Wound-related Complication Rate Research Articles

Megaendoprostheses in the management of malignant tumors of the lower extremities\u2014risk factors for revision surgery

BackgroundImproved oncological and surgical measures now enable curative treatment of malignant lower extremity tumors in majority of cases. Complication rates associated with surgical resection of lower extremity tumors and replacement with megaendoprostheses are high. The aim of this study was to identify risk factors that predispose to revision surgery following the use of megaimplants in curative treatment of malignant tumors of the lower extremities.Methodsthis retrospective study included patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis for tumors or metastatic lesions of the lower extremities between January 2010 and December 2020. Baseline characteristics and information on adjuvant treatment, hospitalization time, comorbidities, mobility, complications, and revision surgery were considered. Primary outcomes were revision surgery and reasons for revision. Secondary outcomes were in-hospital complications and the duration of hospitalization.ResultsFifty-four patients (48% female, age 63 years, SD 15) were available for final analysis. Surgeries were performed at hip level in 37 patients (68.5%) and at knee level in 17 patients (31.5%). Revision for wound-related causes was performed in 12 cases (22.2%), with microbiological proof of infection in 8 cases (14.8%). Revision for hip joint instability was carried out in 4 cases (7.4%) and for disconnection between components of the megaimplant in 2 cases (3.7%). Those patients requiring a wound-related revision had undergone a longer primary surgical intervention than those who required an implant-related revision (276 vs 134 min, p = .002). Wound drains after the primary implantation remained longer in situ in patients who later required revision surgery for wound-related complications (5 vs 3 days, p = .020). An ASA > 3 was associated with an increased likelihood for in-hospital complications in general (p = .041), and in-hospital death in particular (p = .012).ConclusionsThe management of malignant tumors of the lower extremities with megaendoprostheses is associated with a high rate of wound-related complications. Swift surgical performance and early postoperative removal of wound drains minimize the risk of complications in general and the necessity of revision surgery in particular. Patients with more comorbidities were more likely to suffer in-hospital complications.

Muscle Flap Closures in Spine Surgery: Predictors of Usage Patterns and Factors Associated With Postoperative Complications From the NSQIP Database.

Retrospective cohort study using the National Surgical Quality Improvement Program. The objective of this study was to identify preoperative factors that impact the decision to perform prophylactic muscle flap closure and assess risk factors for wound healing complications in patients undergoing spinal procedures with and without muscle flap closure. Prior studies suggest that muscle flap closure following complex spine surgery results in a lower risk of wound healing complications. However, these studies have been limited to single institutions and/or surgeons. The National Surgical Quality Improvement Program database was queried for all patients undergoing spine surgery between 2005 and 2017 with and without concomitant muscle flaps. Preoperative and perioperative variables were extracted. Univariate and multivariate analyses were performed to assess risk factors influencing surgical site infection (SSI) and wound disruption, as well as to delineate which preoperative factors increased the likelihood of patients receiving flap closures a priori. Concomitant muscle flaps were performed on 758 patients; 301,670 patients did not receive a flap. Overall 29 (3.83%) patients in the flap group experienced SSI compared to 5154 (1.71%) in the nonflap group (P<0.0001). Preoperative steroid use [odds ratio (OR) 0.5; P<0.0001], wound infection (OR 0.24; P<0.0001), elevated white blood cell count (OR 1.034; P<0.0001), low hematocrit (OR 0.94; P<0.0001), preoperative transfusion (OR 0.22; P=0.0068) were significantly associated with utilization of muscle flaps. Perioperative factors including a contaminated wound (OR 4.72; P<0.0001), the American Society of Anesthesiologists classification of severe disease (OR 1.92; P=0.024), and longer operative time (OR 1.001; P=0.0024) were significantly associated with postoperative wound disruption. In addition, after propensity score matching for these factors that increase risk of wound complications, there was no difference in the rates of SSI between the flap and nonflap group. Our results suggest that patients with a higher burden of illness preoperatively are more likely to receive prophylactic paraspinal flaps which can reduce the rates of wound-related complications.

