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Tissue Adhesive for Wound Closure Reduces Immediate Postoperative Wound Dressing Changes After Primary TKA

A Randomized Controlled Study in Simultaneous Bilateral TKA

Mont, Michael A. MD

Clinical Orthopaedics and Related Research®: September 2019 - Volume 477 - Issue 9 - p 2039–2040
doi: 10.1097/CORR.0000000000000678

M. A. Mont, Vice President of Strategic Affairs and Director of Joint Arthroplasty, Lenox Hill Hospital, New York, NY, USA

M. A. Mont MD, Lenox Hill Hospital, 100 E 77th St., New York, NY 10075 USA, Email:

This CORR Insights® is a commentary on the article “Tissue Adhesive for Wound Closure Reduces Immediate Postoperative Wound Dressing Changes After Primary TKA: A Randomized Controlled Study in Simultaneous Bilateral TKA” by Gromov and colleagues available at: DOI: 10.1097/CORR.0000000000000637.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received December 24, 2018

Accepted January 22, 2019

Online date: April 27, 2019

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Where Are We Now?

Postoperative wound drainage is a major concern among orthopaedic surgeons as it is a potential precursor to infection [7]. Other specialties have used tissue adhesives to decrease drainage [2], 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 [4] 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 [8] 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 [8]. In the current study, Gromov and colleagues [6] 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 [1].

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Where Do We Need To Go?

Gromov and colleagues [6] 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.

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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.

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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.
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