Abstract
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Wounds in orthopaedic surgery differ from wounds in other surgical fields in various ways.
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Tissues that are highly affected due to the trauma itself, the presence of an orthopaedic implant and the performance of prosthetic surgery in patients with many comorbidities make these wounds need special consideration.
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Complications of the surgical wound in orthopaedic surgery are not unusual, being the main cause of medical care and readmission in the first 90 days.
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There is no consensus on the best way to perform closure in orthopaedic surgery. The national ‘Adequate Wound Management in Orthopaedic Surgery’ survey has shown interindividual variability in wound closure and soft tissue management in orthopaedic surgery at the local level.
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This consensus document, generated by a group of experts in soft tissue management in orthopaedic surgery, proposes recommendations based on evidence (using the GRADE methodology) to promote best practices in this field.
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This document considers recommendations for surgical wound closure, dressing management and haemostasis. In addition, some of the 32 questions in the national survey, plus others relevant to the subject, were taken as a starting point for developing the contents.
Introduction
Wounds in orthopaedic surgery present distinct challenges compared to those in other surgical fields due to factors such as the frequent presence of implants (e.g. plates, pins and joint prostheses), the involvement of severely contused tissues from trauma (fractures) and the high prevalence of procedures in older adults with fragile skin, which increases the risk of complications such as dehiscence, necrosis, infection and haematoma (1, 2).
Of all the surgical interventions in orthopaedic surgery, hip and knee arthroplasties are particularly common, being considered, respectively, the first and fourth most frequent surgical interventions performed in the national health system in some European countries (3). These procedures often lead to wound complications, including dehiscence, necrosis, surgical site infection and haematoma. Among these complications, persistent wound drainage, although often underestimated, is one of the most frequent, affecting 1–10% of cases. It increases length of hospital stay, readmission rate, need for reoperation and healthcare cost as well as decrease the outcomes. Of particular importance is the observed increase of up to 20% in infections in situations with prolonged wound drainage.
Due to the potential risk of complications in these wounds, surgical wound closure is a critical component of orthopaedic procedures. The way in which the closure of the different planes is carried out could have an impact on wound tightness, tissue perfusion, surgical duration, infection rates, wound aesthetics, and postoperative pain. It is therefore of paramount importance to highlight the decisive role that surgical closure plays in the success of the surgical procedure and thus in the benefit of the patient.
Despite the clear significance of this part of the surgical procedure, there is no consensus on the best way to perform surgical wound closure, leading to significant variability in clinical practice among orthopaedic surgeons. One national Spanish survey titled ‘Appropriate Wound Management in Orthopaedics’ conducted by the Spanish Orthopaedic Society (more details of this survey will be presented in this document) suggested that there are no homogeneous criteria for best practices, based on scientific evidence, in this field.
Given the need to establish recommendations to help healthcare professionals involved in surgical wound closure and soft tissue management in orthopaedic surgery, an ad hoc group of experts was set up to carry out a literature search, analyse the level of evidence and draw up recommendations for surgical wound closure and soft tissue management with the aim of seeking to improve clinical outcomes and reduce variability in this surgical area.
Methodology
Three groups of six fellowship-trained orthopaedic surgeons with more than 10 years of experience were involved in the consensus process. The three groups were formed by dividing the surgeons to carry out the systematic review, based on the selected topic: haemostasia (JRCR and AMA), deep layer wound closure (JCMP and JMS) and superficial layer, skin and dressing (PSR and JLMA). Two surgeons were assigned to each group based on their knowledge and preferences. All the participants were responsible for developing the questions and answers based on an extensive review of the literature using PubMed, Embase and the Cochrane Central Register of Controlled Trials. The following terms were included in the search and used in different combinations: (wound closure), (haemostasia), (tranexamic acid), (orthopaedic), (joint replacement), (knee replacement), (hip replacement), (deep layer), (superficial layer), (skin closure), (barbed suture), (staples), (continuous closure), (dressing), (NPWTi) and (skin glue). Additionally, references in the identified studies were searched for relevant studies. Clinical studies with levels of evidence ranging from one to five were included in this analysis. Clinical comparative studies that evaluated the use of tranexamic acid (TXA) during orthopaedic surgery, two or more different ways to close any wound layer and different surgical dressings published in English in a peer review journal were included. Animal and cadaveric studies were included if the authors considered that it could provide valuable information. Clinical studies with less than 15 patients and case reports were excluded. Twenty-two recommendations were developed according to five sections: i) general aspect of wound closure, ii) deep and shallow layer, iii) skin, iv) dressing and v) haemostasia. The answer quality was graded according to the quality of the available studies and was sorted into the appropriate recommendation grade (GRADE) (4). All the authors discussed all the recommendations, led by those responsible for each group, and a final consensus was achieved by all members (Fig. 1).
