Lower Wound Complication Rate Research Articles

INTERNATIONAL DELPHI CONSENSUS ON WOUND CLOSURE AND DRESSING MANAGEMENT IN TOTAL HIP ARTHROPLASTY

The purpose of this modified Delphi study was to obtain consensus on wound closure (including best practices for each tissue layer of closure) and dressing management in total hip arthroplasty (THA), using an evidence-based approach.The Delphi panel included 20 orthopedic surgeons from Europe and North America. Eighteen statements were identified (14 specific to THA and 4 relating to both THA and total knee arthroplasty) using a targeted literature review. Consensus was developed on the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of 75% was required for consensus.In Round 1, 15 of 18 statements achieved consensus via a structured electronic questionnaire. In Round 2, the 3 statements that did not achieve consensus were revised during a virtual face to face meeting. An additional 2 statements were edited for clarity. In Round 3, the 5 revised statements achieved consensus via a structured electronic questionnaire. Wound closure related interventions that were recommended for use in THA included: 1) barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); 2) subcuticular sutures over skin staples (lower risk of infections and higher patient preference); 3) mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); 4) negative pressure wound therapy over other dressings (lower wound complications and reoperations and fewer dressing changes); 5) triclosan coated sutures (lower risk of surgical site infection).Using a modified Delphi approach, a panel of 20 orthopedic surgeons achieved consensus on 18 statements pertaining to multi-layer wound closure and dressing management in THA. This study forms the basis for identifying critical evidence gaps within wound management to help reduce variability in outcomes during THA.

Use of Vacuum-Assisted Closure to Reduce the Likelihood of Wound Complications After Limb-Sparing Resection of Pediatric Primary Bone Sarcomas of the Femur

BackgroundLimb-sparing surgery is the standard of care for primary bone tumors. However, such procedures are associated with high rates of wound complications, specifically in lower-extremity surgeries. Therefore, identifying and implementing interventions to minimize the likelihood of wound complications after limb-sparing resection of the lower extremity is crucial. MethodsPatients who underwent limb-sparing osteosarcoma or Ewing sarcoma resection during a 7-year period at a single institution were retrospectively reviewed. Data were collected on 39 patients who underwent limb-sparing resection of the femur. Patient demographics, tumor characteristics, and perioperative and postoperative data were extracted and analyzed. Patients who underwent resection before April 2017 received conventional postoperative incision dressings. Starting in April 2017, patients received vacuum-assisted closure (VAC) with the 3 M™ Prevena VAC system after surgical closure. Eighteen patients received conventional postoperative incision dressing, and 21 received incisional wound VAC. A wound complication was defined as any Clavien-Dindo classification greater than 0 within a 28-day postoperative period. ResultsPatients who received postoperative incisional wound VAC had lower rates of wound complications than those who received conventional incision dressings (14% vs. 50%; p = 0.035). Additionally, patients in whom wound complications developed had a longer average hospital stay than those without wound complications (5 days vs. 4 days; p = 0.029). ConclusionsWound complications prolong the hospital stay and can delay adjuvant chemotherapy for bone tumors. The use of postoperative incisional wound VAC is associated with less likelihood of wound complications and should be considered in any high-risk surgical closure. Level of EvidenceLevel III Treatment Study.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty

BackgroundThis modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. MethodsAn international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. ResultsAfter 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. ConclusionsThrough a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

Optimizing Recovery After Carpal Tunnel Syndrome Release Surgery: The Role of Counseling in Pain Management and Perioperative Functional Enhancement.

