Deep Wound Complications Research Articles

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications.

Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p=0.03), especially deep incisional infection (4.9% vs. 2.4%; p=0.04). Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

In hospital outcomes of autologous and implant-based breast reconstruction in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a common comorbid condition that can be associated with postoperative mortality and morbidity. However, the outcome profile of patients with COPD after breast reconstruction has yet to be established. Therefore, this study aimed to assess the postoperative outcomes in patients with COPD who underwent autologous (ABR) and implant-based breast reconstruction (IBR). National Inpatient Sample was used to identify patients who underwent ABR or IBR from Q4 2015 to 2020. Multivariable logistic regressions were used to compare inhospital outcomes between COPD and non-COPD patients while adjusting for demographics, primary payer status, hospital characteristics, and comorbidities. There were 1288 (9.92%) COPD and 11,696 non-COPD patients who underwent ABR. Meanwhile, 1742 (9.70%) COPD and 16,221 non-COPD patients underwent IBR. In both ABR and IBR, patients with COPD had higher rates of seroma (ABR, aOR=1.863, 95% CI=1.022-3.397, and p=0.04; IBR, aOR=1.524, 95% CI=1.014-2.291, and p=0.04), infection (ABR, aOR=1.863, 95% CI=1.022-3.397, andp=0.04; IBR, aOR=1.956, 95% CI=1.205-3.176, and p=0.01), and prolonged LOS (p<0.01). Specifically, patients with COPD in ABR had higher risks of respiratory complications (aOR=1.991, 95% CI=1.291-3.071, and p<0.01) and incurred higher total hospital charges (p<0.01). Meanwhile, patients with COPD undergoing IBR had elevated risks of renal complications (aOR=3.421, 95% CI=2.108-5.55, and p<0.01), deep wound complications (aOR=3.191, 95% CI=1.423-7.153, and p<0.01), and a higher rate of transfers out (aOR=1.815, 95% CI=1.081-3.05, and p=0.02). COPD is an independent risk factor associated with distinct adverse outcomes in ABR and IBR. These findings can be valuable for preoperative risk stratification, determining surgical candidacy, and planning postoperative management in patients with COPD.

Comparing Complications Between Mini-Laparotomy and Laparoscopy for Benign Hysterectomy – A Systematic Review

Objective: To perform a comprehensive systematic review comparing complications between mini-laparotomy hysterectomy (MLH) and laparoscopic hysterectomy (LH). Methods: A systematic review of MEDLINE, Clinicaltrials.gov, Embase, Cochrane Library, and Scopus was conducted. Out of 641 initially identified studies, 8 were ultimately included. The primary outcomes were operative time, time to discharge, need for blood transfusion, superficial and deep wound complications, post-operative fever, reoperation, readmission, and conversion to laparotomy. A meta-analysis was performed for each outcome, including measures of heterogeneity among studies. Results: There was a significant difference between mean operative time for MLH (121.6 min) and LH (127.51 minutes). There was no significant difference between time to discharge [ MLH (79.21 hours) vs LH (73.21 hours)], need for blood transfusion [MLH (.03) vs. LH (.01)], superficial wound complications [MLH (.01) vs LH (0)], deep wound complications [MLH (0) vs LH (.01)], post-operative fever [MLH (.02) vs LH (.01)] or reoperation [MLH (.01) and LH (0)]. There was not a significant difference in readmission [MLH (.02) vs LH (.01)], or conversion to laparotomy [ MLH (.01) vs LH (.01)]. There was significant heterogeneity among studies in one or both groups for: operative time, time to discharge, need for blood transfusion, and conversion to laparotomy. Conclusion: In this systematic review comparing complications between MLH and LH, there was significant heterogeneity amongst studies, making it challenging to interpret definitively. Even the definition and technique for performing mini-laparotomy was not well defined. There was an overall trend towards similar rates of complications. Though there was a statistically significant difference in operative time, the mean difference of 6 minutes is clinically unimportant.

Functional Outcomes of Primary Hemiarthroplasty for Unstable Intertrochanteric Fractures in the Elderly: A Prospective Observational Study.