Stent as a bridge to surgery versus urgent surgery for malignant right colonic obstruction: A multicenter retrospective study.

The impact of self-expandable metal stent (SEMS) for malignant right colonic obstruction remains undefined. The aim of this study was to compare short-term postoperative and long-term oncologic outcomes of colonic stenting as a bridge to surgery (SBTS) and urgent colectomy for patients with malignant right-sided obstruction. A total of 98 consecutive patients who underwent SEMS placement during the period 2004-2015 from three hospitals were included. For comparative analyses, patients were matched (1:2) with 196 patients treated with emergency colectomy from our prospective database. The two groups were comparable in terms of demographics and tumor characteristics. The proportion of patients who underwent laparoscopic colectomy was higher in SBTS group than urgent colectomy group (75.5% vs. 37.2%; p < 0.001). Patients treated with SBTS were less likely to have a temporary stoma constructed (3.1% vs. 10.7%; p=0.024). SBTS was associated with significantly less median estimated blood loss (90 vs. 100 ml; p=0.029), shorter length of hospital stay (11 vs. 12 days; p < 0.001), lower overall postoperative complication rate (18.4% vs. 31.3%; p=0.018), and wound-related complication rate (5.1% vs. 14.3%; p=0.019) compared with urgent surgery. Reoperation rate, 30-day mortality, and lymph nodes harvested were not significantly different between two groups. Disease-free survival rate and overall survival rate were similar between the two groups. SEMS insertion is safe and feasible for treating malignant right-sided obstruction. SBTS is associated with better short-term outcomes and equivalent long-term oncologic results compared with urgent colectomy.

Natural orifice versus conventional mini-laparotomy for specimen extraction after reduced-port laparoscopic surgery for colorectal cancer: propensity score-matched comparative study.

Although reduced port laparoscopic surgery (RPLS), defined as laparoscopic surgery performed with the minimum possible number of ports and/or small-sized ports, is less invasive than conventional laparoscopic surgery by reducing the number of surgical wounds, an extension of the incision is still needed for specimen extraction, which can undermine the merits of RPLS. To determine the impact of natural orifice specimen extraction (NOSE) in patients undergoing RPLS for colorectal cancer. The endpoints were perioperative outcome and oncologic safety at 3years. Single-center experience (2013-2019). We retrospectively analyzed our prospectively collected patient records (American Joint Committee on Cancer (AJCC) stage I-III sigmoid or upper rectal cancer (tumor diameter ≤ 5cm) who underwent curative anterior resection via RPLS. We excluded patients who did not undergo intestinal anastomosis. Perioperative and oncologic outcomes were compared between patients undergoing natural orifice (RPLS-NOSE) or conventional (mini-laparotomy) specimen extraction (RPLS-CSE). Patients were matched by propensity scores 1:1 for tumor diameter, AJCC stage, American Society of Anesthesiologists score and tumor location. Of 119 eligible patients, 104 were matched (52 RPLS-NOSE; 52 RPLS-CSE) by propensity scores. Compared with RPLS-CSE, RPLS-NOSE was associated with longer operative time (223.9 vs. 188.7min; p = 0.003), decreased use of analgesics (morphine dose 33.9 vs. 43.4mg; p = 0.011) and duration of hospital stay (4.2 vs. 5.1days; p = 0.001). No statistically significant difference was found in morbidity or wound-related complication rates between the two groups. After a median follow-up of 34.3months, no local recurrence was observed in RPLS-NOSE. The 3-year disease-free survival did not differ statistically significantly between groups (90.9 vs. 90.5%; p = 0.610). NOSE enhances the advantages of RPLS by avoiding the need for abdominal wall specimen extraction in patients with tumor diameter ≤ 5cm. Surgical and oncologic safety are comparable to RPLS with CSE.

Perioperative and oncological outcomes of laparoscopic radical cystectomy with intracorporeal versus extracorporeal ileal conduit: A matched-pair comparison in a multicenter cohort in Japan.