In addition to this literature search and recommendations, the expert group designed a survey to analyse current practices in this field at a national level. The 32-question survey was generated using software developed by BSJ.plus and sent through the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT) database from 15 February 2021 to 3 March 2021.
Main results of the survey
At the end of the survey data collection period, 471 responses were received. Forty-two per cent of the respondents answered that they had not received adequate training in wound closure. However, despite 87% of respondents feeling that wound closure had a direct effect on the results after joint replacement, only 57% of surgeons carried out wound closures themselves.
A summary of the results showed that in half the cases, the resident closes the wound; for deep fascia layer and for subcutaneous layer, the most common type of closure was interrupted stitches with Vicryl or similar (75 and 89%); and for the skin, more than 90% of surgeons use staples. Table 1 shows the summary of the most important elements of the survey.
Summary of the most representative findings of the survey.
| Questions/options | Percent of answer |
|---|---|
| Do you believe wound closure has a direct effect on outcomes after joint replacement? | |
| Yes | 85% |
| No | 15% |
| Do you consider that during the course of your speciality you have received sufficient formal training in surgical wound closure? | |
| Yes | 58% |
| No | 42% |
| Do you perform the surgical wound closure? | |
| Yes | 57% |
| No | 43% |
| How and with what do you usually close your deep layer in joint replacement? | |
| Vicryl interrupted stitches | 69% |
| Non-absorbable suture | 6% |
| Barbed suture | 14% |
| How and with what do you usually close your superficial layer in joint replacement? | |
| Vicryl interrupted stitches | 81% |
| Non-absorbable suture | 8% |
| Barbed suture | 4% |
| How and with what do you usually suture the skin? | |
| Staples | 90% |
| Intradermic | 5% |
| Interrupted | 5% |
The full results of the survey are attached as a supplementary document (see section on Supplementary materials given at the end of this article) to this study.
Recommendations
For the development of this section, some of the survey questions (those considered most important in terms of the clinical impact of soft tissue closure and management) are taken as a starting point and other questions of common practice in orthopaedics are included, followed by their respective recommendations and level of evidence.
General aspect of surgical closure of the wound
During surgical wound closure, the closure technique used (continuous sutures or interrupted stitches) may modify the risk of a puncture during surgery
Recommendation: The use of continuous barbed sutures reduces the risk of a puncture during surgical wound closure by reducing the transfer of sharp material between surgical staff (surgeon/instrumentalist) as well as less handling of the needle by the surgeon (5, 6, 7). The closure technique may also influence the risk of a puncture, with interrupted stitch closure requiring multiple knots and greater needle handling compared to continuous suture closure. Findings from several high-level evidence studies show a significant reduction in the risk of a puncture during knee arthroplasty closure using continuous barbed sutures versus interrupted stitches, making it a good tool for protecting the surgical team (5, 6, 7).
Level of evidence: High.
Grade of recommendation: Strong.
There is a reduction in surgical duration when using barbed sutures for surgical wound closure
Recommendation: Barbed suturing is associated with a shorter surgical duration in all meta-analyses and prospective studies reviewed (6, 7, 8, 9, 10, 11, 12, 13).
Level of evidence: High.
Grade of recommendation: Strong.
The risk of surgical wound infection can be influenced by the quantity of the material used and the type of wound closure (continuous suture or interrupted stitches)
Recommendation: Current evidence recommends the use of continuous barbed sutures for surgical wound closure in both total hip arthroplasty (THA) and total knee arthroplasty (TKA). Continuous barbed sutures achieve a faster and tighter closure of the joint, reducing the quantity of the material used and reducing the risk of surgical wound complications. Interrupted sutures increase the foreign body reaction at the knots, increasing the possibility of abscess formation and surgical wound infection (9, 11, 14). The tension placed on the knots causes tissue ischaemia and increases the risk of surgical wound dehiscence (11). In contrast, barbed sutures compared to standard sutures allow knot-free fixation of the tissues, leading to a shorter surgical duration (6, 9, 10, 15), a tighter closure (16, 17), a more uniform tension (18), less tissue ischaemia and the use of a smaller quantity of material to perform the suture (19). All these advantages mean that the barbed suture reduces the risk of surgical wound complications (10, 15) and achieves shorter hospital stays in both THA and TKA (20).