Background and objective Intertrochanteric fractures pose a growing healthcare challenge among the elderly, demanding effective management strategies. This study addressed the rising incidence of hip fractures, emphasizing the complications associated with traditional nonsurgical approaches. It aimed to explore postoperative functional outcomes and complications associated withprimary hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fractures in the elderly. Materials and methods This study included 20 elderly patients undergoing hemiarthroplasty for unstable intertrochanteric fractures. It evaluated key variables such as patient demographics, comorbidities, fracture characteristics, surgical approach, and postoperative metrics. To perform hemiarthroplasty, weutilized a nonmodular bipolar prosthesis with cement. Postoperative follow-up included an assessment of clinical and radiological parameters, focusing on outcomes and complications. Results The mean age of the participants was 71.65 years; it was found that a significant segment of the participants (n=9, 45%) did not have any comorbidities. The surgical outcomes were characterized by minimal blood loss (275 ± 57.35 ml), short hospital stays (6.55± 1.95 days), and satisfactory operative durations (80.25 ± 10.19 minutes). Additionally, 14 (70%) patients did not require blood transfusions. After the surgery, complications were minimal, and there were no cases of deep wound complications, prosthesis dislocations, or deep vein thrombosis. The Harris Hip Scores reflected favorable outcomes in 14 cases (72.7%), with good or excellent hip scores. Conclusions Our findings revealed that primary hemiarthroplasty is a reliable and effective strategy for managing unstable intertrochanteric fractures in the elderly, providing stable joints and acceptable complication rates. Early mobilization, facilitated by hemiarthroplasty, mitigates postoperative complications, making it a viable alternative for elderly patients.

Polyester Mesh with Liquid Adhesive Compared to Incisional Negative Pressure 2 Therapy for Direct Anterior Total Hip Arthroplasty in the 90-day Postoperative Period

Background Some data suggest higher rates of superficial wound complications following direct anterior approach to total hip arthroplasty (DAA-THA) compared to other approaches, likely owing to proximity of the incision to the groin crease. Increased body mass index (BMI) has also been associated with increased superficial wound complications regardless of approach. We investigated superficial wound complications following DAA-THA comparing two different dressing types, polyester mesh (PM) with liquid adhesive and incisional negative pressure therapy (iNPT), with additional analysis of the association of BMI and medical comorbidities with wound complications in each dressing type cohort. Methods Consecutive DAA-THAs were assessed (n = 711 total, 213 iNPT, 498 PM). Superficial or deep wound complications within 3 months of surgery were recorded. Demographics were compared using student’s t-test with Welch’s correction and Chi-square tests, where appropriate. Logistic regression on wound complication included the following variables: patient BMI, dressing type, active tobacco smoking, diabetes mellitus, liver disease, chronic kidney disease, and anemia. A p-value of &lt; 0.05 was considered statistically significant. Results The overall rate of wound complication was 9.00%. Wound dehiscence was the most frequent complication, affecting 26 patients (3.66%) overall. Multiple logistic regression showed that BMI and tobacco smoking were associated with increased wound complications (aOR=1.072, p=0.007; aOR=3.258, p=0.009) and that PM use was associated with fewer wound complications when compared to iNPT (aOR=0.555, p=0.047). Conclusions In this investigation, PM dressings after DAA-THA were associated with decreased risk of wound complication compared to iNPT. Secondarily, smoking and increased BMI were risk factors for postoperative wound complications.

Management of Cannula Wound Problems with Vacuum-Assisted Therapy for a Child Who Received Berlin Heart EXCOR Implantation.

A child being supported with an extracorporeal ventricular assist device, such as the Berlin Heart EXCOR (Berlin Heart GmbH, Berlin, Germany), must have at least 2 large cannulae for a long period. Management of cannula wounds is crucial since a cannula forms a track of prosthetic material passing the mediastinum to the heart. Deep wound complications, if they occur, can be troublesome and difficult to control with conventional methods. We applied vacuum-assisted closure to a patient who had Berlin-Heart EXCOR and a gap at the cannulation site. Herein, we describe the technical aspects of management in detail.

Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) (p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 (p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

Role of Pie Crusting Technique on Soft Tissues in Preventing Soft Tissue Complications Compared to Conventional Closure of Wound in Fractures of Distal Tibia (PILON) and Fibula

Objective: To demonstrate the effect of performing pie crusting on skin bridging two incisions used for open reduction and fixation to reduce wound complications compared to conventional wound closure.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Orthopedics and Trauma, Combined Military Hospital Rawalpindi from Jan to Nov 2020.&#x0D; Methodology: Forty-seven patients, managed primarily with open reduction and internal fixation for type-43 fractures per AO/OTA classification, were studied. Group-1 comprised patients in whom the pie crusting technique was used during the closure of the wound. Group-2 included patients in whom conventional closure of the wound was performed. Evaluation of complications in the presence or absence of superficial and deep infection and necrosis was done. The time from injury to surgery was 6 hours to 72 hours. Patients were followed for an average of 12 weeks. &#x0D; Results: In group-1 (pie-crust technique), there were 23 patients, whereas group-2 (classic wound closure) comprised 24 patients. In group-1, only 1 (4%) patient had a superficial infection, and no deep infection was reported. Whereas in group-2, six patients (25%) had superficial infection, and two patients (8%) had the deep infection.&#x0D; Conclusion: Results indicated that pie-crust technique significantly reduces the risk of superficial and deep wound complications compared to classic wound closure because it reduces skin tension and allows the drainage of subcutaneous fluids.

Comparison of perioperative complications following surgical treatment of shoulder instability.

BackgroundSurgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.MethodsThis is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.ResultsThis study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (Ptrend < .001).ConclusionIn addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

Use of longitudinal rigid sternal fixation in prevention and treatment of wound complications among high-risk patients after cardiac surgery.

Traditionally, wire cerclage closure has been used to reapproximate the sternum after cardiac surgery. Recent evidence suggests that rigid sternal fixation may reduce the risk of wound complications. The aim of this study was to analyze our 10-year experience with longitudinal rigid sternal fixation (LRSF) for prevention and treatment of wound complications in high-risk patients. We reviewed data from cardiac surgical database of patients who underwent LRSF, and compared their outcomes with conventional wire cerclage closure (CWS). Among these 319 patients were designated as having high-risk for the development of deep wound complications and received primary LRSF (treatment group). We matched their outcomes with 319 patients who met indications for LRSF however, underwent standard closure with CWC (control group). Both groups were comparable regarding preoperative and intraoperative variables. The benefit observed among matched patients who had undergone LRSF was largely driven by a decreased rate of deep wound infections (0.63% vs. 3.45% vs., p < .01), 30-day mortality (1.57% vs. 5.96%) and hospital length (8.2 vs. 11.7 days) p < .05, respectively. A multivariate logistic regression analysis found four independent risk factors for the development of sternal dehiscence. Sternal healing evaluated by computerized tomography scan using 6-point scale at 3 months after surgery was superior in LRSF patients. Pain scores were significantly lower in LRSF patients as well. In patients with an increased risk for sternal instability and wound infections after cardiac surgery, sternal reconstruction using LRSF is an effective technique to stabilize sternum for preventive and treatment purposes.

Evidence to support a drain-free strategy in kidney transplantation using a retrospective comparison of 500 consecutively transplanted cases at a single center

