Total ayak bileği artroplastisinde yara iyileşmesini öngörmede oksijen tensiometresinin rolü

Amaç: Total ayak bileği artroplastisi tipik olarak, yara iyileşme sorunları için bir risk oluşturduğu bilinen, ayak bileğine anterior yaklaşımı içerir. Bu çalışmada, total ayak bileği artroplastisi uygulanan hastalarda yara iyileşme sorunlarını öngörmede oksijen tensiometresi kullanımının rolü araştırıldı. Çalışma planı: Üç yıllık bir süre içinde kurumumuzda STAR (Scandinavian Total Ankle Replacement) ile total ayak bileği artroplastisi uygulanan 25 hastada, transkütanöz oksijen tensiometresi sonuçlarının ameliyat sonrası yara iyileşme sorunlarıyla ilişkili olup olmadığı araştırıldı. Transkütanöz oksijen ölçümleri tüm hastalarda ameliyat sonrasında ve her iki ayak bileğinden yapıldı. Yara iyileşmesinde sorun görülen hastalar ile sorunsuz iyileşen hastalar karşılaştırıldı. Sonuçlar: Ameliyat sonrasında yedi hastada (%28) yara iyileşme sorunu, beş hastada (%20) ise erken dönemde eritem görüldü. İyileşme sorunu beş hastada geç iyileşme, iki hastada ayrışma şeklindeydi. Üç hastada, ameliyat edilen tarafta transkütanöz oksijen tansiyonu 40 mmHg’nin altında (yetersiz oksijenasyon eşiği) bulundu; bunların birinde yara iyileşme sorunu vardı; diğer ikisinde yoktu. Eşik 50 mmHg olarak alındığında ise, yedi hastada (%28) düşük değerler elde edildi; bunların ikisinde yara iyileşme sorunu görüldü. Oksijen ölçümleri açısından, yara iyileşmesi sorunu olan ve olmayan hastalar arasında anlamlı fark yoktu (p=0.3). Çıkarımlar: Total ayak bileği artroplastisinden sonra yara iyileşme komplikasyonu riskinin öngörülmesinde transkütanöz oksijen ölçümünün yeri olmadığı sonucuna varıldı. Cerrahi öncesinde hastanın nabızları yeterliyse, ameliyat sonrası yara iyileşmesi sorunlarının sorumlusu, bölgeye kan desteğinden ziyade ciltte uygulanan aşırı yüzeyel traksiyon sonucu oluşan travmadır.

Anahtar Kelimeler:

Ameliyat sonrası komplikasyonlar, Ayak bileği eklemi, Artroplasti, replasman, Kas, iskelet, Oksijen, Kan gazı izleme, transkütan, Yara iyileşmesi, Testlerin kestirim değeri

Oxygen tensiometry as a predictor of wound healing in total ankle arthroplasty

Objectives: Total ankle arthroplasty (TAA) typically involves an anterior approach to the ankle that has been shown to have a risk for wound healing problems. We explored the possibility of using oxygen tensiometry as a predictor of incision healing problems in patients undergoing TAA. Methods: The study included 25 patients who underwent TAA with the Scandinavian Total Ankle Replacement (STAR) system at our institution during a three-year period. Transcutaneous oxygen measurements of both ankles were obtained postoperatively to determine whether the results of transcutaneous oxygen tensiometry correlated with wound healing problems. Patients with wound healing problems were compared with those who had an uneventful incision healing. Results: Seven patients (28%) had wound healing problems after TAA, and five patients (20%) had early wound erythema. Wound healing problems included delayed healing in five patients and dehiscence in two patients. Three patients had transcutaneous oxygen tension of less than 40 mmHg (a threshold for impaired skin oxygenation) on the operative side, of whom one had healing difficulty whereas two did not. When the threshold was extended to 50 mmHg, seven patients (28%) had low readings, two having wound healing problems. There was no significant difference with respect to oxygen measurements between patients with and without wound healing problems (p=0.3). Conclusion: Oxygen tensiometry is not thought to be useful for predicting patients at risk for postoperative wound healing complications after TAA, suggesting that, if adequate pulses are present before surgery, the trauma of using excessive superficial traction on the skin during surgery is more responsible for wound healing problems than the underlying blood supply.

