October 27, 2021

Optimizing incision management should never be an afterthought.

CREDIT: GIBLIB and Hospital for Special Surgery
EXTRA ATTENTION Orthopedic surgeon Edwin P. Su, MD, believes closing incisions properly is an essential part of his job.

Many surgeons make the mistake of not putting forethought into wound care. For them, the prevailing school of thought is that the important work is done when the procedure is over, and closing incisions is the job of their surgical assistants. That philosophy needs to change, according to Edwin P. Su, MD, a hip and knee surgeon at the Hospital for Special Surgery in New York City, who believes closing incisions properly is a critical part of every procedure.

“As the access point to the surgical site, the wound should be considered a prime area that could permit transmission of bacteria, which could cause a surgical site infection,” says Dr. Su. “Delayed healing of the wound can compromise the results of the surgery.”

Fortunately, says Dr. Su, a new development known as negative pressure wound therapy can promote quick healing and limit the risk of potentially devastating post-op infections. The innovative devices, commonly called wound vacs or incisional vacs, are vacuum-assisted dressings that have increased in usage over the last five years. They apply some negative pressure to the wound that stimulates healing. Patients carry around the portable devices as they get back to normal life routines and do their rehab, clipping them to their pants or storing them in a carrying case with adjustable straps.

“They essentially suck out excess fluid for about a week after procedures and contain it in a chamber that doesn’t need to be changed,” explains Dr. Su. “The method assists in healing and protects the wound during that critical period. He believes appropriate indications for these devices are high-risk patients, including those with high BMIs or who have had multiple previous incisions.

After the devices are placed, the wound is dressed with a water-resistant cover, meaning the patient can shower with the doctor’s permission. “The dressing should never be submersed in water, and direct water spray from the shower shouldn’t hit the dressing,” says Dr. Su. “Before showering, the device should be turned off, disconnected from the dressing, and the clamp on the tube that connects the dressing to the canister where fluid from the incision is collected should be closed. Patients should be instructed to not disrupt the dressing when using a towel to dry.”

The device is worn for about seven days, with some models featuring a rechargeable battery and charger. In addition to removing fluid from the incision site, the devices aid recoveries by protecting the wound from outside sources of infection and assisting in holding the edges of the incisions together until they fully heal.

Dressings and wound flushing keep incisions from being gateways for infections.

DEEP CLEANSE Before wounds are closed, they should be diluted with an irrigating solution to flush bacteria and debris from the site.

Surgical incisions, and every staple hole made to close them, create openings and opportunities for trillions of bacterial cells that live inside of the body. As such, preventing surgical site infections (SSIs) by cleaning, closing and covering wounds must be a top priority for OR teams.

Antibacterial dressings that have sponges impregnated with antimicrobial silver can be applied to patients in the sterile field, where surgeons place the cleanest dressings on the wound. The absorbent silver-laden sponges soak up and handle any fluids that leak from the wound.

“A lot of the dressings we use now are silver impregnated, which are very inhibitory to bacteria, so we apply them to create a sterile environment,” says Jon Minter, DO, an orthopedic surgeon in Alpharetta, Ga., who specializes in advanced surgical management of hip and knee arthritis. “We leave them on our outpatient hip and knee patients for five to seven days, and by that time the wound has healed up quite nicely. These dressings also allow patients to shower without getting the wound wet, and some sutures available now are antibacterial as well, which is fantastic because they inhibit bacterial growth.”

These dressings, which are appropriate for all types of surgeries, are more expensive than non-silver-impregnated options, but can be worth the extra cost, as patients with infections at a minimum will need an antibiotic regimen to treat them. SSIs can also lead to negative patient reviews or, worse, expensive cases to litigate.

The dressing can stay in place for seven to 10 days without the patient needing to change it during this critical healing period, when the wound isn’t yet watertight and thus highly susceptible to contamination.

Dr. Minter adds that the tried-and-true practice of diluting wounds at the end of surgeries with irrigants remains a vital practice to prevent SSIs, because it effectively removes bacteria and debris that could be present. rids the wound of nonviable tissue and exposes healthy tissue. Unflushed bacteria and debris could pool and create abscesses or infections. “The classic statement is, ‘The solution to pollution is dilution,’” he says.

