Nonidiopathic Scoliosis Surgical Wound Closure Technique Findings
Commentary by David S. Feldman, MD
Wound infections following posterior spinal fusion in the treatment of nonidiopathic scoliosis are linked to high morbidity and costs. New findings suggest that use of a plastic multilayered closure technique can lower the infection rate significantly, as reported in the June 24 issue of the Journal of Pediatric Orthopedics.
While it is important to examine all aspects of care when trying to reduce infection rates in spine surgery—including timing of antibiotics and surgical technique—it also is essential to look at wound closure, said study co-author David S. Feldman, MD, Professor of Orthopedic Surgery and Pediatrics, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY.
“There may be multifactorial reasons why infection rates in certain institutions are high, but certainly how the wound is closed is of critical importance,” said co-author David S. Feldman, MD. “I think that is an important message for all institutions. Whether or not they use a plastic surgeon or orthopedic surgeons closing the wounds, there has to be a systematic methodology to how you close the wound,” he said.
The retrospective chart review included 76 patients with primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease who underwent a posterior spinal fusion. Incisions were closed using nonstandardized techniques in 42 patients and using the plastic multilayered technique in 34 patients.
The primary endpoint was acute postoperative wound complication requiring additional hospitalization.
No Wound Complications Occurred With the Multilayered Technique
No wound complications occurred within the first 6 months postoperatively among patients who underwent the plastic multilayered technique, compared with 19% (8 of 42) of patients who underwent nonstandardized wound closure (P=0.007). In addition, the rate of unanticipated return to the operating room for irrigation and debridement of the surgical wound within the first 6 months was significantly lower among patients who received the plastic multilayered technique than among those who received nonstandardized wound closure (0% vs 11.9%; P=0.061)
How the Plastic Multilayered Wound Closure Is Performed
The multilayer wound closure involves limiting the amount of dead space in the musculature, particularly over hardware or a bone graft, where blood may fill in and cause a hematoma and subsequent infection to develop, Dr. Feldman explained.
The plastic surgeon isolates and closes the muscle as one layer with a Jackson-Pratt drain, to provide negative pressure for the vascularized fill of the dead space and prevent a hematoma. The muscle is then re-approximated. The second fascial layer separates the deep compartment from the superficial compartment and functions as a fluid impermeable barrier layer after closure. The third layer involves closure of the remaining soft tissue.
“So you are basically dividing the closure and the different layers to decrease the dead space,” Dr. Feldman noted.
Scoliosis cases often involve the pelvic region, which is an area where breakdown of the skin or of wound may occur, Dr. Feldman explained. For surgeries that involve the pelvis, “you could use muscle-relaxing incisions to have the muscle and fascia advanced over the pelvic screws, avoiding breakdowns,” Dr. Feldman said. “Thus, there is both the multilayered effect and muscle-relaxing incisions so that you don’t get pull off of the muscle, and you can get a better closure,” he said.