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Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review

Open AccessPublished:September 03, 2018DOI:https://doi.org/10.1016/j.arth.2018.08.034

      Abstract

      Background

      Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection.

      Methods

      This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process.

      Results

      Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment.

      Conclusion

      Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial.

      Keywords

      Persistent wound drainage (PWD) after total joint arthroplasty (TJA) is an important problem because of its potential adverse influence on the outcome following TJA, in particular development of a periprosthetic joint infection (PJI) [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ,
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Surin V.V.
      • Sundholm K.
      • Bäckman L.
      Infection after total hip replacement: with special reference to a discharge from the wound.
      ,
      • Butt U.
      • Ahmad R.
      • Aspros D.
      • Bannister G.C.
      Factors affecting wound ooze in total knee replacement.
      ,
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ]. PJI is associated with high morbidity and mortality, and a high socioeconomic burden due to prolonged hospital stay, surgical procedure(s), antimicrobial treatment, and wound care.
      Remarkably, PWD is rarely reported in literature and thereby literature fails to provide conclusive scientific evidence on many issues related to PWD after TJA, including the definition and treatment of PWD. This lack of evidence results in wide variation in diagnosis and treatment in daily practice, often only founded by the surgeon’s opinion. The absence of scientific consensus prompted this review of the available literature.
      We performed a literature search and included all papers relevant to the subject of PWD (Table 1). Articles that were not written in English or did not have full text available were excluded. We included all relevant papers, regardless of the level of evidence [

      Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Lieberati A, et al. Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document). https://www.cebm.net/index.aspx?o=5653, Oxford 2011.

      ]. Although most articles were of low level of evidence, we included these articles because of the small number of available papers on the subject of PWD and due to the lack of articles with a higher level of evidence. Based on this literature review, we developed a classification of PWD and an algorithmic approach to PWD after TJA that may guide clinicians in their decision-making process to select the appropriate treatment for PWD.
      Table 1Overview of Literature Addressing Wound Drainage After Total Joint Arthroplasty.
      AuthorStudy Type and Sample SizeLevel of EvidenceDefinitionIncidence of Wound DrainageResults
      Duration of DrainageAmount of Drainage
      Adelani
      • Adelani M.A.
      • Johnson S.R.
      • Keeney J.A.
      • Nunley R.M.
      • Barrack R.L.
      Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement.
      Retrospective N = 2221 TKAs3N/AN/A0.2%Seventeen patients had noninfectious wound complications (including persistent wound drainage) and 12 patients had deep infection. Patients with complications had lower knee society function scores and a higher incidence of mild or greater pain
      Dennis
      • Dennis D.A.
      Wound complications in total knee arthroplasty.
      OpinionN/A>7 d after TJAN/AN/APersistent wound drainage (not associated with erythema or purulence) can be managed with wound care and immobilization. If wound drainage persists beyond 5-7 d, spontaneous cessation of drainage is unlikely and surgical debridement is indicated
      Hansen
      • Hansen E.
      • Durinka J.B.
      • Costanzo J.A.
      • Austin M.S.
      • Deirmengian G.K.
      Negative pressure wound therapy is associated with resolution of incisional drainage in most wounds after hip arthroplasty.
      Prospective N = 5627 THAs4>3-4 d after TJADrainage that has soaked through the postoperative dressings2.0%NPWT was started after 3-4 d of wound drainage in 109 patients and applied for 2 d. Seventy-six percent did not need additional surgery, 10% needed superficial debridement, 11% needed deep debridement, and 3% required component removal. Predictors for additional surgery were International Normalized Ratio >2, previous hip surgery, and NPWT >48 h
      Jaberi
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      Retrospective N = 11,785 TKAs/THAs3>2 d after TJADrainage that has soaked through the postoperative dressings2.9%Three hundred patients with wound drainage >48 h were treated with local wound care and oral antibiotics. Wound drainage stopped between 2 and 4 d in 72%. The remaining patients underwent single debridement (76%) or additional treatment (repeat debridement, resection arthroplasty, or long-term antibiotics). Timing of surgery and malnutrition predicted failure of the first debridement
      Lonner
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      OpinionN/ASeveral days after TJAN/AN/AWound drainage beyond several days after surgery may increase the risk of infection. Drainage will usually stop after 24-48 h of immobilization. If not, open debridement should be performed, including obtaining cultures, irrigation, and meticulous wound closure. Exercises may be resumed once the wound is stable
      Maathuis
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      Retrospective N = 558 TKAs/THAs3>5 d after TJAN/A16.5%Comparison of an algorithmic approach to an ad hoc approach. In the algorithmic approach, registration of persistent wound drainage was 2-fold (21% vs 11%), but the number of open debridements was lower (17% vs 30%) and the salvage rate higher (94% vs 85%)
      Patel
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      Retrospective N = 2437 TKAs/THAs2>5 d after TJA≥2 × 2 cm area of gauze covering the wound is wet or when the fluid is noted to be originating from the surgical wound20.1%Persistent wound drainage results in longer hospital stay. Each day of wound drainage after day 5 increased the risk of wound infection by 42% following THA (P < .001) and by 29% following TKA (not significant after correction for BMI)
      Saleh
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      Prospective N = 2305 TKAs/THAs3Wound drainageN/AN/AThirty-three patients developed a superficial wound infection. Hematoma formation and days of wound drainage were significant predictors of superficial wound infection. Fifty-eight percent developed a prosthetic joint infection. Patients with >5 d of wound drainage had 12.7 times more risk of developing a prosthetic joint infection
      Surin
      • Surin V.V.
      • Sundholm K.
      • Bäckman L.
      Infection after total hip replacement: with special reference to a discharge from the wound.
      Retrospective N = 803 THAs3N/AN/A12.6%One hundred fifteen patients had superficial wound drainage and cultures were positive in 70 wounds. Thirty-four patients developed a prosthetic joint infection. Patient with superficial wound drainage had a 3.2 times higher risk of developing a prosthetic joint infection. The risk was further influenced by the character of the exudate and the use of prophylactic antibiotics
      Vince
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      Review/opinionN/ALimited amount of timeN/AN/APersistent wound drainage should be treated by wound care and immobilization. If drainage does not stop after 3-7 d, open debridement should be performed. Aggressive surgery may prevent sepsis. Drainage that starts in the late postoperative phase is a great concern as it usually results from a prosthetic joint infection
      Weiss
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      Retrospective N = 597 TKAs4≥4 consecutive days beyond day 5 after TJA≥2 × 2 cm area of gauze covering the wound is wet or when the fluid is noted to be originating from the surgical wound1.3%Eight patients with persistent wound drainage. Open debridement was performed at an average of 12.5 d after index surgery. Twenty-five percent of patients had positive tissue cultures. All patients were successfully treated with adjuvant antibiotics
      N/A, not applicable or not described; THA, total hip arthroplasty; TKA, total knee arthroplasty; TJA, total joint arthroplasty; NPWT, negative pressure wound therapy; BMI, body mass index.

