- Discussion:
- tourniquet:
- some surgeons release tourniquet and achieve good hemostasis before wound closure where as others apply the compression dressing before closure;
- place knee in a position of 35 deg. of flexion during wound closure;
- references:
- Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion.
- The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study.
- Closed suction drainage following knee arthroplasty. Effectiveness and risks.
- The use of postoperative suction drainage in total knee arthroplasty.
- Closed Suction Drainage for Hip and Knee Arthroplasty. A Meta-Analysis.
- Effect of the Timing of Tourniquet Release on Perioperative Blood Loss Associated With Cementless Total Knee Arthroplasty.
- Emboli observed with use of transesophageal echocardiography immediately after tourniquet release during total knee arthroplasty with cement.
AT Berman et al. JBJS. Vol 80-A. No 3. March 1998. p 389.
- Timing of Tourniquet Release in Knee Arthroplasty. Meta-Analysis of Randomized, Controlled Trials.
- wound complications: (Dennis, ICLS 1997) (see contaminated wound care)
- wound complications include prolonged post-operative drainage, superficial soft tissue necrosis, and full thickness soft tissue necrosis;
- wound drainage:
- initial intervention for prolonged drainage at days 3-5 post-op include continuing antibiotic therapy,
local wound care with compressive dressing, and immobilization (holding physical therapy).
- prolonged drainage beyond 5-7 days post-op despite more conservative measures (see above) should be treated aggressively with surgical I&D;
- in addition to wound debridement, hematomas should be evacuated since they increase soft tissue
tension and can serve as a healthy medium for bacteria.
- non-draining hematomas can be treated non-operatively if the wound appears to be healing well otherwise and there is no sign of infection;
- Weiss and Krackow (J Arthroplasty 1993) reviewed 597 TKA procedures and found that the 8 patients with prolonged
drainage following TKA treated with surgical I&D at an average of 12.5 days post-op healed without infection.
- of the 8 patients undergoing I&D, 2 had positive intra-operative cultures but still did not go on to develop infection.
- historically, 17-50% of TKA patients with prolonged drainage go on to develop culture proven infected TKA.
- Weiss and Krackow suggest that prompt surgical management prevents wound problems from becoming established infections.
- wound necrosis: (see wound vac)
- superficial areas of wound necrosis less than 3cm in diameter can be treated with local wound care and delayed secondary closure.
- larger areas typically require split-thickness skin graft, fasciocutaneous flap, or ,rarely, myocutaneous flap coverage.
- full-thickness soft tissue necrosis usually results in exposed prosthetic components.
- this situation must be treated aggressively with surgical I&D followed by immediate myocutaneous flap coverage
in order to prevent infection of the implants.
- gastroc flap:
- medial head of the gastrocnemius offers excellent coverage of the patella and tibial tubercle regions.
- it is larger and 2-3 cm longer than the lateral head.
- additionally, it does not need to pass around the fibula enabling it to cover more area without having to be stretched.
Quadriceps Tendon Rupture After Total Knee Arthroplasty. Prevalence, Complications, and Outcomes.
Bandaging technique after knee replacement.
Diabetes the only major risk factor for early wound problems after primary TKA
Surgical Treatment of Early Wound Complications Following Primary Total Knee Arthroplasty
High Incidence of Complications From Enoxaparin Treatment After Arthroplasty
........................... ............................. ........................................ ......................... ........................................ ........
