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Wound Complications following TKR – Hematoma, Necrosis, Infection

- Management of Complications:
    - see open debridement and retention of components;
    - 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 and hematoma:
                  - 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;
                          - 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 (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. 
                   - references:
                          - Persistent wound drainage after primary total knee arthroplasty.
                          - Intramuscular Hematoma Following a Midvastus Approach During Primary Total Knee Arthroplasty
                          - Early Return to Surgery for Evacuation of a Postoperative Hematoma After Primary Total Knee Arthroplasty

           - 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 must be treated aggressively w/ surgical I&D +myocutaneous flap coverage in order to prevent infection of implants;
                   - gracilis flap:
                         - Reversed Gracilis Pedicle Flap for Coverage of a Total Knee Prosthesis
                  - 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.
                   - refererences:
                         - Diabetes the only major risk factor for early wound problems after primary TKA
                         - Wound Healing Problems in Total Knee Arthroplasty
                         - Angiographic findings in patients with postoperative soft tissue defects following total knee arthroplasty.
                         - Surgical Treatment of Early Wound Complications Following Primary Total Knee Arthroplasty

Quadriceps Tendon Rupture After Total Knee Arthroplasty. Prevalence, Complications, and Outcomes.

Bandaging technique after knee replacement.

High Incidence of Complications From Enoxaparin Treatment After Arthroplasty

Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty

Early Return to Surgery for Evacuation of a Postoperative Hematoma After Primary Total Knee Arthroplasty