      Incidence and Relevance

      The reported incidence of PWD after TJA varies between 0.2% and 21% [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Surin V.V.
      • Sundholm K.
      • Bäckman L.
      Infection after total hip replacement: with special reference to a discharge from the wound.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ,
      • Adelani M.A.
      • Johnson S.R.
      • Keeney J.A.
      • Nunley R.M.
      • Barrack R.L.
      Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement.
      ,
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      ], with higher incidences after revision TJA [
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ]. This wide range in incidence is mainly caused by the variation in definitions of PWD (Table 1), illustrating the lack of consensus regarding the definition of PWD. Moreover, higher awareness results in higher incidences of PWD, as demonstrated by Maathuis et al [
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      ] who found a 21% incidence of PWD when protocol-based surveillance was used to detect wound drainage after TJA.
      Wound drainage is usually a noninfectious disturbance in wound healing of short duration that occurs during the first days after TJA [
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ], but it may be an early symptom of a (developing) PJI. Research published between 1973 and 1983 described PWD as one of the main risk factors for developing a PJI [
      • Surin V.V.
      • Sundholm K.
      • Bäckman L.
      Infection after total hip replacement: with special reference to a discharge from the wound.
      ,
      • McLaughlan J.
      • Smylie H.G.
      • Logie J.R.
      • Smith G.
      A study of the wound environment during total hip arthroplasty.
      ,
      • Franco J.A.
      • Baer H.
      • Enneking W.F.
      Airborne contamination in orthopedic surgery: evaluation of laminar air flow system and aspiration suit.
      ,
      • Fitzgerald Jr., R.H.
      • Nolan D.R.
      • Ilstrup D.M.
      • van Scoy R.E.
      • Washington 2nd, J.A.
      • Coventry M.B.
      Deep wound sepsis following total hip arthroplasty.
      ,
      • Schwan A.
      • Bengtsson S.
      • Hambraeus A.
      • Laurell G.
      Airborne contamination and postoperative infection after total hip replacement.
      ,
      • Andrews H.J.
      • Arden G.P.
      • Hart G.M.
      • Owen J.W.
      Deep infection after total hip replacement.
      ], even though several researchers could not observe a correlation between PWD and PJI [
      • Aglietti P.
      • Salvati E.A.
      • Wilson Jr., P.D.
      A study of the effectiveness of a surgical unidirectional filtered air flow unit during total prosthetic replacements of the hip.
      ,
      • Aglietti P.
      • Salvati E.A.
      • Wilson Jr., P.D.
      • Kutner L.J.
      Effect of a surgical horizontal unidirectional filtered air flow unit on wound bacterial contamination and wound healing.
      ,
      • Wilson Jr., P.D.
      Joint replacement.
      ,
      • Freeman M.A.
      • Challis J.H.
      • Zelezonski J.
      • Jarvis I.D.
      Sepsis rates in hip replacement surgery with special reference to the use of ultra clean air.
      ]. Contemporary research underscored the adverse effects of wound complications, such as an increased risk of PJI, readmission, prolonged hospital stay, reoperations, and higher healthcare costs [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ,
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Butt U.
      • Ahmad R.
      • Aspros D.
      • Bannister G.C.
      Factors affecting wound ooze in total knee replacement.
      ,
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ,
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      ,
      • Berbari E.F.
      • Hanssen A.D.
      • Duffy M.C.
      • Steckelberg J.M.
      • Ilstrup D.M.
      • Harmsen W.S.
      • et al.
      Risk factors for prosthetic joint infection: case-control study.
      ].
      Regarding the consequences of PWD after total knee arthroplasty (TKA), Galat et al [
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ] found a 6% increased cumulative risk of PJI in patients who required early surgical treatment for any early wound healing complication after TKA. Moreover, these patients had 5.3% risk of major additional surgical intervention (resection arthroplasty, muscle flaps, or amputation) in the first 2 years following TKA [
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ]. A different study by Galat et al [
      • Galat D.D.
      • McGovern S.C.
      • Hanssen A.D.
      • Larson D.R.
      • Harrington J.R.
      • Clarke H.D.
      Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty.
      ] showed an increased risk of 10.5% for PJI and 12.3% risk for major reoperation within 2 years after TKA in patients who required surgical intervention for postoperative hematoma.
      Regarding the consequences of PWD after both total hip arthroplasty (THA) and TKA, Parvizi et al [
      • Parvizi J.
      • Ghanem E.
      • Joshi A.
      • Sharkey P.F.
      • Hozack W.J.
      • Rothman R.H.
      Does “excessive” anticoagulation predispose to periprosthetic infection?.
