Salvage Cases Research Articles

Contribution of Plastic Surgery to a Health Care System

With the fluctuating economic conditions and the health care reform taking place in the United States, it is critical for plastic surgeons to be aware of their financial value to health care systems. The authors evaluated surgeon productivity and economic contributions made to their hospital by the Division of Plastic Surgery. Operative case logs for the departments of surgery, neurosurgery, and orthopedics were reviewed for fiscal year 2009. Margins, revenue, and surgeon total relative value units (a measure of productivity) were analyzed. Average relative value unit for all surgical specialties was 94,595, whereas that for the Division of Plastic Surgery was 54,288. Average value per surgeon for the health system was 12,149. For plastic surgery, average value per surgeon was 14,272, and the division was ranked fourth highest among all surgical services. The mean number of relative value units per case was 24.5 among all services; for plastic surgery, it was 31.2. Approximately one-third of all procedures performed by plastic surgery were in collaboration with another surgical specialty. The average net revenue for primary inpatient admissions per relative value unit was $381 for all surgical services and $222 for plastic surgery. A total of $2.2 to $3.7 million was the estimated savings for the hospital from complication salvage cases performed by the division. Plastic surgery contributes significantly to hospital bottom line in performing joint cases and salvaging complications. In the current economic environment, it is crucial for plastic surgeons to be fully cognizant of their positive influence and economic impact on the hospital margin.

A modified thrombin clotting time test as a quality control marker for heparin contamination in obstetric intraoperative cell salvage

To assess if a modified thrombin clotting time test could be used as a simple quality control (QC) method to screen for unfractionated heparin in the product obtained from obstetric intraoperative cell salvage cases before re-infusion. A national QC scheme has recently been piloted to monitor the quality of autologous blood being returned to the patient. Laboratory tests include full blood count and microalbumin. Unfractionated heparin testing should be performed to ensure that there is no gross contamination of heparin in the final product; however, presently, there is no quick cheap test available suitable for heparin detection. Samples were collected into plain non-anticoagulated tubes and centrifuged at 2500 × g for 5 min. Supernatant was mixed with commercially available coagulated normal plasma and a thrombin clotting time test performed. Calibration runs demonstrated that our system was sensitive up to 0 · 14 IU mL(-1) heparin, linear between 0 · 08 and 0 · 14 IU mL(-1). We have shown that the thrombin clotting time test can be modified and used as a cheap and reliable marker for heparin contamination. We have successfully incorporated this modified test into our hospital's obstetric QC scheme.

Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy

The aim of this study was to assess whether the use of the temporoparietal fascia as a free flap for pharyngeal closure reinforcement reduced the incidence of pharyngocutaneous fistula (PCF) in the salvage setting. Consecutive case series. After research ethics board approval, 12 patients who required salvage laryngectomy, including reinforcement coverage of the primarily closed pharyngeal defect with temporoparietal fascia as a free tissue transfer, were analyzed. One (8%) out of 12 patients experienced pharyngocutaneous fistula that responded with conservative wound packing. The PCF rate of 8% is significantly better than in similar salvage cases without flap coverage. Moreover, our PCF rate is comparable to the results shown for the pectoralis major muscle flap. The most obvious benefit of the temporoparietal fascia free flap for pharyngeal coverage in salvage laryngectomy is a reduced PCF rate with diminished donor-site morbidity, including cosmetic outcome, shoulder girdle function, and chest deformity.

Patient‐oriented functional results of total femoral endoprosthetic reconstruction following oncologic resection

Functional outcomes following oncologic total femoral endoprosthetic reconstruction (TFR) are lacking. We compared patient-oriented functional results of TFRs to proximal femur and distal femur reconstructions (PFR and DFR). We also compared function and complications with regard to knee and hip componentry. Fifty-four TFR patients were identified from three institutional prospective databases. Forty-one had fixed- and 13 had rotating-hinge knees, 37 hemiarthroplasty and 17 total hip arthroplasty componentry. Toronto Extremity Salvage Scores (TESS) for n = 27 were compared between groups and to cohorts of PFR (n = 31) and DFR (n = 85) patients using the Mann-Whitney U-test. Follow-up averaged 4 years. Mechanical complications included five hip dislocations and one femoral malrotation. Four dislocations were in fixed-hinge implants, all in those lacking abductor reattachment. TESS averaged 69.3 ± 17.8, statistically decreased from DFR (P = 0.002) and PFR patients (P = 0.036). No significant differences were detected between patients in the fixed-hinge (n = 18) and rotating-hinge (n = 9) groups (P = 0.944), or total hip (n = 8) and hemiarthroplasty (n = 19) groups (P = 0.633). TFR is reserved for extreme cases of limb salvage, portending a poor prognosis overall. Function reflects additive impairments from PFR and DFR. TFR outcomes differ little with rotating- or fixed-hinge, total hip or hemiarthroplasty implants.