Keywords:

Postoperative Complications, Ankle Joint, Arthroplasty, Replacement, Muscle, Skeletal, Oxygen, Blood Gas Monitoring, Transcutaneous, Wound Healing, Predictive Value of Tests,

___

1. Buechel FF Sr, Buechel FF Jr, Pappas MJ. Ten-year evaluation of cementless Buechel-Pappas meniscal bearing total ankle replacement. Foot Ankle Int 2003;24:462-72.
2. Gill LH. Principles of joint arthroplasty as applied to the ankle. Instr Course Lect 2002;51:117-28.
3. Gould JS, Alvine FG, Mann RA, Sanders RW, Walling AK. Total ankle replacement: a surgical discussion. Part II. The clinical and surgical experience. Am J Orthop 2000; 29:675-82.
4. Groth HE, Fitch HF. Salvage procedures for complications of total ankle arthroplasty. Clin Orthop Relat Res 1987;(224):244-50.
5. Henne TD, Anderson JG. Total ankle arthroplasty: a historical perspective. Foot Ankle Clin 2002;7:695-702.
6. Myerson MS, Miller SD. Salvage after complications of total ankle arthroplasty. Foot Ankle Clin 2002;7:191-206.
7. Myerson MS, Mroczek K. Perioperative complications of total ankle arthroplasty. Foot Ankle Int 2003;24:17-21.
8. Stamatis ED, Myerson MS. How to avoid specific complications of total ankle replacement. Foot Ankle Clin 2002;7:765-89.
9. Bolton-Maggs BG, Sudlow RA, Freeman MA. Total ankle arthroplasty. A long-term review of the London Hospital experience. J Bone Joint Surg [Br] 1985;67:785-90.
10. Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prostheses. Three to eight-year followup of fifty-one consecutive ankles. J Bone Joint Surg [Am] 2003;85:1321-9.
11. Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg [Br] 2003;85:334-41.
12. Haskell A, Mann RA. Perioperative complication rate of total ankle replacement is reduced by surgeon experience. Foot Ankle Int 2004;25:283-9.
13. Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int 2009;30:579-96.
14. Johnson DP, Eastwood DM, Bader DL. Biomechanical factors in wound healing following knee arthroplasty. J Med Eng Technol 1991;15:8-14.
15. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40:113-41.
16. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102: 599-616.
17. Cina C, Katsamouris A, Megerman J, Brewster DC, Strayhorn EC, Robison JG, et al. Utility of transcutaneous oxygen tension measurements in peripheral arterial occlusive disease. J Vasc Surg 1984;1:362-71.
18. Harward TR, Volny J, Golbranson F, Bernstein EF, Fronek A. Oxygen inhalation--induced transcutaneous PO2 changes as a predictor of amputation level. J Vasc Surg 1985;2:220-7.
19. Misuri A, Lucertini G, Nanni A, Viacava A, Belardi P. Predictive value of transcutaneous oximetry for selection of the amputation level. J Cardiovasc Surg 2000;41:83-7.
20. Padberg FT, Back TL, Thompson PN, Hobson RW 2nd. Transcutaneous oxygen (TcPO2) estimates probability of healing in the ischemic extremity. J Surg Res 1996; 60:365-9.
21. Pinzur MS, Sage R, Stuck R, Ketner L, Osterman H. Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle. Foot Ankle 1992;13:271-2.
22. Wyss CR, Harrington RM, Burgess EM, Matsen FA 3rd. Transcutaneous oxygen tension as a predictor of success after an amputation. J Bone Joint Surg [Am] 1988;70:203-7.
23. Wyss CR, Robertson C, Love SJ, Harrington RM, Matsen FA 3rd. Relationship between transcutaneous oxygen tension, ankle blood pressure, and clinical outcome of vascular surgery in diabetic and nondiabetic patients. Surgery 1987;101:56-62.
24. Yablon SA, Novick ES, Jain SS, Inhoffer M, Graves DE. Postoperative transcutaneous oxygen measurement in the prediction of delayed wound healing and prosthetic fitting among amputees during rehabilitation. A pilot study. Am J Phys Med Rehabil 1995;74:193-8.
25. Johnson DP. Infection after knee arthroplasty. Clinical studies of skin hypoxia and wound healing. Acta Orthop Scand Suppl 1993;252:1-48.
26. Poynton AR, O’Rourke K. An analysis of skin perfusion over the achilles tendon in varying degrees of plantarflexion. Foot Ankle Int 2001;22:572-4.
27. Moosa HH, Peitzman AB, Makaroun MS, Webster MW, Steed DL. Transcutaneous oxygen measurements in lower extremity ischemia: effects of position, oxygen inhalation, and arterial reconstruction. Surgery 1988; 103:193-8.
28. Russell JC. Prophylaxis of postoperative deep vein thrombosis and pulmonary embolism. Surg Gynecol Obstet 1983; 157:89-104.
29. Rooke TW, Osmundson PJ. Variability and reproducibility of transcutaneous oxygen tension measurements in the assessment of peripheral vascular disease. Angiology 1989;40:695-700.