Taking Another Look at Surgical Traditions in Knee Replacement
As Giles R. Scuderi, MD, sees it, in this era of bundled payments orthopaedic surgeons need to be more cost conscious than ever before.
And it’s not just the cost of implants that should be under the microscope, he said; every aspect of care is worth examining to determine the impact on the overall cost of the procedure.
With that in mind, 4 speakers at ICJR’s Winter Hip & Knee Course in January addressed long-held surgical traditions related to total knee arthroplasty, using the evidence in the literature to suggest where changes might be helpful not only for the bottom line, but also for patient outcomes.
Continuous Passive Motion
Fred D. Cusher, MD, from North Shore-LIJ Orthopaedic Institute, New York, believes continuous passive motion (CPM) machines can cause more problems than they can solve, and that many surgeons use them because of patient expectations: If other surgeons in their region prescribe a CPM machine, they have to prescribe a CPM machine as well.
Much of the science on the use of CPM machines is from older studies that do not reflect current surgical techniques, length of stay, and pain management protocols, Dr. Cushner said – and even those studies did not show significant improvement with the use of a CPM machine.
More recent research cited by Dr. Cushner – a Cochrane meta-analysis  published in 2014 – examined studies that compared patients who did and who did not use a CPM machine. No differences were found between groups in range of motion, function, and pain.
The bottom line for Dr. Cushner is that are more drawbacks than benefits to using a CPM machine, including additional costs for the CPM machine and staff time, bleeding, the risk of peroneal nerve palsy, and impediments to assessing the surgical site for signs of infection or deep vein thrombosis.
Click the image below to watch Dr. Cushner’s presentation.
Indwelling Urinary Catheters and Drains
Indwelling urinary catheters are typically used to reduce the risk for urinary retention following total knee arthroplasty. But are they doing more harm than good? Are they contributing to improved outcomes?
Bernard N. Stulberg, MD, from St. Vincent Charity Medical Center in Cleveland, Ohio, said the answers are unclear: There is nothing specific in the orthopaedic literature on the use of indwelling urinary catheters. The literature from other surgical specialties provides some guidance, however, and Dr. Stulberg summarized that literature as follows:
- Selective use of indwelling urinary catheters is advisable
- Routine avoidance of indwelling urinary catheters is acceptable, and may even be desirable
- Use of an indwelling urinary catheters for 24 hours or less is probably not harmful to the patient or the outcome
Dr. Stulberg also cited a supplement from The Journal of Arthroplasty  that included discussion of urine screening. The recommendation is to avoid routine urine screening for joint replacement patients, reserving it for those who currently have symptoms of urinary tract infection. Patients with an acute urinary tract infection should be treated before the joint replacement procedure based on symptoms, he said.
The orthopaedic literature has much more to say about the use of drains following joint replacement. A meta-analysis, Dr. Stulberg said, indicates that routine use is unnecessary for routine primary joint replacement procedures.  Additionally, a cost analysis found that routine use of drains increased costs and transfusions. 
Dr. Stulberg said he has not used drains in at least 10 years, and the literature supports not using them in most uncomplicated primary procedures. There are situations, however, in which a drain is indicated, he said:
- Lateral retinacular release in total knee arthroplasty
- Morbidly obese patients
- Revision total knee arthroplasty
- Monitoring of nerve function
We talked with Dr. Stulberg about the literature on indwelling urinary catheters and drains. Click the image below to hear his comments.
To watch Dr. Stulberg’s presentation from the Winter Hip & Knee Course, click the image below.
Wound and Skin Closure
Dr. Scuderi, also from North Shore-LIJ Orthopaedic Institute in New York, said the key goals in wound and skin closure are safe technique, watertight closure, and healing without complications such as excessive drainage, infection, dehiscence, and poor cosmesis.
For the arthrotomy, Dr. Scuderi still relies on interrupted sutures to close the wound. There’s no tension on closure or separation, he said. Barbed sutures are an option to reduce closure time and achieve a watertight closure, but some studies are showing closure-related complications. 
For the skin closure, surgeons can use staples, subcuticular sutures, or tissue adhesives, although research is conflicting on the efficacy, economics, complications, and cosmesis related to these techniques.
Dr. Scuderi prefers staples for skin closure, as they are easy to use. Research has shown more favorable blood perfusion with staples, particularly if they are about 6 mm apart, and more favorable closure time and costs compared with sutures and tissue adhesives. [6,7]
Some critics contend that staples can cause tissue reactivity and pain on removal, but Dr. Scuderi countered that technique – not the staples – may be the issue.