To compare the perioperative and oncological outcomes of pure laparoscopic intracorporeal ileal conduit urinary diversion versus extracorporeal ileal conduit urinary diversion after laparoscopic radical cystectomy for bladder cancer in a multicenter cohort in Japan. A total of 455 patients who underwent laparoscopic radical cystectomy carried out at 10 institutions were included in this retrospective study. The perioperative data of the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups were compared using the propensity score matching method. The Kaplan-Meier curves were obtained to elucidate time to ureteroenteric stricture, reoperation, recurrence and survival. In total, 72 matched pairs were evaluated for the final analysis. The median follow-up period was 28 and 23months in the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups, respectively. The operative time in the intracorporeal ileal conduit urinary diversion group was approximately 1h longer than that in the extracorporeal ileal conduit urinary diversion group. The early and late postoperative complication rates were similar in both groups, except for the reduced wound-related complication rates in the intracorporeal ileal conduit urinary diversion group. The median days to regular oral food intake were 4 and 5days in the intracorporeal ileal conduit urinary diversion and extracorporeal ileal conduit urinary diversion groups, respectively (P=0.014). No significant difference was noted in the occurrence of ureteroenteric strictures and reoperation rate. Furthermore, recurrence-free, cancer-specific, and overall survival rates and recurrence patterns did not significantly differ. Laparoscopic intracorporeal ileal conduit urinary diversion is a safe, feasible and reproducible procedure with similar postoperative complication rates, ureteroenteric stricture rate and oncological outcomes when compared with extracorporeal ileal conduit urinary diversion, but faster postoperative bowel recovery and decreased wound-related complication rates.

Risk factors for wound-related complications after microvascular decompression.

Retrosigmoid craniotomy for microvascular decompression (MVD) has been traditionally performed via craniectomy. Various closure techniques have been described, yet factors associated with wound-related complications remain undetermined. Accordingly, herein, we sought to identify risk factors associated with wound-related complications after such procedures. An institutional retrospective case-control study was performed; outcomes of interest were cerebrospinal fluid (CSF) leak, wound dehiscence, wound infection, and pseudomeningocele. Univariate analysis was performed using Wilcoxon rank sum test for non-parametric continuous outcomes and chi-square test for categorical outcomes. Multivariate logistic regression was performed on binomial outcome variables. The study population included 197 patients who underwent MVD for trigeminal neuralgia (83.2%), hemifacial spasm (12.2%), vestibular nerve section (3.0%), and glossopharyngeal neuralgia (1.5%). The overall wound-related complication rate was 14.2% (n= 28), including twelve patients (6.1%) with CSF leak, ten patients (5.1%) with wound infection, ten patients (5.1%) with pseudomeningocele, and nine (4.6%) patients with wound dehiscence. Using multivariate logistic regression, preoperative anemia and current tobacco use were associated with significantly higher rates of complications (OR 6.01 and 4.58, respectively; p< 0.05), including CSF leak (OR 12.83 and 12.40, respectively, p< 0.05). Of note, use of synthetic bone substitute for cranioplasty was associated with a significantly lower rate of complications (OR 0.13, p< 0.01). Preoperative anemia and current tobacco use significantly increased, while synthetic bone substitute cranioplasty significantly decreased, odds of wound-related complications, the need for treatment, and CSF leaks. Additionally, higher BMI, longer operative duration, and prior radiosurgery may increase risk for wound-related complications.

The Obesity-associated Risk in Open and Endovascular Repair of Abdominal Aortic Aneurysm.