Level of evidence: High.
Grade of recommendation: Strong.
The use of antiseptic-coated sutures reduces the risk of infection
Recommendation: Several meta-analyses have shown that triclosan-coated sutures decrease the risk of surgical site infection (21, 22). In prosthetic surgery, there is no evidence of reduced risk of infection (23, 24) (Table 2).
Studies reporting outcomes using antiseptic and regular sutures.
| Study | Study type | LOE | Cases, n | Layer involved | Surgery | Outcomes | |
|---|---|---|---|---|---|---|---|
| All | Triclosan | ||||||
| Ahmend et al. (22) | MA | I | 11,957 | 6008 | NS | Clean surgery | SSI reduction |
| Wu et al. (23) | MA | I | 7458 | NS | Clean surgery | SSI reduction | |
| Sprowson et al. (24) | PS | I | 2546 | 1323 | NS | Triclosan THA/TKA | No differences |
| Sukeik et al. (25) | PS | I | 150 | 81 | NS | Triclosan THA/TKA | No differences |
Abbreviations. LOE, level of evidence; MA, meta-analysis; NS, not specified; PS, prospective study; SSI, surgical site infection; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Level of evidence: High.
Grade of recommendation: Strong.
There is a reduction in costs when using barbed sutures for surgical wound closure
Recommendation: Barbed suturing is unanimously associated in the literature with reduced costs, mainly related to reduced surgical duration and less time spent in the operating room (6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 25). This association with lower costs will therefore depend on the method of economic management of the health system where it is applied. The use of unidirectional barbed sutures has been shown to decrease closure time and, consequently, to result in lower costs (secondary to increased OR efficiency), with no difference in the incidence of wound complications (26).
Level of evidence: High.
Grade of recommendation: Strong.
Deep and shallow wound closure
The use of barbed sutures in arthroplasty wound closure is associated with a decrease in bleeding
Recommendation: Following the literature review, there is no association between the type of suture used for arthrotomy closure and decreased bleeding after arthroplasty (6, 7, 8, 9, 10, 11) (Table 3).
Main results and outcomes reported in studies on interrupted sutures and barbed sutures.
| Study | Study type | LOE | Cases, n | Layer involved | Surgery | Outcomes | |
|---|---|---|---|---|---|---|---|
| All | Barbed sutures | ||||||
| Li et al. (7) | MA | I | 826 | DSL | TKA | Shorter closing time; cost saving; less acupuncture injury | |
| Gililland et al. (6) | PS | I | 411 | 191 | DSL | TKA | Shorter closing time; cost saving |
| Sah et al. (8) | PS | I | 50 | 50 | DSL | bTKA | Shorter closing time; cost saving |
| Meena et al. (9) | MA | I | 1369 | 669 | DSL | TKA | Shorter closing time; higher SSI |
| Zhang et al. (10) | MA | I | 1754 | 814 | DSL | TKA | Shorter closing time; cost saving |
| Han et al. (11) | MA | I | 656 | 345 | DSL | TKA | Shorter closing time; cost saving |
| Chan et al. (12) | PS | I | 123 | 55 | DSL | TKA | Shorter closing time; cost saving; less positive leak tests; less wound complications |
| Malhotra et al. (13) | PS | II | 170 | 80 | DL | TKA | Shorter closing time; less acupuncture injury |
| Li et al. (14) | PS | I | 84 | 84 | DSL | bTKA/bTHA | Shorter closing time |
| Xin et al. (16) | MA | I | 2502 | 1255 | DSL | TKA | Shorter closing time; cost saving |
| Kobayashi et al. (17) | CAD | 9 | 9 | DL | TKA | More watertight; higher resistance | |
| Nett et al. (18) | CAD | 10 | 10 | DL | TKA | More watertight | |
| Sundaram et al. (20) | PS | I | 60 | 30 | DL | THA | Shorter closing time |
| Sutton et al. (21) | RS | IV | 20,486 | 10,243 | NS | TKA/THA | Shorter closing time; shorter length of stay |
| Gamba et al. (26) | PS | I | 85 | DSL | TKA | Shorter closing time(*) | |
| Ting et al. (27) | PS | I | 60 | 31 | DSL | THA/TKA | Shorter closing time |
| Borzio et al. (35) | MA | I | 588 | 290 | NS | THA/TKA | Shorter closing time; cost saving |
| Serrano-Chinchuilla et al. (36) | PS | I | 82 | 39 | DSL | THA | Shorter closing time |
CAD, cadaveric; DL, deep layer; DSL, deep and superficial layer; MA, meta-analysis; NS, not specified; PS, prospective study; RS, retrospective study; SSI, surgical site infection; THA, total hip arthroplasty; TKA, total knee arthroplasty. *Only in deep layer.
