Effectiveness of hydrocolloid dressing in postoperative hip and knee surgery: literature review and our experience.
Abstract: Hydrocolloid dressings are impermeable dressings that provide an optimal environment for wound healing. These dressings are very effective in healing chronic wounds but evidence regarding their use for the post-operative knee and hip surgery is scarce. Our experience shows that hydrocolloid dressing (Duoderm[R]) helps in preventing not only superficial surgical site infection (SSSI) but also blister formation in patients undergoing lower limb orthopaedic surgery.

KEYWORDS Hydrocolloid dressing / Superficial surgical site infection / Blisters / Hip surgery / Knee surgery
Subject: Postoperative care (Analysis)
Authors: Siddique, Khurram
Mirza, Shirin
Housden, Philip
Pub Date: 08/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2011 Source Volume: 21 Source Issue: 8
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168033
Full Text: Introduction

Postoperative wound management has always been a challenge, especially for the orthopaedic surgeons because of the risk of wound infection and blister formation with subsequent prolonged morbidity (Dixon et al 2006, Ravenscroft et al 2006). Superficial surgical site infection (SSSI) has been reported to be one of the most frequent of the healthcare associated infections (HAI) on surgical wards (Ugkay et al 2010). Incidence of SSSI for total hip replacement (THR), revision THR, hemiarthroplasty and revision hemiarthroplasty are reported to be 2.23%, 3.8%, 4.97% and 7.6% respectively in over 100 hospitals of England (Ridgeway et al 2005). Its frequency is 3.3% following knee arthroplasty (Chesney et al 2008). However, the incidence of postoperative blister formation is reported as 7.3% following hip surgery (Koval et al 2007) and 6% following knee arthroscopy (Bhattacharyya et al 2005). SSSI and blister formation result in delayed wound healing which increases the postoperative hospital stay. This in turn can have an impact on the healthcare cost and the patient's quality of life. Whitehouse et al (2002) reported that postoperative SSSI in orthopaedic patients not only increased their hospital stay by a median of two weeks, but also increased the total healthcare costs by more than 300%.

Several surgical and patient related factors affect postoperative wound healing. These include: strict asepsis during interventions, meticulous technique, appropriate antibiotics, proper nutrition and appropriate wound dressings (Phillips 2000). A variety of dressings are now available in the market and our selection should be evidence based. A systematic review conducted on the effectiveness of various dressings and topical agents on surgical wound infection and healing concluded that the trials conducted have been of low quality and do not prove the superiority of one dressing or topical agent over another (Vermeulen et al 2005). Hence the choice of a particular postoperative dressing that can prevent both SSSI and blister formation following hip and knee surgery still remains questionable.

One dressing that can be used for postoperative hip and knee wounds is the hydrocolloid dressing (Thomas 2008). It is an occlusive dressing that was first introduced in the UK in 1982. It has been widely used for chronic wounds but evidence regarding its use for postoperative knee and hip surgery is scarce.

Therefore, we aimed to evaluate the effectiveness of hydrocolloid dressings for postoperative hip and knee wounds by conducting a literature review and a descriptive cross sectional study. The objectives of our study were to determine the prevalence of SSSI and blister formation in postoperative hip and knee wounds irrespective of the elective or emergency nature of the procedures.

Literature review

An electronic search was made on healthcare databases including MEDLINE for Pubmed, Cochrane library, EMBASE, BNI, CINAHL and Google Scholar to answer the following questions:

* Are hip and knee wounds different from other postoperative wounds?

* What are the properties of an ideal dressing?

* Is hydrocolloid dressing an ideal dressing?

* Are hydrocolloid dressings cost effective for these wounds?

Our literature search revealed the following:

Characteristics of postoperative hip and knee wounds:

These wounds are categorised as acute wounds and considered as 'clean'. The margins of the wounds are closed by stitches or clips which are left in place until the edges heal (Baxter 2003). The post-surgical hip and knee wounds are prone to wound infection and blister formation mainly due to increased exudate formation and disturbance ofmobility at the joint site (Ravenscroft et al 2006, Jester et al 2000). High level of exudate can cause skin erythema and maceration leading to the separation of epidermis from dermis thus resulting in blister formation. Once formed, a blister increases the risk of skin breakdown leading to SSSI (Gupta et al 2002). Nevertheless, wound exudate has been reported to contain growth factors which are secreted by the surrounding cells and promote growth and migration of fibroblasts and keratinocytes, leading to an early and quick healing (White & Cutting 2006).

