Patient Developed Skin Necrosis Research Articles

Outcomes of Total Knee Arthroplasty Following a Sham Incision Procedure in Patients with Previous Knee Incisions.

Tenuous blood supply carries a risk of wound-healing problems and subsequent infection following total knee arthroplasty (TKA). This risk may be increased by the presence of previous incisions. Performing a sham incision procedure allows for detection of wound-healing problems prior to performing TKA. The purpose of this retrospective case series is to describe the indications for and technique of a sham incision procedure in patients with previous knee incisions who underwent TKA following this procedure and to report the clinical outcomes observed in these patients following further surgery. Patients who had prior knee incisions, had undergone a sham incision prior to TKA, and had a minimum follow-up of 2 years were identified, and their cases were retrospectively reviewed. The identified cases typically adhered to the surgeon's standard protocol, which consisted of making a midline incision adventitious to TKA, dissecting down to deep fascia, and closing the wound with suture. Incisions were then observed for at least 4 weeks to determine the viability of the skin flaps before TKA was performed via the same incision. A total of 47 knees in 47 patients were included in the study cohort. TKA was performed at an average of 21.1 weeks (range, 4 to 163 weeks) following the sham incision. There were no cases of skin necrosis or periprosthetic joint infection at an average follow-up of 4.6 years (range, 2 to 12 years) after sham incision. A total of 11 patients (23.4%) required manipulation under anesthesia for stiffness. In our series, no patients developed skin necrosis or periprosthetic joint infection following TKA subsequent to a sham incision procedure, suggesting that healed sham incisions are safe to use for TKA and may be considered prior to TKA in cases in which local previous incisions increase the risk of wound-healing problems. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Experience of the Early Penile Fracture Repair: A Cross-Sectional Study in A Tertiary Care Center

Background: Penile fracture is a surgical emergency and most often it can be diagnosed clinically. But delayed presentation due to the embarrassing nature of the injury makes surgical outcome worse. Objectives: This study was conducted to compare results of early and delayed surgical interventions of patients presenting with penile fracture. Methodology: A cross-sectional study was conducted at the department of Urology, in Dhaka Medical College of hospital, Bangladesh from 30th July 2018 to 30th January 2020. Twenty- Seven (27) patients with penile fracture were enrolled in this study. They were diagnosed on the basis of history and clinical findings. They were divided into two groups; early presenter (15 patients) who came within 24 hours and delayed presenter (12 patients) who came after 24 hours. Among the early presenters, 13 patients had unilateral corporeal injury and 2 patients had bilateral corporeal injury. On the other hand, in delayed presenters, 11 patients had unilateral corporeal injury and 1 patient had bilateral corporeal injury. Surgical repair was done in all patients. Results: Patient age range was between 15 to 60 years. The commonest presenting complaints were cracking sound 26 out of 27 (96.30%), penile swelling 24 out of 27 (88.88%), pain 22 out of 27(81.48%) and detumusence during sexual intercourse or an erection 17 out of 27(62.96%), urethra bleeding 3 out 27(11.1%). Among different causes, vigorous intercourse where female on top (62.9%) was the commonest followed by bending during erection (18.5%), masturbation (11.1%) And rolling over bed (7.4%). Out of 15 patients in early group, patients presented with urethral injury. The complications in delayed repair group were, plaque formation 3 out of 15 (20%); penile shaft deformity 2(13.3%); erectile dysfunction 1(6.6%) and skin necrosis 2 (13.3%). But in early repair group only one patient developed skin necrosis which was managed conservatively. Conclusion: Fracture of the penis is a surgical emergency. Immediate surgical repair gives excellent results even in the presence of urethral injury. Early diagnosis by history and clinical examination and timely surgical intervention is essential for better outcome with minimal longterm complications. J Dhaka Med Coll. 2022; 31(2) : 210-214

Implant-based immediate reconstruction in prophylactic mastectomy: is the caudal dermis flap a reliable alternative to synthetic mesh or acellular dermal matrix?

