Eur J Orthop Surg Traumatol (2007) 17:445–448 DOI 10.1007/s00590-007-0205-5
O RI G I NAL ART I C LE
Diathermy versus scalpel incisions for hemiarthroplasty for hip fracture: a randomised prospective trial F. J. Byrne · S. R. Kearns · K. J. Mulhall · J. P. McCabe · K. Kaar · M. Gilmore · M. O’Sullivan · W. Curtin
Received: 14 November 2006 / Accepted: 11 January 2007 / Published online: 8 February 2007 © Springer-Verlag 2007
Abstract As the age proWle of our population expands, we can expect subsequent increases in patients presenting with intracapsular fracture. The onus remains on the surgeon to make all reasonable eVorts to Wnd new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. In this study, 100 patients were randomly allocated into two groups. One group had dissection to the level of the hip joint under direct diathermy control; the other group had dissection using a scalpel with supplementary electrocautery. Intraoperative total blood loss prior to dissection of the abductors was measured by collecting blood using wound swabs and using a local protocol and results were statistically analysed using PROC GLM SAS. We demonstrate a clear advantage in the use of diathermy to create a hip incision showing a signiWcant reduction in wound related blood loss and a reduction, whilst not statistically signiWcant, in total operative blood loss using diathermy incision. Larger randomised prospective trials are necessary to study the eVects of this intervention in a larger patient population so that these end-points can be adequately assessed.
F. J. Byrne (&) · S. R. Kearns · J. P. McCabe · K. Kaar · M. Gilmore · M. O’Sullivan · W. Curtin Department of Orthopaedic Surgery, Merlin Park Regional Hospital, Galway, Ireland e-mail:
[email protected] K. J. Mulhall University of Virginia, Charlottesville, USA
Keywords Diathermy · Scalpel · Hemiarthroplasty · Incision · Hip fracture
Diathermie versus incision au bistouri dans l’arthroplastie intermédiaire pour fracture du col du femur: etude prospective randomisée Résumé Avec le vieillissement de notre population, nous pouvons nous attendre à une augmentation coorélative des patients présentant une fracture intracapsulaire du col du fémur.. C’est une importante responsabilité chirurgicale que de faire tous les eVorts raisonnables aWn de trouver de nouveaux et innovateurs moyens pour réduire la morbidité et la mortalité associées au traitement de ces lésions. Ce déW est particulièrement approprié pour les personnes âgées et pour les patients présentant des comorbidités multiples. Dans cette étude, cent patients ont été aléatoirement répartis dans deux groupes. Un groupe a bénéWcié d’un abord de l’articulation coxofémorale par diathermie d’emblée; l’autre groupe a bénéWcié d’une dissection à l’aide d’un bistouri avec électrocoagulation complémentaire. La perte totale peropératoire de sang avant la dissection des abducteurs a été mesurée en rassemblant le sang à l’aide de tampons et en utilisant un protocole local et les résultats ont été statistiquement analysés en utilisant PROC GLM SAS. Nous démontrons un avantage clair dans l’utilisation de la diathermie pour l’incision de hanche montrant une réduction signiWcative de la perte de sang dans la plaie, ainsi qu’une réduction, celle-ci par contre statistiquement non signiWcative, de la perte eVective totale de sang en utilisant l’incision par diathermie. De plus grandes études
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randomisées sont nécessaires pour étudier les eVets de cette intervention dans une plus grande population de patients aWn que ces limites puissent être évaluées de façon exacte. Mots clés Diathermie · Bistouri · Hémiarthroplastie · Prothèse hanche intermédiaire · Incision · Fracture de hanche
Introduction “In 1990 an estimated 1.3 million fractures of the hip occurred worldwide, a Wgure which is expected to double by 2025 and to increase to 4.5 million by 2050. Approximately half of these fractures will be intracapsular. The average age of these patients is about 80 years and 75% are female” [12]. As numbers of hip fractures increase, the onus is Wrmly on orthopaedic surgeons to Wnd new and innovative means of reducing associated morbidity and mortality of the treatment of these injuries. This challenge is particularly relevant in the elderly and in patients with multiple co-morbidities. Hip hemiarthroplasty has been shown to have an increased in-hospital mortality and morbidity rate compared with internal Wxation at between 4 and 10% [2, 3]. In particular, hemiarthroplasty surgery is associated with increased blood loss and transfusion requirements when compared with internal Wxation [14]. The advantage of hemiarthroplasty surgery however remains the signiWcantly lower re-operation rate, making this the treatment of choice in most elderly patients with displaced femoral neck fractures [4, 14]. While electrosurgical instruments are in widespread use in general surgery for tissue dissection their use in orthopaedic surgery is unproven. Concerns in relation to wound healing and an increase in infection rate secondary to tissue charring and necrosis are particularly critical when prosthetic implantation is being performed. The use of an electrode delivering a pure sinusoidal current, however, allows tissue division without damaging surrounding areas [5]. While beneWts in relation to reduced blood loss and wound related pain have been shown in midline laparotomy [9] and cholecystectomy [8], no such advantage has however ever been shown in either hip arthroplasty or hip fracture surgery [16]. The aim of this study was to compare the use of diathermy and scalpel incision in hemiarthroplasty for hip fracture in terms of incision time, wound-related blood loss, total operative blood loss and rate of post-operative wound complications.