      ] demonstrated that patients who developed a PJI were more likely to have experienced PWD and hematoma than patients without PJI (16.8 and 12.6 times more likely respectively). Similar results were reported by Saleh et al [
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ].
      Although most studies on wound-related complications after TJA have focused on the risk of developing PJI, wound-related complications also predispose patients to worse functional outcome [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ,
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ,
      • Adelani M.A.
      • Johnson S.R.
      • Keeney J.A.
      • Nunley R.M.
      • Barrack R.L.
      Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement.
      ,
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      ,
      • Berbari E.F.
      • Hanssen A.D.
      • Duffy M.C.
      • Steckelberg J.M.
      • Ilstrup D.M.
      • Harmsen W.S.
      • et al.
      Risk factors for prosthetic joint infection: case-control study.
      ,
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ,
      • Ng V.Y.
      • Lustenberger D.
      • Hoang K.
      • Urchek R.
      • Beal M.
      • Calhoun J.H.
      • et al.
      Preoperative risk stratification and risk reduction for total joint reconstruction: AAOS exhibit selection.
      ,
      • Fernandez-Fairen M.
      • Torres A.
      • Menzie A.
      • Hernandez-Vaquero D.
      • Fernandez-Carreira J.M.
      • Murcia-Mazon A.
      • et al.
      Economical analysis on prophylaxis, diagnosis, and treatment of periprosthetic infections.
      ,
      • Kurtz S.M.
      • Lau E.
      • Schmier J.
      • Ong K.L.
      • Zhao K.
      • Parvizi J.
      Infection burden for hip and knee arthroplasty in the United States.
      ,
      • Mortazavi S.M.J.
      • Hansen P.
      • Zmistowski B.
      • Kane P.W.
      • Restrepo C.
      • Parvizi J.
      Hematoma following primary total hip arthroplasty: a grave complication.
      ,
      • Zmistowski B.
      • Karam J.A.
      • Durinka J.B.
      • Casper D.S.
      • Parvizi J.
      Periprosthetic joint infection increases the risk of one-year mortality.
      ]. Mortazavi et al [
      • Mortazavi S.M.J.
      • Hansen P.
      • Zmistowski B.
      • Kane P.W.
      • Restrepo C.
      • Parvizi J.
      Hematoma following primary total hip arthroplasty: a grave complication.
      ] found substantially worse patient satisfaction and lower Harris Hip Scores in patients requiring additional surgery for hematoma after THA. Adelani et al [
      • Adelani M.A.
      • Johnson S.R.
      • Keeney J.A.
      • Nunley R.M.
      • Barrack R.L.
      Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement.
      ] observed similar worse functional outcome for patients with wound complications after TKA. Moreover, published data suggest that patients with PWD after TKA have an increased risk of residual pain and poor functional outcome, similar to patients who develop an infectious complication after TKA [
      • Adelani M.A.
      • Johnson S.R.
      • Keeney J.A.
      • Nunley R.M.
      • Barrack R.L.
      Clinical outcomes following re-admission for non-infectious wound complications after primary total knee replacement.
      ]. Patient expectation after wound complications following TJA should therefore be tempered, even if wound complications do not result in PJI.

      Theoretical and Practical Considerations

      Wound drainage after TJA can be physiological in the first days after index surgery. However, it is unknown when wound drainage should be perceived as persistent or abnormal. Many other issues related to wound complications remain unanswered as well, such as the following: To what extent will wound drainage impair wound healing and/or offer a retrograde gateway for entry of pathogens into the joint space? [
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ] Where does wound drainage originate? If it originates from deeper layers of the joint, does it represent an early deep infection or merely normal drainage from defects in the soft tissues? If it originates from outside the joint, does it represent normal wound drainage or a draining hematoma or abscess? [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ] All these issues are important for the decision-making process but remain difficult to clarify.

      Definition of PWD

      Literature lacks a proven definition of PWD in terms of both duration and amount of drainage. Previous studies used a definition of duration of wound drainage varying from 2 to 9 days after index surgery (Table 1) [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ]. In 2013, the first International Consensus Meeting (ICM) on PJI defined PWD as >2 × 2 cm of drainage in the wound dressing beyond 72 hours after index surgery [
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ,
      • Parvizi J.
      • Gehrke T.
      • Chen A.F.
      Proceedings of the international consensus on periprosthetic joint infection.
      ]. This consensus stated that limiting the definition of PWD to 72 hours postoperative allows for early intervention that may prevent the adverse consequences of PWD. However, the definition of PWD should be further specified and evaluated.

