The Hip: Preservation, Replacement and Revision

THR: Wound Closure

    - place leg on padded Mayo stand in 10 deg of abduction to relieve tension on the thing and the tensor fascia lata;
    - deep soft tissue repair:
           - repair of posterior capsule and reattachment of the external rotators (which may help to decrease posterior dislocation);
           - there is some evidence to suggest that external rotator muscle repair is doomed to failure;
           - references:
                  - Failure of reinserted short external rotator muscles after total hip arthroplasty
                  - Hip Mechanics After Posterior Structure Repair in Total Hip Arthroplasty.
                  - Failure of Capsular Enhanced Short External Rotator Repair After Total Hip Replacement
                  - Posterior Soft Tissue Repair in Total Hip Arthroplasty: A Randomized Controlled Trial
    - superficial closure: 
           - 2-0-PDS-plus Running Verticle Matress Suture
                  - this suture technique takes care of the subcutaneous and skin layers;
                  - it allows for a rapid closure, with optimally everted skin edges, free of asymmetric wound tension
           - references: 
                  - Skin closure using staples and Nylon sutures: a comparison of results
                  - Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis.
                  - Should we still stitch the subcutaneous fat layer? A clinical and ultrasound assessment in 50 hip operations. 
                  - Comparative study of skin closure in hip surgery.
                  - Is a fat stitch required when closing a hip hemiarthroplasty wound without a drain? 
                  - Inverted running interlocking suture (IRIS): a technique for rapid closure of wounds.
                  - Delayed wound healing and nutritional deficiencies after total hip arthroplasty
                  - Comparing wound complication rates following closure of hip wounds with metallic skin staples or subcuticular vicryl suture: a prospective randomised trial.
       - Post Operative Dressing: (off the shelf closed suction wound dressings); 
                  - a cheap alternative to the wound vac concept involves use of gauze, fenestrated drain, and tegaderm;
                  - gauze is applied over the wound, followed by application of fenetrated drain, followed by more gauze;
                  - tegaderm is applied, airtight, and the tubing is applied to wall suction at about 175-200 mm Hg;
                  - apply a "hemovac" type drain over gauze (multi holed tube is positioned over gauze) with the non-fenestrated portion of the tubing exiting outside gauze; 
                  - advantages: the gauze contracts down (paradoxically like a pressure dressing), and the skin edges are pressed together (because of the dressing contraction), so that the dressing often remains free of blood and often does not have to be changed during the post op period;
    - need to drain THR is controversial:
           - some surgeons place one drain deep to fascia, and if the patient is obese, then one drain superficial;
           - references:
               - Closed wound drainage in total hip or total knee replacement. A prospective, randomized study.
               - The effect of suction drains after total hip replacement.
               - The use of postoperative suction drainage in total hip arthroplasty.
               - The efficacy of suction drains after routine total joint arthroplasty
               - Why use drains?
               - The effect of suction drains after total hip replacement.
               - Closed Suction Drainage for Hip and Knee Arthroplasty. A Meta-Analysis.
               - A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty.
               - Simplified wound care and earlier wound recovery without closed suction drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, January 7, 2013 3:51 pm