Graft Coverage Research Articles

Correction of animation deformity with subpectoral to prepectoral implant exchange

Breast animation deformity is a known complication associated with submuscular prosthetic breast reconstruction. Patients often will present months to years after their initial reconstruction complaining of chronic pain and visible contraction deformity of their chest, with minimal voluntary activation of their pectoralis musculature. This is aesthetically displeasing and physically uncomfortable. Our preferred method for addressing existing animation deformity and alleviating patients' symptoms involves reoperation, with implant pocket conversion to the prepectoral plane, with acellular dermal matrix (ADM) coverage. We performed a retrospective review of all patients who underwent prepectoral conversion of their breast reconstruction for correction of animation deformity with the senior author (HS) between March 2016-April 2018. Demographics, operative details, and post-operative outcomes were assessed. Thirty-one patients underwent 55 revision breast reconstructions for a history of significant animation deformity following their initial submuscular breast reconstruction. All initial breast reconstructions were done with partial muscular coverage of their implant at the time of reconstruction. All patients experienced complete resolution of animation deformity without recurrence. Unplanned return to the operating room occurred in 14.5% of reconstructions. This was four cases of capsular contracture, three infections and one hematoma evacuation. Overall rate of infection requiring intravenous antibiotics was 14.5%. One patient lost both of her reconstructed breasts for an overall implant loss rate of 1.8% implant coverage with ADM was performed in 83.6% of cases, whereas 16.4% of reconstructions were performed with implant pocket change alone. The cohort that did not use ADM had a 44.4% instance of capsular contracture requiring reoperation, compared to a 0% rate of capsular contracture when ADM was used (P<0.01). Implant pocket change from the submuscular plane to the prepectoral plane is a safe and effective means of addressing submuscular associated breast animation deformity. The application of preoperative fat grafting and intraoperative ADM coverage contributes towards lower rates of complications and decreases the need for revisionary procedures.

Minimal Ablation of the Tibial Stump Using Bony Landmarks Improved Stability and Synovial Coverage Following Double-Bundle Anterior Cruciate Ligament Reconstruction.

PurposeTo evaluate the clinical effects of using anatomical bony landmarks (Parsons’ knob and the medial intercondylar ridge) and minimal ablation of the tibial footprint to improve knee anterior instability and synovial graft coverage after double-bundle anterior cruciate ligament reconstruction.Materials and MethodsWe performed a retrospective comparison of outcomes between patients who underwent reconstruction with minimal ablation of the tibial footprint, using an anatomical tibial bony landmark technique, and those who underwent reconstruction with wide ablation of the tibial footprint. Differences between the two groups were evaluated using second-look arthroscopy, radiological assessment of the tunnel position, postoperative anterior knee joint laxity, and clinical outcomes.ResultsUse of the anatomical reference and minimal ablation of the tibial footprint resulted in a more anterior positioning of the tibial tunnel, with greater synovial coverage of the graft postoperatively (p=0.01), and improved anterior stability of the knee on second-look arthroscopy. Both groups had comparable clinical outcomes.ConclusionsUse of anatomical tibial bony landmarks that resulted in a more anteromedial tibial tunnel position improved anterior knee laxity, and minimal ablation improved synovial coverage of the graft; however, it did not significantly improve subjective and functional short-term outcomes.

Stent graft coverage of dual-stent strategy in the management of abdominal aortic aneurysms

Treating an abdominal aortic aneurysm (AAA) with a stent graft (SG) and a multilayer stent (MS) is a key technology in isolating flow fields. Clinically, dual stents (an SG in the proximal and an MS in the distal of AAA) are used for treatment of AAA, but only a few studies have examined the relationship between SG coverage and treatment effects. Through numerical simulation of the hemodynamics after SG and MS implantation, the SG coverage and position were simulated at 0% (0 mm), 25% (13.75 mm), 50% (27.5 mm), and 75% (41.25 mm). With increasing SG coverage, the pressure on the aneurysm sac wall and the flow of branch vessels gradually decreased, and the lower wall shear stress (WSS) gradually increased. The changes in pressure, lower WSS, and the mass flow rate of the branch vessels did not change significantly. The coverage of the SG has a nonsignificant effect on hemodynamics in the treatment of AAA; the implantation position need not be very precise. This research can provide theoretic support for clinicians’ decision-making.

