5/11/2013. Financial Disclosure. Introduction. Introduction

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1 Financial Disclosure Erik Hansen, MD Joel Durinka, BA Matthew S. Austin, MD Gregory K. Deirmengian, MD Research support NIH OREF DOD Aircast AOA MTF Stryker Orthopaedics The Knee Society 3M Zimmer Biomemetics Wyeth Intellectual Property/Royalty SmarTech Elsevier Wolters Kluwer Slack Consultant Stryker Orthopaedics Zimmer Biomet Smith and Nephew Convatech Covidien TissueGene Ceramtec OsteoMEM Board Member/Adviser CD Diagnostics Philadelphia Orthopaedic Soc Eastern Orthopedic Assoc. United Healthcare Magnifi Group (Publishers) 3M Introduction Persistent wound drainage after total joint arthroplasty (TJA) has been identified as a risk-factor for PJI Path for fluid egress is potential conduit for retrograde bacterial contamination Goal of management of incisional drainage is to minimize time to achieve a dry wound Introduction Negative pressure wound therapy (Wound VAC ) has been used with great success for complex wound management Successful use of NPWT for closed wound management has been described in the field of orthopaedic trauma Limited publications applying the technology to total hip arthroplasty 1

2 Specific Aims Institutional Protocol ( 06-Present) Assess the safety of NPWT for persistent incisional drainage following hip arthroplasty Incisional Drainage Following Surgery Local Wound Management Substantial Persistent Drainage on POD4 Determine the success rate Identify risk factors for failure No Persistent Drainage NPWT applied (No Abx) Yes No further treatment Repeat NPWT vs. I&D Methods Retrospective, observational study All patients who underwent hip arthroplasty at RI between Institutional billing database Inclusion criteria- use of NPWT over a closed wound for persistent postoperative drainage Exclusion criteria- open wound, NPWT placed in OR, treatment for PJI Methods- Definitions Success: resolution of incisional drainage Failure: need for subsequent surgical procedure for persistent drainage despite NPWT OR for confirmed PJI Safety: any complications due specifically to the application of the NPWT (e.g. skin blistering/ tears) 2

3 Methods- Statistics Methods Patient variables: Age, gender, BMI, ASA/CCI, immunosuppression, tobacco use, individual comorbidities Uni/Multivariate logistic regression analysis performed to determine variables related to treatment failure (p<0.05) Surgical variables: # prior surgeries, primary vs revision Perioperative variables: Post-op INR level >2, surgical complications, medical complications NPWT related variables: POD applied, # days applied, multiple applications Methods Results Of 5,627 hip arthroplasty cases between 06-10, 122 (2.2%) NPWT cases identified 60M; 62F, mean age 64.5 yo Mean BMI 30.6, ASA 2.7, CCI 2.36 Average follow up: 2 years (6wk-62 mo) Surgical Procedures THA (N=81, 66%) Rev THA (22%), Conv THA (8%), Hemi (3%) 3

4 Results- Vac Results- NPWT In >75% of cases, NPWT was placed on POD Wound Vac Application by Post-operative Day In >60% of cases, NPWT was applied for 2 days Days Wound Vac Applied >5 Results- Safety Results- Outcomes There were NO NPWT related skin complications There was NO gross purulence encountered at time of I&D 79% Success N= 96 42% NPWT Cohort N=122 Superficial I&D N=11 100% 88% No Further Sx N=11 100% 46% 21% Failure N=26 Deep I&D N=12 No Further Sx N=12 12% 2 Stage Exchange N=3 (2.5%) 4

5 Results Limitations Predictors of Failure Variable OR (95% CI) P value INR> ( ) o.o40 Multiple prior hip surgeries 2.32 ( ) Multiple VAC application 5.00 ( ) VAC application>48h 1.93 ( ) Retrospective observational study Variability in practice patterns between surgeons Conflicting data in EMR and paper chart No concurrent control group No treatment Treatment other than NPWT Discussion- Historical Control Discussion- Historical Control PRE-2006 Local Wound Care + PO abx I&D N=83 POD4 76% 24% SUCCESS Further Surgery 15% I&D 5% 80% PO abx 2 Stage Rothman Institute of Orthopaedics at Thomas Jefferson University Local Wound Care (-) PO abx POST-2006 Wvac N=122 79% 21% Rothman Institute of Orthopaedics at Thomas Jefferson University SUCCESS Further Surgery 88% 12% I&D 100% 2 Stage SUCCESS 5

6 Conclusion Recommendations Use of NPWT for closed wound drainage after hip arthroplasty appears to be safe Its use was successful in eliminating drainage in 80% of cases When NPWT application fails, surgical intervention is often successful Single, 48 hour application of the NPWT Early surgical intervention, rather than NPWT application, may be indicated in patients with INR>2 or who have had multiple prior hip surgeries THANK YOU. 6