Level of evidence: Moderate.
Grade of recommendation: Weak.
The use of barbed sutures in arthroplasty surgical wound closure is associated with a decrease in infections, whether superficial or prosthetic
Recommendation: Anatomic, water-tight closure and elimination of dead space may help create a barrier to bacterial entry, decrease the occurrence of haematoma and preserve muscle function (27). The evidence reviewed has not demonstrated differences in the use of barbed versus interrupted stitches and their impact on the rate of superficial or prosthetic infections (6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 25). The prospective studies in this review did not reach sufficient sample sizes to find significant differences. In the subgroup analysis of the 2016 study by Zhang et al, the use of barbed sutures for arthrotomy is shown to be associated with a lower risk of deep infection and need for subsequent surgery such as polyethylene exchange (9). There is insufficient scientific evidence to show that the use of barbed sutures decreases prosthetic hip and knee infections.
Level of evidence: Moderate.
Grade of recommendation: Weak.
The use of barbed sutures in arthrotomy closure is associated with better results on functional arthroplasty scales
Recommendation: From the literature review, no conclusion can be reached regarding differences in the functional outcome scales of patients undergoing arthroplasty, depending on the type of closure performed (6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 25). However, the meta-analyses by Zhang et al. in 2016 and Yanghon et al. in 2018 demonstrate a trend towards improved function at three weeks and three months, respectively, when barbed sutures are used for closure, without reaching statistical significance (9, 10).
Level of evidence: High.
Grade of recommendation: Weak.
Closure of the arthrotomy with barbed sutures is associated with improved joint range results in arthroplasties
Recommendation: It cannot be concluded from the literature review that there are differences in the joint range of patients undergoing arthroplasty surgery, depending on the type of closure performed (6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 25).
Level of evidence: Low.
Grade of recommendation: Weak.
Is there a benefit to capsular closure in posterior approaches after total hip replacement?
Recommendation: The main concern with the posterolateral approach is the dislocation rate, although there is sufficient scientific evidence to support capsular closure. Capsular repair and short external rotator techniques have decreased this risk to less than 1% (28, 29). A recent meta-analysis comparing posterior capsule repair vs without posterior capsule repair concluded that with posterior capsule repair, there is a lower incidence of dislocation, less bleeding and better functional results (30).
Level of evidence: High.
Grade of recommendation: Strong.
What about other approaches?
Recommendation: There is no clear evidence on the advantage of capsular closure in anterior or anterolateral approaches. However, capsular closure may decrease the rate of dislocation. Hugues and coworkers showed in a cadaveric study that the force required to cause prosthetic dislocation was greater if the capsule was repaired (31). An anatomical repair can be achieved by reinserting a single flap of the capsule and abductors (27). There are studies suggesting better proprioception after capsular repair using the anterior approach compared to capsulectomy. There is one clinical trial comparing the two techniques that could demonstrate whether capsular closure decreases the risk of dislocation (19, 26, 32, 33, 34, 35).
Level of evidence: Low.
Grade of recommendation: Weak.
The tightness and sealing of the joint is better when the arthrotomy is closed with barbed sutures compared to other types of suture
Recommendation: There are different studies that demonstrate greater joint tightness when the arthrotomy is performed with barbed sutures, such as the studies by Nett et al. from 2011 and Chan et al. from 2016 (11, 17). In the 2018 study by Kobayashi et al., the greatest joint tightness is observed when closure is performed with barbed sutures, especially when at a certain tension (15N) (16). The concept of tightness is important because, in clinical practice, having the joint contained avoids the possibility of extension of possible haemarthrosis into the subcutaneous space.
Level of evidence: Moderate.
Grade of recommendation: wWeak.
Overall complications and the risks of subsequent surgery after arthroplasty are reduced with the use of barbed sutures in closing the arthrotomy
Recommendation: Most of the literature reviewed shows no significant differences in complications based on the type of suture used for wound closure overall (6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 25). The subgroup analysis of the 2016 meta-analysis by Zhang et al. concluded that the use of barbed sutures for arthrotomy closure was associated with a lower risk of subsequent surgeries, deep infection and need for polyethylene replacement surgeries (9). In the 2016 prospective randomized study by Chan et al., higher rates of surgical wound complications were observed when no barbed sutures were used (11).
Level of evidence: Moderate.
Grade of recommendation: Weak.
