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 2

Comparison of OA vs RA Rheumatoid Arthritis Osteoarthritis  Wear and tear  Autoimmune disease  Older patients  Younger patients  Mono-articular  Physiologically older  Systemic immunosuppression  Usually poly-articular  Higher incidence of infection 3

Rheumatoid Arthritis  The surgical treatment of RA is on the decline secondary to  NSAIDS  DMARDs – Antifolates – Steroids – TNF blockers – Interleukin Agonists – CTLA-4 Agonists – Kinase Inhibitors 4

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  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. 5 Title of Presentation Here

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! 6

The Vac Wound Vacuum  5 Basic Parts  Foam  Tube  Drapes  Pump  Canister Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 7 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 8 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 9 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 10 therapy in total hip and knee arthroplasty. World Journal of Orthopedics

The Vac Wound Vacuum  D: The track pad is placed over the hole Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 11 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. Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 12 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 13 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 14 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 15 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 16 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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 17 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  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. 18

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 Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 19 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 outpatient for use by multiple care givers. Marcelo BP Siqueira, Deepak Ramanathan, Alison K Klika. Role of negative pressure wound 20 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 21 Title of Presentation Here

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