Surgical wound complications such as infection, dehiscence, and poor cosmesis are the source of significant morbidity in patients undergoing orthopaedic surgery. Although the overall wound complication rate has not been directly quantified, surgical site infections occur in 1.9% of all operations performed in the United States.1 For orthopaedic procedures, the Center for Disease Control National Nosocomial Infections Surveillance reports infection rates ranging from 0.79-1.04%.2 High risk groups, such as those with open fractures and diabetic neuropathy, are over seven and 15 times as likely to develop wound complications when undergoing lower extremity surgery, respectively.3 Orthopaedic patients who do develop wound infections are hospitalized for an additional 2 wk on average, are twice as likely to require readmission, and sustain a 300% increase in the cost of their care.4 As such, a multitude of techniques and adjunctive modalities have been introduced with the goal of preventing these complications from occurring. An increasing number of research studies have been undertaken to evaluate the efficacy of these measures, but this diverse and growing body of literature has yet to be summarized. A detailed understanding of wound healing, wound closure techniques, and adjunctive treatment modalities is important in minimizing complication rates after orthopaedic surgery.
BASIC SCIENCE OF WOUND HEALING
Classically, the wound healing process is described in three phases: inflammation, proliferation, and remodeling (Figure 1). The inflammatory phase features an intense cellular response that persists for the first 48 hr.5 This response is mounted by neutrophils and macrophages that secrete inflammatory cytokines and growth factors, such as tumor necrosis factor-α, interleukin-6, and transforming growth factor-β. The inflammatory phase is followed by the proliferation phase, which continues through day 10. This phase is characterized by angiogenesis, connective tissue deposition, and granulation tissue formation. The remodeling phase begins at or around day 10 and persists for up to 1 yr and is characterized by remodeling of tissue collagen and extracellular matrices with restoration of tensile strength.
Risk Factors for Poor Wound Healing
Identifying patients at risk for compromised wound healing is crucial in avoiding complications. Risk factors such as patient age, connective tissue disorder, location of incision, prior surgery or history of radiation are not modifiable. However, other risk factors, such as diabetes, obesity, smoking, and nutritional status, can and should be optimized before and after surgery (Table 1).6 Also, patient specific considerations, such as open fractures and poor compliance, can predispose patients to wound healing problems.3 Recent studies have begun to measure the effect of these risk factors on clinical outcomes in orthopaedic surgery. A retrospective analysis of diabetic patients undergoing total joint arthroplasty revealed that hemoglobin A1C values greater than 6.7 preoperatively or blood glucose levels greater than 200 postoperatively have odds ratios of greater than 3 for wound complications.7 Additionally, technical factors such as higher tourniquet cuff pressure (>225 mm Hg) during total knee arthroplasty and prolonged operative time during ankle fracture surgery have been shown to increase wound complications and rates of infection as well.8,9 Optimization of modifiable risk factors is critical in minimizing wound complication rates.
Angiosomes and Incision Placement
An angiosome is a three-dimensional segment of tissue supplied by a single source artery as initially described by Taylor and Palmer.10 Source vessels give rise to branches that perfuse bone, muscle, fascia, and skin. Through detailed anatomical studies, the authors identified reproducible angiosomes throughout the human body (Figure 2).12,13 The angiosome concept underscores the importance of tissue perfusion, particularly in the distal extremities and should be contemplated before making a surgical incision. Attinger et al.14 applied this concept to reconstructive procedures of the injured extremity and highlighted a number of important principles for placing a surgical incision. The incision must provide adequate exposure for the planned procedure and have adequate blood supply on either side of the incision to optimize healing. It should also spare sensory and motor nerves, and consideration should be given to avoiding scar contractures around joints. Being mindful of these concepts, Howard et al.15 demonstrated that a less than 7-cm skin bridge between incisions, previously thought to be critical in avoiding soft-tissue complications in the setting of tibial plafond fractures, could be tolerated when the relevant angiosomes were understood and respected.