      Clinical and Serological Signs of a Developing Infection

      Clinical signs of wound infection (superficial or deep) include systemic and local signs. Systemic signs involve fever, chills, and tachycardia. Local signs include induration, painful skin erythema (especially around the sutures), warmth, purulent drainage, and presence of a sinus tract [
      • Zmistowski B.
      • Della Valle C.
      • Bauer T.W.
      • Malizos K.N.
      • Alavi A.
      • Bedair H.
      • et al.
      Diagnosis of periprosthetic joint infection.
      ]. However, some of these clinical signs are frequently observed in the first days after uncomplicated TJA surgery as an early physiological response to surgical trauma.
      Fever or pyrexia (generally defined as temperature >38.5°C/>101°F) is physiological in the first 3-5 days after index surgery [
      • Shaw J.A.
      • Chung R.
      Febrile response after knee and hip arthroplasty.
      ,
      • Kennedy J.G.
      • Rodgers W.B.
      • Zurakowski D.
      • Sullivan R.
      • Griffin D.
      • Beardsley W.
      • et al.
      Pyrexia after total knee replacement. A cause for concern?.
      ,
      • Summersell P.C.
      • Turnbull A.
      • Long G.
      • Diwan A.
      • Macdessi S.
      • Cooke P.J.
      • et al.
      Temperature trends in total hip arthroplasty: a retrospective study.
      ,
      • Athanassious C.
      • Samad A.
      • Avery A.
      • Cohen J.
      • Chalnick D.
      Evaluation of fever in the immediate postoperative period in patients who underwent total joint arthroplasty.
      ,
      • Ghosh S.
      • Charity R.M.
      • Haidar S.G.
      • Singh B.K.
      Pyrexia following total knee replacement.
      ,
      • Czaplicki A.P.
      • Borger J.E.
      • Politi J.R.
      • Chambers B.T.
      • Taylor B.C.
      Evaluation of postoperative fever and leukocytosis in patients after total hip and knee arthroplasty.
      ,
      • Ward D.T.
      • Hansen E.N.
      • Takemoto S.K.
      • Bozic K.J.
      Cost and effectiveness of postoperative fever diagnostic evaluation in total joint arthroplasty patients.
      ,
      • Guinn S.
      • Castro Jr., F.P.
      • Garcia R.
      • Barrack R.L.
      Fever following total knee arthroplasty.
      ,
      • Tai T.W.
      • Chang C.W.
      • Lin C.J.
      • Lai K.A.
      • Yang C.Y.
      Elevated temperature trends after total knee arthroplasty.
      ,
      • Bindelglass D.F.
      • Pellegrino J.
      The role of blood cultures in the acute evaluation of postoperative fever in arthroplasty patients.
      ,
      • Anderson J.T.
      • Osland J.D.
      Blood cultures for evaluation of fever after total joint arthroplasty.
      ]. In this postoperative phase, additional tests for an underlying infectious cause of fever is unwarranted as it results in patient discomfort, has minor clinical yield, and is accompanied by considerable healthcare costs [
      • Shaw J.A.
      • Chung R.
      Febrile response after knee and hip arthroplasty.
      ,
      • Kennedy J.G.
      • Rodgers W.B.
      • Zurakowski D.
      • Sullivan R.
      • Griffin D.
      • Beardsley W.
      • et al.
      Pyrexia after total knee replacement. A cause for concern?.
      ,
      • Ghosh S.
      • Charity R.M.
      • Haidar S.G.
      • Singh B.K.
      Pyrexia following total knee replacement.
      ,
      • Czaplicki A.P.
      • Borger J.E.
      • Politi J.R.
      • Chambers B.T.
      • Taylor B.C.
      Evaluation of postoperative fever and leukocytosis in patients after total hip and knee arthroplasty.
      ,
      • Ward D.T.
      • Hansen E.N.
      • Takemoto S.K.
      • Bozic K.J.
      Cost and effectiveness of postoperative fever diagnostic evaluation in total joint arthroplasty patients.
      ,
      • Guinn S.
      • Castro Jr., F.P.
      • Garcia R.
      • Barrack R.L.
      Fever following total knee arthroplasty.
      ,
      • Tai T.W.
      • Chang C.W.
      • Lin C.J.
      • Lai K.A.
      • Yang C.Y.
      Elevated temperature trends after total knee arthroplasty.
      ,
      • Bindelglass D.F.
      • Pellegrino J.
      The role of blood cultures in the acute evaluation of postoperative fever in arthroplasty patients.
      ,
      • Anderson J.T.
      • Osland J.D.
      Blood cultures for evaluation of fever after total joint arthroplasty.
      ,
      • Chen A.
      • Haddad F.
      • Lachiewicz P.
      • Bolognesi M.
      • Cortes L.E.
      • Franceschini M.
      • et al.
      Prevention of late PJI.
      ]. However, temperatures >39°C, particularly if present for multiple days and/or later than 3-5 days after surgery, require further diagnostic tests [
      • Chen A.
      • Haddad F.
      • Lachiewicz P.
      • Bolognesi M.
      • Cortes L.E.
      • Franceschini M.
      • et al.
      Prevention of late PJI.
      ].
      Described blood serology parameters in the diagnosis of PJI are C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC). After uncomplicated TJA surgery, the CRP level increases rapidly and reaches maximum level (up to 200-400 mg/L) within 2-3 days, followed by a quick decrease and normalization to preoperative level in 2-8 weeks after uncomplicated TJA, even in patients with rheumatoid arthritis [