As elective joint surgeries move into the ambulatory setting, enhancing patient care and optimizing efficiency and cost are keys to success.

Credit: 3M
3M^™ Prevena^™ Peel and Place Incision Management System.

Total hip or total knee replacement surgeries often require a one-to-two-night stay when performed in the hospital, but as the COVID-19 pandemic progressed outpatient surgery centers have increasingly stepped in to pick up the volume as hospitals didn’t have the capacity to support elective joint replacement surgeries. Orthopedic surgeons adapted to these challenges, and the trend of transitioning elective total joint replacement cases to the ambulatory surgery center (ASC) rose dramatically. In fact, at times in some areas, outpatient ASC settings actually were the only locations total joint arthroplasty (TJA) could be performed in 2020.

While this trend had already started before the COVID-19 pandemic took hold, it was accelerated in 2020 as orthopedic surgeons became more and more comfortable performing TJA surgery in the ASC setting. By 2028, it is estimated that 53% of all TJA in the US will be performed in outpatient settings with an estimated increase of 1105% for knee arthroplasty and 712% for hip arthroplasty in outpatient volumes.¹

An additional force driving TJA to the ASC setting is physician reimbursement, which is now being linked to the cost associated with the episode of care in "bundles." If surgeons can find ways to provide care for less cost, they are incentivized by increased reimbursements. TJAs performed in an ASC setting are often less expensive than a hospital setting. Entrepreneurial orthopedic surgeons, who often own part or all of an ASC, may benefit financially by doing more TJA surgeries in their ASC.

Additionally, previous restrictions placed by Medicare regarding where TJAs can be performed have been lifted.² The stress of COVID-19 on the health care system with a changing reimbursement market combined with costs becoming critical and physician reimbursement more commonly linked to the cost of the episode of care have caused a significant change in the way TJAs are performed nationwide.

Optimizing outcomes for a positive patient experience

Complications in orthopedic surgery can be costly. In fact, 18.8% of unplanned 30-day readmission following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is due to SSI.³ Periprosthetic joint infection complications average costs after TKA and THA, respectively, land at $24,200 and $30,000.⁴ By working to help protect incisions from postoperative complications, 3M^™ Prevena^™ Therapy works to help stop the ripple effect before it begins, protecting patients, surgeons, staff, practices and surgical environments from potential consequences through low touch care.

Helping to optimize surgical outcomes, while driving efficiency, is important. Prevena Therapy can help in a number of ways that can aid in enhancing high-quality patient care. Prevena Therapy helps hold incisions edges together outside of the OR post-surgery, removes fluids and infectious materials, thus helping to reduce the risk of infections, as well as reduces edema and mechanically supports the incision for up to seven days. The dressings are designed for ease of movement and allow for low-touch care in the home helping to provide a positive patient experience.

Prevena Therapy has been shown to aid in the reduction of incision complications. One single-center, prospective, comparative study examining the use of Prevena Therapy after total joint replacement found that patients that received Prevena Therapy (192 patients representing 196 incisions) experienced a 73% reduction in total complications (3/192 ciNPT vs. 22/400 control). The data also showed a 71% reduction in SSIs (2/192 ciNPT vs. 14/400 control) and 28% reduction in pain management 24h postop. (2.6+-1.8 ciNPT vs. 3.6+-2.2 control).

The benefits of Prevena Therapy in the operating room setting are well documented. These benefits are now being observed in the ASC setting as TJA surgery increases in the ASC, helping to improve outcomes and reduce complications.

The effectiveness of Prevena Therapy in reducing the incidence of SSIs and seroma in all surgical procedures and populations has not been demonstrated. See full indications for use and limitations at myKCI.com.

3M^™ Prevena^™ 125 Therapy and 3M^™ Prevena^™ Plus Therapy Units manage the environment of closed surgical incisions and remove fluid away from the surgical incision via the application of -125mmHg continuous negative pressure. When used with legally marketed compatible dressings, Prevena 125 Therapy and Prevena Plus Therapy Units are intended to aid in reducing the incidence of seroma; and in patients at high risk for post-operative infections, aid in reducing the incidence of superficial surgical site infection in Class I and Class II wounds.