Skin wound closure
Are there clinical advantages to using sutures over staples?
Recommendation: Although different authors have published studies concluding that the use of staples seems to increase the risk of infection compared to the use of interrupted or continuous sutures (36, 37), recent literature seems to show that there is no difference in the rate of infection whether one or the other type of closure material is used. There does seem to be a consensus that the use of staples is associated with greater pain compared to continuous suture closure (38, 39). Although they are more debated, it appears that continuous suture closure rather than staples provides a better aesthetic appearance of the wound (40). There is also a consensus that the use of staples instead of thread sutures results in a reduced surgical duration (41, 42, 43). Another aspect to consider is blood perfusion in the wound: the better the wound perfusion, the better the wound healing may be. Cody et al. demonstrated that healing is better with a continuous suture than with vertical stitches or staples (44, 45) (Table 4).
Studies reporting on different ways to close skin.
| Study | Study type | LOE | Cases, n | Design | Surgery | Outcomes |
|---|---|---|---|---|---|---|
| Khalid et al. (37) | MA | II | 683 | Staples vs sutures | Hip, knee, upper limb | Greater wound infection |
| Smith et al. (46) | MA | II | 683 (351) | Staples vs sutures | General orthopaedic | Greater wound infection (especially in hip surgery) |
| Yuenyongviwat et al. (39) | PS | I | 70 (70) | Staples vs sutures | TKA | Reduced wound closure time; greater pain |
| Krishnan et al. (40) | MA | I | 2446 | Staples vs sutures | General orthopaedic | Higher SSI |
| Chen et al. (41) | RS | III | 106 (43) | Subcuticular vs intermittent | TKA | Better cosmesis |
| Daniilidis et al. (42) | RS | III | 61 (29) | Staples vs sutures | Foot and ankle | Reduced wound closure time; less pain |
| Kim et al. (43) | MA | I | 828 (462) | Staples vs sutures | TKA | Less DSI and abscess formation; wound dehiscence; closure time; greater prolonged wound discharge |
| Nepal et al. (44) | PS | I | 62 (31) | Staples vs sutures (SC) | TKA | Faster wound closure; Worse MKS at 6 weeks |
| Wyles et al. (45) | PS | I | 45 | Staples vs sutures (SC) vs vertical matters | TKA | SC best perfusion |
| Sundaram et al. (49) | PS | I | 60 (20) | Glue + mesh vs staples | TKA | Better cosmesis |
| Hettwer et al. (50) | RS | III | 70 (35) | Glue + mesh vs staples | Hip tumour arthroplasty | Less wound complication; reduced length of stay |
LOE, level of evidence; MA, meta-analysis; PS, prospective study; RS, retrospective study; SDI, superficial and deep infection; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Level of evidence: Moderate.
Grade of recommendation: Weak.
What is the role of tissue adhesives in skin wound closure in orthopaedic surgery?
Recommendation: In the field of orthopaedic surgery, the use of 2-octyl cyanoacrylate has demonstrated a lower incidence of wound complications compared to silver dressings in patients undergoing knee arthroplasty (46, 47). Sundaram et al. reported that the use of 2-octyl cyanoacrylate, also in knee arthroplasty, has resulted in better cosmetic and functional outcomes than the use of staples for skin closure (48). In a cohort study, Hettwer observed that the use of 2-octyl cyanoacrylate was associated with less wound exudate in patients undergoing surgery for hip tumours and that this in turn allowed earlier discharge from hospital (49). On the other hand, recent publications have shown that the use of 2-octyl cyanoacrylate may increase the risk of dermatitis in the surgical wound, in some cases even necessitating a skin graft (50, 51). According to Nigro et al., after observing 11 cases of dermatitis in patients undergoing breast plastic surgery, it may be advisable to prevent this type of adverse effect by performing a sensitivity test to 2-octyl cyanoacrylate prior to surgery (52).
Level of evidence: Moderate.
Grade of recommendation: Weak.
Surgical dressings
When is it safe to perform the first surgical wound dressing in orthopaedics?
Recommendation: The first dressing should be applied at least 48 h after surgery, reducing the number of surgical dressing changes to a minimum. The recommendation is that the dressing be changed only when saturated or the maximum duration of the dressing has been reached, according to the manufacturer (53, 54, 55, 56, 57, 58, 59) (Table 5).
