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W4236087998 abstract "Journal of Orthopaedic ResearchVolume 32, Issue S1 p. S108-S119 Research ArticleFree Access Wound Management First published: 24 January 2014 https://doi.org/10.1002/jor.22554Citations: 9AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Liaison Elie Ghanem MD Leaders Volkmar Heppert MD (International), Mark Spangehl MD, FRCSC (US) Delegates John Abraham MD, Khalid Azzam MD, Lowry Barnes MD, Federico Jose Burgo MD, Walid Ebeid MD, Nitin Goyal MD, Ernesto Guerra MD, Kirby Hitt MD, Sofiene Kallel MD, Gregg Klein MD, Yona Kosashvili MD, Brett Levine MD, Laura Matsen MD, Michael J Morris MD, James J Purtill MD, Chitranjan Ranawat MD, FRCS, FRCSC, Peter F Sharkey MD, Rafael Sierra MD, Anna Stefansdottir MD, PhD Question 1A: What is the optimal dressing for a wound after total joint arthroplasty (TJA)? Consensus We recommend the use of occlusive dressings with alginated hydrofiber, when available. Delegate Vote Agree: 63%, Disagree: 25%, Abstain: 12% (Weak Consensus) Justification An occlusive dressing (Aquacel) secured with hydrocolloid was found to have a lower blister rate postoperatively when compared to Mepore (Molnlycke, GA).1-4 and Cutiplast (Smith and Nephew, Memphis, LA)5 and had a lower rate of dressing changes. A clinical audit comparing Mepore to Aquacel found that Aquacel had a lower rate of surgical site infection (SSI) (three in the Mepore group and one in the Aquacel group).1 A prospective, randomized controlled trial (RCT) comparing Mepore and Aquacel showed similar wound inflammation and infection rates in the two groups.2 In one RCT, wound healing was delayed in the occlusive group (e.g., foams, alginates, hydrogels, hydrocolloids, hydrofibers, or films) compared to gauze-based dressings, with an increase in accrued cost.6 There are also inconsistent data comparing hydrofiber and alginate dressings.7, 8 One study aimed to compare the performance of a hydrofiber (Aquacel) and an alginate (Sorbsan) dressing on acute surgical wounds (pilonidal, breast, axilla, groin, and wound abscess) left to heal by secondary intention. A total of 100 patients were prospectively randomized pre-operatively to receive either the hydrofiber or alginate dressing. Dressing performance was measured at operation and postoperatively at 24 h and 7 days. Parameters measured included ease of application and removal of the first dressing, re-application on the first postoperative day, and removal and re-application one week postoperatively. The hydrofiber dressing received higher scores for all of these categories. Patients in this group also experienced less pain (mild or none) on removal of the first dressing and at 1 week. However, these results did not achieve statistical significance and should be seen as a trend. Nevertheless, the authors recommend the use of hydrofiber dressings on open acute surgical wounds.7 A comparative evaluation was conducted involving 428 patients undergoing primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a single hospital between January and April 2006. Patients received either the traditional postoperative dressing (adhesive dressing with an integral absorbent pad, Mepore) or the new dressing regimen (Aquacel secured with hydrocolloid dressing, Duoderm), as well as liquid film-forming acrylate. Patients under the age of 50 and/or with a condition or comorbidity that could compromise wound healing were excluded. A protocol was developed for dressing changes based on the extent of strikethrough. Outcome measures were blister rate, wear time, number of dressing changes, SSI rate, and delayed patient discharge.1 Patients treated with the new dressing design had a lower blister rate, lower incidence of delayed discharge, longer wear time, fewer dressing changes, and a lower SSI rate. Only four cases of SSIs requiring washout were reported in both groups (one for the new dressing design and three for the traditional dressing) and the rest were successfully treated with antibiotics. To date there have been no revisions for deep infection in either group. One hundred twenty-four patients (62 THAs and 62 TKAs) were randomly selected to have either a standard adhesive dressing (Mepore) or jubilee method dressing (Aquacel with hydrocolloid layer, Duoderm). The number of dressing changes, incidence of blistering, leakage, subjective assessment of wound inflammation, infection rate, and the average hospital stay was recorded. The Jubilee dressing significantly reduced the rate of blistering, leakage, and number of dressing changes when compared to a traditional adhesive dressing (p < 0.05). The rate of inflammation and average length of stay in the hospital was not significantly different between the two groups. There were no cases of periprosthetic joint infection (PJI) reported.2 Cutiplast (absorbent perforated dressing