IntroductionThe demand for prophylactic mastectomy has increased significantly over the last 10 years. This can be explained by a substantial gain of knowledge about the clinical risk and outcome of patients with high risk mutations such as BRCA1 and 2, the improved diagnostic possibilities for detecting the genetic predisposition for the development of breast cancer and the awareness for those mutations by health care professionals as well as patients. In addition to expander-to-implant reconstruction and microsurgical flap surgery, definitive immediate reconstruction with subpectoral insertion of breast implants is often preferred. The prosthesis is covered at its inferior pole by a synthetic mesh or acellular dermal matrix. In these cases, in addition to the silicone prosthesis, a further foreign body must be implanted. This can be exposed in the event of wound healing disorder or necrosis of the usually thin soft tissue covering after subcutaneous mastectomy, thus calling into question the reconstructive result. In this study, the coverage of the lower pole by a caudal deepithelialized dermis flap, which allows the implant to be completely covered with well vascularized tissue, is compared to coverage by a synthetic mesh or acellular dermal matrix.Patients and methodsFrom January 2014 to June 2020, 74 patients (106 breasts) underwent breast reconstruction following uni or bilateral prophylactic mastectomy. Reconstruction was performed with autologous tissue (15 breasts), with tissue expander or implant without implant support (15 breasts), with implant and use of an acellular dermal matrix or synthetic mesh (39 breasts) and with implant and caudal dermis flap (37 breasts).In this study, we compared the patients with implant and dermal matrix/mesh to the group reconstructed with implant and dermal flap.ResultsIn the group with the caudal dermis flap, 4 patients developed skin necrosis, which all healed conservatively due to the sufficient blood supply through the dermis flap. In the group with the use of a synthetic mesh or acellular dermal matrix, skin necrosis was found in three cases. In one of these patients the implant was exposed and had to be removed.DiscussionFor patients with excess skin or macromastia, the caudal dermis flap is a reliable and less expensive option for complete coverage of an implant after prophylactic mastectomy. In particular, the vascularized dermis flap can protect the implant from the consequences of skin necrosis after prophylactic mastectomy.

Midline abdominal Incisional hernia repair by component separation technique augmented with prosthetic mesh: Prospective study

Background: Raised intra-abdominal pressure (IAP) makes laparostomy mandatory initially and abdominal wall approximation cannot be completed due to compromised state in most cases. Objectives: To determine the feasibility of component separation technique (CST) with mesh augmentation. Methods: 50 patients were subjected to CST with mesh augmentation. Preoperative defect size mapping, Pre- and post-operative monitoring of IAP were done. Pain scoring by visual analogue scale (VAS), early and late complications was noted. Patients were followed up for 60 months. Results: Out of 50 patients, 17 patients had seroma formation, 2 patients developed skin necrosis, 1 patient had wound dehiscence and none had Hematoma formation. There were 33 females and 17 males and accounts to 66% of female patients. Out of 50 patients 36 patients were operated under General anaesthesia accounting to 73% of patients whereas rest of the 14 patients got operated under Combined Spinal Epidural anaesthesia. 36 out of 50 patients had split thickness skin cover, accounting for 72% of the patients whereas rest of the 14 patients had intact skin cover.

Surgical Outcomes of Articular Surface Crush Injury of Hawkins Ⅲ Talus Neck and Medial Malleolus Fracture