Sutures are used in a variety of patterns to close surgical incisions. However, very little evidence exists to support one configuration over another. Since revascularization of wounds is an essential component of the wound healing process, optimal suture technique approximates the wound edges without compromising skin perfusion. Issues with cutaneous blood flow are likely to arise in the setting of trauma where soft-tissue injury, edema, and wound tension exists. Sagi et al.16 utilized a pig model to investigate the effects of suture pattern on tissue perfusion. With increasing wound tension, the Allgöwer-Donati vertical mattress pattern (Figure 3) maintained more cutaneous blood flow by Doppler flowmetry compared to vertical mattress, horizontal mattress, and simple configurations. Though no clinical studies have yet examined the effects of suture configuration on the rates of wound healing or complications, we prefer the Allgöwer-Donati technique when closing high-risk incisions.
Wound Closure Under Tension
The swelling associated with injury and surgery often leads to wound closure with some tension. Although the decision to attempt primary wound closure rather than resorting to skin grafting or flap coverage can be difficult,17 primary wound closure avoids significant donor site morbidity and additional procedures. There are several techniques that can be applied in these situations. Again, our preference is to employ the Allgöwer-Donati suture pattern when tension exists at the wound edges. Nylon sutures (3-0) are placed at approximately 1-cm intervals along the entire length of the wound and then tensioned and tied sequentially. Wounds that may not initially appear closeable often can be managed using this technique (Figure 4). Alternatively, the use of multiple relaxing skin incisions also has been described in the closure of large wounds under tension. With this technique, multiple small 5- to 10-mm incisions are made in rows 1 cm apart and parallel to the wound. DiStasio et al.18 used this method in 22 patients with lower extremity orthopaedic trauma and achieved favorable outcomes. No instances of wound infection, dehiscence, skin necrosis, or compartment syndrome were reported, and patients were satisfied with the cosmetic results.
If the wound cannot be successfully closed during the index procedure, delayed primary closure can be employed. A staged linear closure can gradually close the wound from each end during successive trips to the operating room until complete closure is finally achieved.19 The shoelace technique can avoid subsequent operating room visits and in one study was used to achieve wound closure in an average of 8.8 days with minimal complications (Figure 5).20 Similarly, commercially available tensioning devices, such as DermaCloseRC® (Wound Care Technologies, Inc, Chanhassen, Minnesota, United States), have been developed and used to successfully attain delayed primary closure of wounds after open fractures.21 Vacuum-assisted closure devices frequently are used in compartment syndrome after fasciotomies.22 This modality can sometimes facilitate primary closure of the wound but more often serves as a bridge to skin grafting or flap coverage. One recent study compared the shoelace technique with vacuum-assisted closure for fasciotomy wounds and found that both methods are effective and reliable; however, the shoelace technique is a faster and more cost-effective way to achieve complete wound closure.23 With an understanding of the risks and benefits, these various strategies can be tailored to individual clinical situations to optimize outcome.
WOUND CLOSURE MATERIALS
When selecting suture materials for closure, the characteristics frequently considered include size, absorbable versus nonabsorbable, rate of absorption, and monofilament versus multifilament (Table 2). In an effort to decrease wound infection rates, one commercially available modification is antimicrobial suture: triclosan-coated polyglactin 910 (Vicryl Plus®; Ethicon, Johnson & Johnson, Somerville, New Jersey, United States), triclosan-coated poliglecaprone 25 (Monocryl Plus®; Ethicon, Johnson & Johnson) and triclosan-coated polydioxanone (PDS Plus®; Ethicon, Johnson & Johnson). Triclosan (5-chloro-2-(2,4-dichlorophenoxy)phenol) is an antibacterial and antifungal agent that reduces bacterial adherence to suture materials.25,26 A metaanalysis of 17 randomized controlled trials including 3720 patients showed that this technology significantly reduced surgical site infections by 30%.27 Given the costs associated with treating surgical site infections, we recommend the use of antimicrobial suture materials when available.
Barbed suture closure has become an increasingly popular practice in joint replacement surgery. These sutures are made of polypropylene monofilament that contains barbs specifically designed to hold various types of tissues. Since their introduction over 50 yr ago, the biomaterial designs of barbed sutures have improved substantially.28 Proposed benefits include evenly distributed wound tension, decreased knot-related complications, and decreased operative time. For subcutaneous tissues, barbed sutures can be deployed in a running, continuous fashion, which requires less time than numerous interrupted sutures used in traditional closure methods. In patients undergoing total knee arthroplasty, barbed suture closure of subcutaneous tissue layers saved an average of 2.3-11.5 min per patient with no differences in wound closure-related complications.29,30 However, significantly higher rates of wound complications, such as infection, dehiscence, and stitch abscess, have been reported when barbed sutures were used for subcuticular closure compared to staple closure.31 Their use in certain anatomic regions, such as the foot, or in patients with thin skin is not recommended, as there have been reports of soft-tissue irritation and scar problems.32 Further investigation of the efficacy and safety of barbed sutures in closure of orthopaedic surgical wounds is indicated.
