A risk-stratification algorithm to reduce superficial surgical site complications in primary hip and knee arthroplasty

Abstract

BackgroundSurgical site complications (SSCs) are the most common cause for readmission after total joint arthroplasty (TJA), increasing costs while predisposing to inferior long-term outcomes. Prophylactic use of closed-incision negative pressure therapy (ciNPT) may lower the risk of these complications, especially in high-risk populations, but appropriate-use guidelines are lacking for patients undergoing primary TJA. We sought to develop a risk-stratification algorithm to guide use of ciNPT dressings and test its use in normalizing the rate of superficial SSCs among high-risk groups.MethodsWe reviewed 323 consecutive primary TJAs, where 38% of those patients considered at elevated risk were risk-stratified to receive ciNPT dressings. An individual risk score was developed, assigning points based on patient-specific risk factors. We identified a historical control population of 643 patients who all received the same postoperative dressing to test the impact of this risk score.ResultsCompared with historical controls, we observed a modest but significant improvement in superficial SSCs after implementation of risk-stratification (12.0% vs 6.8%; P = .013). Among high-risk patients, there was a marked improvement in SSCs when treated prophylactically with ciNPT dressings as compared with historical controls (26.2% vs 7.3%; P < .001). Low-risk patients, who continued to be treated with standard postoperative dressings, demonstrated no significant improvement (8.6% vs 6.5%; P = .344).ConclusionsciNPT dressings are effective at reducing and normalizing risks of superficial SSCs among high-risk primary arthroplasty patients. The proposed risk-stratification algorithm may help identify those patients who benefit most from these dressings.

A Modified Technique for Applying Closed Incision Negative Pressure Therapy Dressing Following Total Joint Arthroplasty

“…When high-risk patients were treated with ciNPT dressings, there was an appreciable improvement in SSCs relative to historical high-risk controls (26.2% vs. 7.3%; p < .001). Patients designated as low risk in the study group, who were treated with standard postoperative dressings, did not demonstrate any significant improvement relative to historical low-risk controls (8.6% vs. 6.5%; p = .344) [ 3 ].…”

“…Despite the effectiveness of these orthopedic interventions, diverse postoperative complications are common occurrences following primary knee and hip arthroplasty [ 3 ]. Surgical site complications (SSCs) may encompass delayed incision healing, protracted drainage at the surgical defect, the development of seromas and/or hematomas, suture-associated abscesses, and surgical site infections (SSIs) [ 3 - 4 ].…”

“…Postoperative swelling or edema is a common SSC associated with increased nociception, reduced range of motion, gait alteration, decreased strength of the quadriceps, and delayed recovery [ 3 - 5 ]. In obese THA or TKA patients, generalized peripheral edema is noted as a common postoperative SSC and is deemed to be of importance to mitigate postoperative edema in order to facilitate the optimization of the quality of care as well as manage resource utilization [ 5 - 6 ].…”

“…It should be noted that if a patient is undergoing a surgical revision of a previous arthroplasty procedure, there is a greater risk of SSC, SSI, and inpatient readmission [ 6 ]. The role of SSCs in postoperative recovery is frequently underplayed even though SSCs represent a leading cause of unscheduled early readmission [ 3 , 13 - 14 ].…”

“…Closed incision negative pressure therapy (ciNPT) has been reported to decrease the incidence of SSC such as incisional dehiscence, hematoma, and seroma, and sequester the wound environment to reduce the incidence of SSI [ 3 , 6 , 15 ]. This paper describes a technique involving the postoperative application of ciNPT over closed incisions originating from joint arthroplasty to facilitate a reduction in the incidence of SSCs.…”