Studies reporting on differences between different dressings.
| Study | Study type | LOE | Cases, n | Design | Surgery | Outcomes | |
|---|---|---|---|---|---|---|---|
| All | Dressing analysed | ||||||
| Cosker et al. (54) | PS | II | 300 | Primapore vs Tegaderm vs OpSite | Orthopaedic | Less blistering and wound discharge with film dressing | |
| Toon et al. (57) | MA | I | 280 | <48 h vs >48 h | Different specialities | No differences | |
| Sharma et al. (59) | MA | I | 12 RCTs | Better wound dressing | Hip and knee | Film and Hydrofiber: fewer complications | |
| Cai et al. (61) | RS | III | 1778 | 903 | Aquacel surgical vs standard gauze | HKA | Lower PJI |
| Grosso et al. (62) | RS | III | 1173 | Aquacel surgical vs standard gauze | HKA | Lower PJI | |
| Tisosky et al. (63) | RS | IV | 834 | 309 | Silver nylon dressing vs standard gauze | HKA | Lower superficial and deep PJI |
| Ravnskog et al. (64) | PS | I | 200 | 100 | Alginate vs Hydrofiber | THA | Fewer blisters |
| Dobbelaere et al. (65) | PS | I | 111 | Zetuvit + Cosmopor E vs Zetuvit + OpSite vs Aquacel S vs Mepilex | TKA | Mepilex: most skin-friendly | |
| Hopper et al. (66) | PS | IV | 100 | 50 | Aquacel vs traditional | HKA | Fewer early dressing changes; blistering; delayed discharge |
| Anderson et al. (48) | RS | III | 353 | 176 | D. Prineo vs Aquacel | TKA | Less delayed wound healing; reoperation |
| Cooper et al. (69) | RS | IV | 69 | ciNWPT vs Hydrofiber | Hip + knee fractures | Fewer wound complications; SSI; reoperation | |
| Redfern et al. (70) | PS | II | 592 | 192 | ciNWPT vs traditional | HKA | Fewer complications |
| Manoharan et al. (71) | PS | II | 33 | 21 | ciNWPT vs traditional | TKA | Less wound leakage |
| Higuera-Rueda et al. (72) | PS | I | 294 | ciNWPT vs traditional | HKA | Less SSI; readmission | |
| Kin et al. (67) | MA | I | 1997 | 763 | ciNWPT vs traditional | HR TKA+ THA+ revision | Less wound complications and SSI |
| Ailaney et al. (68) | MA | I | 1092 | ciNWPT vs traditional | HKA | Less SSI, reoperation and length of stay; higher wound blistering | |
ciNWPT, close incisional negative wound pressure therapy; HKA, hip and knee arthroplasty; MA, meta-analysis; PJI, periprosthetic joint infection; PS, prospective study; RS, retrospective study; SSI, surgical site infection; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Level of evidence: Low.
Grade of recommendation: Strong.
Do you consider that the choice of a particular dressing has an influence on reducing the number of surgical wound complications?
Recommendation: The choice of one dressing over another has a direct influence on surgical wound progression (58, 60, 61, 62). There is sufficient evidence to show that the use of active and interactive dressings significantly reduces the number of surgical wound complications, whether minor (redness, blistering or surgical drainage) or major (surgical wound infection and periprosthetic infection).
Level of evidence: High.
Grade of recommendation: Strong.
What type of dressings do you consider most appropriate in our environment (prosthetic surgery, fractures, etc.)?
Recommendation: Post-surgical use of an active dressing has been shown to decrease the number of surgical wound complications, as well as the number of superficial infections and prosthetic infections. However, there is currently no unambiguous evidence for the superiority of one active dressing over another. Recent publications have shown a shorter healing time and lower reoperation rate with the use of 2-octyl cyanoacrylate dressings vs silver hydrocolloid dressings, although these results still need to be confirmed (47, 60, 61, 63, 64, 65, 66).
Level of evidence: High.
Grade of recommendation: Strong.
There is evidence to support the use of incisional negative pressure therapy in the prophylaxis of surgical wound complications
Recommendation: Incisional negative wound pressure therapy (iNWPT) has been shown to decrease surgical wound complications and the risk of surgical wound infection in high-risk patients. In some scenarios, such as periprosthetic fractures and revision arthroplasty, routine use of iNWPT has been shown to be effective in reducing surgical site complications (including surgical site infection), readmission and reoperation, being a cost-effective intervention. However, although these benefits have been reported after primary arthroplasty in high-risk patients, it is still difficult to define this type of patient (67, 68). Its routine use, after primary joint replacement, does not appear to add any benefit to that seen with other active dressings, substantially increasing the cost in these cases (59, 67, 68, 69, 70, 71, 72, 73).