Preoperative patient education is pivotal in improving patient outcomes during the perioperative phase, involving a thorough explanation of what patients can expect. This enhances adherence and reduces perioperative anxiety. In orthopedics, carpal tunnel syndrome, a common and painful hand condition, is effectively managed through surgical release under local anesthesia. Inadequate counseling before such procedures may intensify intraoperative anxiety and increase pain responses. Thus, this research aims to investigate the effects of comprehensive preoperative counseling on various parameters in carpal tunnel release surgery. A case-control study design was adopted for this study. A retrospective analysis of patients who underwent carpal tunnel release surgery was performed. These patients were categorized into two distinct groups: one group received comprehensive counseling during their clinic visits, while the other group reported receiving less effective counseling. Evaluation encompassed patient-related factors, disease-related aspects, and perioperative variables for both groups. The study comprised 681 participants, with 526 (77.2%) being females, 421 (61.8%) undergoing surgery on the right side, and 519 (76.2%) employed in non-manual occupations. Moreover, 559 (82.1%) were non-smokers, while approximately two-thirds of the cohort had both diabetes and hypertension. The average age of participants was 52 years, and they reported a mean functional disability score of 7.2 out of 10. The comprehensive preoperative counseling group consisted of 333 patients, while the other group included 348 patients. The analysis revealed statistically significant differences between the two groups, including reduced intra-procedural anxiety (p = 0.043), decreased intraoperative pain (p = 0.005), lower rates of wound complications (p = 0.022), and improved self-reported pain relief (p = 0.3). Our study emphasizes the crucial role of preoperative counseling in improving patient experiences during perioperative care, leading to reduced anxiety, milder pain responses, fewer complications, decreased reliance on postoperative pain medication, and increased self-reported pain relief. Level III, Case-control retrospective study.

Real-world Nationwide Outcomes of Minimally Invasive Surgery for Advanced Gastric Cancer Based on Korean Gastric Cancer Association-Led Survey.

The study aimed to investigate real-world surgical outcomes of minimally invasive surgery (MIS) for advanced gastric cancer using Korean Gastric Cancer Association (KGCA)-led nationwide data. A nationwide survey of patients who underwent surgical treatment for gastric cancer in 2019 was conducted by the KGCA. A total of 14,076 patients from 68 institutions underwent surgery, and 4,953 patients diagnosed with pathological stages IB-III gastric cancer were included. Among them, 1,689 patients who underwent MIS (MIS group) and 1,689 who underwent the open approach (open group) were matched using propensity score in a 1:1 ratio. Surgical outcomes were compared, and multivariate analysis was performed to identify the independent factors for overall morbidity. The MIS group had a lower proportion of D2 lymphadenectomy, total omentectomy, and combined resection. However, the number of harvested lymph nodes was higher in the MIS group. Better surgical outcomes, including less blood loss and shorter hospital stay, were observed in the MIS group, and the overall morbidity rate was significantly lower in the MIS group (17.5% vs. 21.9%, P=0.001). The mortality rates did not differ significantly between the 2 groups. In the multivariate analysis, the minimally invasive approach was a significant protective factor against overall morbidity (odds ratio, 0.799; P=0.006). Based on the Korean nationwide data, MIS for stage IB-III gastric cancer had better short-term outcomes than the open approach, including lower rates of wound complications, intra-abdominal abscesses, and cardiac problems.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty.

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Prospective Clinical and Computed Tomography Evaluation of Calcaneus Fractures Treated Through Sinus Tarsi Approach.

The traditional lateral extensile approach to the calcaneus allows for excellent visualization but is associated with high wound complication rates. The sinus tarsi approach has been shown to produce similar radiographic outcomes with much lower rates of wound complications. The purpose of this study is to prospectively determine clinical and radiographic outcomes in calcaneus fractures treated with a sinus tarsi approach. Twenty-nine patients with 30 calcaneus fractures underwent operative fixation through a sinus tarsi approach and were prospectively evaluated. Routine pre- and postoperative radiographs were obtained, in addition to computed tomography (CT) scans at 6 weeks and 12 months after surgery. Patient-reported outcomes including American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) pain score, Veterans Rand 12-Item Health Survey (VR-12), and Foot Functional Index (FFI) were recorded. Patients were followed for a minimum of 1 year postoperation. Twenty-one patients with 22 calcaneus fractures completed 1 year of follow-up. At 12 months postoperation, 20 of 22 patients (91%) had 0 to 2 mm of fracture displacement at the posterior facet on CT scans whereas 2 of 22 patients had 2 to 4 mm of fracture displacement. There was no significant change in posterior facet fracture displacement comparing 6-week and 12-month postoperative CT scans (P > .99). Mean postoperative Bohler angle was 26.1 degrees compared to 13.2 degrees preoperatively. All patients had complete union of fracture site. There were no major wound complications. Four of 22 patients (18.2%) had minor wound complications. AOFAS, FFI, and VAS pain scores improved postoperatively but were not found to correlate with Bohler angle or critical angle of Gissane. We found that in select patients excellent anatomic alignment and good clinical outcomes with low wound complication rates can be achieved when fixing calcaneus fractures through the sinus tarsi approach. Level II, prospective cohort study.

