June 24, 2021

Postoperative breakdowns of the surgical site can be addressed through proper assessment and care.

COSTLY CONDITION Surgical wound dehiscence can lead to hospital stays, delayed healing and, in some cases, additional surgeries.

Surgical wound dehiscence (SWD) is a postoperative complication that occurs when the margins of a closed surgical incision separate. Most commonly seen within four to 14 days after surgery, including those performed on the foot and ankle, SWD can contribute to increased patient morbidity and mortality, along with the attended financial costs for the surgical facility.

A recent article published in Lower Extremity Review examined the phenomenon. Patients at risk for SWD include those over 65 years old due to the compromised tissue repair mechanisms in aging skin, according to author Windy Cole, DPM, CWSP, adjunct professor and director of wound care research at Kent State University College of Podiatric Medicine and student rotation coordinator at UH Richmond Medical Wound Center, both in Cleveland. She says the condition is also more likely to develop in patients who are malnourished or have weakened immune systems due to chronic diseases such as diabetes, AIDS, renal disease, peripheral artery disease, obesity, hypertension and cancer.

Men experience SWD at a higher rate than women. Patient behaviors such as smoking and alcohol abuse can increase the chance of SWD, while stress on the wound site during exercise, lifting and ambulation can also contribute to increased risk. Dr. Cole also cites potential perioperative factors such as poor surgical technique, surgeon experience, prolonged OR time, over-tightening of sutures and inappropriate fixation. Surgical site infections can also lead to SWD, she writes.

"Despite increases in knowledge relative to the process of wound healing, SWD is still a major contributing factor to increased hospital stays, prolonged healing and re-operation rates, which result in higher healthcare costs and resource utilization," says Dr. Cole. "Given the vast number of potential sequelae related to SWD, an ounce of prevention may indeed be worth a pound of cure."

Management of SWD requires extensive treatments, according to Dr. Cole, such as advanced wound care dressings, antibiotic therapy, debridement and, in some cases, additional surgery. "Minor SWD may be effectively treated in outpatient settings, but cases of severe SWD can require hospital admission," she says.

A new wound care technique might be on its way to becoming a key rung in the reconstructive ladder.

Credit: Synovis MCA
NO SKIN GRAFTING Continuous external tissue expansion devices apply constant tension with no need to retighten and no restrictions on blood flow.

A recent study examines the utility of continuous external tissue expansion (CETE) as a tool for soft tissue injury management, noting clinical evidence that support its use in managing numerous wound types, including fasciotomy, trauma, amputation and flap donor sites.

CETE devices can be applied to open wounds as an alternative to skin grafts or other complex, invasive reconstruction options. The idea behind the devices is to apply constant tension without restricting blood flow and without the requirement of repeated tightening.

Among the many applications of CETE devices is postsurgical wound management. "CETE may be considered in complex postsurgical wounds with potentially mobile skin that may be amenable to closure without flap coverage," the authors write. "In revision surgery, CETE may be used to off-load tension on the primary repair to prevent dehiscence."

The authors say the devices are easy to use, not associated with severe complications and could generate cost savings. They stress, however, that further research is required regarding CETE's safety and efficacy in order for surgeons to apply optimal techniques on qualified patients. "This will help to solidify its place in the reconstructive ladder as a valuable additional option for surgeons," the authors write in the paper, which was published in Advances in Wound Care.

Wound complications can occur in total ankle arthroplasty leading to deep wound infection.

Credit: Synovis MCA
Surgeries in the lower extremities can benefit from DERMACLOSE to aid in wound closure.

Foot and ankles surgeries pose challenges that specifically relate to wounds. According to the authors who wrote about the use of a continuous external tissue expander in total ankle arthroplasty, "Despite major improvements in surgical technique and implant designs in total ankle arthroplasty (TAA), wound healing complications are still commonly encountered. Not only do these problems delay postoperative recovery and threaten functional outcomes, they also carry an increased risk of progression to deep wound infection, which can jeopardize ultimate retention of the implant."¹

They note, "In an effort to reduce the high frequency of wound-related complications after TAA, we have incorporated the use of continuous external tissue expansion (CETE) to augment our closures of the anterior ankle incision. CETE is an innovative technique that is currently being used to aid in the rapid closure of acute and chronic full thickness soft tissue defects, including fasciotomy wounds, high grade open fractures, and chronic foot ulcers."¹

This technique facilitates wound edge approximation of full thickness defects, and it also helps take tension off tenuous incisions, allowing them to heal and reducing the chance for wound dehiscence. Wound dehiscence can become life-threatening – when part or all of a wound comes apart, it does not heal completely and can cause complications post-surgery.