with adhesive border; Smith & Nephew) is commonly used following orthopedic operations, but complications with its use have been reported. A prospective RCT was performed to compare the efficacy of Cutiplast versus an Aquacel (hydrofiber dressing; ConvaTec, Skillman, NJ) covered with Tegaderm (vapor-permeable dressing; 3M, St. Paul, MN). Two hundred patients were randomized to receive one of the two dressings following elective and non-elective surgery of the hip and the knee. The authors were able to study 183 patients. The condition of the wound and any complications such as skin blistering or signs of infection were noted, as was the frequency of dressing changes. The Aquacel and Tegaderm dressing was 5.8 times more likely to result in a wound with no complications as compared to a Cutiplast dressing (odds ratio, 5.8; 95% confidence interval (CI) 2.8–12.5; p < 0.00001). Taking blisters alone as a complication, in the Cutiplast group 22.5% of patients had wounds with blisters compared to only 2.4% of the group dressed with Aquacel/Tegaderm. The patients receiving Aquacel covered by Tegaderm had statistically fewer wound dressing changes. Taking the group as a whole, the dressing pain score was statistically lower for the patients receiving the Aquacel/Tegaderm dressing (p < 0.001).5 Two prospective clinical audits were performed over a 6-month period and involved 100 patients undergoing THA or TKA. Fifty consecutive patients with traditional dressings (Mepore) were evaluated prior to a change in practice to a modern dressing (Aquacel). Fifty consecutive patients were then evaluated with the new dressing to complete the audit cycle. Clinical outcome measures were wear time, number of changes, blister rate, and length of hospital stay. Wear time for the traditional dressing (2 days) was significantly shorter than for the modern dressing (7 days; p < 0.001), and required more changes (0 vs. 3; p < 0.001). Blisters developed in 20% of the patients with the traditional dressing compared with 4% in the modern dressing group (p = 0.028). The median length of stay was the same for the modern dressing (4 days) compared with the traditional dressing (also 4 days). In the modern dressing group, 75% of patients were discharged by day 4, whereas in the traditional group this took until day 6.3 Abuzakuk et al. reported the results of a prospective RCT comparing a hydrofiber (Aquacel) and central pad (Mepore) dressing in the management of acute wounds following primary THA or TKA left to heal by primary intention. Dressing performance was measured in 61 patients receiving THA or TKA. There was a significant reduction in the requirement for dressing changes before five postoperative days in the hydrofiber group (43% compared with 77% in the central pad group) and there were fewer blisters among patients in the hydrofiber group (13% compared with 26% in the central pad group).4 Ubbink et al. compared the effectiveness and costs of gauze-based versus occlusive, moist-environment dressings in 205 hospitalized surgical patients with open wounds. Patients received occlusive (i.e., foams, alginates, hydrogels, hydrocolloids, hydrofibers, or films) or gauze-based dressings until their wounds were completely healed. No significant differences in wound healing were observed in chronic wounds (i.e., vascular insufficiency, diabetes, or pressure sores), traumatic wounds, or wounds included in the first versus the second half of the trial (to detect a learning curve effect, if any). However, in postoperative wounds, 62% of all wounds in this trial, wound healing in the occlusive group took significantly (p =0.02) longer (median, 72 days; inter-quartile range, 36–132 days) than in the gauze group (median, 45 days; interquartile range, 22–93 days). The total cost for local wound care per patient per day during hospitalization was €7.48 (US $11.74) in the occlusive group and €3.98 (US $6.25) in the gauze-based group (p =0.002).6 Ravnskog et al. compared the performance of hydrofiber and alginate dressings used in the treatment of primary THA wounds. Patients were randomized into one of two groups, receiving either a hydrofiber or an alginate dressing. Outcome measures included skin damage (erythema, blisters, and skin injuries) and the dressing's ability to handle exudates. Photos of the dressing and the skin area around the wounds were taken. Patients noted skin problems, discomfort at mobilization, and pain at dressing removal. In the alginate group, there were fewer blisters in the wound area compared with the hydrofiber group (7% vs. 18%, p = 0.03). During dressing removal, fewer patients in the alginate group reported pain than patients in the hydrofiber group (2.1% vs. 15%, p = 0.01).8 Question 1B: Does the use of silver-impregnated dressings reduce SSI/PJI? Consensus Silver-impregnated dressings have not been conclusively shown to reduce