      • Bilgen O.
      • Atici T.
      • Durak K.
      • Karaeminoğullari
      • Bilgen M.S.
      C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty.
      ,
      • Kolstad K.
      • Levander H.
      Inflammatory laboratory tests after joint replacement surgery.
      ,
      • Laiho K.
      • Mäenpää H.
      • Kautiainen H.
      • Kauppi M.
      • Kaarela K.
      • Lehto M.
      • et al.
      Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis.
      ,
      • Moreschini O.
      • Greggi G.
      • Giordano M.C.
      • Nocente M.
      • Margheritini F.
      Postoperative physiopathological analysis of inflammatory parameters in patients undergoing hip or knee arthroplasty.
      ,
      • Neumaier M.
      • Metak G.
      • Scherer M.A.
      C-reactive protein as a parameter of surgical trauma: CRP response after different types of surgery in 349 hip fractures.
      ,
      • Foglar C.
      • Lindsey R.W.
      C-reactive protein in orthopedics.
      ,
      • Maury C.P.J.
      • Teppo A.M.
      • Raunio P.
      Control of the acute-phase serum amyloid A and C-reactive protein response: comparison of total replacement of the hip and knee.
      ,
      • Park K.K.
      • Kim T.K.
      • Chang C.B.
      • Yoon S.W.
      • Park K.U.
      Normative temporal values of CRP and ESR in unilateral and staged bilateral TKA.
      ,
      • Honsawek S.
      • Deepaisarnsakul B.
      • Tanavalee A.
      • Sakdinakiattikoon M.
      • Ngarmukos S.
      • Preativatanyou K.
      • et al.
      Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study.
      ,
      • Choudhry R.R.
      • Rice R.P.
      • Triffitt P.D.
      • Harper W.M.
      • Gregg P.J.
      Plasma viscosity and C-reactive protein after total hip and knee arthroplasty.
      ,
      • Niskanen R.O.
      • Korkala O.
      • Pammo H.
      Serum C-reactive protein levels after total hip and knee arthroplasty.
      ,
      • White J.
      • Kelly M.
      • Dunsmuir R.
      C-reactive protein level after total hip and knee replacement.
      ,
      • Shih L.Y.
      • Wu J.J.
      • Yanc D.J.
      Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty.
      ,
      • Aalto K.
      • Osterman K.
      • Peltola H.
      • Räsänen J.
      Changes in erythrocyte sedimentation rate and C-reactive protein after total hip arthroplasty.
      ,
      • Larsson S.
      • Thelander U.
      • Friberg S.
      C-reactive protein (CRP) levels after elective orthopedic surgery.
      ]. An infectious complication in patients with PWD should be suspected if CRP levels increase later than 72 hours after TJA, or remain elevated beyond 7 days after TJA [
      • Foglar C.
      • Lindsey R.W.
      C-reactive protein in orthopedics.
      ,
      • Niskanen R.O.
      • Korkala O.
      • Pammo H.
      Serum C-reactive protein levels after total hip and knee arthroplasty.
      ,
      • White J.
      • Kelly M.
      • Dunsmuir R.
      C-reactive protein level after total hip and knee replacement.
      ,
      • Shih L.Y.
      • Wu J.J.
      • Yanc D.J.
      Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty.
      ,
      • Larsson S.
      • Thelander U.
      • Friberg S.
      C-reactive protein (CRP) levels after elective orthopedic surgery.
      ,
      • Yi P.H.
      • Cross M.B.
      • Moric M.
      • Sporer S.M.
      • Berger R.A.
      • Della Valle C.J.
      Diagnosis of infection in the early postoperative period after total hip arthroplasty.
      ].
      The WBC and ESR are less appropriate for the diagnosis of PJI in case of PWD, since the WBC increases only slightly after surgery and returns to normal within 7 days after index surgery, while the ESR increases only gradually, with peak level between day 5 and 14 and normalization in 19 days up to 9 months after index surgery [
      • Bilgen O.
      • Atici T.
      • Durak K.
      • Karaeminoğullari
      • Bilgen M.S.
      C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty.
      ,
      • Park K.K.
      • Kim T.K.
      • Chang C.B.
      • Yoon S.W.
      • Park K.U.
      Normative temporal values of CRP and ESR in unilateral and staged bilateral TKA.
      ,
      • Honsawek S.
      • Deepaisarnsakul B.
      • Tanavalee A.
      • Sakdinakiattikoon M.
      • Ngarmukos S.
      • Preativatanyou K.
      • et al.
      Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study.
      ,
      • Shih L.Y.
      • Wu J.J.
      • Yanc D.J.
      Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty.
      ,
      • Aalto K.
      • Osterman K.
      • Peltola H.
      • Räsänen J.
      Changes in erythrocyte sedimentation rate and C-reactive protein after total hip arthroplasty.
      ,
      • Larsson S.
      • Thelander U.
      • Friberg S.
      C-reactive protein (CRP) levels after elective orthopedic surgery.
      ,
      • Covey D.C.
      • Albright J.A.
      Clinical significance of the erythrocyte sedimentation rate in orthopaedic surgery.
      ].