Vascular complications and microvascular free flap salvage: The role of thrombolytic agents

Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.

Incomplete Prenatal Torsion of the Testicle—A Successful Salvage

The role of emergent intervention in prenatal testicular torsion is controversial. We report a case of successful testicular salvage of incomplete prenatal torsion. A 1-day-old male infant presented with a bluish-hued scrotum at birth. Testicular ultrasonography demonstrated right testicular torsion with minimal peripheral blood flow. Scrotal exploration was performed, confirming extravaginal torsion; both testes underwent orchiopexy. Subsequent imaging demonstrated normal bilateral testes with good vascular flow. Although intervention of prenatal torsion has been debated, the present case represents prenatal torsion saved by intervention. We propose the presence of any blood flow suggests incomplete torsion and the potential for salvage.

Externally Supported, Noncoated, Knitted Dacron Graft and Gelatin-Coated Knitted Dacron Graft with Rings for Peripheral Arterial Reconstruction.

During the last 14 years, externally supported noncoated knitted Dacron grafts (EXS) and gelatin-coated knitted Dacron grafts with rings (GEL) were used in 176 patients for femoropopliteal bypass (F-P), femorofemoral bypass (F-F) and axillofemoral bypass (Ax-F). In the EXS group, 58 F-P above knee (ak), 42 below knee (bk), 25 F-F, and 19 Ax-F surgeries were performed. Twenty-three F-Pak, 5 F-Pbk, 26 F-F, and 8 Ax-F surgeries were performed in the GEL group. In the F-Pak, primary patency at 5 and 9 years was 75.5 and 53% for the EXS and that at 3 and 5 years was 75.0 and 60.0% for the GEL (n.s.). In the F-Pbk, primary patency at 5 and 10 years was 60.5 and 29.5% for the EXS, while patency at 1 year was 11.1% for the GEL (P < 0.05). In both the EXS and the GEL groups, the F-Pak surgery showed better outcomes than the F-Pbk surgery. The outcomes of the F-P grafts implanted into the legs with claudication were better than those performed for the limb salvage cases. Primary patency of the F-F and the Ax-F showed no differences and there were also no differences between the graft types. For F-Pak surgery, the EXS is the graft of choice. The GEL is not suitable for F-Pbk surgery. For F-F and Ax-F reconstruction, both the EXS and the GEL are acceptable.

Experience-Based Quality Control of Clinical Intensity-Modulated Radiotherapy Planning

To incorporate a quality control tool, according to previous planning experience and patient-specific anatomic information, into the intensity-modulated radiotherapy (IMRT) plan generation process and to determine whether the tool improved treatment plan quality. A retrospective study of 42 IMRT plans demonstrated a correlation between the fraction of organs at risk (OARs) overlapping the planning target volume and the mean dose. This yielded a model, predicted dose = prescription dose (0.2 + 0.8 [1 - exp(-3 overlapping planning target volume/volume of OAR)]), that predicted the achievable mean doses according to the planning target volume overlap/volume of OAR and the prescription dose. The model was incorporated into the planning process by way of a user-executable script that reported the predicted dose for any OAR. The script was introduced to clinicians engaged in IMRT planning and deployed thereafter. The script's effect was evaluated by tracking δ = (mean dose-predicted dose)/predicted dose, the fraction by which the mean dose exceeded the model. All OARs under investigation (rectum and bladder in prostate cancer; parotid glands, esophagus, and larynx in head-and-neck cancer) exhibited both smaller δ and reduced variability after script implementation. These effects were substantial for the parotid glands, for which the previous δ = 0.28 ± 0.24 was reduced to δ = 0.13 ± 0.10. The clinical relevance was most evident in the subset of cases in which the parotid glands were potentially salvageable (predicted dose <30 Gy). Before script implementation, an average of 30.1 Gy was delivered to the salvageable cases, with an average predicted dose of 20.3 Gy. After implementation, an average of 18.7 Gy was delivered to salvageable cases, with an average predicted dose of 17.2 Gy. In the prostate cases, the rectum model excess was reduced from δ = 0.28 ± 0.20 to δ = 0.07 ± 0.15. On surveying dosimetrists at the end of the study, most reported that the script both improved their IMRT planning (8 of 10) and increased their efficiency (6 of 10). This tool proved successful in increasing normal tissue sparing and reducing interclinician variability, providing effective quality control of the IMRT plan development process.