IntroductionRoutine placement of surgical drains at the time of kidney transplant has been debated in terms of its prognostic value.ObjectivesTo determine whether the placement of a surgical drain affects the incidence rate of developing wound complications and other clinical outcomes, particularly after controlling for other prognostic factors.MethodsRetrospective analysis of 500 consecutive renal transplant cases who did not (Drain-free, DF) vs. did (Drain, D) receive a drain at the time of transplant was performed. The primary outcome was the development of any wound complication (superficial or deep) during the first 12 months post-transplant. Secondary outcomes included the development of superficial wound complications, deep wound complications, DGF, and graft loss during the first 12 months post-transplant.Results388 and 112 recipients had DF/D, respectively. DF-recipients were significantly more likely to be younger, not have pre-transplant diabetes, receive a living donor kidney, receive a kidney-alone transplant, have a shorter duration of dialysis, shorter mean cold-ischemia-time, and greater pre-transplant use of anticoagulants/antiplatelets. Wound complications were 4.6% (18/388) vs. 5.4% (6/112) in DF vs. D groups, respectively (P = 0.75). Superficial wound complications were observed in 0.8% (3/388) vs. 0.0% (0/112) in DF vs. D groups, respectively (P = 0.35). Deep wound complications were observed in 4.1% (16/388) vs. 5.4% ((6/112) in DF vs. D groups, respectively (P = 0.57). Higher recipient body mass index and ≥ 1 year of pre-transplant dialysis were associated in multivariable analysis with an increased incidence of wound complications. Once the prognostic influence of these 2 factors were controlled, there was still no notable effect of drain use (yes/no). The lack of prognostic effect of drain use was similarly observed for the other clinical outcomes.ConclusionsIn a relatively large cohort of renal transplant recipients, routine surgical drain use appears to offer no distinct prognostic advantage.

Tibialis Anterior Tendon Partial Release and Plantar Implant Placement for Midfoot Arthrodesis: Technique Tip

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Midfoot arthrodesis is a reliable procedure for deformity correction and pain relief. First tarsometatarsal arthrodesis can be used for correction of hallux valgus deformity with large intermetatarsal angles or first-ray hypermobility. Midfoot arthrodesis is also integral in correction of pes planovalgus deformity with midfoot collapse. First tarsometatarsal arthrodesis has a nonunion rate of 2-15%. Arthrodesis is completed traditionally through a dorsal approach. Due to high nonunion rates, recent studies have investigated plater based plates. These have been shown to have superior strength by creating a tension band construct as the foot is loaded. Tibialis anterior footprint is at risk when accessing first tarsometatarsal joint for arthrodesis. We explore whether the tibialis insertional footprint can be released and repaired with no deleterious effects.Methods:Patients included were undergoing first tarsometatarsal joint or naviculocuneiform joint arthrodesis with a plantar based plate and screw construct for hallux valgus deformity with large intermetatarsal angle or first-ray hypermobility, and those with first TMT joint arthritis, pes planovalgus, Lisfranc injury, or Charcot neuroarthropathy. Medial based surgical approach is centered over the first tarsometatarsal joint. Saphenous neurovascular bundle is retracted dorsally. Release of the capsular structures allowed for complete visualization and distraction of the joint. The distal-most attachment of the tibialis anterior tendon onto the first metatarsal is release in line with the capsulotomy. Primary insertion on the medial cuneiform was preserved. A cuff of released insertional tissue is preserved and reflected distally for repair. Standard tarsometatarsal arthrodesis joint preparation was completed. Plantar plate then fixed and compressed. Deep fascial layers were then closed over the plated were previous tendon release was performed.Results:In 62 patients, none had tibialis anterior tendon rupture, weakness, or irritation, with average follow-up of 36.2 months. Nine wound complications were recognized during the study. Twelve percent of patients experiencing delayed incisional healing that went on to heal with local wound care. Smokers accounted for six of the seven patients (OR 24.62, p<.05), and one of seven patients had Charcot (OR 2.08, p<.05). Deep wound complications, which required return to the operating room for formal irrigation and debridement, were seen in 3% (2 of 62). Both patients were active smokers and had removal of hardware at the time of debridement. Both underwent definitive coverage with split-thickness skin grafts and went on to successful arthrodesis and wound healing.Conclusion:One advantage of applying a plate and screw construct plantarly for midfoot arthrodesis is biomechanical stability. Multiple studies have indicated this plantar construct may be superior. Another benefit may be less hardware prominence due to increased soft-tissue coverage. Subcutaneous positions of dorsal plates have been reported to contribute to incisional irritation and symptomatic hardware. Tibialis anterior tendon damage has been suggested as a limitation of the plantar approach for midfoot arthrodesis, and the tendon insertion must be released to prepare the joint adequately to apply implants. This series shows tendon release can be safely accomplished without any deleterious effects.