SSI/PJI. Delegate Vote Agree: 87%, Disagree: 5%, Abstain: 7% (Strong Consensus) Justification Three prospective RCTs compared silver-impregnated colloid dressings (Aquacel, Alginate) to non-silver dressings in treatment of a variety of wound types including acute surgical wounds, infected and non-infected diabetic foot ulcers, and traumatic wounds, failed to show any difference in terms of outcome in wound/ulcer healing and local infection rates.9-11 One prospective RCT, comparing silver-impregnated alginate dressings to non-silver dressings in the treatment of chronic venous ulcers, found significant improvement in silver dressings in preventing wounds from progressing to infection, as well as a greater rate of wound healing.12 A Cochrane meta-analysis that compared the effect of silver-impregnated dressings to non-silver dressings in infected acute or chronic wounds found no significant difference in wound healing rates, antibiotic use, pain, patient satisfaction, length of hospital stay, and costs.13 Another Cochrane meta-analysis assessing burn wounds and a mixture of non-infected wound types found that the addition of silver to the dressings did not promote wound healing or prevent wound infections.14 Beele et al. observed both the clinical signs and symptoms of wounds at risk of infection; that is, critically colonized (biofilm infected) wounds. They studied the antimicrobial performance of an ionic silver alginate/carboxymethylcellulose (SACMC) dressing in comparison with a non-silver calcium alginate fiber (AF) dressing, on chronic venous leg and pressure ulcers. Thirty-six patients with venous or pressure ulcers, considered clinically to be critically colonized (biofilm infected), were randomly chosen to receive either an SACMC dressing or a non-silver calcium AF dressing. The efficacy of each wound dressing was evaluated over a 4-week period. The primary study endpoints were prevention of infection and progression to wound healing. The SACMC group showed a statistically significant (p = 0.017) improvement in healing, indicated by a reduction in the surface area of the wound over the 4-week study period compared with the AF control group. The SACMC dressing showed a greater ability to prevent wounds progressing to infection when compared with the AF control dressing. The results of this study also showed an improvement in wound healing for SACMC when compared with a non-silver dressing.12 Trial et al. compared the efficacy and tolerability of a new ionic silver alginate matrix (Askina Calgitrol Ag) with that of a standard silver-free alginate dressing (Algosteril). Patients with locally infected chronic wounds (pressure ulcers, venous or mixed etiology leg ulcers, or diabetic foot ulcers) or acute wounds were eligible for this prospective, open-label RCT. Patients were randomized to receive one of the two dressings for a 2-week period. The criteria for efficacy were based on the evolution from day 1 to day 15 of local signs of infection using a clinical score ranging from 0 to 18 and the evolution of the bacteriological status for each wound. The latter was determined by (blind) bacteriological examinations of results obtained from two biopsies performed at days 1 and 15. A 3-point scale (deterioration, unchanged, and improvement) was also used. Acceptability, usefulness, and tolerance were also assessed. Forty-two patients (20 women and 22 men aged 68.9 ± 18.8 and 66.5 ± 15.7, respectively) were randomly assigned to receive either Askina Calgitrol Ag (n = 20) or Algosteril (n = 22). Most had chronic wounds such as pressure ulcers (57%) or venous or mixed-etiology leg ulcers and diabetic foot ulcers (29%), with a few having acute wounds (14%). Clinical scores of infection were comparable in both groups at inclusion, 8.9 ± 2.4 and 8.6 ± 3.2 in the Askina Calgitrol Ag group and the Algosteril group respectively (not significant), but decreased significantly in both groups at day 15, 3.8 ± 2.9 in the Askina Calgitrol Ag group (p = 0.001) and 3.8 ± 3.4 in the Algosteril group (p = 0.007). There was no significant difference between the two groups at day 15. Although there was also no significant difference in bacteriological status between the treatment groups, a trend in favor of Askina Calgitrol Ag was found for the relative risk of improvement, especially in patients who were not treated with antibiotics either at the beginning of or during the study. No differences between groups were observed regarding local tolerance, acceptability, and usefulness of the dressings.9 In a retrospective study, Saba et al. compared Aquacel Ag Hydrofiber dressing (Aquacel Ag) to a standard dressing for the treatment of partial thickness burns in children. The authors used the St. Christopher's Hospital burn center registry to identify 20 pediatric patients who had sustained partial-thickness burns over a 10-month