Wound closure and Limb Salvage following Total Knee Arthroplasty using Amniotic fluid and Amniotic membraneGeorge Swartz, MD & Isabel Kozak, NP, MSN

Department of Veterans Affairs, Phoenix VA Healthcare System

64 year old male veteran underwent left total knee arthroplasty (TKA) at the Phoenix VA Healthcare system in 2005. Complaints of difficulty ambulating and pain led to a left total knee arthroplasty revision on April 15, 2013 at the same VA. A left lateral knee wound was sustained during the revision that resulted in a chronic draining sinus tract. The veteran then went outside the VA for surgical correction and was re-evaluated in 2014 after unsuccessful wound healing.

Medical History: Allergies:Hypertension Penicillin, Tetracycline, ErythromycinDepression/ Anxiety/ PTSD Cefazolin, Ampicillin, SulfaHematuria HydrochlorothiazideChronic SinusitisSmoker ½ ppd x 44 years

The left lateral knee chronic wound was successfully fully closed within 5 months. Two weeks after wound closure chronic drainage had resolved. The wound showed good epithelialization within four weeks and amniotic fluid was injected in the epidermal layer. 13 weeks after wound closure the area was completely epithelialized.

A 64 year old male underwent Left TKA in 2005 with TKA revision in 2013. A lateral knee wound occurred during the revision which had 4 subsequent unsuccessful surgical attempts at closure. In 2014, 3 prominent orthopedic surgeons gave opinions for definitive treatment as above the knee amputation. Surgery for wound closure and limb salvage was performed in April 2014 using amniotic fluid and amniotic membranes. A total knee revision was performed after thorough removal of antibiotic spacer and irrigation with betadine followed by normal saline. The wound was closed using amniotic membrane human mesenchymal stromal cells and pericardial graft in 2 areas: intra-articular and in the epidermal layer. Amniotic fluid was injected into both graft areas. Secondary to multiple allergies, amniotic fluid and amniotic membrane were specifically chosen because of their bacteriocidal and bacteriostatic properties. Two weeks following closure, the epidermal amniotic membrane/ pericardial graft was removed and the area debrided. Four weeks following closure, the wound was injected with amniotic fluid. The wound was treated weekly with local wound care. The wound responded well and after 5 months, is now fully healed.

1- Niknejad, H., Peirovi, H., Jorjani, M., Ahmadiani, A., Ghanavi, J., Seifalian, A.M. (2008). Properties of the amniotic membrane for potential use in tissue engineering. European Cells and Material, 15, 88-99.

2- Yaojiong, W., Wang, J.F., Scott, P.G., Tredget, E.E. (2007). Bone marrow-derived stem cells in wound healing: a review. Wound Repair and Regeneration, 15, 18-26.3- Gruss, J.S., & Jirsch, D.W. (1978). Human amniotic membrane: a versatile wound dressing. Canadian Medical Academy, 118, 1237-1246.4- Shimberg, M. (1938). The use of amniotic-fluid concentrate in orthopaedic conditions. Journal of Bone and Joint Surgery, 20, 167-177.

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The use of amniotic fluid and amniotic membrane can be another method of closing a chronically draining knee wound that was not successfully closed by conventional methods.

The goal of the study was to see if limb salvage can be achieved with a failed total knee arthroplasty through closure of a chronic draining wound with amniotic fluid and amniotic membrane implantation.

Introduction

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Materials and Methods

Results

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George Swartz, MD has been an orthopedic surgeon for 40 years. He has been with the Phoenix VA for 10 years, was the Chief of Orthopedics in Albany, NY and had a private practice in Connecticut. He specializes in total knee arthroplasty surgery and has an interest in innovations for wound care and limb salvage secondary to experiences in Vietnam.

Isabel Kozak, NP, MSN has been a Nurse Practitioner for 15 years specializing in Orthopedic/ Orthopedic spine surgery. She will graduate with a Doctorate in Nursing Practice (DNP) degree in 2015 and has an interest in clinical research.

Further Information

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13 weeks post op 5 months post op

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