<h2>ABSTRACT</h2> The present study was performed to evaluate the effects of the medial and anterolateral approach combined with internal fixation by double head compression screws and countersunk K-wires for Hawkins Ⅲ talus neck and medial malleolus fracture. Eleven patients with articular surface crush injury resulting in Hawkins Ⅲ talus neck fractures accompanied by medial malleolus fractures were reviewed. All patients underwent emergency operations. The fractures were fixed using double head compression screws and countersunk K-wires through combined medial and anterolateral approaches. FAOS, AOFAS ankle-hindfoot scale, and VAS questionnaire scores were recorded. In addition, ROM of the ankle and postoperative complications were assessed. All patients were followed up for a median of 52.45 ± 5.15 months. The multiple scales data of FAOS on the affected side were: pain score 89.14 ± 7.08; activities of daily living score 89.57 ± 8.88; quality-of-life score 89.20 ± 7.44; sports score 75.00 ± 15.49; and other symptoms score 84.74 ± 7.51. The mean overall AOFAS ankle-hindfoot score was 88.36 ± 6.39. The VAS score was 0.72 ± 0.65. Ankle motion included dorsiflexion (13.18° ± 9.02°) and plantar flexion (32.27° ± 12.34°). Subtalar joint motion included eversion (10.91° ± 7.01°) and inversion (11.36° ± 7.45°). All scores of the healthy side were higher than those of the affected side (<i>p</i> < .05). In addition to ROM of the ankle and subtalar joint and sports score, various indicators of recovery rate had scores > 80%. One patient developed skin necrosis, which healed after debridement and wound dressing. Late complications included subtalar and/or ankle traumatic arthritis in six patients, four of whom showed no obvious clinical symptoms. In conclusion, the method of emergency surgery and medial and anterolateral approach combined with countersunk K-wires to fix small bone fragments to restore the integrity of the articular surface is acceptable for Hawkins Ⅲ talus neck with medial malleolus fracture.

Minimally invasive medial plate osteosynthesis in tibial pilon fractures: Longterm functional and radiological outcomes.

The aim of this study was to evaluate the long-term follow-up and functional and radiological outcomes of minimally invasive medial plate osteosynthesis in distal tibia fractures. From January 2011 to November 2015, we reviewed the medical records of 60 patients with 62 tibia fractures (41 men and 19 women; mean age: 45.3±14.9 years) who were treated with open reduction and internal fixation for distal tibia pilon fractures. The mean follow-up time after surgery was 42.7±4.6 months. Union time, coronal plan deformity, complication rates and AOFAS and Olerud-Molander functional outcome scores were evaluated. According to the AO/OTA classification, there were thirty four (54.8%) type 43-A fracture, eight (12.9%) type 43-B fractures, twenty (32.3%) type 43-C fractures. The average time for fracture union was 16.1 weeks. The mean AOFAS score was 86.6±9.1. The mean Olerud-Molander score was 85.6±9.8. There were four patients (6.5%) with a varus of less than 5°, two patients (3.2%) with a valgus of less than 5°, 39 patients (62.9%) with recurvatum (34 of them less than 5°; five of them less than 10°), and 14 patients (22.6%) with procurvatum (12 of them less than 5°; two of them less than 10°). The AOFAS and Olerud-Molander scores in the smoker and diabetic patients were significantly lower than the non-smoker (p=0.002; p=0.005) and non-diabetic patients (p=0.022, p=0.002). The duration of union was significantly higher in both diabetic (p=0.025) and smoker patients (p=0.041). There was no association between the fracture type and the presence of varus, valgus, recurvatum and rotation deformity. The AOFAS score, Olerud-Molander score and plantar-flexion were significantly higher in type A fractures than in type C fractures (p=0.021; p=0.030, and p=0.033, respectively). AOFAS score, Olerud-Molander score, plantar-flexion value did not differ between type B and type C fractures. There was no significant difference among the dorsi-flexion (p=0.211), the follow-up time (p=0.531) and duration of union (p=0.908) of type A, type B and type C fractures. Three patients with open fracture had delayed wound healing. One patient developed skin necrosis. They were treated by local wound care. Minimally invasive medial plate osteosynthesis is a reliable method of treatment for tibial pilon fractures. This technique provides a high fracture healing rate and satisfying functional outcome with minimal wound healing complications. Sagittal plan deformity remains a common complication with minimally invasive medial plate osteosynthesis. Level IV, Therapeutic Study.