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021.

Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm. Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed. A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not. Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Emergency surgery of intra-articular calcaneal fractures using sinus tarsi approach with modified reduction technique

BackgroundThe purpose of this study was to evaluate emergency surgery of calcaneal fractures using the sinus tarsi approach (STA) with modified reduction technique in terms of complication rates, iconography results and functional outcome.MethodsWe evaluated the outcomes of 26 patients treated in an emergency using STA with modified reduction technique. For that, we assessed Böhler´s angle, Gissane angle, reduction of the calcaneal body, and posterior facet, the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, complications, preoperative time, operative time, and in-hospital time.ResultsRecovery of calcaneal anatomy and articular surface were found at final follow-up. The mean Böhler´s angle at final follow-up were 30.68° ± 3.69°, of which was 15.02° ± 3.88° preoperatively (p < 0.001). The mean Gissane angle at final follow-up were 114.54° ± 11.16° of which was 88.86° ±10.96° preoperatively (p < 0.001). All cases had the varus/valgus angle of the tuber within 5 degrees. At the final follow-up, the mean AOFAS score was 89.23 ± 4.63, and the VAS score was 22.73 ± 6.5.ConclusionsEmergency surgery using STA with modified reduction technique is reliable, effective, and safe for treatment of calcaneal fractures. This technique can bring good clinical outcomes and a low rate of wound complications, reducing the in-hospital time, costs, and accelerating rehabilitation.

Comparison of fasciocutaneous and fascial anterolateral thigh free flaps in foot reconstruction

Purpose: This study compared the surgical outcomes and quality of life of patients who underwent fasciocutaneous and fascial anterolateral thigh (ALT) free flaps for the reconstruction of traumatic soft tissue defects in the foot.Methods: A single-institution retrospective review of medical data from 2008 to 2021 was conducted on 20 patients who underwent a fasciocutaneous ALT free flap or fascial ALT free flap in the foot. Information was collected on patients’ baseline information, preoperative characteristics, and postoperative courses. Quality of life was measured through the Foot and Ankle Disability Index (FADI) score. A questionnaire survey was administered to evaluate aesthetic satisfaction and subjective improvement of dryness and sensory function at the surgical site.Results: The mean flap dimensions were 13.96×4.58 cm and 10.75×3.50 cm in the fasciocutaneous and fascial groups, respectively. The overall flap failure and complication rates were higher in the fasciocutaneous group (total necrosis in one case, partial flap loss in two cases, and vascular complications in three cases). While aesthetic satisfaction and functional outcomes (FADI Sports) showed better outcomes in the fascial group, subjective improvement of dryness and sensory recovery showed better results in the fasciocutaneous group.Conclusion: In comparison to fasciocutaneous flaps, fascial free flaps demonstrated lower rates of wound complications, higher aesthetic satisfaction, and better functional outcomes, but less improvement in dryness and sensory recovery at the flap site. Therefore, the choice of a flap for foot reconstruction should depend on the plastic surgeon’s discretion and a thorough discussion with the patient.

Wound Complication and Surgical Site Infection in Sarcoma Patients Undergoing Internal Hemipelvectomy

Abstract Background Hemipelvectomy is associated with a significant risk of wound complications, including infections, bleeding, and injuries to nearby neurovascular structures as well as the gastrointestinal and genitourinary tract. This study aimed to determine the patient characteristics and approach to treatment that could affect the occurrence of surgical site infection or wound complications in sarcoma patients who have undergone hemipelvectomy. Methods We conducted a retrospective analysis of 33 adult patients who underwent hemipelvectomy at a large tertiary academic cancer center from 2008 to 2016. We used χ 2 (exact Fisher) test to investigate the association between wound complication and categorical variables. We used a t test to evaluate the difference in numerical variables for outcomes. Results Among 33 patients, 12 patients (36.4%) experienced wound complications after hemipelvectomy. The average age of patients with wound complications was 63.3 years (57.1 ± 15.4 years), significantly higher than that of patients without wound complications (P = 0.004). Without adjustment, the use of computer navigation had a lower wound complication rate (P = 0.027). Patients with wound complications had longer hospital length of stay (14.8 vs 7.0 days, P = 0.016). Patient and surgical characteristics were not associated with surgical site infection. Five patients (15%) developed surgical site infection, and they had longer hospital stay (19.4 vs 8.1 days, P = 0.001). Conclusion Older patients undergoing hemipelvectomy are at an increased risk of developing wound complications with a prolonged hospital stay. Initial antimicrobial therapy for suspected surgical site infection should include broad-spectrum coverage to include skin and gastrointestinal flora.

