The use of modern surgical dressings to prevent wound complications and surgical site infection SSI after minimally invasive total knee arthroplasty MIS-TKA is lacking. The primary outcome was wound complication SSI and blister. The secondary outcomes were wear time and number of dressing changes in the hospital and patient satisfaction pain, comfort, and ease of use. In the intention-to-treat analysis, there was a significant reduction in the incidence of superficial SSI 0. The study group had longer wear time versus days, and lower number of dressing changes versus times,.
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The use of modern surgical dressings to prevent wound complications and surgical site infection SSI after minimally invasive total knee arthroplasty MIS-TKA is lacking.
The primary outcome was wound complication SSI and blister. The secondary outcomes were wear time and number of dressing changes in the hospital and patient satisfaction pain, comfort, and ease of use. In the intention-to-treat analysis, there was a significant reduction in the incidence of superficial SSI 0.
The study group had longer wear time versus days, and lower number of dressing changes versus times,. Increased patient satisfaction was also noted in the study group. One risk factor related to PJI is superficial wound complication, including surgical site infection SSI , prolonged wound discharge, and skin blisters [ 3 ].
Therefore, prevention of superficial wound complications is necessary after TKA. Minimally invasive surgery MIS has gained popularity in TKA with the advantages of shortened wound length, decreased rehabilitation period, and quicker return to work compared to standard TKA [ 4 ]. MIS-TKA also has higher wound complications, which are related to greater tension on wound edges during surgery [ 5 ].
Therefore, an improved wound care modality is essential. However, patients often complained of pain during dressing change and discomfort during knee range-of-motion exercise after surgery by the use of gauze dressings [ 6 ]. Furthermore, skin blistering and infection are common problems because postoperative movement around the knee joint causes friction between the skin and traditional gauze [ 7 ].
The dressing comprises a core hydrofiber layer containing ionic silver that absorbs exudates to form a cohesive gel and provides antimicrobial protection and an adhesive hydrocolloid backing that fully protects the wound. Both hydrofiber and hydrocolloid layers are extensible to accommodate skin movement during postoperative physiotherapy and prevent blistering [ 9 ].
A prospective, randomized, controlled trial was conducted involving a consecutive series of patients undergoing primary MIS-TKA at a single institute between October and September Written informed consent was obtained from all patients before their participation in the study.
The present study was approved by the institutional review board of our institution and was registered in the public ClinicalTrials. The indication for TKA was severe osteoarthritis of the knee.
Exclusion criteria included patients with condition or comorbidity that could compromise wound healing, including varicose vein, peripheral vascular disease, smokers, poor nutrition, receiving immunosuppressive medications, corticosteroid abuse, and chronic skin disease around the knee e. Patients who had had prior knee replacement, an osteotomy, or a fracture of the ipsilateral knee were also excluded. Therefore, patients were enrolled. Twenty-seven patients were further excluded due to the condition or comorbidity that could compromise wound healing.
Eighteen patients who declined to participate were also excluded from the study. All wounds were closed with interrupted skin stitches. All patients received minimally invasive surgery by the same surgeon. A mini-midvastus approach for TKA was employed, as described by Haas et al. The skin incision was made along the medial aspect of the patella to the medial border of the mid-to-distal tibial tubercle. The patellar components were all resurfaced.
There was no local infiltration of local anesthetic. A suction drain was inserted at the end of the operation and was removed two days after the operation.
At the end of skin closure, a sealed envelope was opened to notify the surgeon of the closure method. The dressing was applied to the wound in the operating theater by the surgeon. All patients received oral Factor Xa inhibitor as deep vein thrombosis prophylaxis for 14 days.
A standard postoperative rehabilitation protocol was applied to all patients, including the use of continuous passive motion of the knee and muscle strengthening exercise immediately after surgery. All patients were taught by a physical therapist to get out of bed with walker support on the first postoperative day.
If there were no indications to change the dressing, it was changed at the day of discharge, usually the 4th or 5th postoperative day POD , and the wound remained covered for 7 days except for exudates across the dressing. The standard dressing consisted of a Sofra-Tulle dressing on the inner layer covered with gauze on the outer layer and was occlusive with tapes over the whole surface of the standard dressing.
The indication for removal of the standard dressing was wound drainage on the dressing. If the wound was not soiled, it was changed on the day of discharge. After being discharged from the hospital, the family conducted the dressing change according to the removal criteria for each dressing. The primary outcome measure was wound complication, including surgical site infection SSI and blister. Wound complication was assessed at each dressing change.
SSI was defined based on the recent recommendations of the Centers for Disease Control and Prevention CDC and divided into superficial SSI only involving skin and subcutaneous tissue within 3 months after surgery, deep SSI involving below the fascia , and organ-space SSI involving the joint within 1 year after surgery [ 15 ].