Outcome of Locked Compressive Nailing in Aseptic Tibial Diaphyseal Nonunions without Bone Defect.

Background:Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft.Materials and Methods:Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20–56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1–20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner–Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann–Whitney U-test were used.Results:Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection.Conclusions:The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.

Clinical and functional results of radial club hand with centralization and pollicization using the second metacarpus: A clinical case series

IntroductionRadial club hand (RCH) is a rare congenital deformity leading in several functional and psychological problems. However, our knowledge about the long-term functional outcomes of treating RCH is limited. In current study, we investigated the outcomes of centralization and pollicization using second or third metacarpal bone in RCH patients. MethodsThere were 15 hands (13 patients) with RCH underwent centralization and pollicization using second or third metacarpal bone or tendon transfer. The patients aged 1.2 ± 1 years at the time of the surgery. On early postoperative x-rays, the forearm-hand angle was measured. The patients were followed for 6.2 ± 2.3 years. At the final visit, disabilities of arm, shoulder and hand (DASH) score was completed. Furthermore, forearm-hand angle and range of motion of both wrists in sagittal and coronal planes were measured. ResultsThe mean of forearm-hand angle increased significantly. In 11 wrists, forearm-hand angle increased only 10 degrees of less. The range of operated wrist was improved in sagittal and coronal planes. The relative range of wrist motion in patients with unilateral deformity in sagittal and coronal planes was 83 ± 11 percent and 61 ± 12 percent. Three patients developed skin necrosis. ConclusionEarly centralization and pollicization using second or third metacarpal bone can significantly restore the range of motion and function in patients with RCH.

Swashbuckler approach and surgical technique in severely comminuted fractures of the distal femur

Background: Multiplanar severely comminuted type C3 distal femoral fractures present many challenges in terms of surgical approach and technique of fixation, which eventually reflect on the final outcome. This prospective study investigates a possible strategy to overcome these problems and hence improve the outcome by using a modified anterior approach to anatomically reconstruct the articular surface, followed by rigid fixation and an early aggressive rehabilitation program. Methods: Nine polytraumatized patients with closed C3-type injuries were included; seven were men, and the mean age was 33.4 yr. The cause of injury was road traffic accident in seven patients and a fall from a height in two. Five patients underwent surgery during the first week and four during the second after injury. The procedure was an anatomical reconstruction through a Swashbuckler approach, preserving the integrity of the quadriceps muscle and extensor mechanism. The mean follow-up was 17.6 mo (14–26 mo). Results: All patients had good clinical and radiographic healing without nonunion or malunion. Mean radiographic healing time was 19.2 wk. Clinically, three patients had excellent results, four had good results, one had a fair result, and one had a poor result. No patient developed skin necrosis, deep infection, or implant failure. However, the two patients with a fair and poor result had limited knee flexion to 85°; one required subsequent quadricepsplasty. Conclusions: The use of this anterior approach facilitated anatomical reconstruction of severely comminuted type C3 distal femoral fractures while preserving the integrity of the quadriceps muscle and extensor mechanism. This procedure had fewer than expected complications, had a favorable clinical outcome, and avoided future interference with any total knee arthroplasty surgery.

Intraoperative use of fluorescent imaging with indocyanine green changes management of abdominal wall flaps during open ventral hernia repair.