The rising pandemic of obesity in modern society should direct attention to a more comprehensive approach to abdominal aortic aneurysm (AAA) treatment in the affected population. Although overweight patients are considered prone to increased surgical risk, studies on the subject did not confirm or specify the risks well enough. Associated comorbidities inevitably lead to a selection bias leaning towards endovascular abdominal aortic repair (EVAR), as a less invasive treatment option, which makes it hard to single out obesity as an independent risk factor. The increased technical difficulty often results in prolonged procedure times and increased blood loss. Several smaller studies and two analyses of national registries, including 7935 patients, highlighted the advantages of EVAR over open repair (OR) of abdominal aortic aneurysm, especially in morbidly obese population (relative risk reduction up to 47%). On the other hand, two other studies with 1374 patients combined, concluded that EVAR might not have an advantage over OR in obese patients (P = 0.52). Obesity is an established risk factor for wound infection after both EVAR and OR, which is associated with longer length of stay, subsequent major operations, and a higher rate of graft failure. Percutaneous EVAR technique could present a promising solution to reducing this complication. EVAR seems like a more feasible treatment option than OR for obese patients with AAA, due to lower overall morbidity and mortality rates, as well as reduced wound-related complication rates. However, there is a clear lack of high-quality evidence on the subject, thus future prospective trials are needed to confirm this advantage.

Accuracy in Deep Brain Stimulation Electrode Placement: A Single-Surgeon Retrospective Analysis of Sterotactic Error in Overlapping and Non-Overlapping Surgical Cases

Background: Many surgeons utilize assistants to perform procedures in more than one operating room at a given time using a practice known as overlapping surgery. Debate has continued as to whether overlapping surgery improves the efficiency and access to care or risks patient safety and outcomes. Objective: To examine effects of overlapping surgery in deep brain stimulation (DBS) for movement disorders. Methods: In this retrospective analysis of overlapping and non-overlapping cases, we evaluated stereotactic accuracy, operative duration, length of hospital stay, and the presence of hemorrhage, wound-related complications, and hardware-related complications requiring revision in adults with movement disorders undergoing DBS. Results: Of 324 cases, 141 (43.5%) were overlapping and 183 (56.5%) non-overlapping. Stereotactic error, number of brain penetrations, and postoperative length of hospitalization did not differ significantly (p ≥ 0.08) between the overlapping and non-overlapping groups. Mean operative duration was significantly longer for overlapping (81/141 [57.4%], 189.5 ± 10.8 min) than for non-overlapping cases (79/183 [43.2%], 169.9 ± 7.6 min; p = 0.004). There were no differences in rates of wound-related complications or hemorrhages, but overlapping cases had a significantly higher rate of hardware-related complications requiring revision (7/141 [5.0%] vs. 0/183 [0%]; p = 0.002). Conclusions: Overlapping and non-overlapping cases had comparable DBS lead placement accuracy. Overlapping cases had a longer operative duration and had a higher rate of hardware-related complications requiring revision.

Is Wound Complication a Deterrent to Lateral Extensile Approach in Calcaneus Fracture?

Introduction: The lateral extensile approach has been a widely accepted surgical approach in treatment of intraarticular calcaneal fracture. It provides good exposure for fixation by correcting the hindfoot varus, fracture reduction and restores calcaneal height but it has a high wound complication rate. Methods and materials: 36 intraarticular calcaneal fractures (Sanders II, III and IV) treated using the lateral extensile approach in 34 patients presenting between 2015 and 2018 were retrospectively reviewed. Wound complication in the early stage (day 1 to day 3), intermediate (2 weeks) and late (6 weeks) were documented. Results: We found early (Day 1 - Day 3) infection rate of 5.6%, intermediate (2 weeks) at 17.6% and late wound complication (6 weeks) at 2.9%. Conclusion: Lateral expansile approach is a reliable surgical exposure for fracture reduction of calcaneal fractures with acceptable wound related complication rate. Minimally invasive techniques and the sinus tarsi approach are being used for less comminuted fractures, but those techniques are technically more demanding. Smoking, long duration of surgery and soft tissue handling also play a role in increasing wound complication rates.