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms

ObjectiveThe aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. MethodsA retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. ResultsBetween January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]). ConclusionsThe majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI.

Functional and cosmetic outcomes of posterior interosseous artery flap in reconstructing hand defects

Objective The objective of this study was to evaluate the fu ncti onal and cosmetic results of reversed-flow posterior interosseous artery (PIA) flap for reconstruction of hand defects and to assess them by follow-up and physiotherapy. Background Reconstruction of soft-tissue defects in the hand needs a single-stage procedure that can provide well-vascularized graft coverage at the earliest to give the best functional result. Patients and methods This follow-up study that included 20 patients (16 male and four female) was carried out in Menoufia University, Plastic and Reconstructive Surgery Department, from March 2015 to January 2017, with assessment by a follow-up period of 12 months and physiotherapy. All our patients had PIA flap for coverage of the defects. The defects were due to post-traumatic raw areas in 15 cases, postburn deformities in two cases, postcongenital hand deformity surgeries in one case, and post-tumor ablation in two cases. The first webspace defect occurred most often and the largest flap was 10 × 12 cm2. The donor site was covered by split skin graft in 14 cases, and in six cases the donor site was directly closed. Results Regarding flap course and survival, 15 (75%) flaps passed uneventfully, four (20%) flaps suffered from venous congestion, and one (5%) flap showed ischemia. Three flaps (the ischemic flap and two congested flaps) suffered total loss. Two congested flaps survived without loss, and thus we had 17 (85%) survived flaps. All cases were satisfied with cosmetic outcome. Conclusion The reverse-flow flap based on PIA is a reliable and versatile source for coverage of complex soft-tissue defects in the hand.

Abstract: Outcomes of Reconstructive Limb-Salvage Surgery in Lower Extremity Soft Tissue Sarcomas: A 20-Year Experience

INTRODUCTION: Extremity sarcoma management follows a multidisciplinary approach involving orthopedic oncologists, plastic surgeons, medical oncologists, and radiation oncologists. Surgical resection of lower extremity soft tissue sarcomas often leads to large, complex defects with exposure of underlying neurovascular structures, tendons, and/or bone. Subsequent reconstructive surgery is often required in order to provide adequate soft tissue coverage and allow for functional preservation of the limb. We report our 20-year experience with limb-salvage surgery following lower extremity soft tissue sarcoma resection. METHODS: We performed a retrospective review on all patients 18 years or older at the time of operation that underwent soft tissue reconstructive surgery following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. Medical records were reviewed for patient demographics, tumor characteristics, details of tumor resection and plastic surgery reconstruction, administration and timing of chemo/radiation therapy, and postoperative outcomes. RESULTS: 136 patients underwent plastic surgery reconstruction following tumor resection. The average age was 55.7 years. The majority of tumors were high grade (47.1%), greater than 5 cm (66.9%), AJCC stage 3 (38.2%) and located in the proximal thigh (41.2%). 93.4% of reconstructive procedures were performed in the same operative setting as the oncologic resection. Approximately 90% of the advanced plastic surgery reconstructions involved a flap for coverage. Local flap reconstruction was most common for proximal thigh wounds (69.6%) and microvascular free flap reconstruction was most common for distal leg wounds (60.9%) (p=0.013). Skin grafts alone were most common for tumors ≤5cm (p=0.043), superficial wounds (p=0.001), and re-excisions (p=0.029) due to incomplete margins or recurrent disease. In conjunction with surgery, seventy-two patients (52.9%) received neoadjuvant radiation and twenty-six patients (19.1%) received neoadjuvant chemotherapy. The utilization of neoadjuvant radiation or neoadjuvant chemotherapy was not associated with the type of reconstruction utilized following tumor resection. Wound complications occurred within 6-months postoperatively in 52.9% of patients. The most common complication was wound dehiscence (26.4%), followed by infection (18.4%), and seroma (15.4%). Thirty-two patients (23.5%) required a re-operation for wound complications. Average time to healing was 13.0 weeks. Limb survival was 94.9%. There was no significant difference in the incidence of overall wound complications, re-operations, time to heal, or limb survival, between patients receiving local flap, free flap, or skin graft coverage. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease through last known follow up, respectively. There was no significant difference in local recurrence or metastatic disease between the different reconstructive techniques. CONCLUSION: Patients with extensive lower extremity soft tissue defects often require plastic surgery soft tissue reconstruction after sarcoma resection. Based on our results, in patients that cannot undergo primary closure, local flaps can effectively reconstruct the majority of lower extremity sarcoma defects. However, microvascular free tissue transfer may be warranted for large wounds, areas of previous irradiation damage, or in the distal lower extremity. The post-operative management of sarcoma patients remains challenging due to high rates of wound complications. Local recurrence and metastatic disease confer additional morbidity and mortality in this patient population.