Surgical staples have established a diverse range of applications including the closure of orthopaedic wounds. This method allows surgeons to quickly close wounds without the risk of needle-stick injuries associated with suturing. One study in the knee arthroplasty literature has suggested that staples placed at least 6 mm apart permit greater skin perfusion than subcuticular Vicryl closure.33 Reported disadvantages of this modality include higher material cost, poorer cosmesis, and increased pain with removal. However, recent literature suggests that staples are cost-effective and provide equivalent or better patient satisfaction and cosmetic scores.34,35
The question of staples versus sutures for the closure of orthopaedic surgical incisions remains controversial. Although numerous clinical trials have investigated the matter, many have been underpowered and have yielded mixed results. A retrospective review of wound complication rates after 278 consecutive primary joint arthroplasties found that staples had lower rates of complications compared with traditional sutures and barbed sutures.31 Smith et al.36 performed a metaanalysis of 683 patients and compared the clinical outcomes of those that underwent suture with staple closure after varying orthopaedic procedures. The relative risk of superficial wound infections was three times greater after staple closure compared with suture closure, and staples used in hip surgery carried a four-fold risk of wound infection compared with the suture group. Conversely, Shantz et al.37 conducted a prospective randomized trial comparing sutures with staples in 148 patients with no significant differences in wound complications between the two groups. With persistent uncertainty, additional research is indicated to define the role of staples for orthopaedic wound closure.
Adhesive tape strip application is a popular method of supplementing wound closure. They are available in a variety of dimensions and materials and can be used in conjunction with interrupted nylon or running subcuticular skin closure. The rationale behind these strips is to diminish tension at the wound edge, and as such, it is our preference to use full-length strips to maximize contact area. Because they have the capacity to stretch, flexible wound closure strips can be used when significant swelling is expected in the postoperative period to avoid skin shear and blistering.
Coaptive films can be used on a larger scale in place of sutures for closing surgical incisions. Commercially available coaptive films, such as Steri-Strip S® (3M, St Paul, Minnesota, United States), have been able to achieve wound closure without reports of wound complications in children undergoing extremity and spine surgery.38,39 This technique required less than half the time for closure and produced equivalent cosmetic results compared to subcuticular suture closure. Although these studies suggest that adhesive films may be a suitable alternative for wound closure, further validation of safety and efficacy is necessary.
Tissue adhesives have been established as an acceptable method of managing lacerations, yet their role in the closure of surgical incisions is still being defined.40 Compounds that polymerize through an exothermic reaction on contact with fluid, such as 2-octylcyanoacrylate (Dermabond®; Ethicon, Johnson & Johnson) and butyl-2-cyanoacrylate (Indermil®; Covidien, Mansfield, Massachusetts, United States), hold wound edges together while avoiding the foreign-body reaction sometimes associated with sutures. Adhesives also provide a barrier that prevents bacterial contamination and do not require a follow-up visit for removal. However, skin edges must be well apposed as wound healing can be impeded if the adhesive is placed within rather than atop the wound.
