total joint arthroplasty.

    Disclosures

    Dr. Nazarian has no disclosures relevant to this presentation.

    References

    1. Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Ortho Res. 2002 May;20(3):506-15.
    2. Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am. 2013 Dec 18;95(24):2177-84. doi: 10.2106/JBJS.L.00789.
    3. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997 Jun;38(6):563-76; discussion 577.
    4. Kelm J, Schmitt E, Anagnostakos K. Vacuum-assisted closure in the treatment of early hip joint infections. Int J Med Sci. 2009 Sep 2;6(5):241-6.