12/13/2016
Disclosures
Modern Approach To Wound Dressings
Fred D Cushner,
Cushner, MD
• Consultant
– Smith and Nephew
– Pacira
– CHE
New York, New York
Other Disclosures
• My fellows/PA’s Close The Wound
– Per My Protocol
• I Take The Credit For How Good The Wound Looks
– They Get Blame in Any Leakage
Wound is Like A Burger
Perfect Wound Closure
• Watertight Arthrotomy
• Skin Edges Approximated
– Sub Q
– Sub Cutaneous
– Skin Level
• Dressing
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My Closure Evolution
• Staples
Why Necessary ?
• Infection
• Infection
• Infection
– Lots of them
• 3.0 Nylon
• Prineo Closure System
– Mesh
– Dermabond
– No Staples/Sutures
Why Do Knees Fail ?
Danger Is Everywhere
Risk Factors for PeriProsthetic
Infection
BMI 50
• Infection
• Infection
• Infection
•
•
•
•
•
•
•
•
Rheumatoid arthritis
Steroid therapy
Diabetes mellitus
Prior septic arthritis
Prior arthroplasty
Malignancy
Lymphocyte <1.5x109
More than 4 hospital days
prior to TJR
• Homologous blood
transfusion within 24 hrs of
prosthetic surgery Duration
of hospitalization
• Decubitus ulcers
• NNIS 1 or greater
• Superficial wound infection
• Wound drainage
• Wound hematoma
• Wound dehiscence
Berbari EF, et al. Clin Infect Dis.1998;27(5):1247-54.
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New Dressings
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New Dressings Help Avoid Blisters
• Non
Non--Circumferential
• Tolerate Swelling
• Enhanced Healing Environment
Dressing Options
•
•
•
•
Standard
4X4
Ace Wrap
Xeroform
• Non-Occlusive
• Require Frequent
Changes
• Cost
Tourniquet and Blisters
• Heller et al – J Arthop 2015
– Blister Incidence
• Dressing after Tourniquet Deflation
Deflation-- 2.2 %
• Dressing Before Deflation – 7.5%
Benefits of New Occlusive Dressings
1. Permeable
1.Promotes Healing
2.Avoids Excessive Moisture
2. Hospital Infective Environment
– Contamination Avoidance
3. Hypoxic Environment
1.Enhances Healing
2.No Need To Change
National Institute for Health and Clinical Excellence. Surgical site infection prevention and treatment of surgical site infection. CG74 Surgical site infection:
full guideline. http://guidance.nice.org.uk/CG74/Guidance/pdf/English. October 2008 .
Modern Dressings
• Langlois
Langlois-- International Orthop 2015
– Favored By Patients
– Favored B Nurses
– Less Frequent Dressing Changes
– Similar Wound Appearance
OPSITE™ Post
Post--Op Visible: visible solutions
• Superior absorption5,6
• BacteriaBacteria-proof6
• Waterproof
• Provides clear visibility
of your surgical wounds.
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AQUACEL® Ag SURGICAL Dressing
Example of dressing fluid handling
Skin-friendly hydrocolloid
technology flexes with the
skin during body movement
Patented Hydrofiber® Technology
absorbs and locks in fluid,
including harmful bacteria.* 1
Unique construction enhances
extensibility and flexibility 2
Polyurethane film provides a
waterproof viral and bacterial
barrier* (when intact and with no
leakage)
*As demonstrated in vitro
1Walker
M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilization in a carboxymethyl cellulose (Aquacel) and alginate
dressings. Biomaterials. 2003;24(5):883-890.
2 Clarke JV, et al. A prospective clinical audit of a new dressing design for lower limb arthroplasty wound. J Wound Care. 2009;18(1):5-8, 10-1.
Why Silver ?
Aerobic bacteria
*
Staphlococcus aureus (NCTC 8532)
Staphlococcus aureus (clinical isolate)
Pseudomonas aeruginoss (clinical isolate, x2 strains)
Enterobacter cloacae (clinical isolate)
Streptococcus pyogenes (clinincal isolate)
Klebsiella pnuemoniae (clinical isolate, x3 strains)
Enterococcus faecals (clinical isolate)
Escherichia coil (NCIMB 8545)
Escherichia coil (NCIMB 10544)
Acnetobacter baumannii (NCIMB 9214
Anaerobic bacteria
*
Bacteroides fragilis (clinical isolate)
• Antimicrobial properties of
silver well documented in
literature
• Silver ions bind to the DNA of
bacteria and reducing their
ability to replicate (Ballard
2002; Cooper 2004).
• Controlled release of ionic
silver
• Prospective randomized study of standard surgical dressing vs
AQUACEL® Dressing
• 200 pts
AQUACEL® dressing 5.8 x more likely to result in a wound with
NO complications
Peptostreptococcus anaerobius (clinincal isolate)
Clostridium ramosum (clinincal isolate)
Clostridium clostridioforme (clinincal isolate)
Clostridium cadaveris (clinincal isolate)
Clostridium perfringens (clinincal isolate)
Tissierella praeacute (clinincal isolate)
• Only silver exposure when
exudate is present
• Blister rate 22.5 % in standard group vs 2.4% in AQUACEL®
dressing group
*As demonstrated in vitro
1.
Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber® dressing. Wound Repair Regen. 2004;12:288-294.
Ann R Coll Surg Engl. 2006;88(1):18-22.
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Complex Cases
PICO™
PICO
™
• Revision
• Obese
• Spidey Sense
• Incredibly simple, ultra-personal
NPWT that can help more
patients and reduce the human
and economic costs of wounds
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PICO™
PICO
™ dressing: How does it work?
The PICO dressing is constructed from 4
layers:
1.
2.
3.
4.
The future of NPWT
SEM image of a cross-section of dressing
• NPWT is becoming more widely
understood and utilized through
innovation:
A high MVTR upper film
Absorbent layer
Airlock layer
Silicone adhesive layer
PICO™
• Simple application and operation
• Clinically effective
• Cost effective
• Powered canister
canister--free NPWT
Pressure is evenly transmitted by the airlock
layer (3), which doesn’t collapse under
negative pressure
The perforated silicone adhesive layer (4)
transmits negative pressure to the wound bed
and removes fluid
• Enhanced portability
• Improve patient experience
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Summary
Wound Rescue Protocol
•
•
•
•
•
Quill Closure
Prineo on Skin
Simple Dressing for 2 days
Smart Dressing For 7 Days on D/C
Wound Vac if needed
Thank You
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