Wound closing method with 2‑octyl cyanoacrylate after single-incision laparoscopic surgery for colorectal cancer

The use of 2‑octyl cyanoacrylate (CA) for the umbilical wound after single-incision laparoscopic surgery (SILS) for colorectal cancer has not been described. A consecutive experience of SILS for colorectal cancer is presented. Three hundred sixty-four patients (172 women) were treated with SILS for colorectal cancer between December 2010 and December 2015. Our institution introduced CA in September 2012. The data of patients treated with CA were compared to a historical group who underwent standard sutured skin closure with thin adhesive strips (AS) at our institution. The Centers for Disease Control and Prevention criteria were used for the diagnosis of superficial surgical site infection (SSI). Of these 364 patients, 20 patients (5.5%) were converted to laparotomy including the extension of the skin incision longer than 3 cm. In 344 patients completed with SILS, CA was used in 247 patients. Superficial SSI occurred in two patients (0.81%) with CA and one (1.03%) with AS. No patients completed with SILS suffered wound dehiscence in this series. There were no significant differences in wound-related complication rate between the two groups. CA provides sufficient wound closure in SILS for colorectal cancer. SILS with CA has the possibility to provide a lower superficial SSI rate in patients with colorectal cancer.

Effect of intra-operative glove changing during cesarean section on post-operative complications: a randomized controlled trial.

To compare the rates of wound-related complications among women undergoing a cesarean section when the surgical team used intra-operative glove changing versus usual care. All women undergoing a cesarean section at a single, county hospital were randomized to usual care or intra-operative glove changing prior to abdominal closure. Participants were randomized at the time of decision for cesarean section; surgeons were not blinded to the randomization arm. The primary outcome was any wound-related complication, including wound hematoma, seroma, skin separation of at least 1cm, wound infection, or other incisional abnormality requiring treatment within 8weeks of surgery. To detect a reduction in the primary outcome from 17% in the control group to 9% in the intervention group with 80% power, a total of 554 women (277 per group) were required. Secondary outcomes included other infectious complications including endometritis and other superficial or deep soft tissue infections. From August 2015 to November 2016, 277 women were randomized to usual care and 276 women were randomized to intra-operative glove changing. The two groups were well balanced in terms of demographic data, comorbid conditions and surgical characteristics. Intra-operative glove changing led to a significant decrease in composite wound complications from 13.6% in the control group to 6.4% in the intervention group (p = 0.008). Intra-operative glove changing prior to abdominal closure during cesarean section significantly reduced the incidence of post-operative wound complications.

Impact of Robotic Platforms on Surgical Approach and Costs in the Management of Morbidly Obese Patients with Newly Diagnosed Uterine Cancer.

Minimally invasive surgery (MIS) is associated with decreased complication rates, length of hospital stay, and cost compared with laparotomy. Robotic-assisted surgery-a method of laparoscopy-addresses many of the limitations of standard laparoscopic instrumentation, thus leading to increased rates of MIS. We sought to assess the impact of robotics on the rates and costs of surgical approaches in morbidly obese patients with uterine cancer. Patients who underwent primary surgery at our institution for uterine cancer from 1993 to 2012 with a BMI ≥40mg/m(2) were identified. Surgical approaches were categorized as laparotomy (planned or converted), laparoscopic, robotic, or vaginal. We identified two time periods based on the evolving use of MIS at our institution: laparoscopic (1993-2007) and robotic (2008-2012). Direct costs were analyzed for cases performed from 2009 to 2012. We identified 426 eligible cases; 299 performed via laparotomy, 125 via MIS, and 2 via a vaginal approach. The rates of MIS for the laparoscopic and robotic time periods were 6% and 57%, respectively. The rate of MIS was 78% in this morbidly obese cohort in 2012; 69% were completed robotically. The median length of hospital stay was 5days (range 2-37) for laparotomy cases and 1day (range 0-7) for MIS cases (P<0.001). The complication rate was 36 and 15%, respectively (P<0.001). The rate of wound-related complications was 27 and 6%, respectively (P<0.001). Laparotomy was associated with the highest cost. The robotic platform provides significant health and cost benefits by increasing MIS rates in this patient population.