      An Algorithmic Approach to the Decision-Making Process

      In clinical practice, assessment of the origin (intra-articular or extra-articular) and type of wound drainage (physiologic or infectious secretion) is often difficult. Weiss and Krackow [
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ] concluded that wound drainage can offer a pathway where pathogens can enter the wound and joint, acting as a retrograde pathway for infection. This implies that PWD should be perceived as potential imminent PJI, hence justifying a low threshold for early surgical intervention [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Wilson M.G.
      • Kelley K.
      • Thornhill T.S.
      Infection as a complication of total knee replacement arthroplasty. Risk factors and treatment of sixty-seven cases.
      ]. However, advocating early surgical intervention may result in unnecessary operations, while delaying early surgical intervention may result in the development of PJI.
      An evidence-based algorithmic approach on PWD may ease the decision-making process in the diagnosis and timing of treatment. In literature, some authors merely provided general statements on the evaluation of wound complications [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Galat D.D.
      • McGovern S.C.
      • Larson D.R.
      • Harrington J.R.
      • Hanssen A.D.
      • Clarke H.D.
      Surgical treatment of early wound complications following primary total knee arthroplasty.
      ,
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ]. Only few studies specifically addressed PWD [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Surin V.V.
      • Sundholm K.
      • Bäckman L.
      Infection after total hip replacement: with special reference to a discharge from the wound.
      ,
      • Butt U.
      • Ahmad R.
      • Aspros D.
      • Bannister G.C.
      Factors affecting wound ooze in total knee replacement.
      ,
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ,
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      ] and only one of these studies described an algorithmic approach [
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      ]. In this study, the algorithmic approach was compared to an ad hoc approach in which the surgeon decided upon own discretion. Even though the reported percentage of PWD was 2 times higher in the algorithmic cohort (21% vs 11%), the number of surgical interventions was lower (17% vs 30%) and the salvage percentage was higher (94% vs 85%) [
      • Maathuis P.
      • de Hartog B.
      • Bulstra S.K.
      Timing of open debridement for suspected infection of joint prosthesis: a report on 551 patients.
      ]. This suggests that an algorithmic approach may lead to increased awareness of PWD and an improved decision-making process with a lower frequency of surgical interventions and better outcome.

      Timing of Treatment

      The optimal timing of starting nonsurgical or surgical treatment in patients with PWD remains to be established. Patel et al [
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ] stated that each day of PWD beyond day 5 after TJA surgery increased the risk of wound infection with 42% after THA and 29% after TKA. Saleh et al found a 12.7 times higher risk of developing PJI when the wound drained for more than 5 days after THA/TKA compared to patients with shorter duration of wound drainage. Based on these findings, they advised on performing open debridement in case of hematoma or PWD for more than 7 days postoperative [
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ].
      More recently, Jaberi et al [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ] (defining wound drainage as persistent when drainage soaked postoperative dressing for more than 2 days) showed that draining wounds after THA and TKA healed uncomplicated within 2-4 days of nonsurgical treatment (wound care and antimicrobial treatment) in 72% of patients. The remaining 28% underwent open debridement. This was successful in 76% of patients, while the remaining 24% underwent subsequent treatment including repeated debridement, resection arthroplasty, or suppressive antimicrobial treatment. These authors recommended early surgery within 7 days after index surgery even though their successful debridement antibiotic and implant retentions were performed at a mean of 14 days (range 4-32 days) after index surgery [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ]. Based on these studies, the ICM formulated the statement that surgical treatment should be performed if wound drainage persists for longer than 5-7 days after index surgery [
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ].

