Abstract
Obtaining primary wound healing in total joint arthroplasty (TJA) is essential to a good result. Wound healing disturbances (WHD) can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromise factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphodema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor nutrition. Low serum albumin, total lymphocyte count, and low transferrin increase WHD. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to modify healing responses. Use of tourniquet in obese patients also increases WHD.
Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thusly, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKA's without tourniquet to enhance blood flow and tissue viability. The use of perioperative anticoagulation will increase wound problems.
If wound drainage or healing problems do occur, immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count (less than 2500), differential (less than 60% polys), and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound.