Hybrid Percutaneous Management of Acute Midsubstance Achilles Tendon Ruptures

Background: Operative management techniques of Achilles tendon ruptures can be categorized into open repair, mini-open repair, or percutaneous repair. Indications: Surgical repair of acute ruptures of the Achilles tendon is indicated in athletic populations, with percutaneous repair being an effective technique with more favorable outcomes. Technique: With the patient prone, the Achilles rupture is identified and the Percutaneous Achilles Repair System (PARS) jig is inserted under the proximal paratenon. A series of Keith needles and flat braided SutureTape sutures are passed transversely across the proximal stump of the tendon. The sutures are then shuttled through the distal stump using a SutureLasso through medial and lateral percutaneous incisions on the distal medial and distal lateral borders of Achilles, respectively. Sutures are passed, tensioned, and secured to the posterior tuberosity of the calcaneus with two SwiveLock anchors. Results: Percutaneous repair, compared with open repair, results in lower wound complication rates, improved cosmetic appearance and fewer adhesions. Following surgery, patients follow a 5-stage rehabilitation protocol with return to sport when patients demonstrate dynamic neuromuscular control during multiplane activities without pain or swelling. Outcome studies have compared percutaneous repairs to open repairs, with percutaneous repairs demonstrating a quicker return to work or baseline activities (2.8 months versus 5.6 months) and a shorter return to play for athletes (average 18 weeks). Also, a greater number of PARS patients were able to return to baseline activities within 5 months (98%), compared with open repair patients (82%; P = .0001). In a prospective randomized controlled trial of 33 patients, Lim et al reported no postoperative wound infections in the percutaneous group and a 21% infection rate in the open repair group ( P = .01). Finally, in a recent systematic review of only percutaneous repairs, reported rates of sural nerve injury and rerupture were only 3.3% and 2.1%, respectively. Discussion/Conclusion: Compared to open repair, percutaneous Achilles repair allows for decreased risk of soft-tissue complications with comparable functional outcomes and earlier return to activity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Questioning Prophylactic Antibiotic Use for Pyloromyotomy: Analysis of the Pediatric Health Information System Database

BackgroundPyloromyotomy has a low rate of wound complications, yet antibiotic prophylaxis is still given. The Pediatric Health Information System (PHIS) database was queried to determine whether prophylactic antibiotics decreased wound complications. MethodsRecords for infants with pyloric stenosis between 2016 and 2021 were extracted from the PHIS database and analyzed for demographics, comorbid conditions, and complications within 30 days of pyloromyotomy. Logistic regression was used to evaluate the effect of antibiotic prophylaxis on complications. ResultsAmong 14,247 infants who underwent pyloromyotomy, 29.5% had antibiotic prophylaxis. These patients were more likely to have been admitted to the NICU and have chronic conditions and prematurity (p < 0.01). Antibiotic utilization varied among hospitals from 2.3 to 58.5%. Complication rates among those who received antibiotics was 1.64% versus 1.62% for those who did not. The odds for developing complications in those who received prophylaxis compared to those who did not was 1.10, (0.73, 1.41, 95%, p = 0.93) suggesting there is no effect of antibiotics on complication rates. ConclusionsThere was a wide variation among hospitals in the usage of prophylactic antibiotics for pyloromyotomy. There was no difference in complication rates whether or not patients received antibiotics. These results suggest antibiotic prophylaxis is unnecessary for pyloromyotomy. Level of EvidenceIII.

Use of Endoscopic Vein Harvest Yields Improved Outcomes in Popliteal Artery Aneurysm Repair