Wound Complications after 2-Octyl Skin Closure Systems for Total Joint Arthroplasty.

Introduction: Total joint arthroplasty is projected to expand rapidly by 2030. With large numbers of patients undergoing TJA, the choice of incisional closure has come into question. We compared the 2-Ocyl cyanoacrylate closure system of Dermabond ® Prineo ® with Exofin Fusion ® to compare rates of adverse wound outcomes after total joint arthroplasty. Secondary outcome measures were age, sex, and medical comorbidities between groups.Methods: We retrospectively reviewed adverse wound outcomes with skin closure in TJA in 281 patients (160 Dermabond Prineo and 121 Exofin Fusion). Clinical charts were analyzed out to the 6-week post-op visit.Results: The rate of overall adverse superficial wound outcomes was similar between the two groups with Dermabond Prineo (N=20) and Exofin Fusion (N=19). The rate of cellulitis was significantly higher for Dermabond Prineo when compared to Exofin Fusion (P=0.033). No other significant differences were found for rate of superficial or deep wound complications or for secondary outcomes.Conclusions: The two 2-octyl wound closure systems had similar adverse superficial wound complications. Except for Dermabond Prineo having a higher rate of post-operative cellulitis, there were no statistically significant differences for other superficial or deep adverse wound outcomes or secondary outcomes. A future randomized control trial or prospective cohort study is needed for a more robust analysis.

Treatment of Catastrophic Failures of Achilles Tendon Repairs Due to Deep Wound Complications

Category: Sports Introduction/Purpose: The Achilles tendon is the most commonly injured tendon in the lower extremity. Whether these ruptures are acute or chronic, a surgical Achilles repair or reconstruction is often needed to restore tendon integrity and function. Risks from such surgeries include superficial or deep wound infections and/or dehiscence. To date, there is scant literature regarding the treatment of catastrophic failures of Achilles tendon repairs or reconstructions from deep wound infection and dehiscence. The purpose of this study is to retrospectively examine clinical outcomes from uniform single-stage surgical treatment of catastrophic failures of Achilles tendon repairs or reconstructions from deep wound complications. Methods: Between 2007 and 2016, 10 patients developed a deep wound infection and dehiscence after surgical treatment of an acute or chronic Achilles rupture. Medical co-morbidities included obesity in 4, diabetes in 3, and nicotine use in 2 patients. Six and 4 patients had a mid-substance and insertional Achilles rupture respectively. Three patients had an acute injury that received an end-to-end suture repair. Seven patients had a chronic injury with Achilles retraction, which necessitated proximal Achilles or gastrocnemius lengthening. These patients required surgery for their wound problem due to depth and involvement of their Achilles repair/reconstruction site. Surgery involved a single-stage wound irrigation and debridement, Achilles excisional debridement at the repair/reconstruction site, flexor hallucis longus transfer to the calcaneus to replace the compromised or failed Achilles repair/reconstruction, and primary or vacuum assisted wound closure. Patients were followed for 6 months after this surgery and invited for recent follow-up to collect data. Results: With uniform surgical treatment, full resolution of deep wound infection and dehiscence after Achilles repair/reconstruction was achieved in all 10 patients. No patients developed a recurrence of wound complications and/or infection to necessitate any further surgical debridements. All 10 patients presented for recent follow-up at a mean of 57.3 months. Mean Foot and Ankle Ability Measures increased from 36.3% at initial presentation before Achilles repair/reconstructive surgery to 84.2% at latest follow-up (P&lt;0.05). Mean Visual Analog Scores of pain decreased from 6.6 of 10 before the Achilles repair/reconstruction to 1.5 of 10 at latest follow-up (P&lt;0.05). All patients were able to return to normal gait and full activities at home, with 3 reporting difficulties with prolonged ankle activities at work. Conclusion: This study demonstrates that our method of single-stage surgical treatment of catastrophic failures of Achilles tendon repairs or reconstructions from deep wound complications can achieve a high rate of improved patient function and pain relief. Clinical outcomes of treating patients with this particular complication of Achilles repair/reconstruction in this manner have not been previously reported in the orthopaedic literature. As catastrophic failures of Achilles tendon repairs or reconstructions from deep wound complications are studied further, our method of surgical care should be strongly considered as treatment.