period. Ten of these patients had been treated with Aquacel Ag Hydrofiber dressing and 10 were treated with conventional Xeroflo gauze with Bacitracin Zinc ointment, the institutional standard of care for nonoperative partial-thickness burn wounds. Outcomes measured for the Aquacel Ag versus the Xeroflo gauze with Bacitracin Zinc ointment group included hospital length of stay (2.4 vs. 9.6 days), total number of in-house dressing changes (2.7 vs. 17.1), pain on a 10-point scale associated with dressing changes (6.4 vs. 8.2), total number of intravenous narcotic administrations (2.3 vs. 14.4), nursing time adjusted for percentage total body surface area (1.9 vs. 3.5 min), time to wound reepithelialization (10.3 vs. 16.3 days), and patient primary caregiver satisfaction score using a 4-point scale, with four delineating maximum satisfaction (3.8 vs. 1.8). All variables were significant (p < 0.001).15 Storm-Versloot et al. searched the Cochrane Wounds Group Specialized Register (6 2009), The Cochrane Central Register of Controlled Trials (CENTRAL) (2009 Issue 2), Ovid MEDLINE (1950 to April Week 4 2009), Ovid EMBASE (1980 to 2009 Week 18), EBSCO CINAHL (1982 to April Week 4 2009), and Digital Dissertations (to 2009) for relevant RCTs comparing silver-containing wound dressings and topical agents with non silver-containing versions on uninfected wounds. This review identified 26 trials involving 2,066 participants that compared silver-containing dressings or creams against dressings or creams that did not contain silver. Twenty of the trials were on burn wounds, while the others were on a mixture of wound types. Most studies were small and of poor quality. The authors concluded that there is not enough evidence to support the use of silver-containing dressings or creams, as generally these treatments did not promote wound healing or prevent wound infections. Some evidence from a number of small, poor-quality studies suggested that one silver-containing compound (silver sulfadiazine) has no effect on infection and slows down healing in patients with partial-thickness burns.14 In a prospective, multicenter study, Jude et al. compared the clinical efficacy and safety of Aquacel hydrofiber dressings containing ionic silver (AQAg) with those of Algosteril calcium alginate (CA) dressings in managing outpatients with type 1 or 2 diabetes mellitus and non-ischemic Wagner Grade 1 or 2 diabetic foot ulcers. Patients stratified by antibiotic use on enrolment were randomly assigned to similar protocols, including off-loading, AQAg (n = 67), or CA (n = 67) primary dressings and secondary foam dressings for 8 weeks or until healing. The mean time to healing was 53 days for AQAg ulcers and 58 days for CA ulcers (p = 0.34). AQAg-treated ulcers reduced in depth nearly twice as much as CA-treated ulcers (0.25 cm vs. 0.13 cm; p = 0.04). During the study, the incidence of clinical infection adverse events in the study ulcer group was comparable, with 11 AQAg subjects (16%) and 8 CA subjects (12%) reporting infection as adverse events in the study ulcer group. The median time for clinical infection to resolve without recurrence during the study was comparable for AQAg and CA subjects: 9 days for the 8 (88.9%) AQAg-resolved infections and 15 days (p = 0.35) for the 10 (76.9%; p = 0.48) CA-resolved infections.10 A prospective RCT by Jurczak et al. compared pain, comfort, exudate management, and wound healing and safety with hydrofiber dressing with ionic silver (hydrofiber Ag dressing) and with povidone-iodine gauze for the treatment of open surgical and traumatic wounds. Patients were treated with hydrofiber Ag dressing or povidone-iodine gauze for up to 2 weeks. Pain severity was measured with a 10 cm visual analogue scale (VAS). Other parameters were assessed clinically with various scales. Pain VAS scores decreased during dressing removal in both groups and decreased while the dressing was in place in the hydrofiber Ag dressing group (n = 35) but not in the povidone-iodine gauze group (n = 32). Pain VAS scores were similar between treatment groups. At final evaluation, hydrofiber Ag dressing was significantly better than povidone-iodine gauze for overall ability to manage pain (p < 0.001), overall comfort (p < 0.001), wound trauma on dressing removal (p = 0.0001), exudate handling (p < 0.001), and ease of use (p < 0.001). Rates of complete healing at study completion were 23% for Hydrofiber Ag dressing and 9% for povidone-iodine gauze (not significant). No adverse events were reported with hydrofiber Ag dressing and one subject discontinued povidone-iodine gauze due to an adverse skin reaction. During study treatment, four (11.4%) subjects in the hydrofiber Ag dressing group and four (12.5%) subjects in the povidone-iodine gauze group had infected wounds (not significant).11 In another meta-analysis, Vermeulen et al. evaluated the effects of