September 8, 2022

A number of interventions in combination can greatly reduce the risk.

Knee and hip replacement patients who develop deep wound infections postoperatively can suffer dire consequences. Infected patients require several weeks of antibiotic treatments and often must undergo two-stage revision surgeries to remove and replace infected implants. Deep wound infections are also expensive to manage, costing many thousands of dollars to treat, all with no guarantee the infection will be eradicated.

One key to preventing these devastating infections is to identify patients who are most at risk for them. Joint infection patients with multiple comorbidities, including uncontrolled diabetes, obesity, hypertension or a compromised immune system, are at high risk of infection. Facilities must blend appropriate patient selection with mitigating the risk factors of selected patients leading up to surgery.

Ronald Singer, MD, an orthopedic surgeon with OrthoCarolina in Charlotte, provides some examples of mitigation triggers. He says high-risk patients should variously quit smoking over a month before the procedure, lose weight to get their BMI under an acceptable threshold or treat their diabetes with medication, diet and exercise until their A1C is under 7. "Patients should also improve their diets at least 30 days before surgery by hydrating properly and eating plenty of proteins, and continue a high-protein diet for six weeks post-op," he says.

Dr. Singer successfully employs the following additional strategies to prevent wound infections:

Nasal decolonization. "About 80% of wound infections are traced to patients' own nasal flora, so treating patients' noses before surgery is a proven way to reduce infection risks," says Dr. Singer, who adds that 25% of individuals in a community carry nasal Staphylococcus aureus and 3% are MRSA carriers, meaning between 25% and 28% of patients entering your ORs could already be colonized. Preoperative nasal decolonization protocols can address this issue. Dr. Singer's patients also bathe with chlorhexidine gluconate (CHG) liquid cleanser or treat the surgical site with CHG wipes the night before surgery, and pre-op nurses wipe patients from head to toe with CHG wipes on the day of surgery.

Intraoperative treatment. In the OR, Dr. Singer irrigates wounds for three minutes with CHG 0.05% lavage, which has a 99.99% kill rate, before applying an antibiotic-impregnated cement around implants and again just before wound closure.

Wound closure. Dr. Singer avoids staples to close wounds. "Staples alone aren't necessarily a cause of post-op infection, but they have been linked with increased length of wound drainage, which is believed to be a marker of infection," he says. He instead employs negative pressure wound dressings, which are attached by a plastic tube to a small pump that creates negative pressure at the wound to prevent fluid from collecting in surrounding tissue. The pump fits in patients' pockets and runs for seven days. Dr. Singer says randomized controlled trials and observational studies have shown this technique could halve infection rates and lower delayed wound healing in a large number of patients. He also inserts a silver membrane mesh that can kill MRSA.

Limiting blood loss. Dr. Singer performs tourniquet-free joint replacements to lower the risk of hematomas forming in tissue around joints or hemarthrosis occurring in the joint space, both of which increase the risk of infection. "Forgoing tourniquets to create a bloodless surgical field requires the use of other methods to control intraoperative bleeding," he says. "I've opted for a water-cooled radiofrequency probe to cauterize tissue and carefully control bleeding in real-time in order to reduce the risk of post-op hemarthrosis."

Patient warming. Patients who maintain normothermia before, during and after procedures are at reduced risk of post-op wound infection. Dr. Singer uses a conductive warming device that warms patients with over-body blankets and under-body mattresses.

Dr. Singer says these interventions work together to greatly reduce infection rates, as they have in his own practice.

Protocols, patient education and policy shifts keep ASC's SSI rate less than 1%.

The surgical site infection (SSI) prevention program at Missoula (Mont.) Bone & Joint Surgery Center employs multiple tried-and-true protocols that are consistently applied to every patient. The facility's infection rate, currently 0.4%, reflects those efforts as it perpetually strives for the coveted zero-SSIs mark. Here's an outline of what the ASC does to keep its patients and staff infection-free.

Patient selection and qualification. The patient's BMI must be below 50, and they must be in relatively good health with no high-risk comorbidities. "We consider all our total joint and spine patients to be higher risk for SSIs by default, so our anesthesiologists and surgeons conduct a thorough review of the patient's medical history to determine whether they'll accept each case," says Clinical Director Kelly O'Brien, MSN, RN, CPAN.

Patient education and engagement. All patients must attend a comprehensive class conducted by the facility's total joints coordinator and physical therapy staff. A friend or loved one must accompany them, and they are designated as the patient's coach. The class addresses all components of the upcoming episode of care from preoperative nutrition to wound care, which is key to preventing post-op infections.