Off-label use of rhBMP-2

Off-label use of rhBMP-2

Torsional Stability of Uncemented Femoral Stems in Oncologic Reconstructions

Modular oncology implants using uncemented fixation represent a popular reconstruction technique for limb salvage patients. Initial stability is critical to facilitate bony ingrowth of host bone into the stem of a press-fit oncologic modular rotating-hinge total knee arthroplasty (TKA). The impact of stem design on initial stability has not been defined. The goal of this study was to evaluate the initial stability of 3 different stem designs as defined by torsional load to failure. An analysis of imaging was also performed. The pilot study consisted of 5 femora in each of 3 groups based on stem design. The specimen was mounted on a multi-axis biomechanical test frame equipped with a Vicon 3D motion analysis 4-camera system (Vicon Motion Systems, Lake Forest, California) to track the relative motion between the implant and the femur. Torsional force was applied until failure. The straight-fluted stem design had the highest average torsional stiffness (18.3±8.2 Nm/deg) and average torque at 150 μm of implant micromotion (23.2±10.6 Nm) of the 3 stem types tested.The results of this study will help to guide surgical decision making in limb salvage cases. Further investigation is warranted.

Impact of Independent Data Adjudication on Hospital-Specific Estimates of Risk-Adjusted Mortality Following Percutaneous Coronary Interventions in Massachusetts

As part of state-mandated public reporting of outcomes after percutaneous coronary interventions (PCIs) in Massachusetts, procedural and clinical data were prospectively collected. Variables associated with higher mortality were audited to ensure accuracy of coding. We examined the impact of adjudication on identifying hospitals with possible deficiencies in the quality of PCI care. From October 2005 to September 2006, 15 721 admissions for PCI occurred in 21 hospitals. Of the 864 high-risk variables from 822 patients audited by committee, 201 were changed, with reassignment to lower acuities in 97 (30%) of the 321 shock cases, 24 (43%) of the 56 salvage cases, and 73 (15%) of the 478 emergent cases. Logistic regression models were used to predict patient-specific in-hospital mortality. Of 241 (1.5%) patients who died after PCI, 30 (12.4%) had a lower predicted mortality with adjudicated than with unadjudicated data. Model accuracy was excellent with either adjudicated or unadjudicated data. Hospital-specific risk-standardized mortality rates were estimated using both adjudicated and unadjudicated data through hierarchical logistic regression. Although adjudication reduced between-hospital variation by one third, risk-standardized mortality rates were similar using unadjudicated and adjudicated data. None of the hospitals were identified as statistical outliers. However, cross-validated posterior-predicted P values calculated with adjudicated data increased the number of borderline hospital outliers compared with unadjudicated data. Independent adjudication of site-reported high-risk features may increase the ability to identify hospitals with higher risk-adjusted mortality after PCI despite having little impact on the accuracy of risk prediction for the entire population.

High-pressure Water Injection of the Foot with Associated Subcutaneous Emphysema: A Case Report

A review of the literature yields few reported cases of industrial-strength high-pressure water injection injuries involving the foot, and sources of information for industrial-strength high-pressure water injection injuries reside primarily in the hand surgical literature. Toxic materials, such as grease, paint, and diesel oil, are relatively common agents involved in injection injuries, and these substances are associated with increased morbidity in comparison with injection of water or air. Treatment of high-pressure injection of a toxic substance is a surgical emergency requiring irrigation, debridement, antibiotic administration, and monitoring for signs and symptoms of compartment syndrome. There are, however, documented cases where less extreme treatment regimens have met with success. We report a successful limb salvage case, and review of the literature, related to a high-pressure water injury involving the foot with associated extensive subcutaneous emphysema.