topical silver and silver dressings on wound healing in the treatment of contaminated and infected acute or chronic wounds. They searched for relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Wounds Group Specialized Register in March 2006, and in MEDLINE, EMBASE, CINAHL, and Digital Dissertations databases up to September 2006. In addition, the authors contacted companies, manufacturers, and distributors for information to identify relevant trials, seeking RCTs that assessed the effectiveness of topical silver in the treatment of contaminated and infected acute or chronic wounds. Three RCTs were identified, comprising a total of 847 participants. One trial compared silver-containing foam (Contreet) with hydrocellular foam (Allevyn) in patients with leg ulcers. The second trial compared a silver-containing alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a silver-containing foam dressing (Contreet) with best local practice in patients with chronic wounds. The data from these trials show that silver-containing foam dressings did not significantly increase complete ulcer healing as compared with standard foam dressings or best local practice after up to 4 weeks of follow-up, although a greater reduction of ulcer size was observed with the silver-containing foam. The use of antibiotics was assessed in two trials, but no significant differences were found. Data on pain, patient satisfaction, length of hospital stay, and costs were limited and showed no differences. In one trial, leakage occurred significantly less frequently in patients with leg ulcers and chronic wounds treated with a silver dressing than with a standard foam dressing or best local practice. There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for the treatment of infected or contaminated chronic wounds.13 However, evidence in emerging that appears to endorse the role of occlusive, silver impregnated dressing in reducing incidence of SSI/PJI. In a recent single institution retrospective study, the incidence of acute PJI (occurring within 3 months) was compared between 903 consecutive patients undergoing total joint arthroplasty who received the Aquacel surgical dressing and 875 consecutive patients who received standard gauze dressing. After performing a multivariate analysis, the investigators found that Aquacel dressing was an independent factor for reduction of acute PJI with an acute PJI incidence of 0.44% for patients who received the Aquacel dressing compared to 1.7% of patients who received the standard gauze dressing (p = 0.005). Aquacel Ag dressing compared to standard surgical dressing showed statistically significant reductions in wound complications, blisters, number of dressing changes, and overall patient satisfaction with the Aquacel Ag surgical dressing.16 Question 2: What is considered to be persistent drainage from a wound after TJA? Consensus Persistent wound drainage after TJA is defined as continued drainage from the operative incision site for >72 h. Delegate Vote Agree: 80%, Disagree: 15%, Abstain: 5% (Strong Consensus) Justification Studies in the literature have a wide range of definitions for persistent wound drainage (48 h to 1 week). However, limiting wound drainage to 72 h postoperatively allows for earlier intervention and may limit the adverse consequences of persistent drainage. Persistent wound drainage after TJA is defined by time, type of secretion (hematogenous or clear), site (wound secretion, secretion after removal of suction drains), and microbial content. The timing of drainage is defined in multiple ways: Forty-eight hours.17 Postoperative day 3 or 4.18 Beyond postoperative day 4.19 Several days after surgery.20 Two days postoperative for non-infected cases, 5.5 days postoperative for infected cases.21 Limited amount of time.22 One week.23 The amount of drainage is alternately defined as: Drainage has soaked through the postoperative dressings.17, 18 Greater than 2 cm × 2 cm area of drainage covering gauze.24 Discharge from the wound. Microorganism cultured from drainage.25 This workgroup believe that substantial drainage (>2 cm × 2 cm area of gauze) from a wound beyond 72 h should be considered abnormal. We strongly recommend against performing culture of the draining wound. Question 3A: What are non-surgical strategies to address a draining wound after TJA? Consensus Persistent wound drainage for >72 h after TJA should be managed by wound care. Delegate Vote Agree: 65%, Disagree: 26%, Abstain: 9% (Weak Consensus) Justification Various studies recommend using medical management to attempt wound drainage control prior to surgical intervention. Other interventions, such as antibiotics, are discouraged because they can mask an underlying infection. Observation alone is highly discouraged, given the fact that persistent wound drainage is correlated with PJI.17, 21, 24, 26 The risk of infection