Antimicrobial showers and prep. All total joints and spine patients are instructed to shower using 4% chlorhexidine soap both the night before and the morning of their surgery. When they arrive for surgery, they are screened for MRSA and MSSA. Positive results are treated with a mupirocin antibiotic ointment as part of the facility's nasal decolonization protocol, as well as IV vancomycin preoperatively.

Reducing flash sterilization. To keep use of immediate use steam sterilization (IUSS) under 10%, the facility shifted to rigid containers and made other operational changes, including purchasing new instrumentation. Its IUSS rate is now less than 3%.

Adenosine triphosphate (ATP) testing. The facility employs a device that detects the presence of ATP, which indicates live bacteria when swabbed on high-touch surfaces. These test results led the facility to purchase keyboard covers for the ORs that make disinfecting them easier. Monthly tests are administered in the OR and recovery room, and were even conducted in the waiting room during the height of the COVID-19 pandemic.

Patient warming. Active warming in pre-op and in the OR on all patients is employed for procedures expected to last longer than an hour. "We primarily warm patients to minimize risks of complications and infections," says Ms. O'Brien. "Inadvertent perioperative hypothermia is linked to greater intraoperative blood loss and increased chances of surgical wound infection."

Hand hygiene. Hand hygiene audits are performed monthly using an observation method to verify compliance and share results. A supervisor doesn't perform the audits. Instead, team members volunteer. While these volunteers work, they secretly observe colleagues' hand hygiene practices for a certain period. The resulting statistics are reported on in quarterly quality improvement meetings.

Ms. O'Brien says patients benefit from the center's constant vigilance. The facility's operations recently so impressed a visiting sterile processing consultant that they said they might use the practice as a model for other facilities.

3M^™ Prevena^™ Therapy helps decrease the risk of postoperative complications.

With the emergence of COVID-19 in 2020, the healthcare system of the United States was significantly impacted. Major hospital systems were overflowing with critically ill patients, death rates and COVID-19 cases climbed and medical resources were, at times, sparse. Elective surgeries were halted in most US cities in the spring of 2020, and some continued to see further restrictions throughout the year. Hospitals, where many patients often spent 1 to 2 nights after total hip or total knee replacement surgeries, did not have the capacity to support elective joint replacement surgery patients.

Orthopedic surgeons adapted to these stresses, and the trend of transitioning elective total joint replacement cases to the ambulatory surgery center (ASC) rose dramatically. At many times in 2020, outpatient ASC settings were the only locations total joint arthroplasty (TJA) could be performed. While this trend had already started before COVID-19, it was accelerated in 2020 as orthopedic surgeons became more and more comfortable performing TJA surgery in the ASC setting. By 2028, it is estimated that 53% of all TJA in the US will be performed in outpatient settings with an estimated increase of 1105% for knee arthroplasty and 712% for hip arthroplasty in outpatient volumes.¹

An additional force driving TJA to the ASC setting is physician reimbursement, which is now being linked to the cost associated with the episode of care in "bundles." TJAs performed in an ASC setting are often less expensive than a hospital setting.

Entrepreneurial orthopedic surgeons, who often own part or all of an ASC, may benefit financially by doing more TJA surgeries in their ASC. Additionally, previous restrictions placed by Medicare regarding where TJAs can be performed have been lifted.²

In general, total hip arthroplasty (THA) and total knee arthroplasty (TKA) are very successful operations.³ Unfortunately, complications (e.g., surgical site infections [SSI], seromas and dehiscence) can occur. These complications have been extensively studied and many risk factors have been identified.⁴ Some risk factors, such as smoking, diabetes and obesity, are considered modifiable. Other risk factors, such as hypercoagulability or autoimmune disease, are not modifiable and must be managed around the time of surgery. A great deal of time and effort is spent optimizing patients before elective TJA.³

One tool that has become available to help decrease the risk of postoperative complications is 3M^™ Prevena^™ Therapy. Clinical studies have been published supporting the use of Prevena Therapy after TJA surgery to reduce postoperative complications.^5-7 Additional studies have shown significant improvement in reducing rates of SSI, dehiscence and reoperations after hip and knee replacement revision surgery and after fixation of periprosthetic fractures.^8,9

When patient optimization before surgery is not feasible, Prevena Therapy can be especially useful. Significant benefits are being reported in these patient populations in the literature. A recent randomized controlled clinical trial showed reduced rates of 30-, 45- and 90-day surgical site complications and 90-day readmissions with Prevena Therapy after knee revision surgeries and was stopped at the mid-study evaluation point due to the remarkable differences between the two treatment arms and the obvious benefit with the use of Prevena Therapy.⁷

Many orthopedic surgeons are now using Prevena Therapy in their primary hip and knee replacement patients in selective, higher risk clinical situations and have observed clinical improvements as a result.¹⁰ When used in the patient at high-risk for complications, Prevena Therapy may help decrease the chance for postoperative complications and potentially improve patient outcomes and patient satisfaction, thus reducing "bundle busters," increasing physician reimbursement and decreasing overall cost of care. Additionally, orthopedic surgeons may be comfortable increasing the BMI cutoff for their ASC patients if Prevena Therapy is used. This expands the number of TJA patients seen in the ASC, which may provide opportunities for treating more complex patients.