NOTE: Specific indications, limitations, contraindications, warnings, precautions and safety information exist for these products and therapies. Please consult a clinician and product instructions for use prior to application. Rx only.

Even patients who say they don’t care about surgical scars actually do.

A key pillar of patient satisfaction is to engage in patient-centered care, which in many respects means giving them what they want. When it comes to scarring, however, take it from surgeons who know: There’s a huge difference between what patients say they want and what they actually want.

It’s not unusual for patients to claim they don’t care about the aesthetics of their surgeries. The truth is, however, that no patient goes into surgery hoping they leave with a thick red scar. When surgery leaves a mark, their tune often changes, and the scar plays a major role in the patient’s overall satisfaction with their surgical experience.

Matthew Regulski, DPM, a foot and ankle surgeon and medical director at the Wound Care Institute of Ocean County in Toms River, N.J., says scars often trump the most stellar of clinical outcomes because they serve as an ugly, permanent reminder of the time they spent at your facility. That’s why he includes a discussion about scarring in the pre-op patient education phase of the episode of care, even with the patients who say it’s a non-issue. The discussion should take place before the day of surgery, so patients aren’t too nervous or sedated to process it.

Dr. Regulski minimizes scarring by performing subcuticular stitching — putting absorbable sutures just under the skin — in concert with skin glue, or by performing a subcuticular closure with nonabsorbable sutures.

Sherwin S.W. Ho, MD, a professor of orthopedic surgery and rehabilitation medicine and director of the sports medicine fellowship program at University of Chicago Medicine, employs wound-closure technology that uses tiny hooks or micro-anchors that dig into the dermis. This technique applies an even tension that stretches the skin around the incision and compresses the wound to bring the skin together.

”Patients love how their skin looks after healing,” says Dr. Ho. “These are the people who will talk to their friends and family and spread positive reviews about your facility.”

Could alternate devices one day supplant traditional sutures and staples?

Emerging wound-closure devices can be just as good if not better than traditional sutures and staples, say two prominent surgeons bullish on several new technologies for four key reasons.

Patient satisfaction. “There’s a real fear among patients about having staples removed,” says Asit K. Shah, MD, PhD, an orthopedic surgeon at Englewood (N.J.) Hospital. “With a knee revision, we’re talking about 30 to 50 staples that need to be removed.” In addition to reducing the need for inconvenient follow-up staple-removal appointments, the use of non- or less-invasive adhesive wound closure alternatives can improve patients’ overall impressions of your facility. “If a patient sees the surgeon is on the cutting edge and using these staple-free devices, he’s likely to tell his friends and family,” says Dr. Shah.

Safety. “I was working side-by-side with a resident,” says plastic surgeon Richard Vagley, MD, FACS, of Spectrum Aesthetics in Coral Gables, Fla. “I zigged, he zagged and I wound up with a needle in my finger.” Accidental pricks that occur with sutures are an all-too-common sharps injury. Noninvasive wound closure products remove this safety hazard, while also addressing patient safety concerns. “Staples leave little holes in the body,” says Dr. Shah. “That’s a possible source of infection. It hasn’t been clinically proven, but it’s always a concern for surgeons.”

Time savings. This is an important consideration for facilities that might initially balk at the higher cost of alternative wound closure products versus relatively inexpensive sutures and staples. “You might be paying $20 for staples versus $80 for an alternative closure device,” says Dr. Shah. “That shouldn’t be a prohibitive cost, especially if you’re looking at the big picture.” That big picture involves the time surgeons save by not needing to remove staples from patients — time that’s better spent seeing other patients.

Ease of use. Many alternative closure products are so simple and intuitive to use that surgeons can delegate closures to surgical assistants, which can be invaluable in high-volume facilities. “If you’re alternating between two rooms and can delegate the closure to an assistant, there’s potential to complete more cases per day,” says Dr. Vagley.