Prospective Randomized Evaluation of Intraoperative Application of Autologous Platelet-Rich Plasma on Surgical Site Infection or Delayed Wound Healing

Prevention of surgical site infections and the reduction of wound-related complication rates have become increasingly emphasized by hospital task groups and government agencies given the degree of economic burden it places on the health care system. Platelet-rich plasma (PRP) contains growth factors and other biomolecules that promote endogenous microbicidal activity. We hypothesized that PRP would help prevent postoperative infection and delayed wound healing (DWH). We randomized patients having foot or ankle surgery to the treatment group receiving intraoperative PRP (applied to operative field) and platelet-poor plasma at closing (PPP, on the sutured skin) or the control group (no PRP/PPP). The incidence of deep surgical site infection and DWH (collectively called endpoints) was compared between groups (n = 250/group). PRP had a mean 5.3-fold platelet concentration compared to whole blood, with concentrated white blood cells. Mean age (±SD) of patients was 52 years (±15), 65% were women. Minor and major operative procedures were included. Patients were followed for 60 days. Seventy controls had PRP prepared for assay of growth factors. Procedure mix, ASA scores, mean operative times, and comorbidity mix were similar between groups. The primary result was no difference in number of endpoints between groups: 19 patients in the PRP group (7.6%) versus 18 controls (7.2%). Endpoints were deep surgical site infections in 2 PRP/PPP patients and 1 control, and DWH in 17 PRP/PPP patients and 17 controls. Analysis of PRP samples revealed a large variation in growth factor concentrations between patients. Intraoperative application of PRP/PPP did not reduce the incidence of postoperative infection or DWH. Growth factor profiles varied greatly between patients, suggesting that the potentially therapeutic treatment delivered was not consistent from patient-to-patient. Level I, prospective randomized trial.

National trends and in-hospital outcomes in HIV-positive patients undergoing spinal fusion.

A retrospective analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample. To examine the trends and in-hospital outcomes of patients with human immunodeficiency virus (HIV) infection undergoing spinal fusion on a national level. Highly active antiretroviral therapy has provided healthier lives and prolonged the life expectancy of HIV-positive patients. However, few previous studies have reported trends and outcomes of HIV-positive patients undergoing spinal surgery. Clinical data were derived from the US Nationwide Inpatient Sample between 2000 and 2009. Patients who underwent spinal fusion were identified. Data regarding HIV, patient- and health care system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between HIV-positive and -negative patients and analyzed with the use of multivariate logistic regression. A total of 5,070 HIV-positive patients underwent spinal fusion in the United States during the last decade. From 2000 to 2009, population-adjusted incidence of HIV-positive patients who underwent spinal fusion has increased more than 3-fold (0.094 per 100,000 in 2000 to 0.303 per 100,000 in 2009; P < 0.001). Comparison between HIV-positive and -negative patients showed that HIV-positive patients had a significantly higher respiratory complication rate (6.2% vs. 3.2%), wound-related complication rate (2.7% vs. 1.7%), overall in-hospital complication rate (12.2% vs. 9.5%), and in-hospital mortality rate (1.6% vs. 0.3%), as well as longer hospital stay (6.6 d vs. 4.2 d). The risk of in-hospital mortality was 3.53 times higher in HIV-positive patients after controlling for other factors (95% confidence interval, 2.02-6.14; P < 0.001). During the last decade, the incidence of HIV-positive patients undergoing spinal fusion has increased in the United States. In this study, HIV infection was an independent risk factor for in-hospital mortality in patients undergoing spinal fusion. 3.

Outcome of laparoscopic versus open resection for rectal cancer in elderly patients