Prevena Therapy can be used in the ASC in specific patient populations to decrease risk of postoperative complications and "bundle busters."10 Such factors to consider are diabetes, inflammatory arthritis on immune modulating medications, elevated BMI (greater than 35), patients on anticoagulants at increased risk of postoperative bleeding, those with immune compromise such as HIV/AIDS, and smokers.⁴

The benefits of Prevena Therapy in the hospital operating room setting are well documented in the literature, along with reports of patient care cost reductions associated with Prevena Therapy usage. These benefits are now being observed in the ASC setting. The judicious use of Prevena Therapy in the ASC setting may provide orthopedic surgeons with confidence to drive even more volume to the ASC, potentially decreasing the cost of TJA surgery.

Note: For more information please go to 3m.com/PrevenaCentral.

Findings could grow in significance due to an aging population with more comorbidities.

A recent study that examined the health insurance records of patients revealed that those who used negative pressure wound therapy (NPWT) combined with remote therapy monitoring (RTM) had lower adjusted 90-day wound-related costs than those with NPWT alone.

The paper, published in the American Journal of Managed Care, describes a retrospective cohort study based on collection and analysis of payer claims for 1,105 patients who received NPWT with or without RTM in the post-acute setting between March 2018 and May 2019. After controlling for differences in age, payer type and wound type, the researchers found a significant reduction in 90-day wound-related costs in the RTM group ($11,119) compared with the non-RTM group ($14,752). The RTM group had higher NPWT costs ($3,757 vs. $3,289) but lower wound-related non-NPWT costs ($7,361 vs. $11,462).

"This study demonstrated the value of RTM in supporting NPWT adherence and decreasing the costs of wound care in these patients," the authors write. "RTM influenced the proper use of NPWT via continuous patient engagement, filling a gap in the home care environment and thereby saving on non-NPWT wound-related costs."

The authors' work builds on a previous study that reported that patients receiving NPWT with RTM required fewer therapy days than patients receiving NPWT alone, possibly reducing costs of care. "In the outpatient setting, combining RTM with NPWT can support improved adherence to prescribed therapy," they note.

Significantly, the RTM patients in their study were significantly older than the non-RTM patients and had a higher percentage of ulcers and more severe comorbidities. "This exercise emphasizes the importance of evaluating total cost of care and total cost of wound care rather than only the cost of the device and service," the authors say. "It demonstrated that a significant decrease in costs could be obtained despite the additional investment required for the RTM service. This benefit of NPWT with RTM may become even more evident in the future, especially as an aging, comorbid population brings increasing economic challenges to the healthcare industry."

Negative pressure wound therapy could also reduce blistering of surgical wounds.

A research team that reviewed 44 studies that included a total of more than 11,000 patients concluded that negative pressure wound therapy (NPWT) is likely to have reduced the resulting amount of surgical site infections (SSIs) more than standard dressings did.

The researchers, who published their study in Cochrane Database of Systematic Reviews, also investigated whether NPWT caused more or fewer wound reopenings or blisters than standard dressings did. The study focused heavily but not exclusively on knee, hip and abdominal surgeries among U.S., European and Australian patients.

Their conclusion: "NPWT probably results in fewer SSIs than standard dressings in people with closed wounds after surgery (but) probably makes no difference to the proportion of people with wound reopening after surgery. NPWT may increase the number of people with skin blistering after surgery."

The study says SSI rates in patients whose wounds heal by primary closure using stitches or staples can be as high as 40%. These infections can cause pain and discomfort, increase lengths of hospital stays, hike costs of treatment and even result in death. NPWT, intended to mitigate these issues, attaches sealed wound dressings to a vacuum pump that sucks fluid away from the wound. Standard dressings are usually simply gauze and tape.

The review shows that 8.7% of participants who received NPWT experienced an SSI, compared with 11.75% whose wounds were treated with standard dressings. Meanwhile, 6.6% of the NPWT patients suffered wound dehiscence, compared to nearly 7% of those treated with gauze.