skin closure in primary total hip arthroplasty at the...
TRANSCRIPT
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Skin Closure in Primary Total Hip Arthroplasty at
The Northern Hospital
Dr Sam Bewsher
Mr Raphael Hau
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Disclosure
Neither of the Authors have any disclosures
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Aims
To investigate the outcomes of Staples vs Monocryl for skin closure after Primary Total Hip Replacements in regards to:
1. Incidence of adverse events
2. Incidence of dressing change and Incidence of temporary cessation of chemical VTE prophylaxis
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Methods
• Retrospective cohort study
• Consecutive primary THRs from a 3 year period (Nov 2009 – Oct 2012)
• All wounds closed with either 3-0 subcuticular monocryl or staples
• Any revision procedure excluded
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Methods
Data collected
– Age, sex, length of stay
– smoking and diabetes
– Surgeon and registrar, wound closure method, use of a drain
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Staples Vs Monocryl Primary Outcome
Incidence of Adverse Events: Oral or IV antibiotics for wound issues Readmission to hospital or return to theatre for wound complications
Secondary Outcomes
Postoperative dressing change or reinforcment due to wound discharge until would is healed Temporary cessation of chemical VTE prophylaxis and subsequent confirmed VTE
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Results • 188 THRs on 175 patients by 16 consultants and 23 registrars • 108 Females and 80 Males, Mean age 66 • 18 for # NOF, 170 for OA • Minimum follow up 10 months • 16% had a drain • All wounds dressed using a waterproof dressing with absorbent pad • 184 were given 40mg or renally adjusted dose Clexane daily started D1
postop with compression stockings and foot pumps • 4 were given rivaroxiban 10mg daily started D1 postop with compression
stockings and foot pumps
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Epidermis
Dermis
Subcutaneous Fat
Fascia
Muscle
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Fascia closed with 1 Vycril
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Fat closed with 1 Vycril
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Dermis closed with 2-0 Vycril
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Skin closed with Staples or Monocryl
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Results - Primary
Staples Monocryl
N= 136 52
Adverse Event
Oral antibiotics IV antibiotics readmission
return to theatre
10 (7.4%)
4 2 2 2
1 (1.9%)
0 0 1 0
OR 4.05 (0.51-32.44) P=0.19
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Results - Secondary
OR P Value
Day 0-2 12.38 (4.94-31.03) P<0.001
Day 3-5 2.07 (1.07-4) P=0.030
Day 6 and Subsequent 1.94 (0.98-3.83) P=0.055
Staples Monocryl
N= 136 52
Total Dressing Changes 322 48
Changes per Patient 2.4 0.9
OR P Value
Any Dressing Change 5.6 (2.15-11.38) P<0.001
3 or more changes 7.18 (3.14-16.40) P<0.001
5 or more changes 21.25 (2.84-159.1) P=0.003
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Results - Secondary Staples Monocryl
N= 136 52
Temporary VTE prophylaxis cessation
26 (19.1%) 2 (3.9%)
PE DVT Total
3 6
9 (6.7%)
0 0
0 (0%)
Temporary cessation of Chemical VTE prophylaxis resulted in no incidence of VTE No patient on Rivaroxiban suffered wound complications or VTE
OR 5.91 (1.35-25.87) P=0.018
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Results
Age, Gender, Use of a drain, smoking, diabetes, consultant and registrar were not independent risk factors for adverse events, dressing changes
or temporary cessation of chemical VTE prophylaxis
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Results Independent Risk Factors for Adverse Outcomes
3 or more dressing changes
OR 5.98 (1.26-28.48) P=0.025
Clexane cessation OR 5.58 (1.57-19.77) P=0.008
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Discussion
Smith et al – Staples have 4x risk of wound complications in hip surgery
– 4 articles pertaining to hips deemed suitable for inclusion
– 2 strongest pro-suture articles had poor outcome measures
– Single study deemed methodologically sound found no difference (authors now use staples)
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Discussion
Patel et al (2007)- Prolonged wound drainage leads to higher infection rate (p<0.001)
Saleh et al - P=0.01
Eveillard et al - P=0.02
Surin et al - P<0.01
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Discussion
Limitations – Low numbers
– Wound closer not documented
– Minimal co-morbidities recorded
– Wounds dressed at acute hospital or rehab
– Nursing discretion
– Documentation
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Conclusions Primary Outcome
There is no statistically significant difference in rates of adverse events using either staples or Monocryl to close primary THR wounds
Secondary Outcomes Using staples rather than Monocryl leads to increased rates of dressing
changes and clexane cessation for prolonged wound discharge
Dressing changes and cessation of clexane for prolonged wound discharge are independent risk factor for adverse
events
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Acknowledgements
• Lori McLeod-Mills – Orthopaedic Research Coordinator
• Ana Hutchinson – Northern Clinical Research Unit Statistician
• Dr Hardeep Sandhu – Orthopaedic Resident
• Dr Phaethon Karragianis – Orthopaedic Resident
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References 1. Smith et al Sutures versus Staples for Skin Closure in Orthopaedic
Surgery: Meta Analysis BMJ 2010;240:c1199 2. Patel et al Factors Associated with Prolonged Wound Drainage after
Primary Total Hip and Knee Arthroplasty JBJS (Am) 2007;89(1):33-8 3. Saleh et al Predictors of Wound Infection in Hip and Knee Joint
Replacements: Results from a 20 year Surveillance Program J Orthop Res 2002;20:506-15
4. Surin et al Infection after Total Hip Replacement. With Special Reference to a Discharge From the Wound JBJS (Br) 1983;65:412-8
5. Eveillard et al [Risk of Deep Infection in First Intention Total Hip Replacement. Evaluation Concerning a Continuous Series of 790 Cases] Presse Med 2001;30:1868-75 (Article in French)