Level of evidence: Moderate.
Grade of recommendation: Strong.
Haemostasia
Do you consider that TXA could be an adjuvant factor in reducing the incidence of in situ infections in hip and knee arthroplasties?
Recommendation: Intravenous or topical administration of TXA has been shown to be an effective method to reduce bleeding, perioperative blood loss and allogeneic blood transfusion requirements after both THA and TKA (74). A meta-analysis of 25 randomized clinical trials (with a total of 1608 patients enrolled) demonstrated that the use of TXA not only reduced blood loss (intraoperative, postoperative and total) but also resulted in a 2% reduction in the rate of surgical wound complications (75). Recently, Yazdi et al. (76) and Lacko et al. (77) have confirmed the protective effect of TXA on periprosthetic joint infection (PJI) in observational studies, with a significant reduction in the risk of developing PJI after primary total joint arthroplasty (TJA) (Table 6).
Studies reporting on haemostasia.
| Study | Study type | LOE | Cases, n | Design | Surgery | Outcomes |
|---|---|---|---|---|---|---|
| Fillingham et al. (73) | MA | I | 34* | TXA vs none | THA | Reduced blood loss and transfusion risk |
| Sukeik et al. (74) | MA | I | 1608 | TXA vs none | THA | Reduced blood loss and wound complications |
| Yazdi et al. (75) | RS | III | 6340 (3683) | TXA vs none | TJA | Reduced blood loss and transfusion risk; PJI |
| Lacko et al. (76) | PS | III | 1529 (787) | TXA vs none | TKA | Lower PJI |
| Zhang et al. (78) | MA | I | 618 | TXA + DC vs TXA | TKA | Reduced transfusion and blood loss |
| Liao et al. (79) | MA | I | 839 | TXA + DC vs TXA | TKA | Reduced transfusion and blood loss |
| Han et al. (80) | MA | I | 479 | TXA + DC vs TXA | TKA | Reduced transfusion and blood loss |
| Ye et al. (82) | MA | I | 1678 | Oral TXA vs none | TKA+ THA | Reduced blood loss; length of stay |
| Teng et al. (83) | MA | I | 646 | ADR vs none | TJA | Postoperative bleeding volume |
| Yu et al. (86) | MA | I | 493 | TXA + ADR vs TXA | TJA | Perioperative blood loss |
| Wang et al. (84) | MA | I | 703 | TXA + ADR vs TXA | THA | Reduced transfusion; total blood loss |
| Wu et al. (77) | MA | I | 426 (213) | TXA + ADR vs TXA | THA | Reduced drainage volume; total blood loss |
TXA, tranexamic acid; ADR, adrenaline; DC, drain clamping; TKA, total knee arthroplasty; THA, total hip arthroplasty; MA, meta-analysis; PS, prospective study; RS, retrospective study; LOE, level of evidence.
*refers to number of publications.
Level of evidence: Low.
Grade of recommendation: Weak in favour.
A recent meta-analysis seems to indicate that the use of TXA decreases the occurrence of intra-articular haematoma, especially when administered topically. Do you advocate no further drainage when using this route of administration of TXA?
Recommendation: Despite clear evidence in favour of the use of synthetic TXA in arthroplasty, there is still an ongoing debate as to whether or not its preoperative use in conjunction with postoperative drain clamping increases its efficacy in reducing blood loss, with some authors stating that after minimally invasive TKA, drain clamping is routinely unnecessary if TXA is administered preoperatively (78).
The results of three recent meta-analyses, conducted by Zhang et al. (79) , Liao et al. (80) and Han et al. (81), seem to indicate the advantage (in terms of drainage blood loss, total blood loss, haemoglobin drop and need for transfusion) of the combined use of preoperative TXA and postoperative clamping of surgical drainage, although they all point to the need for further high-quality controlled studies focused on identifying both the most effective dose of TXA and the optimal duration of clamping time. In the latter regard, we believe it is worth noting that, in a now classic paper on this point, Yamada et al. (82) demonstrated that clamping the drain for one hour in the immediate postoperative period offers better results in terms of reduced bleeding than clamping for 24 h.
Level of evidence: Moderate.
Grade of recommendation: Weak in favour.
Some recent work also seems to show that intra-articular administration of TXA associated with low doses of adrenaline reduces blood loss in knee and hip arthroplasties even more efficiently. Do you consider the use of this combination justified?