Use of tissue adhesives to close surgical incisions across a variety of surgical disciplines was evaluated by a systematic review in the Cochrane Database.41 The authors concluded that tissue adhesives took more time to apply and were inferior to sutures for minimizing wound dehiscence. Investigators have begun to evaluate the efficacy of tissue adhesives in orthopaedic surgery specifically with inconsistent results among studies. A single-blinded, randomized trial compared wound closure using butyl-2-cyanoacrylate with sutures in 50 patients undergoing hand surgery.42 There were no significant differences found between the two study groups for cosmetic scores. Although three of 20 patients in the butyl-2-cyanoacrylate group and two of 24 patients in the suture group developed wound dehiscence, no patients required any further intervention. In a prospective, randomized, controlled trial of hip and knee arthroplasty wound closure, patients whose wounds were closed using 2-octyl cyanoacrylate had less wound discharge initially after the procedure compared with those that received suture and staple closure.43 However, patients who underwent knee arthroplasty and received wound closure with tissue adhesives developed more wound discharge during early rehabilitation. Overall rates of wound dehiscence and cosmesis were the same for all groups. Another prospective, randomized, controlled trial compared tissue adhesives with staples after total hip arthroplasty.44 No differences in cosmesis or rates of infection were identified; however, tissue adhesives were more expensive and took longer to apply than staples. At present, tissue adhesives appear to be a promising method of wound closure but may require more operative time.
ADJUNCTIVE WOUND THERAPIES
Incisional Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) was first introduced in 1996 by Argenta and Morykwas45 to treat chronic wounds. They found that applying continuous subatmospheric pressure to problematic wounds provides a favorable healing environment by four mechanisms: wound contraction, wound environment stabilization, removal of edema or extracellular fluid, and microdeformation at the foam-wound interface.46 In orthopaedic surgery, NPWT has been shown to be effective under a variety of circumstances, including as an adjunctive measure in the setting of high-risk surgical incisions. Hansen et al.47 demonstrated that most patients with persistent wound drainage after total hip arthroplasty (THA), who would have previously met indications for debridement, went on to uneventful wound healing with the application of incisional NPWT. Similarly, in a small prospective randomized trial, Pachowsky et al.48 found decreased rates of seroma formation after THA with incisional NPWT. Prophylactic use of incisional NPWT after acetabular fracture surgery also has been shown to significantly reduce the incidence of deep wound infections and wound dehiscence.49 Furthermore, Reddix et al.50 reported that a small series of morbidly obese patients (body mass index >40) undergoing acetabular fracture surgery treated with incisional NPWT went on to heal their surgical incisions without wound complications. Stannard et al.49 performed a multicenter, randomized clinical trial, comparing incisional NPWT and standard postoperative dressings after surgical treatment of lower extremity fractures caused by high-energy trauma. In this study as well, there were significantly reduced rates of infection and wound dehiscence in patients treated with incisional NPWT compared with the control group.49 Incisional NPWT appears to be a promising adjunct in the management of difficult surgical wounds.
Supplemental and Hyperbaric Oxygen Therapy
Oxygen plays a vital role in the wound healing process. Increased oxygen tension is associated with increased collagen production, angiogenesis, epithelialization, and bacteriocidal activity.51 The administration of supplemental inspired postoperative oxygen has been associated with decreased infection rates in the vascular surgery literature, and ongoing research to explore the role of supplemental oxygen in orthopaedic patients is underway.52 Hyperbaric oxygen therapy has been used in the treatment of several orthopaedic conditions, such as refractory osteomyelitis, necrotizing soft-tissue infections, and healing of problematic wounds. Bouachour et al.53 conducted a randomized controlled trial comparing hyperbaric oxygen treatment versus placebo in patients with crush injuries (Gustillo type II or III) demonstrating superior wound healing rates in the hyperbaric oxygen group that were statistically significant. No patient who received hyperbaric oxygen treatment required subsequent amputation of the injured extremity, whereas two patients in the placebo group required an amputation. Although hyperbaric oxygen therapy has been shown to be safe, efficacy in preventing orthopaedic wound complications has yet to be established in a large-scale study.54 Supplemental inspired oxygen has the potential to optimize wound healing in orthopaedic patients and although high-risk patients may benefit from hyperbaric oxygen, the potential benefits must be balanced against the significant costs and logistical challenges associated with this treatment.
Surgical wound closure is a necessary step of every orthopaedic procedure and a myriad of available wound closure techniques and adjunctive modalities are being subjected to increasing scientific scrutiny. Wherever possible, all modifiable risk factors should be mitigated preoperatively and postoperatively. Relevant angiosomes should be understood in planning surgical approaches. Allgöwer-Donati vertical mattress sutures using 3-0 nylon work well for virtually all high-risk surgical wounds. Full-length adhesive strips with the capacity to stretch help decrease wound tension and are commonly employed. Incisional NPWT should be considered in the setting of high-risk wounds or obesity.
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