      Nonsurgical Treatment Strategies

      Nonsurgical treatment strategies are usually performed prior to surgical intervention [
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ]. Since PWD is associated with an increased risk of PJI, observation only is highly discouraged [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Patel V.P.
      • Walsh M.
      • Sehgal B.
      • Preston C.
      • DeWal H.
      • Di Cesare P.E.
      Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.
      ,
      • Saleh K.
      • Olson M.
      • Resig S.
      • Bershadsky B.
      • Kuskowski M.
      • Gioe T.
      • et al.
      Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program.
      ,
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ]. Acceptable nonsurgical treatment is adequate wound care by using absorbent dressings and pressure bandages (hand-made spica for the hip), supplemented by several days of joint immobilization and interruption of physical therapy [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Hahn G.J.
      • Grant D.
      • Bartke C.
      • McCartin J.
      • Carn R.M.
      Wound complications after hip surgery using a tapeless compressive support.
      ]. Bed rest and braces may impair early rehabilitation, but this outweighs the potential risk of prolonging the duration of PWD and increasing the risk of PJI [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      ]. Good results were reported on the use of silver-impregnated dressings [
      • Percival S.L.
      • Slone W.
      • Linton S.
      • Okel T.
      • Corum L.
      • Thomas J.G.
      The antimicrobial efficacy of a silver alginate dressing against a broad spectrum of clinically relevant wound isolates.
      ] and negative pressure wound therapy (NPWT) [
      • Hansen E.
      • Durinka J.B.
      • Costanzo J.A.
      • Austin M.S.
      • Deirmengian G.K.
      Negative pressure wound therapy is associated with resolution of incisional drainage in most wounds after hip arthroplasty.
      ,
      • Pachowsky M.
      • Gusinde J.
      • Klein A.
      • Lehrl S.
      • Schulz-Drost S.
      • Schlechtweg P.
      • et al.
      Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty.
      ,
      • Masden D.
      • Goldstein J.
      • Endara M.
      • Xu K.
      • Steinberg J.
      • Attinger C.
      Negative pressure wound therapy for at-risk surgical closures in patients with multiple comorbidities: a prospective randomized controlled study.
      ,
      • Webster J.
      • Scuffham P.
      • Stankiewicz M.
      • Chaboyer W.P.
      Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention (review).
      ]. However, a Cochrane meta-analysis could not find definitive evidence for the effectiveness of NPWT [
      • Webster J.
      • Scuffham P.
      • Stankiewicz M.
      • Chaboyer W.P.
      Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention (review).
      ].
      The ICM advised on early analysis and correction of anticoagulation, anemia, glucose regulation in diabetic patients, and malnutrition [
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ]. One study retrospectively evaluated 11,785 THAs/TKAs and found malnutrition to predispose for failure of surgical debridement and an increased risk of PJI in patients with PWD. Therefore, they recommended consultation of a nutritional physician in order to treat in case of wound drainage persisting longer than 48 hours [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ]. With regard to anticoagulation, Parvizi et al showed that patients with a mean International Normalized Ratio higher than 1.5 had an increased risk of developing wound complications and PJI after THA/TKA. Hence, they stressed the importance of cautious anticoagulant treatment in order to prevent formation of a hematoma and subsequent wound drainage [
      • Parvizi J.
      • Ghanem E.
      • Joshi A.
      • Sharkey P.F.
      • Hozack W.J.
      • Rothman R.H.
      Does “excessive” anticoagulation predispose to periprosthetic infection?.
      ].
      Although antimicrobial treatment during PWD has been described [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ], current consensus discourages antimicrobial treatment due to a lack of evidence on decreasing the risk of PJI [
      • Hansen E.
      • Durinka J.B.
      • Costanzo J.A.
      • Austin M.S.
      • Deirmengian G.K.
      Negative pressure wound therapy is associated with resolution of incisional drainage in most wounds after hip arthroplasty.
      ,
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      ]. Furthermore, it may confound culture results thus impairing the diagnosis of an early PJI. And finally, concerns about the increase in antimicrobial resistance cannot be ignored [
      • Zmistowski B.
      • Della Valle C.
      • Bauer T.W.
      • Malizos K.N.
      • Alavi A.
      • Bedair H.
      • et al.
      Diagnosis of periprosthetic joint infection.
      ].

      Surgical Treatment Strategies

      Most publications advocate early surgical treatment in case wound drainage persists despite a period of adequate nonsurgical treatment [
      • Vince K.
      • Chivas D.
      • Droll K.P.
      Wound complications after total knee arthroplasty.
      ,
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ,
      • Dennis D.A.
      Wound complications in total knee arthroplasty.
      ,
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ]. Surgical treatment typically consists of open deep debridement and thorough irrigation, using 6-9 L of saline administered by low-pressure pulsatile jet lavage [
      • Crowley D.J.
      • Kanakaris N.K.
      • Giannoudis P.V.
      Irrigation of the wounds in open fractures.
      ]. Optionally, diluted povidone-iodine or chlorhexidine gluconate can be used to irrigate the joint cavity [
      • Lineaweaver W.
      • McMorris S.
      • Soucy D.
      • Howard R.
      Cellular and bacterial toxicities of topical antimicrobials.
      ,
      • Brown N.M.
      • Cipriano C.A.
      • Moric M.
      • Sporer S.M.
      • Della Valle C.J.
      Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection.
      ,
      • Ruder J.
      • Springer B.
      Treatment of periprosthetic joint infection using antimicrobials: dilute povidone-iodine lavage.
      ]. However, it should be recognized that these recommendations on irrigation are derived from literature on primary TJA and trauma surgery, mostly from animal and basic science studies.
      Whenever possible, modular components should be exchanged as it offers a better potential for thorough debridement and irrigation deep to these modular components. Moreover, modular component exchange is advised because the polyethylene component (acetabular liner or tibial inlay) may be colonized by pathogens [
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ]. The soft tissue should be meticulously closed in a multilayer fashion [
      • Lonner J.H.
      • Lotke P.A.
      Aseptic complications after total knee arthroplasty.
      ,
      • Ghanem E.
      • Heppert V.
      • Spangehl M.
      • Abraham J.
      • Azzam K.
      • Barnes L.
      • et al.
      Wound management.
      ]. NPWT is a plausible alternative when wound closure is not possible [
      • Webster J.
      • Scuffham P.
      • Stankiewicz M.
      • Chaboyer W.P.
      Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention (review).
      ]. In these cases, consultation of a plastic surgeon is recommended.
      Administration of prophylactic antimicrobial treatment is advised prior to incision [
      • Zmistowski B.
      • Della Valle C.
      • Bauer T.W.
      • Malizos K.N.
      • Alavi A.
      • Bedair H.
      • et al.
      Diagnosis of periprosthetic joint infection.
      ,
      • Atkins B.L.
      • Athanasou N.
      • Deeks J.J.
      • Crook D.W.
      • Simpson H.
      • Peto T.E.A.
      • et al.
      Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty.
      ]. Various deep tissue samples for bacterial cultures are obtained, preferably 5 samples to increase pathogen detection. Each tissue sample is obtained using a clean instrument to avoid contamination. Tissue swabs are not advised [
      • Zmistowski B.
      • Della Valle C.
      • Bauer T.W.
      • Malizos K.N.
      • Alavi A.
      • Bedair H.
      • et al.
      Diagnosis of periprosthetic joint infection.
      ]. Tissue samples should be cultured up to 14 days and antimicrobial treatment is continued until culture results are definitive [
      • Zmistowski B.
      • Della Valle C.
      • Bauer T.W.
      • Malizos K.N.
      • Alavi A.
      • Bedair H.
      • et al.
      Diagnosis of periprosthetic joint infection.
      ]. In case of positive culture results, targeted antimicrobial treatment should be continued in consultation with an infectious disease specialist, usually 6-12 weeks. Jaberi et al found positive deep periprosthetic tissue cultures in 34% (28 of 83 cases) after surgical treatment for PWD after THA/TKA. Cultures were more often positive in the failure group (17 of 20, 85%) compared to the success group (11 of 63, 17%) [
      • Jaberi F.M.
      • Parvizi J.
      • Haytmanek C.T.
      • Joshi A.
      • Purtill J.
      Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty.
      ]. Weiss and Krackow [
      • Weiss A.P.
      • Krackow K.A.
      Persistent wound drainage after primary total knee arthroplasty.
      ], reporting PWD in 8 of 597 primary TKAs, showed that 25% (2 of 8 cases) had positive cultures after surgical debridement at a mean of 12.5 days after surgery (range 8-18 days). However, issues can be raised on the statistical power of this study cohort.