Prevention of sternal wound complications after sternotomy: results of a large prospective randomized multicentre trial†

A prospective randomized multicentre trial was performed to analyse the efficacy of a vest (Posthorax support vest®) to prevent sternal wound infection after cardiac surgery, and to identify risk factors. From September 2007 to March 2010, 2539 patients undergoing cardiac surgery via median sternotomy were prospectively randomized into those who received a Posthorax® vest and those who did not. Patients were instructed to wear the vest postoperatively for 24 h a day for at least 6 weeks; the duration of follow-up was 90 days. Patients who did not use the vest within a period of 72 h postoperatively were regarded as study dropouts. Statistical calculations were based on an intention-to-treat (ITT) analysis. Further evaluations comprised all subgroups of patients. Complete data were available for 2539 patients (age 67 ± 11years, 45% female). Of these, 1351 were randomized to receive a vest, while 1188 received no vest. No significant differences were observed between groups regarding age, gender, diabetes, body mass index, chronic obstructive pulmonary disease (COPD), renal failure, the logistic EuroSCORE and the indication for surgery. The frequency of deep wound complications (dWC: mediastinitis and sternal dehiscence) was significantly lower in vest (n = 14; 1.04%) vs non-vest (n = 27; 2.27%) patients (ITT, P < 0.01), but superficial complications did not differ between groups. Subanalysis of vest patients revealed that only 933 (Group A) wore the vest according to the protocol, while 202 (Group BR) refused to wear the vest (non-compliance) and 216 (Group BN) did not use the vest for other reasons. All dWC occurred in Groups BR (n = 7) and BN (n = 7), although these groups had the same preoperative risk profile as Group A. Postoperatively, Group BN had a prolonged intubation time, a longer stay in the intensive care unit, greater use of intra-aortic balloon pump, higher frequency of COPD and a larger percentage of patients who required prolonged surgery. Consistent use of the Posthorax® vest prevented deep sternal wounds. The anticipated risk factors for wound complications did not prove to be relevant, whereas intra- and postoperative complications appear to be very significant.

EComment. Poststernotomy infections without flaps

This well written and referenced study by Heilmann and colleagues [1] describes the experience of a single-centre over a period of two years, and includes 1297 patients. Of these, 2% (n = 24), developed deep incisional surgical site infection (SSI) and organ/space SSI according to a 1991, Centers for Disease Control (CDC) Guideline. A few salient points warrant highlighting. If we accept that microbial swabs (n = 82) were taken of all suspected and confirmed superficial and deep wound complications (n = 76), the analysis of the infective agent is representative. Two points are then of interest: firstly, the finding that coagulase-negative Staphylococci (CoNS) were involved in all deep, but none of the superficial poststernotomy wound infections supports an earlier observation that CoNS is becoming more of a threat and more specific preventative measures should be developed to counter this (threat) [2]. Secondly, the microbial swabs and cultures were negative in two (8.3%) of the 24 patients who presented with clinical deep sternal wound infections. This figure is high enough to emphasize that alertness to the possibility of a deep sternal wound infection is more important than reliance on the outcome of microbial swabs alone. Finally, 62.5% (15 of 24, not 45%, as the authors suggested) of patients with deep sternal wound infections required sternal and a slightly lower percentage (58%) were additionally managed with vacuum assisted closure (VAC) therapy. It would be of interest to know how the rest of the group of patients was managed, if not by VAC-therapy: was continuous drainage or an alternative method of open management used? Of particular interest, no mention of revascularization by means of flap surgery (muscle or omentum) was made. Unless the authors routinely advance the pectoral muscles medially, following sternal revision and wound closure, the lack of need for flap surgery could indicate that the diagnosis was made very early, when no or minimal sternal destruction had occurred and for this, the authors should be commended. Conflict of interest: none declared.