There is growing literature showing that endoscopic vein harvest (EVH) is safe, with excellent patency rates and decreased wound complications when treating infrainguinal occlusive disease. Our institution has performed EVH since 2003 with a dedicated team of providers specializing in endoscopic vein harvest. The purpose of this study was to evaluate major outcomes of EVH as an adjunct to standard, open operative repair of popliteal artery aneurysms. We performed a 12-year retrospective single-institution chart review from January 2005 to December 2017, identifying all patients undergoing popliteal artery aneurysm repair with EVH. Primary outcomes were procedural technical success, operative time, wound complication, major morbidity, and freedom from amputation. A total 37 limbs (in 31 patients) received EVH popliteal artery aneurysm repair at an average age of 65.2±10years; 65% of the patients presented without symptoms or with claudication and 35% with rest pain or tissue loss. Coexisting aneurysm was present in 68% of patients: 49% had contralateral popliteal artery aneurysms and 19% had concurrent aortic aneurysms. Of 37 limbs, 33 (89%) were treated through a medial approach with aneurysm ligation, and 4 patients (11%) were treated through a posterior approach. The average vein size was 4.4±1.1mm, with 86% harvested by the ipsilateral great saphenous vein. Average operative time was 3.89±0.82hr, with a median hospitalization of 2days and a median of 1day of intravenous narcotics use. Only 2 patients (5.4%) had Szilagyi class-2 surgical site infections remedied with debridement and antibiotics. Kaplan-Meier data showed a 5-year primary patency of 82.3% and primary-assisted patency of 88.2%. Additionally, 30-day primary patency was 89.2% and primary-assisted patency of 97.3%. EVH for popliteal aneurysmal disease provides a safe and efficacious means of popliteal artery aneurysm repair with shorter hospitalization, lower wound complication rates, and excellent long-term patency compared to standard open technique.

Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation.

In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N=49) versus femoral artery (FA: N=31). Patients in the AX group were older (AX: 59 years vs. 52 years, p=.006), and less likely to have extracorporeal cardiopulmonary resuscitation (0%vs. 12.9%, p=.040). Survival to discharge (AX, 81.6%vs. FA. 90.3%, p=.460), incidence of stroke (10.2%vs. 6.5%, p=.863), VA-ECMO cannulation-related bleeding (6.1%vs. 12.9%, p=.522), and arm or limb ischemia (0%vs. 3.2%, p=.816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1%vs. FA, 45.2%, p<.001) including the wound infections (2.0%vs. 32.3%, p<.001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p<.001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.

Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: Trends in Utilization and Evaluation of Complication and Revision Surgery Rates.

Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures. Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery. In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point. From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF. Level III retrospective cohort study.

The use of novel knotless barbed sutures in posterior long-segment lumbar surgery: a randomized controlled trial

BackgroundThe study carries the aim to compare the clinical efficacy and economic outcomes of using barbed suture closure versus conventional closure for wounds after posterior long-segment lumbar surgery.MethodsOne hundred and eighty-one patients undertaking posterior long-segment lumbar surgery participated in the prospective randomized controlled trial study to receive either barbed suture wound closure (n = 91) or conventional suture closure (n = 90). Outcome measures included operating room time (ORT), wound closure time, length of incision, length of hospital stay (LOS), 90-day readmission rates, wound complications of dehiscence and infection, and costs.ResultsBarbed suture group was related with significantly lower ORT (P = 0.036), wound closure time (P < 0.001) and average wound closure time (P < 0.001), and significantly lower wound complication rates (dehiscence and infection) (P = 0.031). No significant differences were found when compared with conventional suture group in terms of length of incision (P = 0.086), length of hospital stay (P = 0.174), readmission rates up to 90 days after the surgical procedure (P = 0.232) and costs (P = 0.205).ConclusionThe study suggested the knotless barbed suture technique outperformed the conventional suture in shortening operating room time, wound closure time and average wound closure time, and reducing wound complication rates.

The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery

The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice. A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present. A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts. Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs. Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.

No Difference in Return to Duty Between Minimally Invasive, Percutaneous Achilles Tendon Repair and Nonoperative Functional Rehabilitation in Active Duty Military Members