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Materials and methods One hundred consecutive patients admitted for hemiarthroplasty for fracture of the neck of the femur were studied. Exclusion criteria were diabetes, concurrent warfarin use and previous hip surgery. Patients on aspirin were included in the study. Patients were randomised prospectively into scalpel or diathermy incision groups by coin-toss upon the patient’s arrival to the operating suite. All patients involved provided informed consent and the study was approved in line with local ethics committee standards. An experienced hip surgeon (one of the authors) performed all hip surgeries using a modiWed anterolateral approach [13]. In the diathermy group the skin was scored with a scalpel blade and all further dissection was performed with diathermy, while diathermy was used for haemostasis in both groups. Diathermy incision were created using a standard pen electrode set on cutting and delivering a 500-kHz sinusoidal current. All patients received intravenous antibiotic prophylaxis: zinacef 1.5 g (GlaxoSmithKline, Dublin, Ireland) at induction and for two post-operative doses. Those patients allergic to penicillin were given 1 g erythromycin (Abbot Laboratories, Dublin, Ireland). Wounds were closed in layers, in a standardised fashion using: PDS (Ethicon, Dublin, Ireland) to abductors and fascia, vicryl (Ethicon, Dublin, Ireland) to fat and surgical clips to skin [Weck Visistat 35 W (Weck Closure Systems, NC 27709, USA)]. Incision dimensions were measured with a Xexible sterile ruler. The length and depth of the incision was recorded at the end of the procedure, the depth being measured from the skin to the fascia lata. Swabs used exclusively while opening and closing the hip incision were weighed to assess wound related blood loss. An independent observer in the operating theatre recorded the time taken to complete the wound from initial skin incision to complete opening of the fascia lata with total haemostasis. In all cases total operative blood loss was recorded. Post-operatively patients received prophylaxis for deep venous thrombosis as per the regimen of their consultant surgeon. Wound complications occurring at any stage after surgery and at 6-week follow-up were recorded for all patients. Wound infection was deWned as the discharge of pus or Xuid containing pathogenic organisms [11]. Results from all sections of the study were expressed as mean § SEM for the ‘Diathermy’ and ‘Scalpel’ groups. Statistical calculations were performed using the PC version of PROC GLM SAS (SAS/STAT Users guide, 8.2 edn. Statistical Analysis Systems Institute,
Eur J Orthop Surg Traumatol (2007) 17:445–448
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Cary, NC 2001). Post-hoc analysis was carried out using Tukey’s pairwise analysis. Statistical signiWcance was achieved if P < 0.05.
185.9 § 13.78 ml; P = 0.1). However, this result did not reach statistical signiWcance (Table 1). Wound complications
Results Patient demographics There were no signiWcant demographic diVerences between those patients randomised to either group. The mean § SEM age in the diathermy group was 81.4 § 0.7 compared with 76.2 § 1.9 years in the scalpel group (Table 1). Three patients in the scalpel group and two in the diathermy group were on aspirin preoperatively (data not shown). Operative parameters The two groups did not diVer signiWcantly in relation to the size of the wound area. The use of diathermy to create hemiarthroplasty surgical incisions caused signiWcantly less blood loss (ml) (1.75 § 0.1 vs. 0.64 § 0.01 ml/cm2, respectively; P = 0.001) and total blood loss per cm2 [61.2 (4.3) vs. 32.7 (2.9) ml, respectively; P = 0.0004] than scalpel incisions. The time taken to achieve haemostasis per cm2 wound area was signiWcantly less in the diathermy group compared to the scalpel incision group (i.e., 3.39 § 0.28 vs. 4.78 § 0.59 s/cm2, P = 0.039). Diathermy incision reduced total operative blood loss (221.1 § 16.02 vs.
Table 1 Comparison of technique of hemiarthroplasty surgical incisions in relation to patient demographics and operative parameters
Patient demographics Age (years) Sex (M/F) Operative parameters Total blood loss (ml) % Wound blood loss relative to total operative blood loss (%) % Wound blood loss per cm2 wound area (%) Time taken to achieve haemostasis per cm2 wound area (s/cm2)
Diathermy
Scalpel
81.4 § 0.7 28 F, 22 M
76.2 § 1.9 26 F, 24 M
185.9 § 13.78 0.64 § 0.01*
221.1 § 16.02 1.75 § 0.1
32.7 § 2.9*
61.2 § 4.3
3.39 § 0.28*
4.78 § 0.59
Results are presented as mean § SEM. Statistical analysis was performed using one way analysis of variance and Tukey’s pairwise post hoc analysis. n = 50 patients per group SEM standard error of the mean, F female, M male * Means in the same row are statistically diVerent at P < 0.05
Overall there was a low rate of post-operative woundrelated complications. Four patients in the scalpel group developed persistent post-operative serous discharge from their wounds compared with two in the diathermy group. There were no wound infections or haematomas in either group.