A Narrative Review on Contrast-Enhanced Ultrasound in Aortic Endograft Endoleak Surveillance.

Endovascular repair of abdominal aortic aneurysms have been performed successfully since 1991. However, 20% to 50% of these patients may develop an endoleak or continued aneurysmal sac expansion or perfusion despite stent graft coverage. Current recommendations suggest lifelong surveillance with computed tomographic angiography (CTA) at least 1 month after intervention and yearly after that. In select patients with a stable aneurysm sac on computed tomography performed 1 year after treatment, future screening could be performed with ultrasonography. However, color Doppler ultrasound can fail to detect as many as 31% of endoleaks. Contrast-enhanced ultrasound (CEUS) provides an alternative approach to excluded aneurysm sac follow-up imaging. The Society for Vascular Surgery notes a need for further research on the role of CEUS in endovascular aortic repair surveillance. The European Federation of Societies for Ultrasound in Medicine and Biology suggests that early results are promising. Meta-analyses report pooled sensitivities and specificities of CEUS compared with CTA for the detection of endoleak between 89% and 98% and 86% and 88%, respectively. Owing to the dynamic flow information it provides, CEUS may actually be more sensitive than CTA at detection and characterization in select circumstances. Challenges with adoption, patient selection, and operator dependency remain, but current and future research suggests a role for CEUS in endoleak surveillance.

Microvascular “on-top-plasty”: An Alternative for Thumb Reconstruction in Constriction Band Syndrome

Constriction band syndrome affecting the hand and importantly the thumb may require reconstruction to improve function. This case report presents a patient with auto-amputation through the proximal phalanx of the middle, index, and thumb. Microvascular reconstruction was used to perform an on-top-plasty with the remaining index finger to the thumb. The case also involved skin graft coverage, venous grafting, and tendon reconstruction. The patient presents with 12 months follow up after index procedure and 3 months after revision. She has the ability to grasp large objects. Sensation remains present in pulp of new thumb. Cosmesis subjectively improved per patient’s family and physician. Strength continued to improve and reached 2 Kg of grip strength by 12 months. Microvascular on-top-plasty is a possible option for improving function in constriction hand syndrome affecting multiple digits.

Correction: Changes in aortic pulse wave velocity of four thoracic aortic stent grafts in an ex vivo porcine model.

[This corrects the article DOI: 10.1371/journal.pone.0186080.].

The 3rd Annual Meeting of The Mountain West Society of Plastic Surgeons

Salvage of infected vascular bypass grafts continues to present one of the most complex reconstructive algorithms for both vascular, and plastic surgeons. Graft infection necessitates graft explantation and extra-anatomic bypass, most often with additional synthetic material. These multiply comorbid patients suffer long periods of convalescence in the ICU with attendant bed-rest, ventilator dependency and sepsis. The omentum is an established and effective source of intra-abdominal coverage for gastrointestinal and urological anastomoses, as well as vascular graft coverage. The omentum is also an established method for coverage of extra-abdominal pathology and as a free flap it may be used in any location. However, its use as a pedicled flap for extra-abdominal reconstruction has hitherto been largely limited to chest wall reconstruction.

Outcome after Thoracic Endovascular Aortic Repair with Complete or Partial Stent Graft Coverage of the Left Subclavian Artery

Outcome after Thoracic Endovascular Aortic Repair with Complete or Partial Stent Graft Coverage of the Left Subclavian Artery

