Polyester mesh dressings reduce delayed wound healing rates after total hip arthroplasty compared with silver-impregnated occlusive dressings

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7] years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p < 0.05), 44% lower LOS (1.4 vs 2.5 days, p < 0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p < 0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90 days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9 days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Barbed sutures and skin adhesives improve wound closure in hip and knee arthroplasty

PURPOSE

This study aimed to formulate evidence-based recommendations for optimising wound management in hip and knee arthroplasty by exploring alternative methods such as barbed sutures and skin adhesives.

METHODS

A Delphi panel, comprising seven orthopaedic surgeons, one musculoskeletal infectious disease specialist, and one health economics expert, was convened to evaluate the use of barbed sutures and skin adhesives for wound closure in hip and knee arthroplasty. Two systematic reviews informed the development of questionnaires, with panelists ranking their agreement on statements using a 5-point Likert scale. Consensus was achieved if ≥75% agreement. Unresolved statements were revisited in a second round.

RESULTS

Consensus was reached on 11 statements, providing evidence-based recommendations. The expert panel advocates for a multilayer watertight technique using barbed sutures to prevent surgical site infections (SSI), reduce complications, shorten surgical times, optimise resources and improve cosmetic appearance. For skin closure, the panel recommends topical adhesives to decrease wound dehiscence, enhance cosmetic appearance, promote patient compliance, prevent SSIs, and optimise resources.

CONCLUSION

The Delphi consensus by Italian total joint arthroplasty experts underscores the pivotal role of barbed sutures and skin adhesives in optimising outcomes. While guiding clinical decision-making, these recommendations are not prescriptive and should be adapted to local practices. The study encourages further research to enhance current evidence.

LEVEL OF EVIDENCE

Level III.

Silver as an Antibiotic-Independent Antimicrobial: Review of Current Formulations and Clinical Relevance

Background: The increase of multi-drug-resistant organisms has revived the use of silver as an alternative antibiotic-independent antimicrobial. Although silver's multimodal mechanism of action provides low risk for bacterial resistance, high local and uncontrolled concentrations have shown toxicity. This has resulted in efforts to develop novel silver formulations that are safer and more predictable in their application. Optimization of silver as an antimicrobial is crucial given the growing resistance profile against antibiotics. This article reviews formulations of silver used as antimicrobials, focusing on the mechanisms of action, potential for toxicity, and clinical applications. Methods: A search of four electronic databases (PubMed, Embase, MEDLINE, and Cochrane Library) was conducted for relevant studies up to January 2022. Searches were conducted for the following types of silver: ionic, nanoparticles, colloidal, silver nitrate, silver sulfadiazine, silver oxide, silver carboxylate, and AQUACEL^® (ConvaTec, Berkshire, UK). Sources were compiled based on title and abstract and screened for inclusion based on relevance and study design. Results: A review of the antimicrobial activity and uses of ionic silver, silver nanoparticles, colloidal silver, silver nitrate, silver sulfadiazine, silver oxide, Aquacel, and silver carboxylate was conducted. The mechanisms of action, clinical uses, and potential for toxicity were studied, and general trends between earlier and more advanced formulations noted. Conclusions: Early forms of silver have more limited utility because of their uncontrolled release of silver ions and potential for systemic toxicity. Multiple new formulations show promise; however, there is a need for more prospective in vivo studies to validate the clinical potential of these formulations.

Multilayer Watertight Closure to Address Adverse Events From Primary Total Knee and Hip Arthroplasty: A Systematic Review of Wound Closure Methods by Tissue Layer

Background

Wound closure is a key, and often underrecognized, component of hip and knee arthroplasty. Methods for wound closure are an important consideration to better avoid wound-related adverse events; however, there is a lack of consensus on optimal methods. The objective of the following review was twofold: to characterize the wound closure methods used by layer in the total knee arthroplasty and total hip arthroplasty literature and summarize optimal wound-healing strategies to address the risk of adverse events.

Methods

A systematic literature review was performed to identify total knee arthroplasty and total hip arthroplasty randomized controlled trials and nonrandomized studies reporting wound closure methods by layer and wound-healing adverse events (including superficial, deep, or periprosthetic joint infections, wound dehiscence, or prolonged wound drainage). Studies on revision procedures were excluded. Wound closure methods and adverse events were summarized qualitatively as meta-analyses were not possible because of study heterogeneity.