BackgroundLaparoscopic colorectal resection has been gaining popularity over the past two decades. However, studies about laparoscopic rectal surgery in elderly patients with long-term oncologic outcomes are limited. In this study, we evaluated the short-term and long-term outcomes of laparoscopic and open resection in patients with rectal cancer aged ≥70 y. MethodsFrom 2007–2012, a total of 294 consecutive patients with rectal cancer from a single institution were included, 112 patients undergoing laparoscopic rectal resection were compared with 182 patients undergoing open rectal resection. ResultsSeven (6.3%) patients in the laparoscopic group required conversion to open surgery. The two groups were well balanced in terms of age, gender, body mass index, American society of anesthesiologists scores, site, and stage of the tumors. Laparoscopic surgery was associated with significantly longer median operating time (220 versus 200 min; P = 0.005), less estimated blood loss (100 versus 150 mL; P < 0.001), a shorter postoperative hospital stay (8 versus 11 d), lower overall postoperative complication rate (15.2% versus 26.4%; P = 0.025), wound-related complication rate (7.14% versus 17.03%; P = 0.015), less need of blood transfusion (8.04% versus 16.5%; P = 0.038), and surgical intensive care unit after surgery (12.5% versus 22.0%; P = 0.042) when compared with open surgery. Mortality, quality of surgical specimen, lymph nodes harvested, positive distal, and circumferential margin rate were not significantly different between two groups. The estimated 3-y survival rates were similar between two groups. ConclusionsLaparoscopic rectal surgery is safe and feasible in patients >70 y and is associated with better short-term outcomes when compared with open surgery.

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

Safety and Efficacy of Multimodal Thromboprophylaxis Following Total Knee Arthroplasty: A Comparative Study of Preferential Aspirin vs. Routine Coumadin Chemoprophylaxis

Multimodal thromboprophylaxis encompasses preoperative VTE risk stratification, regional anesthesia, mechanical prophylaxis, and early mobilization. We determined if aspirin can be safely used for adjuvant chemoprophylaxis in patients who have a low thromboembolic risk. 1016 consecutive patients undergoing TKA received multimodal thromboprophylaxis. Aspirin was used in 67% of patients and Coumadin 33% (high risk patients, or who were on Coumadin before surgery). This study group was compared to 1001 consecutive patients who received multimodal thromboprophylaxis and routine Coumadin chemoprophylaxis. There was no significant difference in rates of VTE, PE, bleeding, complications, readmission and 90-day mortality between the two groups. There was a significantly higher rate of wound related complications in the control group (p=0.03). Multimodal thromboprophylaxis with aspirin given to the majority of patients at a low VTE risk is safe and effective in patients undergoing primary TKA.

Neoadjuvant chemotherapy for adult soft tissue sarcomas: A phase II trial.

10069 Background: Treatment of soft tissue sarcomas (STS) is characterized by high rates of local control, but poor overall survival because of distant relapses and high rates of wound complications, when preoperative radiation is used. The objective of this study was to test the effectiveness of a protocol with neoadjuvant chemotherapy for STS. Methods: A phase II single-arm prospective trial was carried out. Only adult patients with high grade extremity lesions and tumors deep and larger than 5 cm were included. A total of four cycles of chemotherapy was administered pre-operatively. The chemotherapeutic regimen was: ifosfamide – total of 9.0 g/m2 per cycle, infused in 2 hours from Day 1 to Day 5 (1.8 mg/m2/day). Half of the equivalent dose of mesna was infused 15 min pre-ifosfamide and 4 hours post-ifosfamide. Doxorubicin – total of 60mg/m2 per cycle, was infused in bolus on Day 1. Filgrastima 300 mcg, SC, was administered after the last dose of chemotherapy for 5 days. Radiation was given after surgery. Toxicity was classified by the NIH Toxicity Criteria and response was determined by the RECIST criteria. The others endpoints were the amputation and the wound-related complication rates. Results: Between January, 2005 and May, 2011, 42 patients were included. 21(50%) patients have completed the 4 cycles. Nineteen patients (45.2%) have grade 3 or 4 toxicity, and one (2.3%) death related to treatment had occurred. Between severe complications, febrile neutropenia was the most frequent. By using the RECIST criteria, we observed 10(24.5%) cases of progression, 24(58.5%) cases of stable disease, and 7(17%) partial responses. No complete clinical or radiological response was observed. In the pathological analysis of the surgical specimens, 4(9.7%) cases showed no residual disease (complete pathological response), and a total of 6 (14.6%) showed ≤ 5% of viable residual cells. The amputation rate was 4.8% (2 cases) and complications related to the wound were observed in 9 patients (21.9%). Conclusions: The protocol showed a good rate of objective and pathological response, low rate of complications related to the operative wound, and maintained an acceptable amputation rate. On the other hand, we observed high rate of progression, by RECIST criteria.