Clinical management of Gustilo IIIB and IIIC type open fractures of forearm

Objective To evaluate the clinical effects of different methods in the treatment of GustiloⅢB andⅢC type open fractures of forearm. Methods From December 2006 to June 2014, 28 cases of forearm open fractures with severe soft tissue injuries were treated in our department. According to Gustilo open fracture classification, 10 cases were typeⅢB and 18 cases were typeⅢC. Fractures were treated by plate fixation at first stage in 9 cases, external fixation at first stage in 4 cases, external fixation at first stage and plate fixation at second stage in 15 cases. The wounds of 7 cases were closed at first stage, and the rest 21 cases were treated by wound open with VSD coverage at first stage and free skin graft or flap coverage at second stage. Results All the patients were follow-up for 12 to 24 months with an average of 17.5 months. Postoperative osteomyelitis and bone nonunion occurred in one case which was healed 12 months after the second operation of plate fixation after complete debridement and simultaneous shortening of the radius and ulna. The healing time of other 27 cases ranged from 8 to 14 months with an average of 9.3 months. According to Anderson's forearm fracture evaluation standard, the results were excellent in 16 cases, good in 8 cases, and fair in 4 cases. Conclusion Complete debridement, reasonable fixation and one or two stage wound closure for the treatment of GustiloⅢtype forearm fracture accompanied with different degree of soft tissue injury can maximally achieve limb salvage and reduce the occurrence of postoperative infection, osteomyelitis and bone exposure. Key words: Forearm; Fractures,open; GustiloⅢtype; Severe soft tissue injury

Total hip arthroplasty with structural bone graft of superolateral acetabulum for developmental dysplasia of the hip

Objective To assess the mid- or long-term clinical outcomes of the structural bone graft of superolateral acetabulum in total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH). Methods Thirty-three patients with DDH (33 hips) were treated by THA with the structural bone graft of superolateral acetabulum technique between April 2002 and December 2011. There were 28 females and 5 males with the mean age at surgery 54.0±14.5 years (21-76 years). The degree of dislocation was graded preoperatively as Crowe II in 12 patients, Crowe III in 8 patients, and Crowe IV in 13 patients. The following outcomes were assessed, Harris hip score (HHS), the leg-length discrepancy, the height and horizontal distance of center of hip rotation, rate of cup coverage, the coverage ratio of bone graft, periprosthetic osteolysis, bone ingrowth, and cup loosening. Results The average follow-up was 9.3±3.3 years (5-15 years). The HHS improved from 40.9±13.7 preoperatively to 93.6±7.8 at the final follow-up (t=21.483, P=0.000). The leg-length discrepancy decreased from 24.2±17.1 mm pre-operatively to 3.7±3.5 mm at post-operative 3 months (t=6.747, P=0.000). The height and horizontal distance of center of hip rotation decreased from preoperative 45.9±16.0 mm and 42.9±8.7 mm to postoperative 23.8±5.8 mm and 23.6±2.9 mm (t=7.460, P=0.000; t=12.090, P=0.000) at post-operative 3 days, respectively. The cup coverage and coverage ratio of bone graft was 100% and 27.1%±6.9%, respectively. All grafts appeared to be incorporated without evidence of resorption and collapse. The mean time of incorporation was 7.6±2.8 months. The coverage ratio of bone graft >25% have a significantly long time of incorporation than that <25% (9.4±2.3 months versus 6.3±2.4 months, t=5.357, P=0.000). At the final follow-up, all hips showed bone ingrowth fixation of the acetabular cup and stem. Five hips showed osteolysis, two hips in acetabular zone II, three hips in femur zone I and five hips in femur zone VII. The main complications were intraoperative femoral fractures (61%) without neurological damage, nonunion and dislocation. Conclusion The structural bone graft of superolateral acetabulum in THA for DDH can achieve satisfactory mid- or long-term outcomes. The superolateral acetabular deficiency can be reconstructed by bone graft. The bone graft coverage less than 25% is conducive to fusion of bone graft and acetabular bone. However, intraoperative femoral fracture is common complication. Key words: Bone diseases, developmental; Bone transplantation; Arthroplasty, replacement, hip

