61 year old with RA develops a small wound dehiscence: old fashioned - - PowerPoint PPT Presentation

61 year old with RA develops a small wound dehiscence: old fashioned antibiotics versus the new vac? Amar S. Ranawat, MD

Associate Professor of Orthopaedic Surgery Weill Cornell Medical College Hospital for Special Surgery New York, NY

Disclosures

• DePuy
• Stryker
• ConforMIS
• Ceramtec
• Convatec
• Nova
• GLG
• Strathspey Crown
• Arthrex

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Comparison of OA vs RA

Osteoarthritis

 Wear and tear  Older patients  Mono-articular

Rheumatoid Arthritis

 Autoimmune disease  Younger patients  Physiologically older  Systemic immunosuppression  Usually poly-articular  Higher incidence of infection

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Rheumatoid Arthritis

• The surgical treatment of RA is
• n the decline secondary to

 NSAIDS  DMARDs

– Antifolates – Steroids – TNF blockers – Interleukin Agonists – CTLA-4 Agonists – Kinase Inhibitors

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Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis

Bongartz, T. Halligan, C. S. Osmon, D.R. Arthritis Care and Research. November 2008

Title of Presentation Here 5

• Patients with RA who undergo total hip or knee replacement are at

increased risk of prosthetic joint infection, which is further increased in the setting of revision arthroplasty and a previous prosthetic joint

• infection. These findings highlight the importance of perioperative

prophylactic measures and vigilance during the postoperative period.

Rheumatoid Arthritis is different

• Post-Operative Wound Complication

 The wound does not heal 2 to immunosuppresion  The diagnosis of infection is more challenging  Aspiration (sometimes of all replaced joints) is essential  Antibiotics alone are often ineffective  Aggresssive local wound care with reoperation is usually the best treatment

 In rare cases,

a wound vac!

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The Vac

Wound Vacuum

• 5 Basic Parts

 Foam  Tube  Drapes  Pump  Canister

7 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac

Wound Vacuum

 A: The foam is placed over the wound with a size equal or little bigger than

wound’s dimension

8 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac

Wound Vacuum

 B: A drape is placed over the foam to cover it completely and to attach it on

the around normal skin

9 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac

Wound Vacuum

 C: A hole is made on the drape over the foam

10 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac

Wound Vacuum

 D: The track pad is placed over the hole

11 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac

Wound Vacuum

 E: Starting therapy led to the foam size reduction due to negative pressure.

12 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Wound Vacuum

• Mechanism of Action

 Macrodeformation of the wound bed  Microdeformation of the wound bed  Fluid Removal  Stabilization of the wound

environment

13 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Wound Vacuum

• Macrodeformation of the wound

bed

• Contraction of the foam after pressure

applied

• Exerts centripetal traction  decreased

wound surface area

• Increase in pressure to the tissue below

the wound bed  increased vascularity

14 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Wound Vacuum

• Microdeformation of the wound bed
• Porous surface of the foam induces

microdeformations in the underlying tissue by creating an rippled surface of the wound bed.

• Cell deformation  cytoskeletal stretch 

Cell proliferation

15 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Wound Vacuum

• Fluid Removal
• Fluid prevents normal blood flow
• Eventually leads to dense fibrous tissue
• Wound vacuums:

– Complete coverage of the wound – Constant interstitial fluid removal

• Less toxins, exudates and bacteria

– Mechanical stimulation of surrounding tissues

16 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Wound Vaccuum

• Stabilization of the wound

environment

• Open Wound  Closed Wound
• Semiocclusive drapes around the foam
• Thermal stability
• Prevents evaporative water losses
• Stabilize osmotic and oncotic gradients of

the wound surface

• Reduces risk of external contamination

17 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Role of negative pressure wound therapy in total hip and knee arthroplasty

Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika World Journal of Orthopedics

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• There is little evidence to support the use of Negative Pressure Wound

Therapy (NPWT) as an adjunctive treatment for surgical wound drainage, and for this reason surgical intervention should not be delayed when indicated.

• The prophylactic use of NPWT after arthroplasty in patients that are at

high risk for postoperative wound drainage appears to have the strongest clinical evidence.

Incisional Wound Vacuum

 To manage healing of the closed incisional wound

post-surgery to avoid serious infections and other wound complications in high-risk patients.

 Especially in patients with a high risk for drainage

– RA – Blood thinners – Obese – Malnourished – Revisions

19 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

Incisional Wound Vacuum

• Advantages:

 Peel-and-place dressings exist  Or a full incisional wound vac for large incisions or

for large expected volumes of drainage

 Easy transition from the OR to the hospital and/or

• utpatient for use by multiple care givers.

20 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound therapy in total hip and knee arthroplasty. World Journal of Orthopedics

61 year old with RA develops a small wound dehiscence: old fashioned antibiotics versus the new vac?

• Consider incisional wound vac in the OR
• If dehiscence is noted after IWV removal
• Hold antibiotics
• Evaluate for capsular involvement (range knee)
• Aspirate
• Low threshold for I&D with cultures and reclosure with motion limits
• If purely skin with subcutaneous tissue and proximal dehiscence

consider wound vac/silvadene/local wound care. If treatment failing have a low threshold for exploration and reclosure

• Evaluate other replaced joints

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THANK YOU

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