LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland.
Wrightington Hospital, Wigan, United Kingdom.
Surg Technol Int. 2022 Nov 15;43:279-288. doi: 10.52198/23.STI.43.OS1748.
The successful management of wound healing after total knee arthroplasty (TKA) depends on several aspects of ancillary intraoperative techniques and surgical variables. Many of these have been evaluated in a few recent reports. The prior reviews studied many aspects of wound healing and, for example, found lower risks of wound complications with barbed sutures compared with interrupted closure with non-barbed sutures, no differences in wound complications between adhesives, subcuticular sutures, staples, glue, or mesh adhesives for the closure of the skin layer, and that mesh adhesives may be associated with faster closing times compared to subcuticular sutures or staples in TKA. However, some topics that can be influenced by the surgeon were not covered in these previous reviews. Namely, the use of deep vein thrombosis (DVT) prophylaxis, tourniquet application, management of intraoperative drains, surgical approach selection, and patellar handling techniques can all potentially influence wound healing. Therefore, in this comprehensive systematic review of the literature, we focused on these five factors that may influence wound healing. Specifically, we evaluated: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the role of tourniquet application on wound closure and potential infection risks; (3) the effects of intraoperative drain usage on wound healing; (4) the influence of different surgical approaches on wound closure and postoperative infection rates; and (5) the effects of varying patellar handling strategies on wound healing and infection rates.
A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing auxiliary surgical techniques and their impact on wound healing in total knee arthroplasty (TKA). Relevant terms like "knee," "arthroplasty," and "wound healing" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 24 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in TKA, which included evaluating methodological quality parameters like sample sizes, follow-up durations, and clinical effect measurements. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level.
There were seven reports on DVT prophylaxis that showed no statistically significant differences in wound complications among various treatment methods and medications in patients undergoing total knee arthroplasty (TKA), with wound complication rates ranging from 0.25 to 1%, except that aspirin appeared to have lower wound complications rates in three recent studies than other methods. There were five reports on tourniquet application that showed a generally increased rate of wound complications, but no increase in deep infections. The five reports on intraoperative drain use showed that while there is an increase in total blood loss in the group with drains, ranging from 568ml to 1,856ml, compared to 119ml to 535ml in the no-drain group, there are no significant differences in wound complications, infection rates, or other postoperative outcomes such as swelling, deep vein thrombosis, and range of motion between the drain and no-drain groups. There were three studies on surgical approaches revealing no differences in wound complication rates between the mini-subvastus and medial parapatellar incisions. Also, the surgical variables of patella eversion and anterior tibial translation were only studied in one report.
The current literature highlights the importance of using aspirin when possible for DVT prophylaxis and the possibility that tourniquets may lead to increased superficial wound complications. Drains or surgical approach do not appear to lead to wound problems. Surgical variables, such as patella eversion and anterior tibial translation, need more study.
全膝关节置换术（TKA）后伤口愈合的成功管理取决于辅助术中技术和手术变量的几个方面。最近的一些报告已经评估了其中的许多方面。之前的综述研究了伤口愈合的许多方面，例如，与非带刺缝线的间断关闭相比，带刺缝线可降低伤口并发症的风险，黏合剂、皮内缝线、订书钉、胶水或网片黏合剂用于闭合皮肤层时，伤口并发症无差异，并且与皮内缝线或订书钉相比，网片黏合剂可能与更快的闭合时间相关。然而，一些可以被外科医生影响的主题在这些之前的综述中没有涵盖。即，深静脉血栓形成（DVT）预防、止血带应用、术中引流管理、手术入路选择和髌骨处理技术的使用都可能影响伤口愈合。因此，在这项对文献的全面系统综述中，我们专注于可能影响伤口愈合的这五个因素。具体来说，我们评估了：（1）不同 DVT 预防方法对伤口愈合和感染率的影响；（2）止血带应用对伤口闭合和潜在感染风险的作用；（3）术中引流使用对伤口愈合的影响；（4）不同手术入路对伤口闭合和术后感染率的影响；以及（5）不同髌骨处理策略对伤口愈合和感染率的影响。
对包括 PubMed、Cochrane 图书馆、Medline 和 Embase 在内的电子数据库进行了系统搜索，以确定评估辅助手术技术及其对全膝关节置换术（TKA）中伤口愈合影响的研究。使用“膝关节”、“关节置换术”和“伤口愈合”等相关术语对搜索进行了细化，包括截至 2023 年 5 月 1 日的英语出版物。两名作者和第三名调解员进行了独立筛选，有 24 项研究符合标准。使用改良 Coleman 方法评分（MCMS）评估这些研究的证据水平和方法学质量。对 TKA 中的伤口愈合结果进行了比较，包括评估样本量、随访时间和临床效果测量等方法学质量参数。对研究进行了数据综合，按证据水平进行了分类。
有 7 项关于 DVT 预防的报告显示，接受全膝关节置换术（TKA）的患者中，各种治疗方法和药物之间在伤口并发症方面没有统计学显著差异，伤口并发症发生率在 0.25%至 1%之间，除了阿司匹林在最近的三项研究中似乎比其他方法的伤口并发症发生率更低。有 5 项关于止血带应用的报告显示，虽然使用止血带会增加伤口并发症的发生率，但不会增加深部感染。有 5 项关于术中引流使用的报告显示，与无引流组的 119ml 至 535ml 相比，引流组的总失血量增加，范围从 568ml 到 1856ml，但引流组和无引流组之间在伤口并发症、感染率或其他术后结果（如肿胀、深静脉血栓形成和运动范围）方面没有显著差异。有 3 项关于手术入路的研究表明，迷你小隐静脉和内侧髌旁入路之间的伤口并发症发生率没有差异。另外，髌骨外翻和胫骨前移位等手术变量仅在一项报告中进行了研究。
目前的文献强调了在可能的情况下使用阿司匹林预防 DVT 的重要性，以及止血带可能导致伤口表面并发症增加的可能性。引流或手术入路似乎不会导致伤口问题。髌骨外翻和胫骨前移位等手术变量需要更多的研究。
