Reduce Wound Complications Research Articles

Comparative analysis of negative pressure wound therapy (PICO) and standard dressing application after arterial vascular reconstructions.

Surgical site infections following arterial reconstructions with femoral exposures are common and potentially preventable. Negative pressure wound therapy has emerged as a potential solution to minimize groin wound complications. Our study evaluates efficacy of a negative pressure therapy (PICO dressing) in reducing groin wound complications after vascular reconstructions. A retrospective single center comparative analysis of vascular reconstructions involving common femoral artery dissection was performed between July 2021 and June 2023. Patients were divided into two groups: patients treated with PICO device and patients who received standard dressing (non-PICO). Patient demographics, comorbidities, vascular evaluation, and procedure indications were compared. Previous interventions, incision orientation and procedure types were noted. The wound complication categories were graded according to the Szilagyi classification: grade 1 (superficial infection/minor dehiscence), grade 2 (deep infection/major dehiscence), and grade 3 (artery or prosthetic involvement). Statistical significance level was determined at p < .05 for all analyses. A total of 217 groin dissections in 184 patients were analyzed with 132 and 85 groin dissections in the PICO and non-PICO groups, respectively. The baseline characteristics were similar between the groups in terms of age, sex, BMI, and procedure indications. Prior endovascular procedures and re-operative groin surgeries were more prevalent in the PICO group. The use of antibiotics post-operatively for groin wound complication was greater in the non-PICO group. The incidence of wound complications was higher in the non-PICO group (29.4% vs 10.6%, p < .001). Multivariate logistic regression analysis determined that PICO dressing as well as hybrid and endovascular index procedures were associated with lower risks of groin complications. PICO dressing decreased the incidence of groin wound complications in patients undergoing open vascular reconstructions. This study highlights the value of adjunctive negative pressure therapy in reduction of wound complications after arterial reconstructions in the inguinal region.

Cohen versus Pfannenstiel Cesarean Skin Incision for BMI =35 kg/m2: a Randomized Controlled Trial

Background: Maternal obesity is recognized as a significant risk factor for adverse pregnancy outcomes, including increased cesarean delivery rates and heightened surgical complications. It is unclear if the Cohen or Pfannenstiel skin incisions at cesarean delivery are associated with different outcomes. Objective: To evaluate the impact of either Cohen or Pfannenstiel cesarean skin incision type on maternal morbidity. Study Design: Pregnant individuals with a BMI of ≥35 kg/m2, carrying either singleton or multiple gestations, were consented prenatally and in labor. Eligible participants who underwent a cesarean delivery between 24 and 41 weeks of gestation were randomized to either Pfannenstiel or Cohen skin incisions at Thomas Jefferson University Hospital from October 2016 to March 2020. The study aimed to recruit 284 participants based on a sample size calculation assuming a 50% reduction in wound complications with Cohen versus Pfannenstiel incisions (80% power, α=0.05), but recruitment was terminated early after 72 participants were randomized. The primary outcome was a composite maternal morbidity within six weeks, which consisted of the following: wound infection, hematoma, seroma, separation of skin ≥1 cm, readmission for wound complications, endometritis, and postpartum hemorrhage. Statistical analyses included bivariate tests, t-tests, and non-parametric analyses. Results: Of 331 pregnant individuals consented prenatally and in labor, 72 eventually underwent cesarean delivery and were randomized, 34 to Cohen and 38 to Pfannenstiel skin incisions. The mean BMI was >42 kg/m2, about two thirds of the patients had a pannus, 56% were Black, 47% had diabetes, and 56% hypertensive disorders. The primary outcome of composite maternal morbidity occurred in 47.1% in the Cohen and 36.8% in the Pfannenstiel groups (RR 1.24, 95% CI 0.71-2.08), and was also similar regardless of the presence of a pannus, or by degree of obesity. Surgical site infection, hematoma, seroma, wound separation/dehiscence, endometritis, and postpartum hemorrhage were each similar between Cohen and Pfannenstiel participants. Neonatal outcomes were also similar between the Cohen and Pfannenstiel groups, except that the Cohen group was found to have statistically significant lower Apgar score at 5 minutes and higher need for respiratory support compared to the Pfannenstiel group, possibly related to the trend for a longer time from skin incision to delivery. Physicians were found to be significantly less satisfied with the Cohen compared to the Pfannenstiel incision. Conclusion: In pregnant patients with BMI of ≥35 kg/m2, obstetrical providers can chose from either a Cohen or an Pfannenstiel skin incision, as they are associated in general with similar outcomes, except for lower Apgar scores and lower physician satisfaction associated with the Cohen incision. The findings of this study are limited by its early cessation for logistical reasons, leading to an underpowered analysis. It is crucial to acknowledge that these results must be interpreted cautiously due to the reduced sample size and the circumstances surrounding the study's termination. These data can inform future trial design and implementation as well as fuel individual patient level meta-analyses on this topic.