Conservative Management of Mesh-Site Infection in Hernia Repair

Mesh hernioplasty is the preferred surgical procedure for large abdominal wall hernias. Infection remains one of the most challenging complications of this operation. Salvaging infected prosthetic material after ventral hernia repair is rarely successful. Most cases require mesh excision and complex abdominal wall reconstruction, with variable success rates. In this article, we report 3 cases of mesh salvage after laparoscopic ventral herniorrhapy with a novel use of percutaneous drainage and antibiotic irrigation. Three patients developed infected seromas after laparoscopic ventral hernia repair. The fascial defect of the first patient was repaired with a commercially available 20 x 18 cm polytetrafluoroethylene (PTFE) mesh. A complex fluid collection developed the following month in the anterior abdominal wall overlying the patient's mesh. The cultures grew Staphylococcus aureus. The second patient had a 30 x 20 cm PTFE mesh placed, which developed a fluid collection with Enterococcus faecalis and Escherichia coli. The third case underwent repair, using a another commercially available 22 x 28 cm PTFE mesh. A fluid collection measuring 20 x 10 cm in the anterior abdominal wall developed, growing Staphylococcus lugdunensis. In all 3 cases, a percutaneous drain was placed within the fluid collection and long-term intravenous (i.v.) access was obtained. I.v. antibiotics were initiated. In addition, gentamicin (80 mg) with 20 mL of saline was infused through the drain 3 times a day. All patients have remained free of clinical signs of infection following the completion of therapy. Infected mesh after laparoscopic ventral herniorrhapy without systemic sepsis may be amenable to nonoperative treatment. A conservative approach that includes percutaneous drainage followed by antibiotic irrigation is a potential alternative to prosthetic removal in carefully selected patients. Further evaluation of this technique is warranted to define the most appropriate management strategies for these patients.

Fertility preservation following torsion and severe ischemic injury of a solitary testis

To present a case of solitary testicular torsion and an adolescent faced with future hypogonadism and infertility. Case report. University-affiliated teaching hospital. A 16-year-old male with solitary testicular torsion of >8 hours' duration. Immediate scrotal exploration, orchiopexy, and sperm cryopreservation. Maintenance of testosterone production and determination of preservation after detorsion of an ischemic testis. Color flow Doppler ultrasound showed markedly decreased flow to solitary testis. A subjectively dead testis was seen upon scrotal exploration, with the decision to proceed with orchiopexy. Semen analysis of cryopreserved specimen 50 hours after onset of symptoms showed 1.4 mL, normal sperm concentration (89 million/mL), 67% motility, and 28% World Health Organization morphology. Normal levels of testosterone were found at 4 and 12 weeks after surgery. Testicular salvage with normal intratesticular blood flow was seen by ultrasound at 4 and 12 weeks after surgery. To our knowledge, this is the first reported case of testicular salvage after torsion of a solitary testicle with subsequent normal semen analysis and cryopreservation. This demonstrates the need to attempt salvage even in cases of subjectively dead testicle and the importance of offering expedient sperm cryopreservation in such cases.

Vascular pedicle avulsion in free flap breast reconstruction: A case of diep flap salvage following early avulsion of venous anastomosis and literature review

Free flap vascular pedicle avulsion represents an extremely rare complication in reconstructive microsurgery. Very few cases have been reported in the literature, most of them identified in free flap breast reconstruction. As a result, little data is currently available on the etiology and treatment of this rare complication. Herein, we report a unique case of early venous anastomosis avulsion following free DIEP flap transfer for delayed breast reconstruction. Venous outflow was successfully restored with the use of an interposition vein graft, and the flap survived completely. In addition, the relevant literature is reviewed; and the possible causes, preventive strategies, and management options are analyzed.

Treatment of Full-Thickness Chondral Defects with Hyalograft C in the Knee

Background Tissue engineering has become available for cartilage repair in clinical practice. Hypothesis The treatment of full-thickness chondral defects in the knee with a hyaluronan-based scaffold seeded with autolo-gous chondrocytes provides stable improvement of clinical outcome up to 7 years. Study Design Case series; Level of evidence, 4. Methods Fifty-three patients with deep osteochondral defects in the knee were treated with Hyalograft C. The mean age at implantation was 32 6 12 years, the mean defect size was 4.4 6 1.9 cm2, and the mean body mass index was 24.5 6 3.8 kg/m2. Implantations were performed with miniarthrotomy or arthroscopy. The primary indications for implantation with Hyalograft C included young patients with a stable joint, normal knee alignment, and isolated chondral defects with otherwise healthy adjacent cartilage. The secondary indications were patients who did not meet the primary indication criteria or were salvage procedures. Forty-two patients with primary indications and 11 patients with secondary indications were evaluated. Outcome was evaluated with the International Cartilage Repair Society and International Knee Documentation Committee scales, the Lysholm score, the modified Cincinnati score, and with Kaplan-Meier survival analysis. Statistical analysis consisted of bivariate correlation analysis and unpaired, 2-tailed t tests. Results A highly significant increase (P<001) in all knee scores was found in patients treated for the primary indications. Nine of 11 secondary indication cases underwent total knee arthroplasty due to persisting pain between 2 and 5 years after implantation. Graft failure occurred in 3 of 42 patients with primary indication between 6 months and 5 years after implantation. Kaplan-Meier survival demonstrated significantly different chances for survival between primary and secondary outcome and between simple, complex, and salvage cases, respectively (P <.001). Conclusion Hyalograft C autograft provides clinical improvement in healthy young patients with single cartilage defects. Less complicated surgery and lower morbidity are considered advantages of the technique. The results of treatment with Hyalograft C as a salvage procedure or in patients with osteoarthritis are poor.