Results

Forty studies met the inclusion criteria: 22 randomized controlled trials and 18 observational studies. Across studies, 6 categories and 22 unique techniques for closure were identified. Conventional closure methods exhibited large ranges of adverse event rates. Studies of multilayer barbed sutures with topical skin adhesives and polyester mesh or multilayer antimicrobial sutures reported narrow ranges of adverse events rates.

Conclusions

Considerable variability exists for wound closure methods, with a wide range reported in adverse events. Recent technologies and methods for standardized watertight, multilayer closure show promise for avoiding adverse events and unnecessary health-care costs; however, higher quality, comparative studies are required to enable future meta-analyses.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Potential Use of Annona Genus Plants Leaf Extracts to Produce Bioactive Transdermal Patches by Supercritical Solvent Impregnation

The objective of the present work was to develop a bioactive transdermal patch functionalized with Annona leaf extracts (ALE) by means of supercritical impregnation technique. The potential of six different Annona leaf extracts (ALE) obtained with the enhanced solvent system formed by carbon dioxide + ethanol/acetone was evaluated taking into account the antioxidant activity, total phenol composition and global extraction yields. For the impregnation of ALE, two drug supporting systems were tested: hydrocolloid sodium carboxymethyl cellulose (NaCMC) and polyester dressings (PD). The effect of the impregnation conditions, including pressure (P), temperature (T), percent of co-solvent (ethanol) and ALE/polymer mass ratio, was determined with regard to the loading and the functional activity of the impregnated samples. The optimal impregnation conditions of ALE were established at 55 °C and 300 bar which led to obtained transdermal patches with antioxidant and antimicrobial capacity. In order to understand the behavior of the process, the homogeneity of the samples in the vessels was also evaluated. The best results were obtained at higher proportions of co-solvent in the system.

Direct Anterior Approach for Revision Total Hip Arthroplasty: Anatomy and Surgical Technique

There has been increased interest and literature on the efficacy of direct anterior approach (DAA) for total hip arthroplasty (THA). Developments in surgical technique and instrumentation, along with exposure earlier in orthopaedic residency training, may augment the adoption of this approach among practicing orthopaedic surgeons. With the increasing number of primary THA performed through the DAA, understanding the indications and techniques associated with revision THA via the DAA has proved increasingly important. Patient positioning, understanding surgical anatomy and extensile maneuvers, and applying key reconstructive methods are essential for obtaining adequate exposure and fixation. Acetabular exposure can be facilitated through capsular and soft-tissue release, along with extensile approaches to the pelvis and acetabulum. Extensile distal extension can be performed for safe access to the femur, including extended femoral osteotomies. The purpose of this review is to describe indications, surgical anatomy, intraoperative tips, clinical outcomes, and complications after DAA for revision THA.

Polyester Mesh Dressings Reduce Delayed Wound Healing and Reoperations Compared with Silver-Impregnated Occlusive Dressings after Knee Arthroplasty

Background

New dressings aimed at reducing surgical wound complications after knee arthroplasty continue to evolve. We compared wound complications and reoperations between 2 dressings: 2-octyl cyanoacrylate adhesive and polyester mesh (Dermabond® Prineo®, “mesh”) and silver-impregnated occlusive dressings and n-butyl-2-cyancacrylate adhesive (AQUACEL® Ag SURGICAL cover dressing with SwiftSet™, “standard").

Methods

This retrospective cohort study reviewed 353 consecutive partial and total knee arthroplasties performed by a single surgeon; 6 were excluded for not using either dressing type. Thus, 347 cases were separated into 2 cohorts: mesh (n = 176) and standard dressing (n = 171). Demographics and risk factors were similar, except for age. Surgical and closure techniques were consistent in all patients. Delayed wound healing was assessed by the surgeon at the 2-week office visit for drainage, suture abscess, or wound edge separation. Secondary outcome measures include infection, office-based closure, and return to the operating room for reclosure.

Results

There were 2 instances of delayed wound healing in the mesh group and 16 in the standard dressing group (1.14% vs 9.36%, P ≤ .0001). There were significantly fewer reoperations in the mesh group than in the standard group (0 vs 2.33%, P = .04). There were no infections or office-based closures.

Conclusion

Mesh dressings were associated with fewer episodes of delayed wound healing and reoperations than the standard dressing. A possible mechanism may be that this brand of mesh distributes wound tension more evenly. In addition, because it remains in place longer during the immediate postoperative period, it may work via prolonged wound edge support.