Discussion Hip fracture surgery represents an ever-increasing challenge to orthopaedic surgeons worldwide. The best treatment of displaced intracapsular hip fractures in particular remains the subject of intense debate in the literature. Hemiarthroplasty surgery reduces the reoperation rate signiWcantly but is associated with an increase in operative blood loss, transfusion requirements and early morbidity and mortality [4, 14]. The use of diathermy to create surgical wounds has been widely applied in other surgical specialties [5, 6, 9, 10, 15], however its use in hip surgery remains limited. This restriction may be related to concerns raised by early research into the use of the technique in which the use of primitive machines was associated with signiWcant charring and burning of tissues [6]. Initial animal studies further reduced the orthopaedic uses of this technique by showing increased wound infection rates [1]. Modern oscillator electrosurgical units however have overcome many of these problems by delivering a pure sinusoidal current, vapourising cells to create an incision. The potential advantages of such an incision include reduced blood loss, reduced surgical time and less wound related pain [6, 9]. The only previous study assessing the use of diathermy in hip surgery did not demonstrate any diVerence in blood loss using the diathermy knife to perform hip arthroplasty [16]. However, the authors of that study did not comment on wound related loss but total blood loss and in their small series the beneWts of diathermy incision may have been obscured by other intra-operative variables such as blood loss from reaming. This study has demonstrated a clear advantage in the use of diathermy to create a hip incision showing a signiWcant reduction in wound related blood loss and a reduction, whilst not quite signiWcant, in total operative blood loss using diathermy incision. Of particular signiWcance, given the poor baseline medical condition of this cohort of mainly elderly patients, was the observation
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that the time taken to achieve haemostasis per cm2 wound area was signiWcantly less in the diathermy group compared to the scalpel incision group. This may contribute to an overall decrease in total operative time. While the size of this study limits comments on wound related complications and deep infection, no diVerences were found in these complications in this study. Worldwide, there is increasing pressure on transfusion services to provide suYcient blood products for surgical procedures. In an interesting recent study preoperative haemoglobin was shown to correlate with peri-operative mortality and outcome following hip fracture surgery [7]. Transfusion of blood products in itself is associated with signiWcant potential patient morbidity and even mortality. Simple eVective measures such as the use of diathermy may be able to reduce blood loss, transfusion requirements and even potentially, mortality in hip fracture surgery. This study demonstrates the need for a large randomised prospective trial to study the eVects of this intervention in a larger patient population so that these end-points can be adequately assessed. Acknowledgments The authors would like to acknowledge the assistance of Dr. Sinéad Waters in the statistical analysis of data generated in this study.
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Eur J Orthop Surg Traumatol (2007) 17:445–448 3. Bhattacharyya T, Iorio R, Healy WL (2002) Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am 84A:562–572 4. Davison JN, Calder SJ, Anderson GH et al (2001) Treatment for displaced intracapsular fracture of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years. J Bone Joint Surg Br 83:206–212 5. Dixon AR, Watkin DF (1990) Electrosurgical skin incision versus conventional scalpel: a prospective trial. J R Coll Surg Edinb 35:299–301 6. Glover JL, Bendick PJ, Link WJ (1978) The use of thermal knives in surgery: electrosurgery, lasers, plasma scalpel. Curr Probl Surg 15:1–78 7. Gruson KI, AharonoV GB, Egol KA et al (2002) The relationship between admission hemoglobin level and outcome after hip fracture. J Orthop Trauma 16:39–44 8. Hussain SA, Hussain S (1988) Incisions with knife or diathermy and postoperative pain. Br J Surg 75:1179–1180 9. Kearns SR, Connolly EM, McNally S et al (2001) Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg 88:41–44 10. Kiriakopoulos A, Dimitrios T, Dimitrios L (2004) Use of a diathermy system in thyroid surgery. Arch Surg 139:997–1000 11. Ljungqvist U (1964) Wound sepsis after clean operations. Lancet 13:1095–1097 12. Parker MJ (2000) The management of intracapsular fractures of the proximal femur. J Bone Joint Surg Br 82:937–941 13. Parker MJ, Pervez H (2002) Surgical approaches for inserting hemiarthroplasty of the hip. Cochrane Database Syst Rev (3):CD001707 14. Parker MJ, Khan RJ, Crawford J et al (2002) Hemiarthroplasty versus internal Wxation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. J Bone Joint Surg Br 84:1150–1155 15. Sheikh B (2004) Safety and eYcacy of electrocautery scalpel utilization for skin opening in neurosurgery. Br J Neurosurg 18:268–272 16. Widman J, Isacson J (1999) Diathermy knife does not reduce bleeding in surgery for primary hip arthroplasty. Acta Orthop Scand 70:23–24