increases by 29% after TKA and by 42% after THA with each day of persistent wound drainage.24 Studies have recommended various interventions to reduce the amount of wound drainage after TJA. One prospective RCT evaluated negative pressure wound therapy (NPWT) in patients with large surgical wounds after THA and found that NPWT decreased the size of postoperative seromas.27 A pilot study of patients undergoing THA who developed postoperative drainage treated with NPWT that was applied for an average of 2 days (range, 1–10 days) found that 76% of the patients did not require further intervention while 24% had subsequent surgery.18 However, a prospective RCT comparing NPWT to standard dry dressings on surgical incisions (primary closure or delayed primary closure of the lower extremity or abdominal wounds) found no significance in dehiscence rates, mean time to dehiscence, wound infection, and reoperation rates between the NPWT and dry dressing groups.28 A Cochrane meta-analysis included trials that compared NPWT with other types of wound dressings or compared one type of NPWT with a different type of NPWT for persistently draining wounds in skin graft patients, orthopedic patients undergoing arthroplasty, and general and trauma surgery. The authors concluded that there is no evidence for the effectiveness of NPWT on the complete healing of wounds expected to heal by primary intention.29 A retrospective review of 300 patients who developed persistent (>48 h postoperatively) wound drainage revealed that drainage stopped spontaneously between 2 and 4 days of drainage in 72% of the patients treated with local wound care and oral antibiotics. It is discouraged to use >24 h of postoperative antibiotics to treat persistent wound drainage after TJA because there is no evidence supporting the statement that it decreases PJI.18, 20 Additionally, administering antibiotics in light of a persistently draining wound may confound the culture findings if an arthrocentesis is performed to determine if any organisms are present within the synovial fluid. This workgroup discourages the use of oral antibiotic for management of wound drainage. Question 3B: What are surgical strategies to address a draining wound after TJA? Consensus Surgical management consisting of opening the fascia, performing a thorough irrigation and debridement (I&D) with exchange of modular components should be considered if wound drainage has persisted for 5–7 days after the index procedure. Delegate Vote Agree: 77%, Disagree: 16%, Abstain: 7% (Strong Consensus) Justification After 5 days of persistent wound drainage, surgical intervention should be carried out to reduce the likelihood of developing a PJI. Surgery should consist of opening the fascia, performing a thorough I&D with exchange of modular components, and performing a meticulous fascia and wound reclosure. In case meticulous reconstruction of the fascia and skin is not possible, NPWT might be a viable option, followed by coverage of the wound by a plastic surgeon after cultures and other data exclude early PJI. Deep cultures should be taken at the time of reoperation and antibiotics should be administered according to the sensitivity of the organism. We recommend against taking wound swab cultures. An older retrospective study by Weiss and Krackow26 encouraged surgical intervention in TJA patients with persistent wound drainage, including I&D, polyethylene exchange, and parenteral antibiotics. However, this was performed at 12.5 days postoperatively, which would have allowed more bacteria colonization on polyethylene. A study by Jaberi et al.17 demonstrated that patients who failed medical management of persistent wound drainage after postoperative day 4 and subsequently underwent a single-stage I&D had a cessation of drainage in 76% of patients. However, despite this early intervention, 24% of patients underwent subsequent treatment, including long-term antibiotics, resection arthroplasty, or repeat debridement. A review paper supported reoperation for exploration, deep culture, irrigation, and meticulous wound reclosure.20 If the deep cultures were positive, then the authors encouraged parenteral antibiotic therapy for 6 weeks. To ensure adequate debridement of the affected area, a study by Kelm et al.30 injected methylene blue dye into the fistula, performed a debridement with acetabular polyethylene and femoral head exchange, and closed the wound using a vacuum-assisted closure. Persistent drainage that is more concerning should be treated as an infected TJA22 with a low threshold for performing I&D or exchange arthroplasty.31 Open debridement with polyethylene exchange has variable results. There is a high failure rate associated with polyethylene exchange and may lead to future resection arthroplasty.32 Question 3C: Should oral" @default.
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