A Closer Look At An Emerging Option To Reduce Post-Op Infections

“I don’t have complications.” Raise your hand if you had an attending say this during residency. All of us know someone that has this attitude when treating patients operatively and non-operatively, whether it’s a bunion correction or Charcot reconstruction. We all know this assertion is false.

I am always looking to learn from complications (my own and others’), such as under-correction and over-correction. We all benefit from doing so as our training and education can easily stagnate if we do not stay on top of the literature and research. I try to inject the newest and most effective technologies into my everyday practice while maintaining the quality of my training.

Common complications that occur in the foot and ankle surgical arena include wound complications, incision dehiscence, and pin site infections. Each of these complications may lead to re-operation. The overall re-operation rate for infections in the US across the board for foot and ankle cases ranges from one to 40 percent,^1-4 but the associated costs can be detrimental to the health care system. In an era of decreasing reimbursements and increased institutional costs, we should all be aware of opportunities to control outcomes.

One such way to control outcomes and reduce surgical infections is to adapt a protocol above and beyond a standard povidone-iodine incisional dressing. I have observed early adopters and thought leaders trying to introduce silver technologies into their post-operative dressings. Although promising in theory, this method is costly and does not necessarily assist with wound healing.⁵ However, research is being done in this field of silver technologies in the wound care space. 

Why don’t we assist the incision in healing and also reduce the microbe count? An emerging technology that I have been using for incision dressings and pin site care is an organic polymer microbicidal barrier called DuraDerm®. It has Food and Drug Administration (FDA) 510(k) clearance and is indicated for closed incisions. Importantly, it is not indicated for diabetic foot ulcers.  

This product does not take the place of sutures and is not a wound closure device.  One would close incisions as usual with absorbable subcuticular suture or a running non-absorbable suture, depending on the case and/or surgeon preference. I then apply the polymer on the incision, ensuring that it covers at least 0.5 cm beyond the its borders. Next is application of a non-adherent, sterile compressive dressing. Typically the patient is seen within 10 to 14 days to assess the incision and assess pain control. 

My results with DuraDerm have been phenomenal to say the least. In my experience utilizing DuraDerm, I have noted improved healing rates without wound complications or side effects. A secondary outcome with DuraDerm is reduced scarring. The polymer forms a thin biofilm that reduces pH, driving the incision to heal more quickly. This biofilm is also microbicidal on contact with the skin. Typically, at the first post-operative visit, one removes the sutures and the incision is healed.

We can control how much we correct a bunion or how well we reduce a pilon fracture. That is the easy part. However, there are some factors we still need to harness. With the DuraDerm product and technique, I have been able to give my patients an “insurance policy” previously not available. Due to the product’s smooth application and a low side effect profile, I feel it could make an easy and effective addition to assist in reducing the risk of post-op infections. 

Dr. McAlister completed an advanced foot and ankle surgical fellowship at the Orthopedic Foot and Ankle Center in Columbus, OH. He is board-certified by the American Board of Foot and Ankle Surgery and is in private practice in Phoenix, AZ. 

References

1. Liu X, Zhang H, Liu L, Fang Y, Huang F. Open Talus Fractures: Early infection and its epidemiological characteristics. J Foot Ankle Surg. 2019;58(1):103-108.
2. Rubio-Suarez JC, Carbonell-Escobar R, Rodriguez-Merchan EC, Ibarzabal-Gil A, Gil-Garay E. Fractures of the tibial pilon treated by open reduction and internal fixation (locking compression plate-less invasive stabilising system): Complications and sequelae. Injury. 2018;49 Suppl 2:S60-S64.
3. Macera A, Carulli C, Sirleo L, Innocenti M. Postoperative complications and reoperation rates following open reduction and internal fixation of ankle fracture. Joints. 2018;6(2):110-115.
4. McKenzie JC, Rogero RG, Khawam S, et al. Incidence and risk factors for pin site infection of exposed kirschner wires following elective forefoot surgery. Foot Ankle Int. 2019. doi: 10.1177/1071100719855339. E-pub ahead of print, accessed June 17, 2019.
5. Graham C. The role of silver in wound healing. Br J Nurs. 2005;14(19):S22,S24,S26.