Surgical Wound Closure in Orthopaedic Surgery
Surgical Wound Closure in Orthopaedic Surgery
Negative pressure wound therapy (NPWT) was first introduced in 1996 by Argenta and Morykwas to treat chronic wounds. They found that applying continuous subatmospheric pressure to problematic wounds provides a favorable healing environment by four mechanisms: wound contraction, wound environment stabilization, removal of edema or extracellular fluid, and microdeformation at the foam-wound interface. In orthopaedic surgery, NPWT has been shown to be effective under a variety of circumstances, including as an adjunctive measure in the setting of high-risk surgical incisions. Hansen et al. demonstrated that most patients with persistent wound drainage after total hip arthroplasty (THA), who would have previously met indications for debridement, went on to uneventful wound healing with the application of incisional NPWT. Similarly, in a small prospective randomized trial, Pachowsky et al. found decreased rates of seroma formation after THA with incisional NPWT. Prophylactic use of incisional NPWT after acetabular fracture surgery also has been shown to significantly reduce the incidence of deep wound infections and wound dehiscence. Furthermore, Reddix et al. reported that a small series of morbidly obese patients (body mass index >40) undergoing acetabular fracture surgery treated with incisional NPWT went on to heal their surgical incisions without wound complications. Stannard et al. performed a multicenter, randomized clinical trial, comparing incisional NPWT and standard postoperative dressings after surgical treatment of lower extremity fractures caused by high-energy trauma. In this study as well, there were significantly reduced rates of infection and wound dehiscence in patients treated with incisional NPWT compared with the control group. Incisional NPWT appears to be a promising adjunct in the management of difficult surgical wounds.
Oxygen plays a vital role in the wound healing process. Increased oxygen tension is associated with increased collagen production, angiogenesis, epithelialization, and bacteriocidal activity. The administration of supplemental inspired postoperative oxygen has been associated with decreased infection rates in the vascular surgery literature, and ongoing research to explore the role of supplemental oxygen in orthopaedic patients is underway. Hyperbaric oxygen therapy has been used in the treatment of several orthopaedic conditions, such as refractory osteomyelitis, necrotizing soft-tissue infections, and healing of problematic wounds. Bouachour et al. conducted a randomized controlled trial comparing hyperbaric oxygen treatment versus placebo in patients with crush injuries (Gustillo type II or III) demonstrating superior wound healing rates in the hyperbaric oxygen group that were statistically significant. No patient who received hyperbaric oxygen treatment required subsequent amputation of the injured extremity, whereas two patients in the placebo group required an amputation. Although hyperbaric oxygen therapy has been shown to be safe, efficacy in preventing orthopaedic wound complications has yet to be established in a large-scale study. Supplemental inspired oxygen has the potential to optimize wound healing in orthopaedic patients and although highrisk patients may benefit from hyperbaric oxygen, the potential benefits must be balanced against the significant costs and logistical challenges associated with this treatment.
Adjunctive Wound Therapies
Incisional Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) was first introduced in 1996 by Argenta and Morykwas to treat chronic wounds. They found that applying continuous subatmospheric pressure to problematic wounds provides a favorable healing environment by four mechanisms: wound contraction, wound environment stabilization, removal of edema or extracellular fluid, and microdeformation at the foam-wound interface. In orthopaedic surgery, NPWT has been shown to be effective under a variety of circumstances, including as an adjunctive measure in the setting of high-risk surgical incisions. Hansen et al. demonstrated that most patients with persistent wound drainage after total hip arthroplasty (THA), who would have previously met indications for debridement, went on to uneventful wound healing with the application of incisional NPWT. Similarly, in a small prospective randomized trial, Pachowsky et al. found decreased rates of seroma formation after THA with incisional NPWT. Prophylactic use of incisional NPWT after acetabular fracture surgery also has been shown to significantly reduce the incidence of deep wound infections and wound dehiscence. Furthermore, Reddix et al. reported that a small series of morbidly obese patients (body mass index >40) undergoing acetabular fracture surgery treated with incisional NPWT went on to heal their surgical incisions without wound complications. Stannard et al. performed a multicenter, randomized clinical trial, comparing incisional NPWT and standard postoperative dressings after surgical treatment of lower extremity fractures caused by high-energy trauma. In this study as well, there were significantly reduced rates of infection and wound dehiscence in patients treated with incisional NPWT compared with the control group. Incisional NPWT appears to be a promising adjunct in the management of difficult surgical wounds.
Supplemental and Hyperbaric Oxygen Therapy
Oxygen plays a vital role in the wound healing process. Increased oxygen tension is associated with increased collagen production, angiogenesis, epithelialization, and bacteriocidal activity. The administration of supplemental inspired postoperative oxygen has been associated with decreased infection rates in the vascular surgery literature, and ongoing research to explore the role of supplemental oxygen in orthopaedic patients is underway. Hyperbaric oxygen therapy has been used in the treatment of several orthopaedic conditions, such as refractory osteomyelitis, necrotizing soft-tissue infections, and healing of problematic wounds. Bouachour et al. conducted a randomized controlled trial comparing hyperbaric oxygen treatment versus placebo in patients with crush injuries (Gustillo type II or III) demonstrating superior wound healing rates in the hyperbaric oxygen group that were statistically significant. No patient who received hyperbaric oxygen treatment required subsequent amputation of the injured extremity, whereas two patients in the placebo group required an amputation. Although hyperbaric oxygen therapy has been shown to be safe, efficacy in preventing orthopaedic wound complications has yet to be established in a large-scale study. Supplemental inspired oxygen has the potential to optimize wound healing in orthopaedic patients and although highrisk patients may benefit from hyperbaric oxygen, the potential benefits must be balanced against the significant costs and logistical challenges associated with this treatment.