SELECTED PROCEEDINGS FROM THE 2017-18 EUROPEAN KNEE SOCIETY MEETINGS
Where Are We Now?
Postoperative wound drainage is a major concern among orthopaedic surgeons as it is a potential precursor to infection . Other specialties have used tissue adhesives to decrease drainage , but few trials have addressed this technique in orthopaedics [4, 8]. Additionally, this method may carry some risk, as allergic contact dermatitis and pruritus have been reported in association with its use [3, 5].
El-Gazzar and colleagues  examined the use of an adjunctive tissue adhesive after TKA and found it decreased drainage shortly after surgery. However, in an earlier study of 85 TKAs, Khan and colleagues  found more wound drainage in a group of patients treated with a tissue adhesive compared to a group of patients who received sutures or staples . In the current study, Gromov and colleagues  report on a trial of 30 patients undergoing simultaneous bilateral TKA with adhesive versus a three-layer closure with staples. The authors found that the latter group had more dressing changes, but did not find changes in ASEPSIS score (Additional treatment, the presence of Serous discharge, Erythema, Purulent exudate, and Separation of the deep tissues, the Isolation of bacteria, and the duration of inpatient Stay), which assesses wound healing .
Where Do We Need To Go?
Gromov and colleagues  should be commended for taking the early step in evaluating these tissue adhesives for use in TKA. However, more work needs to be done on this topic. Since this technique is being used routinely without true knowledge of its efficacy, it is important to understand its impact. Because their study had a limited followup (3 weeks), we do not know the true risk of drainage or infection risk, however, we would not expect there to be any late differences between the groups. There are many other factors to consider concerning this topic for any study. For example, the mean BMI for patients in their study was 28 kg/m2, which is relatively low. We need to know how wound adhesives will perform in patients with obesity, who would be expected to have more wound problems; likewise, we need to investigate wound adhesives in patients with diabetes, patients with immunocompromise, those who have undergone revisions, and many other scenarios where one would expect a higher rate of wound-healing problems. In addition, in our cost-conscious environment, we need to determine its cost effectiveness. Larger studies need to be performed and the most-important major outcome—the potential to decrease periprosthetic infections—still needs to be assessed.
How Do We Get There?
We can gain some insight from centers that have switched to adhesives but have kept other factors the same. We also might look at larger databases, potentially, the Medicare and/or Humana databases, where we have larger numbers (and so a greater ability to determine differences in uncommon occurrences like infection) and some ability to control for confounding variables (such as diabetes, immunocompromise, and higher or lower BMIs). However, an important test of this technique will be the performance of a larger controlled trial(s) that assesses efficacy, which I believe can be accomplished because many centers perform bilateral TKAs or have high-patient volumes. Nevertheless, given the rarity of infections, large numbers of patients will need to be evaluated, which is potentially best served with large-database or registry-based trials as noted above. In addition, there are several different products being introduced to the marketplace and they need to be evaluated individually.
1. Byrne DJ, Napier A, Cuschieri A. Validation of the ASEPSIS method of wound scoring in patients undergoing general surgical operations. J R Coll Surg Edinb. 1988;33:154–155.
2. Dumville JC, Coulthard P, Worthington H V, Riley P, Patel N, Darcey J, Esposito M, van der Elst M, van Waes OJF. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2014:CD004287.
3. Durando D, Porubsky C, Winter S, Kalymon J, O’Keefe T, LaFond AA. Allergic contact dermatitis to dermabond (2-octyl cyanoacrylate) after total knee arthroplasty. Dermatitis. 2014;25:99–100.
4. El-Gazzar Y, Smith DC, Kim SJ, Hirsh DM, Blum Y, Cobelli M, Cohen HW. The use of dermabond(R) as an adjunct to wound closure after total knee arthroplasty: Examining immediate post-operative wound drainage. J Arthroplasty. 2013;28:553–556.
5. Ezeh UE, Price HN, Belthur M V. Allergic contact dermatitis to mastisol adhesive used for skin closure in orthopedic surgery: A case report. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e037.
6. Gromov K, Troelsen A, Raaschou S, Sandhold H, Nielsen CS, Kehlet H, Husted H. Tissue adhesive for wound closure reduces immediate postoperative wound dressing changes after primary TKA: A randomized controlled Study in simultaneous bilateral TKA. Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000000637.
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