Salvage of Donor Graft with Decitabine and Maintenance Post Allogeneic Stem Cell Transplantation in Myelodysplastic/Myeloproliferative Disease: A Case Report

Allogeneic stem cell transplantation (ASCT) is the only curative treatment option for patients with myelodysplastic syndrome (MDS). High 1-year ASCT mortality and relapse rates have necessitated the development of novel therapies to improve clinical outcomes. Recently, 5-azacitidine, a DNA hypomethylating agent, was reported to be used for graft salvage in patients undergoing cytogenetic relapse after ASCT. We report a similar case of graft salvage and maintenance after transplantation in an MDS patient using decitabine, another DNA hypomethylating agent known to induce cytogenetic remissions with a manageable side effect profile.

Circumferential pharyngeal reconstruction: History, critical analysis of techniques, and current therapeutic recommendations

Reconstruction of circumferential pharyngeal defects following total pharyngolaryngectomy presents major challenges with respect to surgical morbidity and restoration of functional deficits, which are often made more demanding by the increasing trend to utilize primary chemoradiation protocols with surgery reserved for salvage cases. The present review evaluates the reconstructive techniques described in the literature, including historical techniques as well as more recent innovative methods. Each technique is critically appraised with particular reference to postoperative morbidity and functional rehabilitation. Treatment recommendations are made based on the available evidence.

Kryoablation des lokalisierten Prostatakarzinoms

Due to continuous technical developments for more than half a century followed by better clinical results with minimal side effects, cryoablation of the prostate for localized prostate cancer has evolved as a true alternative therapeutic option in selected cases. The current version of cryoablation has almost nothing in common with those versions established in the 1960s and 1970s and further developed in the 1980s and 1990s. The present version is minimally invasive and has a high efficacy for treatment of high risk carcinomas and failure of other therapeutic modalities. Cryoablation of the prostate is indicated if there are absolute or relative contraindications for radical surgery. In salvage cases cryoablation is the therapy of choice for localized prostate cancer. Standardization of the procedure, definition of freeze-thaw cycles and structured training programs have led to this status.

A novel approach for salvaging infected prosthetic mesh after ventral hernia repair

Salvaging infected prosthetic material after ventral hernia repair is rarely successful. Most cases require mesh excision and complex abdominal wall reconstruction, with variable success rates. We report two cases of mesh salvage with a novel use of percutaneous drainage and antibiotic irrigation. Two patients developed infected seromas after laparoscopic ventral hernia repair. One patient with a remote history of methicillin-resistant Staphylococcus aureus (MRSA) mesh infection underwent laparoscopic ventral hernia repair with a 20 x 23-cm piece of Parietex composite mesh. Two weeks post-operatively, he developed fevers and MRSA was aspirated from the seroma. Another patient had a 32 x 33-cm piece of ePTFE placed for repair. He subsequently developed a massive seroma requiring repeated aspirations. Four months following the repair, he developed an infected seroma with Klebsiella pneumonia. Each patient underwent percutaneous drainage of their abscesses with a six-French-pigtail catheter under ultrasound guidance. After 2 weeks of parenteral antibiotics and clinical resolution, the patients were placed on 4 weeks of gentamicin irrigations (80 mg in 30 cc solution) via the drain three times per day. Once therapy was completed, the drains were removed. The first patient also remains on daily oral doxycycline for suppression for his MRSA. Both patients have remained free of clinical signs of infection at 12 and 16 months, respectively, following the completion of therapy. Percutaneous drainage followed by antibiotic irrigation is a potential alternative to prosthetic removal when treating infected mesh in carefully selected patients.