Outcomes of thoracic endovascular aortic repair for chronic aortic dissections

BackgroundOpen surgical repair remains the “gold standard” treatment for chronic type B aortic dissection (cTBD) with aneurysm. Thoracic endovascular aortic repair (TEVAR) has gained popularity in recent years for the treatment of thoracic aortic diseases, including cTBD. We assessed the effectiveness of TEVAR in the treatment of cTBD using the Vascular Quality Initiative (VQI) database. MethodsThe VQI registry identified 4713 patients treated with TEVAR from July 2010 to November 2015, including 125 repairs for cTBD. We analyzed TEVAR outcomes in this cohort per the Society for Vascular Surgery reporting standards for TEVAR. ResultsMedian age was 65.0 years (interquartile range [IQR], 56.0-72.0 years), and 85 (68.0%) were male. Median aneurysm diameter was 5.5 cm (IQR, 4.8-6.3 cm). Sixty-two (49.6%) patients were asymptomatic on presentation, 57 (45.6%) were symptomatic, and 6 (4.8%) presented with rupture. Median length of stay was 8.0 days (IQR, 4.0-11.0 days). Fluoroscopy time was 17.3 minutes (IQR, 10.5-25.6 minutes). The distal landing zone was aortic zone 4 in 27 (21.6%) and aortic zone 5 and distal in 98 (78.4%) patients. Successful device delivery occurred in 123 (98.4%) patients. Conversion to open repair occurred in one (0.8%) patient. A type IA endoleak was present in 2 (1.6%), type IB endoleak in 2 (1.6%), and type II endoleak in 2 (1.6%) patients. Perioperative complications included stroke in 1 (0.8%), respiratory complications in 6 (4.8%), and spinal cord ischemia symptoms present at discharge in 3 (2.4%) patients. In-hospital mortality occurred in three (2.4%) patients. Reintervention was required in two (1.6%) patients for false lumen perfusion and in two (1.6%) patients for extension of the dissection. Follow-up was available for 43 patients at a median time of 239 days (IQR, 38-377 days). Median change in sac diameter was −0.2 cm (IQR, −0.5 to 0.1 cm). Sac shrinkage of 0.5 cm was noted in 12 (27.9%), with sac growth >0.5 cm in four (9.3%) patients. Extent of stent graft coverage did not affect sac shrinkage (P = .65). Patients with aneurysms ≥5.5 cm compared with <5.5 cm were more likely to demonstrate shrinkage (−0.6 cm vs 0.0 cm; 95% confidence interval, 0.3-11.7; P = .04). ConclusionsTEVAR for cTBD may be performed with acceptable rates of morbidity and mortality. Changes in sac diameter in the midterm are promising. Long-term data are needed to determine whether this approach is durable.

Changes in aortic pulse wave velocity of four thoracic aortic stent grafts in an ex vivo porcine model.

ObjectivesThoracic endovascular aortic repair (TEVAR) has been shown to lead to increased aortic stiffness. The aim of this study was to investigate the effect of stent graft type and stent graft length on aortic stiffness in a controlled, experimental setting.MethodsTwenty porcine thoracic aortas were connected to a pulsatile mock loop system. Intraluminal pressure was recorded at two sites in order to measure pulse wave velocity (PWV) for each aorta: before stent graft deployment (t1); after deployment of a 100-mm long stent graft (t2); and after distal extension through deployment of a second 100-mm long stent graft (t3). Four different types of stent grafts (Conformable Gore® TAG® Device, Bolton Relay® Device, Cook Zenith Alpha™, and Medtronic Valiant®) were evaluated.ResultsFor the total cohort of 20 aortas, PWV increased by a mean 0.6 m/s or 8.9% of baseline PWV after deployment of a 100-mm proximal stent graft (P<0.001), and by a mean 1.4 m/s or 23.0% of baseline PWV after distal extension of the stent graft (P<0.001). Univariable regression analysis showed a significant correlation between aortic PWV and extent of stent graft coverage, (P<0.001), but no significant effect of baseline aortic length, baseline aortic PWV, or stent graft type on the percentual increase in PWV at t2 or at t3.ConclusionsIn this experimental set-up, aortic stiffness increased significantly after stent graft deployment with each of the four types of stent graft, with the increase in aortic stiffness depending on the extent of stent graft coverage.

Twenty-Year Review of a Single Surgeon's Experience Using a Unique Surgical Technique to Correct Lambdoidal Synostosis.

Numerous techniques for the surgical management of lambdoidal synostosis have been previously described; however, no best practice technique currently exists. Surgical procedures range from complete posterior calvarial reconstruction to distraction osteogenesis techniques. Our primary purpose is to describe a novel approach to correct unilateral or bilateral lambdoidal synostosis. A retrospective review was performed on a single surgeon's experience with craniosynostosis (1994-2014). Specifically, craniosynostosis cases involving the lambdoidal suture, which were repaired using a novel 'tongue and groove' technique, were identified. A total of 664 craniosynostosis cases were retrieved, with 21 primarily involving the lambdoidal suture (3.2%). Of these, 18 were unilateral and 3 were bilateral lambdoidal synostosis. Male-to-female ratio was 3:1. Average age of first encounter with a craniofacial physician was 33 weeks (8 months). Average age at time of surgery was 43 weeks (10.75 months). Complications of this technique included 1 patient who experienced refusion of his lambdoidal suture and fusion of his sagittal suture, and 4 who returned for bone graft coverage of full-thickness calvarial defects owing to a lack of complete reossification. The "tongue and groove" technique represents a novel method for the management of lambdoidal synostosis with good esthetic outcomes, allowing immediate cranial stabilization with increased skull volume. This technique, used by the senior author for >20 years, provides a reproducible and reliable method of correcting lambdoidal synostosis.