Wound complications after median sternotomy: a single-centre study

Sternal wound complications following median sternotomy remain a challenge in cardiac surgery. Changes in both patient profile and type of operations have been observed in recent years. Therefore, we analysed current wound healing complications after median sternotomy at our centre. All adult patients undergoing a median sternotomy between January 2009 and April 2011 were included in this retrospective analysis. Transplants and assist devices implantations were omitted. We assessed outcome, prognostic factors and microbiological results of standardized wound swabs. In total, 1297 patients with an average age of 67.0 ± 12.7 years were analysed. Operation types included 598 solitary coronary artery bypass grafts (CABGs), 213 solitary valve procedures, 105 CABGs with aortic valve replacement and 116 solitary aortic operations or conduit implantations. Furthermore, 255 of the remaining 265 were combined or otherwise complex procedures. Superficial healing disorders occurred in 43 patients (3.3%), while 33 (2.5%) developed deep wound complications. Six patients with sternal wound complications (7.9%) died in-hospital. In 7 patients, no pathogen was identified and the wound appeared uninfected (21% of all deep complications or 0.05% of all patients). These healing disorders were considered deep dehiscences. Patients with insulin-dependent diabetes mellitus, BMI of >40 kg/m(2) and who underwent reoperation were prone to superficial infections. Risk factors for all deep sternal wound complications were insulin-dependent diabetes mellitus, COPD and reoperation. Moreover, multivariate analysis revealed 'emergency' as an independent prognostic factor for all sternal wound complications. Microbial swabs of the sternal wound were taken in 82 of the 1297 patients (6.6%). Pathogens of the normal skin flora represented the majority of pathogens in both superficial and deep wound complications. Eight patients with deep, but only 2 patients with superficial complications suffered from polymicrobial infections. All deep polymicrobial infections involved coagulase-negative Staphylococci. Wound complications following median sternotomy remain a challenge to cardiac surgery. Redo and emergency operations are the most important risk factors in this contemporary series. More efforts seem mandatory to decrease this arduous morbidity and the costs of prolonged treatment.

Management of Deep Wound Complications With Vacuum‐Assisted Therapy After Berlin Heart EXCOR Ventricular Assist Device Placement in the Pediatric Population

Wound complications after ventricular assist device (VAD) placement remain a formidable challenge to surgeons. The Berlin Heart EXCOR VAD is a versatile pulsatile system that has been successful in pediatric patients of all ages and sizes. Prevention of device-related complications such as infection, particularly in pediatric patients, remains an essential issue in minimizing patient morbidity and mortality. The introduction of vacuum-assisted wound closure (VAC) therapy and its application in VAD-related wound complications provide an efficient and effective method for wound healing. We report our experience in the management of deep wound complications in two pediatric patients after placement of the Berlin Heart EXCOR VAD. The wound VAC system proved to achieve complete wound healing without any infectious complications.

Ipsilateral talar and calcaneal fractures: A retrospective review of complications and sequelae

Background Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series. Objective To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures. Methods Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review. Main outcome measurements Post-operative complications, the need for secondary surgery, and the visual analogus pain score. Results Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0. Conclusion The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation.

Vacuum‐assisted closure for radiation‐associated wound complications

Vacuum-assisted closure (VAC) technology has proven to be effective in the management of soft tissue loss from infections, vascular insufficiency, and traumatic disorders and may have a similar benefit in the musculoskeletal oncology patient. This study reports a single institution's experience with VAC technology in the management of radiation-associated wound complications in patients with soft tissue sarcomas. Twenty-two patients treated with both surgical intervention and radiation therapy developed either superficial or deep wound complications that were managed with the VAC device. This study group was compared to a retrospectively identified comparison group of 19 patients, in which the VAC device was not used. Hospital stay (P < 0.025), length of overall treatment (P < 0.025), number of operative debridements (P < 0.05) and success of wound closure without the need for soft tissue transposition (P < 0.01) was found to be significantly less in the study groups as compared to those not treated with the VAC device. VAC technology appears to be safe and effective in the treatment of radiation-associated wound complications.