Wound complications including infection and necrosis remain common during complex open ventral hernia repair. Advancements or enhancements in imaging technology may abate some of these issues but requires more investigation. Laser-assisted fluorescent imaging with indocyanine green (Spy Elite, LifeCell Corporation, Branchburg, NJ) allows visualization and quantification of perfusion, facilitating management of poorly perfused tissue. Ten patients, who underwent large or massive ventral or incisional hernia repair with biologic graft reinforcement and either perforator-sparing components separation or primary open repair, underwent intraoperative laser-assisted fluorescent imaging with indocyanine green from August 2012 to August 2013. The cases were reviewed by an independent data collector with primary outcomes of postoperative skin infection and/or abdominal wall necrosis. Three (30%) patients had adequate perfusion, while seven (70%) patients had inadequate skin perfusion and necessitated excision of additional tissue. Of the patients whose ischemic tissue was removed, four (57%) patients had an infection and no patients developed necrosis postoperatively. Of the patients who had no removal of additional skin, one (33%) patient developed an infection and one (33%) patients developed skin necrosis. The intraoperative use of laser-assisted fluorescent imaging with indocyanine green may change management of abdominal wall flaps, even in perforator-sparing operations. Our study series is small and cannot suggest statistical significance in the potential benefit of intraoperative imaging, but shows that up to 70% of patients may require change in management due to poorly perfused tissue flaps.

Cetuximab versus cisplatin concurrent with IMRT in locally advanced head and neck cancer (LAHNC)

e17030 Background: Concurrent chemoradiation of LAHNC with cetuximab or cisplatin improves survival. The purpose of this study is to compare cetuximab chemoradiation (ExRT) with cisplatin chemoradiation (ChRT) in patients treated with IMRT. Methods: Between January 2005 and August 2008, 24 patients with LAHNC were treated with definitive chemoradiation utilizing IMRT. ExRT was reserved for those whose age or comorbidities precluded ChRT. 15 patients were treated with ChRT and 9 patients were treated with ExRT. Patient charts and Tumor Registry data were reviewed for acute and late toxicity and for local/regional failure (LRF), distant metastases and death. Results: The ExRT cohort was significantly older (median age 71 vs 58, p=0.005) and had more larynx/hypopharynx primaries (44% vs 27%). The cohorts were otherwise balanced with respect to T- and N-stage. Median follow-up for the ExRT and ChRT cohorts was 11 and 12 months, respectively. Overall treatment time in compliant patients was lower in ExRT patients (46 vs 50 days, p=0.05), reflecting increased use of accelerated radiation fractionation (66% vs 40%). See Table for toxicity outcomes. There was a trend toward increased ≥G3 acute mucositis in the ExRT group (p=0.07). However, there was less weight loss (p=0.05). There were similar acute epidermitis and hospitalizations for malnutrition/hydration rates and a nonsignificant decrease in prolonged mucosal toxicity. 1 patient developed skin necrosis and another osteoradionecrosis in the ChRT group. 1-year freedom from LRF was 89% in the ChRT group vs 56% in the ExRT group (p=0.07). Overall survival (OS) at 1 year was 100% (ChRT) vs 88% (ExRT). Conclusions: ExRT showed a trend toward worse acute mucosal toxicity but not late toxicity despite increased rates of altered fractionation with a higher daily dose. ExRT was associated with worse LRC and OS. A randomized study would best compare outcomes and toxicity profiles. Until such analysis, cetuximab should be reserved for patients unable to tolerate ChRT. [Table: see text] No significant financial relationships to disclose.