Properties of an ideal dressing for postoperative hip and knee wounds:

The underlying principle in surgical wound management is to enhance wound healing by minimising physical trauma and preventing microbial invasion (Pukki et al 2006). An ideal dressing is the one that maintains an optimal moist wound environment, absorbs the excess exudate, provides protection to the newly formed tissue and avoids maceration of the surrounding skin (Chaby et al 2007, NICE 2008). Hip and knee surgical wounds provide a favourable environment for microorganisms which may be pathogenic (Ravenscroft et al 2006). The dressing should be able to entrap these bacteria at the wound site and prevent their spread (Stashak et al 2004).

Properties of hydrocolloid dressing:

In the early 1900s, it was thought that a wound should be covered by a suitable material (traditionally a gauze dressing) that could soak up the wound fluid and keep it dry until the scab formed and the wound ultimately healed. However, other scientists have reported that if a wound is provided with a moist environment, it heals more quickly (Boateng et al 2008).

The term 'hydrocolloid' was first used in 1960 when a mucoadhesive dressing was being developed for mouth ulcers (Thomas 2008). This consisted of carboxymethyl cellulose in combination with other adhesives and tackifiers. At first, hydrocolloid dressing was derived from the stoma adhesive products but later on was tailored for wound care. It was launched in the UK as Granuflex in 1982 and as Duoderm in the USA in 1983, and was followed by other similar products (Thomas 2008). Later these dressings were modified for application on various anatomical sites of the body.

Hydrocolloid is a type of dressing which consists of a gel forming agent (e.g. sodium carboxymethyl cellulose) and gelatin on a semi permeable film that promotes rehydration and debridement of the wounds (Thomas 2008). In the presence of exudate, it absorbs liquid and forms a gel. As the gel forms, the dressing becomes more permeable and loses water in the form of vapour. This increases the capability of the dressing to cope with the exudate production (Thomas & Loveless 1997). These dressings soften the dry wound and do not cause trauma on removal. Moreover the occlusive properties prevent the spread of bacteria and viruses (Stashak et al 2004). The moist environment keeps the cells viable, enabling them to produce the cytokines and growth factors that promote wound healing (Eaglstein 1993). It also facilitates an autolytic milieu and hence promotes debridement (NHS 2008). The moist and hypoxic environment created by the hydrocolloid dressings in turn accentuates angiogenesis (Stashak et al 2004), and promotes granulation tissue formation and collagen synthesis by increasing the number of fibroblasts (Stashak et al 2004). These properties make it an ideal dressing for postoperative hip and knee wounds.

Hydrocolloid dressing for postoperative wounds, evidence from literature

A literature review from 1980 to the present showed that hydrocolloid dressings have been used for postoperative wound healing by primary and secondary intention with varying results (Thomas 2008). A multicenter trial conducted on 95 patients with 102 sutured wounds showed that a hydrocolloid dressing required less dressing change and was more comfortable for the patient than a gauze and tape dressing (Hermans 1993). Another study, in which patients served as their own control (hydrocolloid dressing applied on half of the postoperative wound and gauze dressing applied on the other half), depicted that the ability of the hydrocolloid dressing to contain the exudate and protect the wound was higher than that of the gauze dressing (Michie & Hugill 1994).

Hydrocolloid dressing was reported 'not to increase the risk of infection' in abdominal incisions when compared with the conventional postoperative island dressing (Holm et al 1998). In another randomised controlled trial (RCT), Ravenscroft et al (2006) found that hydrofiber in combination with hydrocolloid dressing (Aquacel and Tegaderm) was almost six times more likely to result in hip and knee wounds 'with no complication' than an absorbent perforated dressing with an adhesive border. The design of this study was strong but the effect of hydrocolloid dressing alone is difficult to tease out from that of the hydrofiber dressing. Hydrocolloid dressing has also been found to be beneficial in the wounds that heal by secondary intention (Viciano et al 2000, Estienne & Di Bella 1989) leading to less bacterial infection, less pain and reduced healing time.

Cost effectiveness of hydrocolloid dressing for postoperative hip and knee surgery

Evidence shows that a hydrocolloid dressing requires less dressing change (Ravenscroft et al 2006, Dillon et al 2007), has increased wear time and reduces postoperative stay (Dillon et al 2007) for patients undergoing lower limb orthopeadic surgery. Moreover Dillon et al (2007) observed a reduction in the total cost of application of this dressing in UK.

