Original Research

Role of Surgical Dressings in Total Joint Arthroplasty: A Randomized Controlled Trial

Am J Orthop. 2015 September;44(9):415-420

References

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There were statistically significantly (P < .0001) fewer dressing changes in the occlusive dressing group. Mean number of dressing changes was 0.14 (median, 0; interquartile range, 0-0) in the occlusive group and 2.8 (median, 2; interquartile range, 1-3) in the standard group.

Compared with patients in the standard dressing group, patients in the occlusive dressing group reported significantly higher satisfaction scores. Mean overall patient satisfaction score was 92 in the occlusive group and 81 in the standard group (P < .0001). Patients in the occlusive group were more satisfied with their ability to take care of their personal hygiene, to change clothes, and to sit and sleep comfortably (Table 4).

Discussion

Wound complications after TJA are common, occurring in up to 30% of patients,^1-6 and are associated with development of superficial and deep surgical site infections, increased resource utilization, and longer hospital stays.^5-11 Although the role of surgical dressings has received little attention in TJA practice, other subspecialties have found that occlusive barrier dressings can reduce wound complications and promote wound healing.^16,17 Mitotic cell division and leukocyte activity, which are critical in wound healing, increase under occlusive dressings. This cellular activity is disrupted with every dressing change, delaying wound healing (biological activity takes 3-4 hours to resume).²² In addition, occlusive dressings increase hypoxia, which promotes angiogenesis and accelerates wound healing.²³

Despite being a prospective RCT, this study had several limitations. Because of the need to evaluate wounds and obvious differences between the 2 dressings (eg, color, ability to shower), it was not possible to blind the patient or surgeon to the dressing used. When rating satisfaction, patients were not able to directly compare the 2 dressings. The primary endpoint of the study was the complication rate; however, the deep periprosthetic infection rate may be a superior endpoint and would require a much larger study. Although we assumed that wound complications may be harbingers for periprosthetic infections, no patient in either group developed periprosthetic infection. Therefore, we cannot conclude that surgical dressings play a role in reducing infections. In addition, as the standard dressing was changed on POD 2 (per standard protocol) and the occlusive dressing could remain in place for up to 7 days, there was a selection bias in the evaluation of the number of dressing changes. However, given the characteristics of the standard dressing (eg, tape, gauze, nonocclusive), leaving it in place after POD 2 is not optimal. Therefore, we would expect to see a difference in the number of dressing changes. We think this comparison remains valid, as occlusive dressings were changed when there were indications of wound problems (eg, excessive drainage [strike-through], surrounding erythema, blistering). With an average of less than 1 dressing change in the occlusive group, we think this is a surrogate for uneventful wound healing and decreased wound complication, and our data support this. It is also important to test both dressing durability and patient tolerance for wearing a single dressing for 7 days.

Our RCT results showed that, compared with a standard dressing, an occlusive antimicrobial dressing was associated with a significant decrease in overall wound complications and blisters. These findings are similar to those of other studies of occlusive dressings in a number of surgical subspecialties.^16,18 In an RCT of 200 patients who underwent elective and nonelective hip and knee surgery and were randomized to either absorbent perforated dressing with adhesive border (Cutiplast, Smith & Nephew) or Aquacel (ConvaTec) covered with vapor-permeable dressing (Tegaderm, 3M), Ravenscroft and colleagues²⁰ found that Aquacel-plus-Tegaderm was 5.8 times more likely than Cutiplast to produce an uncompromised wound. Similarly, in an RCT of hydrofiber (Aquacel) and central pad (Mepore, Mölnlycke) dressings after primary THA and TKA, Abuzakuk and colleagues¹⁹ found significantly fewer dressing changes (43% vs 77%) and blisters (13% vs 26%) in the hydrofiber group than in the pad group.

Hopper and colleagues²⁴ compared 50 consecutive patients treated with modern dressings (Aquacel) with 50 historical control patients treated with traditional surgical dressings (Mepore). Blisters developed in 20% of the patients in the traditional group and 4% of patients in the modern group (P = .028). The authors concluded that adverse outcomes of wound healing can be minimized with modern dressings.

A recent retrospective study by Cai and colleagues²⁵ evaluated the incidence of acute periprosthetic infection (≤3 months after surgery) with use of occlusive (Aquacel) and standard dressings. Incidence of acute periprosthetic infection was 0.44% in the occlusive group and 1.7% in the standard group (P = .005). Incidence of wound-healing problems was not evaluated.