The authors say, "Since introducing CETE to the closure of our TAA incisions, we have seen a decrease in the number of postoperative wound complications and time to wound healing. Based on our experience, we believe that the use of CETE for the prophylactic management of tenuous surgical incisions, specifically those used in the anterior approach to the ankle during TAA, is both safe and efficacious."¹

Orthopedic and foot and ankle surgeons use a special device (DERMACLOSE) to help them achieve primary closure, avoid skin grafts and donor sites, and also help them improve surgical outcomes. The DERMACLOSE Continuous External Tissue Expander reduces time to closure with no need to re-tighten or readjust. It provides delayed primary closure of full thickness wounds. This CETE can benefit successful outcomes for foot and ankle surgeries.

The technique was deemed safe, well-tolerated and effective.

When it comes to postoperative complications surrounding ankle and distal tibia fractures, surgical wound healing tops the list. A recent study sought to compare the effectiveness of incisional negative pressure wound therapy (INPWT) versus conventional dressings in preventing wound complications.

The authors cited the literature in saying that complications in surgical wound healing for ankle fractures range from 7.2% to 30%. They took inspiration from the encouraging results reported regarding INPWT's use in elective orthopedic procedures and decided to put it to the test for trauma cases.

The study, published in the journal Acta Biomedica, examined 65 patients considered at risk for wound complications — such as smokers and those with BMIs over 30, older than 65 years or affected by diabetes — who underwent open reduction internal fixation (ORIF) for bi/tri-malleolar ankle fractures or distal tibia fractures. The authors chose these two procedures — the first highly common and the second exceedingly rare — due to their high level of complexity and complication rates in terms of wound healing, and the fact that ORIF is the gold standard for treating both. Complications, which include local infection, dehiscence and skin necrosis, can lead to high costs for surgical facilities.

After surgery, patients were randomized to receive a conventional dressing or INPWT. The authors found that the rate of minor and major complications between the two groups was not significantly different, though they noted a trend toward a lower minor complications rate in the INPWT group (12.6% vs 34.7%).

The authors concluded that INPWT is safe, well-tolerated and delivers promising results in preventing surgical wound complications in ankle and distal tibia fractures. To minimize complication risks, the authors recommend detailed analysis of patients' general conditions and comorbidities along with a careful evaluation of compromised soft tissues.

Increased collaboration between infection diseases physicians and podiatrists could improve patient outcomes.

A recent study investigated the viability of a joint infectious disease-podiatry clinic (JIDPC) model for treating patients with diabetic foot infections. Under the model, both an infectious diseases physician and a podiatrist see patients with diabetic foot infections together once a week. The goal of the study was to investigate if JIDPC can improve patient adherence and reduce recurrent infections, with the possibility of some patients being referred for outpatient surgeries.

The study, published in the journal Advances in Skin & Wound Care, retrospectively analyzed patients with diabetic foot infections admitted to Wheeling (W.Va.) Hospital between 2013 and 2018. From 2013 through 2016, patients were followed by infectious diseases doctors and podiatrists separately in their clinics. In 2017 and 2018, patients were followed under the JIDPC model. The authors compared recurrent infection, mortality and loss to follow-up among the two groups.

They found that the JIDPC approach produced several notable changes:

• Surgeries were performed in 52.5% of the preintervention group, but 81.9% of the postintervention (JIDPC) group.
• The preintervention group was more likely to be lost to follow-up (30.3% vs 9.1% ).
• Risk of infection recurrence in six months was significantly higher in the preintervention group (36.1% vs 20.8%).
• Mortality and 90-day readmission were not significantly different.

"Implementation of JIDPCs may decrease the incidence of recurrent infections among patients with diabetic foot infections," the authors write. The results point to the continued need for coordinated multidisciplinary care to produce optimal patient outcomes.