      Summary

      The reported incidence of PWD after TJA varies between 0.2% and 21%, with higher incidences after revision TJA. This wide range in incidence is mainly caused by the variation in definitions of PWD. The ICM formulated a definition that defines PWD as >2 × 2 cm for longer than 72 hours, but this definition should be further specified and validated.
      Clinical signs of infection and blood serology can be helpful in diagnosing PJI in case of PWD, although some clinical signs can be a normal physiological response in the first days after TJA. An increase in CRP later than 72 hours after index surgery or persistent elevated levels of CRP beyond 7 days can indicate development of an infectious complication.
      Nonsurgical treatment of PWD generally involves absorbent dressings, pressure bandages, and temporary joint immobilization. Present consensus discourages the use of antimicrobial treatment. Nutritional consultation and correction of anticoagulation and metabolic imbalances should be considered.
      Surgical treatment should be performed when wound drainage persists for more than 5-7 days after index procedure despite adequate nonsurgical treatment. Nonetheless, establishing this time frame needs validation in future research. Surgical treatment should include thorough open debridement and irrigation, obtaining tissue samples (cultured up to 14 days) and exchange of modular components. Empirical broad spectrum antimicrobial treatment is administered in consultation with an infectious diseases specialist.

      Proposed Algorithm

      Based on this literature review, the authors developed an algorithm to facilitate the decision-making process of PWD after TJA (Fig. 1). Although we aimed to differentiate between PWD in THA and TKA in this algorithm, we did not find enough scientific evidence to make this distinction. In addition to the algorithm, we also propose a classification of PWD that divides wound drainage into 4 categories based on the amount of drainage (Table 2). As this classification is merged into the algorithm, the amount of drainage is combined with the duration of drainage (Fig. 1), in which larger amounts of wound drainage are tolerated for a shorter period. Hopefully, this algorithm offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing risks and benefits. Currently, a multicenter randomized controlled trial on the optimal treatment of PWD after TJA is being conducted to examine the validity and applicability of such a classification and algorithm in daily clinical practice [
      • Löwik C.A.M.
      • Wagenaar F.B.M.
      • van der Weegen W.
      • Poolman R.W.
      • Nelissen R.G.H.H.
      • Bulstra S.K.
      • et al.
      LEAK study: design of a nationwide randomised controlled trial to find the best way to treat wound leakage after primary hip and knee arthroplasty.
      ].
      Figure thumbnail gr1
      Figure 1Proposed algorithm for diagnosis and treatment of persistent wound drainage after total joint arthroplasty.
      Table 2Proposed Classification of Persistent Wound Drainage After Total Joint Arthroplasty.
      CategoryDescription
      1 (Limited)A stripe of blood in the wound dressing in the line of the wound or less than 2 × 2 cm in size
      According to the 2013 International Consensus Meeting on Periprosthetic Joint Infection [28,33].
      2 (Moderate)More than 2 × 2 cm drainage in absorbent gauze or dressing but without the need for change in the wound dressing (ie, dressing is not soaked)
      3 (Excessive)One dressing change per day due to soaked absorbent gauze or dressing
      4 (Massive)Two or more daily dressing changes due to soaked absorbent gauzes or dressings
      a According to the 2013 International Consensus Meeting on Periprosthetic Joint Infection
      • Ng V.Y.
      • Lustenberger D.
      • Hoang K.
      • Urchek R.
      • Beal M.
      • Calhoun J.H.
      • et al.
      Preoperative risk stratification and risk reduction for total joint reconstruction: AAOS exhibit selection.
      ,
      • Parvizi J.
      • Gehrke T.
      • Chen A.F.
      Proceedings of the international consensus on periprosthetic joint infection.
      .

      Conclusion

      This review summarizes the available literature addressing several issues in the field of PWD after TJA. There are limited scientific data on PWD and absence of an evidence-based guideline regarding diagnosis and treatment, partially caused by the lack of a universally accepted definition. We developed a classification of PWD and an algorithmic approach for the management of PWD after TJA to offer the orthopedic surgeon a practical guideline for daily clinical practice.

      Appendix A. Supplementary Data

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