Recommendation: Although most studies recommend both topical intra- and periarticular (2 g) and systemic intravenous administration at standardized doses (10–20 mg/kg body weight, preferably three doses) (83), few studies have evaluated the efficacy and safety of topical administration of TXA associated with diluted adrenaline (TXA–ADR), although the latter has been shown to be able to decrease local blood loss safely by different mechanisms (84).
Three recent meta-analyses have evaluated the efficacy and safety of this combination in both THA and TKA and, more generally, in TJA (85, 86, 87). Considering the results of these studies, it is suggested that the combined administration of low-dose (0.25 mg) TXA–ADR has demonstrated efficacy and safety in both THA and TKA, but given the small number of randomized control trials (RCTs) on which they are based, and their short follow-up times, more high-quality clinical studies are needed to fully and certainly recommend its widespread use in these types of procedures.
Level of evidence: Moderate.
Grade of recommendation: Weak in favour.
Do you consider that intra-articular TXA could be detrimental to the synovial microenvironment and the articular chondrocyte in the context of joint fractures or partial arthroplasty?
Recommendation: There is no clear evidence regarding the effects that TXA may have on native articular cartilage (88).
Although there are no specific clinical studies demonstrating the cytotoxicity of this molecule, there is sufficient scientific evidence indicating an increase in cytotoxicity in chondrocytes, synoviocytes, tenocytes and periosteal cells with TXA concentrations higher than 20 mg/mL (89). The authors conclude that current scientific evidence suggests a dose-dependent toxic effect of TXA on intra-articular tissues, indicating the need for extreme caution when THA is to be administered topically in procedures requiring the preservation of native cartilage. While intra-articular concentrations of 20 mg/mL or less are expected to be safe in these procedures, the authors believe it would be equally advisable to conduct human clinical trials to clarify the long-term safety of this type of topical TXA application (89).
Level of evidence: Moderate.
Grade of recommendation: Weak in favour.
Conclusions
The consensus was generated to present the best possible recommendations for wound closure and soft tissue management in orthopaedic surgery. By way of outlining some of the key recommendations for wound closure and soft tissue management in orthopaedics, Table 7 presents some of the key points to consider in surgical practice.
Key recommendations for wound and soft tissue management in orthopaedics.
| Key recommendations | LOE | GOR |
|---|---|---|
| Surgical wound closure | ||
| Evidence suggests that barbed sutures are associated with a shorter surgery duration, greater joint tightness, greater strength than conventional interrupted stitch suturing, and decreased accidental punctures during surgery | High | Strong |
| Capsular closure in hip arthroplasty via the posterolateral approach is associated with a reduced rate of dislocation and bleeding. It is also associated with better functional outcomes. Evidence for the benefit of capsular closure in anterior and anterolateral approaches is limited | High | Strong |
| Evidence suggests that the use of triclosan-coated sutures decreases the risk of surgical site infection. In prosthetic surgery, there is no evidence of reduced risk of infection | High | Strong |
| There is no significant difference in complication rate depending on the type of suture used for deep closure | Moderate | Weak |
| The use of 2-octyl cyanoacrylate has a demonstrated lower incidence of wound complications compared to silver nitrite dressings in patients undergoing knee arthroplasty | Moderate | Weak |
| It cannot be concluded that there are differences in joint range in knee arthroplasty depending on the type of closure used | Low | Weak |
| Dressings | ||
| There is sufficient evidence to show that the use of active and interactive dressings significantly decreases the number of minor and major surgical wound complications | High | Strong |
| Incisional negative pressure therapy has been shown to decrease surgical wound complications and the risk of surgical wound infection in high-risk patients | Moderate | Strong |
| The first dressing should be applied at least 48 h after the procedure. It is recommended that the dressing be changed when the dressing is saturated or after the maximum duration of the dressing according to the manufacturer | Low | Strong |
| Haemostasis | ||
| It is suggested that the combination of TXA with low-dose adrenaline reduces blood loss in knee and hip arthroplasties | Moderate | Weak |
| There is no clear evidence regarding the effects that TXA may have on native articular cartilage | Moderate | Weak |
| Evidence suggests that the use of TXA is associated with a reduced risk of developing periprosthetic joint infection | Low | Weak |
LOE, level of evidence; GOR, grade of recommendation.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-24-0002.
Declaration of interest
The authors of the manuscript declare that they have participated as consultants in advisory events for Ethicon within the framework of generating this consensus document.
Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
Author contribution statement
PSR planned the study, collected the data, reviewed the literature and wrote the manuscript. JRCR, JCMP, AMA, JLMA and JMS collected the data, reviewed the literature and reviewed the manuscript. All the authors discussed the data provided, and votes were taken until a consensus was reached.
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