Two-Year Experience with the Avelar Abdominoplasty

Objective: To evaluate our 2-year experience with a modified Avelar abdominoplasty in an outpatient office surgery center setting and to compare our complication rate with other studies reported in the literature. Methods: A retrospective review of the medical charts of 80 patients who underwent a modified Avelar abdominoplasty between June 2005 and June 2007. Seventy-seven patients underwent full abdominoplasties and 3 patients had mini abdominoplasties. Patients included 79 women and 1 man. Their ages ranged from 24 to 76 years. Mean age was 44 years. Of the patients, 47 (59%) had tumescent local anesthesia with conscious sedation. The remaining 33 (41%) patients had tumescent infiltration with general anesthesia. Surgical Technique: The technique presented modifies the Avelar technique by using tumescent anesthesia infiltration and conscious sedation, the Mangubat disruptor, less aggressive liposuction in the lower abdomen, subcutaneous excision of the lower flap down to the fascia in larger patients, a different technique for umbilical transposition, and platelet-rich plasma is sprayed in the flap closure and on the incision to promote healing. With liposuction to help mobilize the skin, the upper flap undermining can be limited to the midline, and blood vessels in the area can be preserved. Results: Most patients were happy with their results, and they especially liked the body sculpting with additional liposuction of their flanks. In the 80 patients who underwent the modified Avelar abdominoplasty, there were 3 cases of skin necrosis (3.7% incidence), 10 seromas (12.5 % incidence), 1 episode of aspiration of gastric contents, and 1 episode of postoperative urinary retention requiring Foley catheter placement for 2 days. There were no cases of significant blood loss and no incidence of deep vein thrombosis. Most patients had significantly less pain than occurred with traditional abdominoplasty and most returned to work in 10 to 14 days. Discussion: The Avelar abdominoplasty is touted as a safe procedure with fewer complications than the traditional abdominoplasty because the perforator vessels, nerves, and lymphatics are not damaged during the operation. The few published studies using only the Avelar technique or a modification of it have demonstrated a low complication rate. The seroma rate found in this study of 12.5% falls within the reported rates of 0 to 32%. Skin necrosis is caused by profound devascularization in the area between the umbilicus and the horizontal scar. Even with sparing of the superior axial vasculature, this area is susceptible to skin necrosis. In the current study 3 patients developed skin necrosis in this area. One patient was a heavy smoker. The second patient was exposed to significant secondhand smoke; and the third patient was obese and had chronic hypertension. All patients had limited dissection in the midline. Conclusion: In the current study, where modifications of the Avelar technique was used, the complication rate was in the low range compared with the complication rates reported in the literature.

Adverse events associated with intravenous phenytoin in children: a prospective study

A prospective study was undertaken to assess the type and frequency of adverse side-effects following the use of intravenous phenytoin in children. Twenty-two children received a total of 100 doses over a 10-month period. Six patients (27%) experienced one or more side-effects, including extravasation of the drug, hypotension and cardiac arrhythmia. No patient developed skin necrosis, including the ‘purple glove syndrome’. Recovery from all adverse side-effects was spontaneous and complete. It is possible that some or all of these side-effects may have been caused by an excessive rate of infusion of phenytoin or the saline ‘flush’ following administration of the drug. The overall frequency of side-effects was perhaps less than expected.

Total skin electron irradiation for mycosis fungoides: relationship between acute toxicities and measured dose at different anatomic sites

From June 1978 to June 1986, 50 patients with primary and recurrent mycosis fungoides were treated with total skin electron irradiation (TSEI), using the Stanford technique, to a total dose of 3600 cGy. TSEI was used alone, or in combination with low dose total body photon irradiation, or MOPP. Thermoluminescent dosimeter (TLD) measurements of the prescribed skin dose were obtained on twenty patients. The dorsum of the foot was 24% higher. The axillae, the bottom, and the arch of the foot were significantly underdosed. Frequencies of acute toxicities noted at 2000 cGy were: Skin, Grade I-II (RTOG) 80%. Partial epilation: scalp, 100%; eyebrows and at eyelashes, 20%. Nail dystrophy, 48%. Edema: hands and feet, 44%. Bullae: dorsum of feet, 8%; hands, 4%; and 3600 cGy: Skin, grade 111 22%. Total epilation: scalp, 66%; eyebrows and eyelashes, 56%. Nail loss, 38%. Edema: hands and feet, 76%. Bullae: dorsum of feet, 34%; hands, 12%. Conjunctivitis, 4%. Large bullae, were more significant on the dorsum of the feet. Severe moist desquamation occurred in eight patients who had ulcerated lesions on initial presentation. Three patients were hospitalized due to ulceration and skin infection. All patients completed treatment after a short to moderate break. No patient developed skin necrosis, or corneal ulceration. No correlation exists between dose level, degree and onset of toxicity with previous chemotherapy or TBI. We conclude that the overall toxicity of TSEI is well tolerated.