The secondary outcome was patient satisfaction about the dressings. Patient satisfaction was evaluated by three parameters pain, comfort, and ease of use on the day of the first postoperative visit. The pain severity was reported by the patient during dressing removal. The comfort and ease of use were classified as excellent, good, fair, or poor [ 17 ].
Wear time of the dressing and number of dressing changes in the hospital were also recorded. All the patients completed the outcome evaluation. An a priori sample size was estimated using a 2-tailed Fisher exact test with a 0.
Based on the study conducted by Burke and colleagues [ 9 ], we estimated the incidence of wound complication at 4. The categorical data were summarized as an absolute value and percentage. The continuous data were presented as mean and standard deviation.
Independent samples t -test was used to compare the continuous variables and the chi-squares test was used to compare the categorical variables.
The primary prespecified analysis was an intention-to-treat analysis. The intention-to-treat population included all patients who underwent randomization.
We also performed a prespecified per-protocol analysis. The per-protocol population included patients in both groups who had used the same dressings throughout the study. All data were analyzed with the use of MedCalc software version A total of patients underwent randomization Figure 1. Three patients in the control group refused to participate in the study after allocation due to the lack of family care after discharge and then switched to use AQUACEL Ag Surgical dressing.
All patients were included in the intention-to-treat analysis, whereas of patients No patients were lost during two-year follow-up. The basic demographic data were similar between the two groups Table 1. The length of hospital stay did not differ significantly between the two groups versus days,. Patients in the study group had a longer mean wear time days than those in the control group days,.
The mean number of dressing changes prior to discharge was significantly lower in the study group times than in the control group times,. Of the eight dropouts, only one patient developed blisters in the study group. None of these dropouts developed surgical site infection.
In the intention-to-treat analysis, the incidence of blistering was lower in the study group at 2. The incidence of superficial SSI in the study group was statistically significantly lower at 0. One patient developed deep SSI in the control group 0. The patient satisfaction is shown in Table 3.
The mean VAS pain score was lower in the study group compared with the control group when the dressing was removed versus ,. In the study group, most patients experienced excellent comfort when the dressing was in place Excellent ease of use was rated higher in the study group compared with the control group during application of the dressing AQUACEL with or without silver-impregnated dressing has been shown to be an effective dressing to significantly reduce the occurrence of acute PJI [ 11 ], blister formation [ 10 ], and SSI [ 8 , 9 ] after total joint arthroplasty compared to other adhesive dressings in previous studies Table 4.
In a case-control study by Cai et al. Dobbelaere et al. They found no infection in all patients with the use of these three innovative wound dressings. Springer et al. The silver-containing dressing has been proven to fight against commonly encountered wound pathogens, including antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, aerobic and anaerobic bacteria, and yeasts in an in vitro study [ 18 ].
Upon hydration of exudates, the hydrofiber dressing responds to changes in wound fluid and silver ions are continuously made available during dressing wear time, which reduced SSI in the clinical study. However, we did not find differences in blister formation between the two types of dressings.
We considered two reasons. First, our cases were performed using minimally invasive surgery, which avoided eversion of the patella and dissection of the lateral skin flap of the knee [ 14 ]. Therefore, the blood supply of the skin flap around the knee may be less compromised. Second, the standard dressing used in our study has nonadherent properties. According to Dobbelaere et al. In a prospective randomized clinical trial, hydrofiber dressing with ionic silver was better for managing pain, overall comfort, wound trauma upon dressing removal, exudate handling, and ease of use compared to povidone-iodine gauze for the treatment of open surgical and traumatic wounds [ 17 ].
Similar results were reported when hydrofiber dressing was applied for chronic leg ulcerations [ 20 ]. The individual fibers in hydrofiber dressings are fine and flexible. The hydrocolloid layer is skin-friendly and comfortable during body movement [ 21 ]. In Taiwan, there are approximately 25 thousand TKAs performed annually. Infection after TKA has been reported with an incidence ranging from 1. We have acknowledged some limitations in this study.
First off, allocation concealment was performed using opaque envelopes. However, the differences in the dressing sizes would most certainly mean that those involved in administering the intervention dressings were not blinded and would be aware of upcoming assignments.
Silver Dressing Aquacel® Ag Surgical 3-1/2 X 12 Inch Rectangle Sterile
The use of modern surgical dressings to prevent wound complications and surgical site infection SSI after minimally invasive total knee arthroplasty MIS-TKA is lacking. The primary outcome was wound complication SSI and blister. The secondary outcomes were wear time and number of dressing changes in the hospital and patient satisfaction pain, comfort, and ease of use. In the intention-to-treat analysis, there was a significant reduction in the incidence of superficial SSI 0.
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