Methods

We conducted a cross sectional descriptive study at the orthopeadic department of the William Harvey Hospital, Kent, UK from October 2008 to April 2009. Non probability convenient sampling was done to select the patients undergoing total hip replacement (THR), total knee replacement (TKR) and emergency surgeries like hemiarthroplasty and dynamic hip screw. Informed consent was taken from all the patients. Those not giving consent, those with renal or hepatic pathologies, and severely debilitated patients were excluded.

Sample size was calculated by Epi Info (Dean et al 1996). At least 50 patients were required taking into account the least frequency of SSSI in lower limb post-surgical wounds as 2.23% and the worst as 7.6% (Ridgeway et al 2005) at 99% confidence level (minimizing the type I error, thus increasing internal validity of the study) and a power of 80%.

Only one dose of prophylactic antibiotic was given to all patients. All postoperative wounds were dressed with Duoderm dressing. Wounds were observed for SSSI and blister formation on the first, third and fifth post operative days by a trained surgeon uniformly in all cases. SSSI was assessed according to the standard criteria set by National Nosocomial Infections Surveillance (NNIS) programme (NNIS 2002), and the findings noted on a proforma.

Infection was defined by demonstration of at least one of the following features:

* Purulent drainage from the incision.

* Isolation of organisms from an aseptically obtained culture of fluid or tissue from the wound.

If the following symptoms or signs of infection including pain or tenderness, localised swelling, redness or heat were observed, the wound was opened by the surgeon. However, the wound was left intact if the culture was negative. The data were analyzed on SPSS version 14 (SPSS 2005).

Results

Of the 50 patients included in our study, 60% were female. The mean age of the patients was 69 years (range: 55 to 87 years). Thirty patients underwent elective surgery and 20 underwent emergency procedures for trauma (see Table 1).

Serious discharge at the wound site was observed in 14% (7) patients. No bacteria were isolated in any of the wound swabs. None of the patients developed blister or vesicles around the post-operative wound (Figure 1).

[FIGURE 1A OMITTED]

[FIGURE 1B OMITTED]

Discussion

The literature review showed that hydrocolloid dressing has the properties of an ideal dressing for postoperative hip and knee surgery. The evidence generated and author's own descriptive study depicts coherent findings. Hydrocolloid dressings can be used safely without the risk of infection or blister formation in patients undergoing hip and knee surgery.

This review has described the characteristics of postoperative healing of the lower limb wounds, as well as providing an in-depth reflection on the structure of hydrocolloid dressings, with the aim of assisting the reader in understand the properties and mechanism of action of the dressing. The review also provides evidence of the type of dressing which should be used for such wounds.

Evidence regarding the use of hydrocolloid dressing in postoperative hip and knee wounds is scarce and the available studies do not provide conclusive evidence (Thomas 2008, Vermeulen et al 2005). This made us conduct a descriptive study to determine the rate of SSSI and blister formation, which are two of the major challenges of these wounds after the application of Duoderm (Dixon et al 2006, Ravenscroft et al 2006). We consider this one of the strengths of this article. Another strength of our descriptive study is that SSSI was to be recorded according to the definition of the NNIS program (NNIS 2002), thus reducing the chances of subjectivity in measurement.

One of the limitations of our study was its small sample size. Although small, the sample was large enough to fulfill the power of the study, thus increasing the internal validity. There was no comparison group present and we were therefore unable to address the issue of cost-effectiveness. The literature review did provide support for cost effectiveness of the hydrocolloid dressing in managing postoperative wounds (Ravenscroft et al 2006, Dillon et al 2007). Nonetheless, it forms a baseline for future research in this area.

No competing interests declared

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Correspondence address: Khurram Siddique, General Surgery, East Kent Hospitals University NHS Foundation Trust, Kent, CT13NG. Email: sk.sid@hotmail.co.uk

About the authors

Khurram Siddique MCPS, FCPS, MRCS

Specialist Registrar, Department of Trauma & Orthopaedics, William Harvey Hospital, Ashford

Shirin Mirza MBBS, MSc (Epi & Bio)

Epidemiologist, Department of Trauma & Orthopaedics, William Harvey Hospital, Ashford

Philip Housden FRCS

Consultant Orthopaedic Surgeon, Department of Trauma & Orthopaedics, William Harvey Hospital, Ashford
Table 1

Procedure                 Number

THR                       11
TKR                       13
revised THR                4
revised TKR                2
hemiarthroplasty          12
dynamic hip screw          6
interlocking nailing of    2
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