Category:Sports; Trauma; OtherIntroduction/Purpose:Achilles tendon ruptures are common injuries in the active duty US military population. Timely rehabilitation has critical importance in force readiness. There remains debate about optimal treatment of Achilles tendon ruptures. Recent studies have found decreased risk of rerupture but increased complication rates with operative management, with similar times to full recovery. The development of a minimally invasive, percutaneous Achilles tendon technique has shown lower rates of wound complications than open management, with similar re-rupture rates. However, there exists no comparative studies between the percutaneous, minimally invasive Achilles tendon surgery and nonoperative management. This was a retrospective cohort study comparing the results of the Percutaneous Achilles Repair System (PARS) and nonoperative management in the active duty military population.Methods:All Achilles tendon injuries in active duty patients were identified using the MHS system M2 from January 1, 2016 to December 31, 2020. Inclusion and exclusion criteria were applied and charts were reviewed. Demographic and treatment information were recorded. Time to return to duty, rerupture, complications, and deep vein thrombosis (DVT) were recorded and compared between each cohort. 47 patients met inclusion criteria with an average age of 38.7 years. There were 23 patients in the percutaneous operative group and 24 patients in the nonoperative group. Patients in the nonoperative group underwent regular functional rehabilitation supervised by a licensed physical therapist under the tri-service rehabilitation guidelines, based on the Willits protocol for nonoperative management (2010). 2 patients failed nonoperative management and underwent open Achilles reconstruction. They were excluded from the time to return to duty analysis. Demographics were described. There were no significant differences in group demographics.Results:There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repair (160.5 days, 5.35 months vs 161.7 days, 5.39 months) cohorts (p=0.47). No patient failed to return to duty due to treatment of an Achilles rupture. There were no DVTs in either group. There was 1 wound complication (infection) (4.3%) and 3 instances of postoperative paresthesias (2 sural, 1 peroneal) 13% in the operative cohort. 2 patients failed nonoperative management (reruptured Achilles tendon) and underwent open reconstruction with flexor halluces longus augmentation (8%). The operative cohort had a higher rate of complications (17.3% vs 8.3%, p=0.42, OR=2.11, CI= (0.34, 12.86)), although this was not statistically significant. There were no reruptures in the operative cohort.Conclusion:There was no difference in time to return to duty in the nonoperative and percutaneous Achilles tendon repairs. There was a higher rate of reruptures in the nonoperative group. Percutaneous operative treatment had a higher risk of complications. There were no failures in the operative cohort. The final decision on management of acute Achilles tendon ruptures should be based on specific patient factors and shared decision to return military members back to duty as quickly as possible. Prospective or well designed randomized controlled trials are necessary in the future to better delineate outcomes between nonoperative and percutaneous Achilles rupture management.

Percutaneous Modified Lapidus Procedure with Early Weightbearing: Technique and Early Outcomes of the First 30 Cases

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Minimally invasive techniques (MIS) have focused on first metatarsal osteotomies in hallux valgus correction. Concurrently, new fixation methods allow early weightbearing protocols with the open Lapidus procedure, with nonunion rates comparable to those of more traditional protocols requiring nonweightbearing. We aimed to assess clinical and radiographic results of an MIS-modified Lapidus technique with axial nail fixation (Phantom Lapidus Intramedullary Nail: Paragon28, Englewood, CO USA) and early weightbearing.Methods:After institutional review board approval, the first 30 consecutive percutaneous MIS-modified Lapidus procedures by a single surgeon were retrospectively reviewed. Indications for surgery included moderate to severe hallux valgus deformity with or without first tarsometatarsal joint (TMT) instability, first TMT arthritis, adolescent bunion, and failed prior surgery. All patients initiated weightbearing within 12 days and returned to regular footwear by 6 weeks postoperatively. Patients had a minimum follow-up period of 3 months (average 8.3 months). The pre- and postoperative visual analog scale (VAS) pain scores, intra- and postoperative complications, and need for revision surgery were recorded. Pre- and postoperative radiographs were used to evaluate the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and sesamoid station. Postoperative radiographs were evaluated for signs of hardware loosening and union of the first TMT arthrodesis site. A postoperative CT scan was obtained if nonunion was suspected.Results:Thirty consecutive percutaneous modified Lapidus procedures were performed in 28 patients. VAS scores improved from 4.1 preoperatively to 1.8 at final follow-up. The IMA decreased 8.3 degrees to an average of 5.9 degrees. The HVA decreased 19.2 degrees to 11.7 degrees. The medial column was shortened by 0.6%. There were no intraoperative complications. There were two reoperations, including one nonunion requiring revision first TMT fusion with autograft and one hallux valgus recurrence requiring a distal chevron osteotomy. There were no wound complications, surgical site infections, hardware complications, postoperative transfer metatarsalgia, or nerve-related problems.Conclusion:The current study provides clinical evidence that the intramedullary nail is a biomechanically stable construct evidenced by the high union rate, lack of hardware failure, and tolerance for early weightbearing. This percutaneous modified Lapidus technique may allow for a low rate of wound complications, accelerated rehabilitaion, and improved cosmesis.