Our second aim in the present study was to evaluate the number of dressing changes required. There were significantly fewer dressing changes in the occlusive dressing group than in the standard dressing group. Therefore, wear time (amount of time a single dressing remains in place) was substantially longer for the occlusive group. In the study by Hopper and colleagues,24 wear time was significantly shorter for the traditional dressing than for the modern dressing (2 vs 7 days; P < .001), and the traditional dressing required more changes (3 vs 0; P < .001).
These findings are important for several reasons. Standard surgical dressings often require frequent changes. If left in place, they create an excessively moist wound environment that promotes blistering and delays wound healing. However, frequent dressing changes expose the wound and increase the risk for surgical site infection.26 A barrier dressing left in place from time of surgery prevents bacteria from entering and contaminating a healing wound. A study by Clarke and colleagues21 demonstrated higher skin colonization rates for patients who had dressings changed on POD 1 than for patients who had their first dressing change on POD 6.
Our third study aim was to evaluate patient satisfaction with surgical dressings. The orthopedic literature has little on this topic.23 Blisters and other wound complications can negatively affect satisfaction.2,3 Our data showed significant improvement in satisfaction, particularly regarding sterility and hygiene.
Other surgical subspecialties have found similar improvement in patient satisfaction with occlusive barrier dressings. In an RCT of 88 pediatric patients, Rasmussen and colleagues27 found that patients reported significantly less pain during changes of an occlusive adhesive dressing (Duoderm, ConvaTec) than during changes of a conventional Steristrip (3M) plus Cutiplast. According to the authors, the occlusive wound dressing seemed to minimize the physical and psychological trauma to the infant or child and lessen disruption of the child’s and the parents’ daily routines, because the children could be bathed immediately after surgery.
Our study did not specifically address cost. Cai and colleagues25 estimated that, if the Aquacel dressing were routinely used in every hip and knee arthroplasty, it would add about $27 million in cost. However, this must be balanced by the cost of managing infection after TJA. In the United States, at an estimated $50,000 to $100,000 per case and an annual incidence of 1% to 2%, the low-end cost for the treatment of periprosthetic infection would be $500 million.28 Cai and colleagues25 found a 4-fold reduction in periprosthetic infection when use of occlusive dressings was implemented. In addition, wound complications remain the number one reason for hospital readmission after TJA.12,13 Cost of hospital readmission, as well as financial penalties to institutions for unplanned readmission for wound complications, must be considered.
Conclusion
Our RCT results demonstrated that use of occlusive antimicrobial barrier dressings (vs standard surgical dressings) significantly reduced wound complications and dressing changes and improved overall patient satisfaction. These findings are similar to those in the literature on TJA and other surgical subspecialties. We conclude that occlusive surgical dressings reduce wound complications after TJA.