Tissue adhesives may not be appropriate for total knee arthroplasty, which Dr. Scuderi referred to as a “mobile wound.” Research has shown, he said, that the bond between the adhesive and the wound edges cannot withstand early range-of-motion exercises, which may promote wound drainage. 
For the dressing, Dr. Scuderi prefers an occlusive dressing that provides a sterile seal, promotes range of motion and function, allows for assessment of the wound and drainage, and minimizes the need for dressing changes. Occlusive dressings are associated with a lower infection rate than non-occlusive dressings, Dr. Scuderi said. 
Click the image below to watch Dr. Scuderi’s presentation.
Many joint replacement patients are colonized with Staphylococcus species, putting them at risk for postoperative infection. In a study of 67,000 inpatients in the US over a 5-year period, the number with methicilliln-resistant Staphylococcus aureus cultured from their nares went from 12 in 1000 to 41 in 1000. 
In a study of 1495 hip and knee replacement patients, 912 were screened for colonization in the nares, with 25% testing positive for S. aureus.  They were treated with mupirocin, the gold standard for nasal colonization with S. aureus.
The infection rate for the treated patients was 1.3%, compared with 0.6% for screened and non-colonized patients and 1.7% for non-screened patients. Overall, there was a 4-fold reduction in infections as a result of the screening and decolonization program in this study. 
Theoretically, screening all patients prior to surgery and then treating those who are colonized with nasal mupirocin could significantly reduce the risk of infections.
But there are problems with these screening programs, said David G. Nazarian, MD, from the University of Pennsylvania in Philadelphia, including:
- Accuracy of the cultures and the speed of getting results
- Compliance with the 5-day mupirocin treatment protocol
- Possible resistance to mupirocin
Dr. Nazarian said that screening can be done to determine if intravenous vancomycin should also be initiated, but at his institution, all patients are decolonized – not screened – before joint replacement surgery. He and his colleagues use a new product, a nasal povidone-iodine gel that is administered on the day of surgery, with 2 swabs in each nare before the procedure.
A recent study comparing mupirocin with povidone-iodine gel found a surgical site infection rate of 1.7% with mupirocin versus 0.6% with povidone-iodine gel; Staphylococcus infections were 0.6% vs. 0.1%, respectively. 
For Dr. Nazarian’s presentation, click the image below.
- Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev. 2014 Feb 6;2:CD004260. doi: 10.1002/14651858.CD004260.pub3.
- Proceedings of the International Consensus on Periprosthetic Joint Infection. Journal of Arthroplasty. 2014;29(2 suppl):1-130.
- Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2004 Jun;86-A(6):1146-52.
- Bjerke-Kroll BT, Sculco PK, McLawhorn AS, Christ AB, Gladnik BP, Mayman DJ. The increased total cost associated with post-operative drains in total hip and knee arthroplasty. J Arthroplasty 2014 May;29(5):895-9. doi: 10.1016/j.arth.2013.10.027. Epub 2013 Nov 6.
- Patel RM, Cayo M, Patel A, Albarillo M, Puri L. Wound complications in joint arthroplasty: comparing traditional and modern methods of skin closure. Orthopedics 2012 May;35(5):e641-6. doi: 10.3928/01477447-20120426-16.
- Graham DA, Jeffery JA, Bain D, Davies P, Bentley G. Staple vs. subcuticular vicryl skin closure in knee replacement surgery: a spectrophotographic assessment of wound characteristics. Knee. 2000 Dec 1;7(4):239-243.
- Eggers MD, Fang L, Lionberger DR. A comparison of wound closure techniques for total knee arthroplasty. J Arthroplasty 2011 Dec;26(8):1251-8.e1-4. doi: 10.1016/j.arth.2011.02.029. Epub 2011 Apr 29.
- Khan RJ, Fick D, Yao F, et al. A comparison of three methods of wound closure following arthroplasty: a prospective, randomised, controlled trial. J Bone Joint Surg Br. 2006 Feb;88(2):238-42.
- Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Am J infect Control 1990 Aug;18(4):257-68.
- Jarvis WR, Jarvis AA, Chinn RY. National prevalence of methicillin-resistant Staphylococcus aureus in inpatients at United States health care facilities, 2010. Am J infect Control 2012 Apr;40(3):194-200. doi: 10.1016/j.ajic.2012.02.001.
- Hacek DM, Robb WJ Paule SM, Kudrna JC, Stamos VP, Peterson LR. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res. 2008 Jun;466(6):1349-55. doi: 10.1007/s11999-008-0210-y. Epub 2008 Mar 18.
- Philips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidemiol 2014 Jul;35(7):826-32. doi: 10.1086/676872. Epub 2014 May 21.