A Closer Look at Total Joint Wound Care Tech

An integrated focus on infection prevention, early ambulation and patient satisfaction has enabled this orthopedic surgeon to optimize the post-op healing of incisions.

Optimal healing of surgical incisions is essential in total joint surgeries for several reasons.

Obviously, infection prevention is one of those reasons, especially with joint surgeries carrying such a high risk for surgical site infections (SSIs).  But there’s more.

Wound healing is also important to support the patient’s early ambulation. The type of wound healing technology used is important in this regard, as it can be more difficult physically and potentially more painful for the patient to move when staples or non-dissolvable sutures are involved.

A third factor is patient satisfaction. If the patient needs to return to the office for suture or staple removal, it’s an uncomfortable and inconvenient experience for them.

Diverse arsenal

Edwin Su, MD, an orthopedic surgeon at Hospital for Special Surgery in New York City, is acutely aware of these factors. That’s why he uses a multiple-layer closure with dissolvable suture for subcuticular closure and acrylate adhesive to close the skin layer. He finishes with a sliver-impregnated anti-bacterial dressing that stays on for a week.

The combination works for 98% of Dr. Su’s patients. For outlier patients who are allergic to the skin adhesive, he uses porous surgical tape strips to close the skin layer. With certain patients, including those at risk for above-average wound drainage and/or who have a high BMI, he uses a closed-loop negative pressure wound vac dressing that allows for drainage that doesn’t invite infection.

Wound healing actually begins during Dr. Su’s surgeries, not just after. By irrigating the wound throughout the procedure and before closure, he says, SSI risk is further reduced. Depending upon a patient’s risk profile, typical irrigants used in Dr. Su’s practice include normal saline, povidone-iodine solution and hydrogen peroxide.

As one of the first surgeons in the country to practice hip resurfacing, a procedure that preserves the joint by using a metal implant, Dr. Su consistently evaluates emerging technologies in the interest of achieving the best postoperative outcomes, especially for young and active patients with hip and knee arthritis.

Find your go-to closure approach

FOOTLOOSE A closure method should be efficient for your surgical team and also offer the best in postoperative care to minimize the risk for infection and maximize patient comfort.

Dr. Su describes his diverse and sometimes patient-individualized wound closure approach as being his “go-to” for several years now. He recognizes it as a “new normal” that was once considered a mere alternative to traditional staples.

His philosophy regarding wound closure and care is both evidence-based and pragmatic. “You want to pick a closure method that is efficient for your surgical team and also offers the best in postoperative care to minimize the risk for infection and maximize patient comfort,” says Dr. Su.

His wound closure approach is based on several key factors.

• Strong evidence. To investigate all new surgical technologies, including those used for wound closure, Dr. Su consults numerous sources, starting with the literature. He describes a good collection of studies on combined dissolved suture for subcuticular closure with adhesive for skin closure that have been published over the last decade. These studies also include randomized controlled trials that address silver-impregnated dressing and negative pressure therapy. He says the wound closure practices described in several of the studies found reduced incidence of both wound drainage and deep infection in the joint.

• Infection prevention. Research shows that infection at the surgical site can influence how a joint heals, and the infection risk further rises when a surgical wound has drainage. This is why Dr. Su has investigated advances in negative pressure wound dressings, which he says have improved greatly over the last decade. These devices are smaller than they once were, and are now self-contained with a tube connected to the dressing over the incision with battery-pump suction. He likes the product he uses because it confines the drainage in a closed system, which provides him reassurance that this type of dressing won’t increase the patient’s risk for infection.

• Patient movement and satisfaction. Strict attention to all aspects of wound closure is necessary for successful postoperative outcomes. Dr. Su emphasizes that the closure should never be rushed. For example, using skin adhesive instead of staples requires drying time, which extends the length of the procedure.

Dr. Su is fine with that, because he is looking beyond the immediate perioperative phase for his patients. “Extra time and attention to detail during closure saves time in the long run if you consider the time a patient gets to keep by not having to get in the car and come back in a week for staple removal,” he says. Other benefits of adhesive closure compared to staples include less scarring and less pain, says Dr. Su.

Patient comfort for movement during recovery is another area of focus for Dr. Su. When closing a surgical site during total joint surgery, he makes sure the joint is bent at the proper angle for closure. This gives the patient optimum range to bend the incision during early ambulation and when starting physical therapy. “My goal is to ensure the closure does not inhibit bending and especially doesn’t open up when a patient tries to bend,” he says.

Wound care advances

WHEN IT’S OVER Surgical wound healing, with as little scarring as possible, remains an essential part of the patient’s experience.

Dr. Su advises to keep abreast of emerging wound care alternatives through scientific journals, make time to explore the latest and greatest products and technologies presented at medical conferences, and learn from colleagues who are trialing new closure products and technologies in their own practices. “We are always trying to decrease complications for our patients,” he says. Evidence-based results help surgeons like Dr. Su make these determinations.

In terms of new wound closure technologies on the horizon, Dr. Su shares two alternatives he is currently learning more about.

• Zip closure. Similar to adhesive, zip closure for a surgical incision is designed to be applied to the skin after subcuticular closure has been completed. Benefits can include increased mobility, reduced scarring and easy removal by the patient at home.

• Barbed suture. This method incorporates barbs in the suture that hold the incision together, eliminating the need to tie knots. Available in both absorbable and nonabsorbable material, barbed suture is used for a range of operations, often in cosmetic surgery but also for a variety of minimally invasive procedures.

When evaluating any advance in wound care, Dr. Su says you should combine your focus on how it impacts each of three equally important factors: comfort, recovery and infection prevention. Dr. Su’s patients appreciate wound closure methods that allow them to shower and don’t require return visits for suture or staple removal.

“I’m always looking to new technologies that can improve a patient’s final outcome, and surgical wound healing remains an essential part of this equation,” he says. OSM