Fibrin sealant for the prevention of axillary seroma formation after axillary lymph node disection. A prospective randomized study.

Abstract Abstract #4139 Background&amp;#x2028; The most frequent postoperative complication after axillary limph node dissection is the axilary seroma (AS) formation. Currently accepted practice includes insertion of one or more drainage system for fluid evacuation. Several methods have been proposed to decrease AS formation, such as closed suction catheters, shoulder immobilisation, tetracycline sclerotherapy, talc podrage and closure of dead space; however no of them have reduced the incidence of AS. Seromas are associated with wound infection, wound dehiscence and skip flap necrosis, which prolong the recovery and can extend patient´s stay in Hospital.&amp;#x2028; The aim of this prospective randomized controlled trial was to evaluate the efficacy of fibrin sealant (FS) on the prevention of AS.&amp;#x2028; Material and Methods&amp;#x2028; Sixty-two patients undergoing axillary lymph node dissection were randomized to treatment with drainaje alone (arm A, n=49), drainage plus FS (arm B, n=12), or FS alone (arm C, n=53). Arm B was cancelled after primary results. Efficacy was evaluated in terms of lengh of hospital stay, volumen of fluid drainage and rate of wound related complications (seroma, hematoma, infection, dehiscence) in each arm.&amp;#x2028; Results&amp;#x2028; No significative differences are detected neither type of surgery, nor histlogycal characteristics.&amp;#x2028; &amp;#x2028; The mean result is a difference of almost minus 3 days in postoperative stay in the FS group.&amp;#x2028; &amp;#x2028; Conclusions&amp;#x2028; 1- Application of fibrin sealant reduces the amount of serosanguinous drainage and the length of postoperative stay in patients who have undergone axillary lymph node dissection.&amp;#x2028; 2- Fibrin sealant allows to avoid the insertion of an axillar drainage system&amp;#x2028; 3- It is very important the correct preparation and application of the fibrin sealant and it should be performed by a qualified surgeon.&amp;#x2028; 4- Future clinical trials toasses the role of fibrin sealant seroma are warranted. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4139.

GORE PRECLUDE® MVP® dura substitute applied as a nonwatertight “underlay” graft for craniotomies: product and technique evaluation

Background While watertight closure of the dura is a long-standing tenet of cranial surgery, it is often not possible and sometimes unnecessary. Many graft materials with various attributes and drawbacks have been in use for many years. A novel synthetic dural graft material called GORE PRECLUDE® MVP® dura substitute (WL Gore & Associates, Inc, Flagstaff, Ariz) (henceforth called “MVP”) is designed for use both in traditional watertight dural closure and as a dural “underlay” graft in a nonwatertight fashion. One surface of MVP is engineered to facilitate fibroblast in-growth so that its proximity to the underside of the dura will lead to rapid incorporation, whereas the other surface acts as a barrier to reduce tissue adhesion to the device. Methods A series of 59 human subjects undergoing craniotomy and available for clinical and radiographic follow-up underwent nonwatertight underlay grafting of their durotomy with MVP. This is an assessment of the specific product and technique. No attempt is made to compare this to other products or techniques. Results The mean follow-up in this group was more than 4 months. All subjects have ultimately experienced excellent outcomes related to use of the graft implanted with the underlay technique. No complications occurred related directly to MVP, but the wound-related complication rate attributed to the underlay technique was higher than expected (17%). However, careful analysis found a high rate of risk factors for wound complications and determined that complications with the underlay technique could be avoided by assuring close approximation of the graft material to the underside of the dura. Conclusions MVP can be used as an underlay graft in a nonwatertight fashion. However, if used over large voids (relaxed brain or large tumor bed), “tacking” or traditional watertight closure techniques should be used. The underlay application of MVP is best applied over the convexities and is particularly well-suited to duraplasty after hemicraniectomy.