Orthopedic wounds

Recommendations

Identify and Treat the Cause
1 Assess and correct systemic factors, such as malnutrition and anemia, prior to elective joint replacement surgery. Level of Evidence
Not Assessed
2 Glycemic control and aggressive management of diabetic foot ulcers may reduce the incidence of osteomyelitis and the need for amputation. Level of Evidence
Not Assessed
3 Evaluate and modify as necessary immunosuppressive medication regimens in RA patients undergoing joint replacement. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
4 Provide individualized education about post-operative care. Level of Evidence
5


Provide Local Wound Care
5 Identify and manage infection aggressively in patients after joint replacement surgery. Consider implant retention if the infection occurs within 4 weeks of surgery. Level of Evidence
Not Assessed
6 Optimize wound healing environment. Level of Evidence
Not Assessed


Provide Organizational Support
7 Establish and empower an interprofessional team to provide post-operative care. Level of Evidence
5


Background

Surgery to replace the hip and knee joints is an increasingly common orthopedic procedure, which may be required as a result of osteoarthritis, rheumatoid arthritis (RA), aseptic necrosis, fractures and dislocation. In addition, RA and diabetic complications may necessitate orthopedic procedures of the foot and ankle. As the majority of these procedures are performed on elderly patients, a variety of systemic factors may compromise healing. These factor include, in addition to diabetes and RA, anemia, nutritional deficiencies, and immunosuppression due to medications used to treat RA.

The major complications of joint replacement surgery are infection and delayed wound healing. Hematoma formation and wound discharge are risk factors for infection, including infection of the prosthesis. Neither open nor closed vacuum-assisted wound drainage systems affect hematoma formation, infection, or the need for revision surgery. Closed systems, however, increase the need for blood transfusion. Allogeneic transfusion is associated with both infection and delayed wound healing after joint replacement. The use of erythropoietin or autologous transfusion can substantially reduce transfusion risk in high-risk patients, especially in older women with low body weight or decreased hemoglobin.

If infection develops within 4 weeks of surgery, wound debridement and long-term antibiotic therapy (at least 6 weeks), based on culture and sensitivity, may effectively treat the infection and allow retention of the implant. Infections occurring later than 4 weeks after surgery may also require revision of the components, often using a two-stage procedure.

In RA patients, as leflunamide has been found to increase the incidence of early wound healing complications and infection, it is recommended that treatment be interrupted preoperatively to reduce this incidence. In contrast, tumour necrosis factor-α (TNF-α) inhibitors, such as etanercept and infliximab, and immunosuppressive drugs, including methotrexate and corticosteroids, have not been shown to affect healing in these patients.

In diabetic patients, osteomyelitis may develop from typical polymicrobial infection of diabetic foot ulcers. Salvage of the foot usually requires aggressive debridement, including resection of infected bone; revascularization; and antibiotic therapy. These wounds are allowed to heal by granulation. Acute life-threatening infection or chronic infection that is unresponsive to medical treatment may necessitate amputation. Early identification of the need for amputation can reduce overall morbidity. Early reduction and arthrodesis of Charcot arthropathy may preserve function and prevent ulceration.

References

Essential Publications
1 Antibiotics – Open limb fractures Quality Indicator
 Type: Systematic review
Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003764. DOI: 10.1002/14651858.CD003764.pub2.
The purpose of this review was to determine the ability of antibiotics in reducing the risk of infection in open limb fractures. Antibiotics were very effective at decreasing the incidence of early infections, but more research needs to be conducted on bone infection and long-term morbidity.
2 Closed suction surgical wound drainage Quality Indicator
 Type: Systematic review
Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001825. DOI: 10.1002/14651858.CD001825.pub2.
In this paper, the effectiveness of closed suction drainage systems in orthopedic surgery and its ability to reduce the incidence of hematoma and infection is examined. The difference between draining and not draining orthopedic wounds on incidence of hematoma and infection was found to be non-significant. More research is required to verify these results.
3 Pin site care Quality Indicator
 Type: Systematic review
Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004551. DOI: 10.1002/14651858.CD004551.
Different cleansing and dressing methods of orthopedic percutaneous pin sites were evaluated to determine their effect on infection rates in this review. Only one randomised controlled trial was found, but it suggested that cleansing was better than no cleansing at reducing infection rate. Further research is required to better understand this topic.
4 Pulse lavage Quality Indicator
 Type: RCT
Hargrove R, Ridgeway S, Russell R, Norris M, Packham I, Levy B. Does pulse lavage reduce hip hemiarthroplasty infection rates? J Hosp Infect 2006;62(4):446-449.
The purpose of this paper was to determine if pulse lavage reduces infection rates during hemiarthroplasty to treat hip fractures. Infection rate was significantly lowered by pulse lavage.


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