Surgical regenerative treatment of peri-implantitis

Data sourcesOvid, Medline, PubMed, Embase and Dentistry and Oral Sciences Source. Databases were searched from January 2006 to March 2016 and restricted to English, manual searches were also carried out in the relevant major journals.Study selectionTwo reviewers independently selected studies. Human prospective and retrospective observational studies with a minimum sample size of ten implants and involving at least one surgical regenerative treatment method for peri-implantitis were considered. Excluded studies included animal and in vitro studies, patients with uncontrolled systemic disease that put the implant at risk and ceramic or coated implants.Data extraction and synthesisData abstraction and quality appraisal were carried out by two independent reviewers. The Cochrane Collaboration tool for assessing risk of bias in randomised trials was used.1 Meta-analysis of similar studies was conducted and the main outcome measures were; changes in radiologic bone level, probing depth and bleeding on probing change.ResultsEighteen studies were included, eight prospective clinical studies, seven case series and three randomised clinical trials (RCTs). A total of 528 patients with 713 implants were treated. Two studies were at low risk of bias, one moderate, and three high. The remainder were classified as unclear.ConclusionsWithin the limits of this systematic review, surgical regenerative treatment is a predictable option in managing peri-implantitis and improving clinical parameters of peri-implant tissues. There is no fundamental advantage of membrane use for bone graft coverage or submergence of the healing site on the final outcome of peri-implant defect regeneration. Due to the limited number of randomised clinical trials, at the time there is a lack of scientific evidence in the literature regarding the superiority of the regenerative versus non-regenerative surgical treatment.

Reconstructive microsurgical approach for the treatment of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare type of autoimmune disease that results in progressive ulcers with or without previous trauma. However, PG is not well understood to date, and its treatment therefore remains a challenge. Because of the disease's systemic characteristic and the unpredictability of the clinical course, no gold standard treatment is available, especially concerning the surgical procedures to treat pyodermic lesions. Often, PG is not recognized during routine clinical practice, and standard ulcer treatment (conservative wound care, debridement, skin grafting, and local flap coverage) is initiated; this induces an autoinflammatory response, resulting in disastrous ulcers, thereby making free flap coverage necessary. The purpose of this study was to assess the outcome of microvascular free-tissue transfer as a treatment option for extended soft-tissue defects resulting from PG. We retrospectively evaluated 8 cases in 5 patients suffering from PG of the lower extremity who received defect closure with a microvascular free-tissue transfer under immunosuppressive and corticosteroid therapy. The average patient age was 60 years; three were male, and two were female. Seven defects were covered with free gracilis muscle flap. One patient received an anterolateral thigh flap. The average defect size was 93cm2. No flap loss was observed during follow-up. All patients received broad-spectrum antibiotic treatment and corticosteroids. Two patients also received infliximab. PG once diagnosed is not a contraindication for microvascular free-tissue transfer. Multidisciplinary evaluation of each case is fundamental. All surgical treatments should be performed only with sufficient protective immunosuppression therapy. If the defect requires free flap coverage, it should be considered as a surgical option despite the potential risk of a pathergic response in PG and was a safe treatment option in all our cases. In conclusion, we share our experience regarding preoperative, intraoperative, and postoperative care of patients with PG receiving free flap surgery.

Early Results of the PETTICOAT Technique for the Management of Acute Type A Aortic Dissection.

Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD.

Overstenting the hypogastric artery during endovascular aneurysm repair with and without prior coil embolization: A comparative analysis from the ENGAGE Registry

BackgroundEndovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. MethodsData from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization—coils or plugs—was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. ResultsIn 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P = .464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P = .346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P = .080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P = .057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P = .225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. ConclusionsThis study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required.