Comparison of the safety and efficacy of three superficial skin closure methods for multi-layer wound closure in total knee arthroplasty: a multicenter, prospective, randomized controlled trial

BackgroundGood wound healing is critical to infection prophylaxis and satisfactory rehabilitation in Total Knee Arthroplasty (TKA). Currently, two techniques, i.e., barbed continuous subcuticular suture without skin adhesive or combined use skin adhesive (n-butyl-2) are being used for superficial wound closure of TKA. While a new skin adhesive (2-octyl) with self-adhesive mesh has been employed as an alternative to conventional surgical skin closure in TKA, its superiority, especially in reducing wound complications and improving wound cosmetic outcomes has not been investigated. This study aimed to compare 2-octyl, n-butyl-2, and no skin adhesive in terms of safety and efficacy in TKA superficial wound closure.MethodsWe conducted a multicenter, prospective, randomized controlled study in 105 patients undergoing primary TKA between May 2022 and October 2023. Each patient’s knee was randomized to receive 2-octyl, n-butyl-2, or no skin adhesive skin closure with all using barbed continuous sutures in deep tissue. Wounds were followed 1, 3, 5 days, 2, 6 weeks, and 3 months after surgery. Wound discharge, complications, cosmetic outcomes, patient satisfaction, and wound-related costs were compared among these three methods.ResultsWound discharge was less in 2-octyl group and n-butyl-2 group than in non-adhesive group at 1 day, with the discharge only being less in 2-octyl group than in the non-adhesive group at day 3 and day 5 days (P < 0.05). There was no statistical difference in the incidence of other wound complications among the groups (P > 0.05). The 2-octyl group achieved better cosmetic effects than the other two groups in 6 weeks and 3 months (P < 0.05). Compared to the non-adhesive group, 2-octyl group scored higher in overall patient satisfaction score in 2 weeks and incurred lower costs (P < 0.05).ConclusionsSkin closure in TKA using 2-octyl adhesive material showed superiority when compared to no skin adhesive or n-butyl-2, in reducing wound discharge, improving the cosmetic outcomes, without increasing wound complications. In addition, the use of 2-octyl yielded better patient satisfaction and also was less costly compared to no skin adhesive. Our study exhibited that 2-octyl was a safe and effective wound closure technique for patients undergoing TKA.Trial registrationThis study has been registered at Clinical Trials. Gov (No. ChiCTR210046442).

U-T Flap for Distal Symes Toe Amputation. A New Flap Adapted to Diabetic Ulcers of the Pulp of the Lesser Toes

The surgical management of diabetic ulcers of the tip of the toes complicated with osteomyelitis of the distal phalanx usually consists of the excision of the bone and soft tissue using a distal Symes toe amputation. This surgery is usually conducted through 2 coronal flaps. When the ulcer is away from the nail or extends further on the plantar side of the pulp, wound closure could be difficult to achieve resulting in wound dehiscence. In addition, the remaining toe is often too short when compared with the neighboring digits. The objective of this surgical technique is to propose a new flap design that could be simple and easy to learn, mainly when dealing with small-to-moderate–sized wounds. The U-T flap is designed to reduce wound complications and yield better esthetics. We found the U-T flap to be a reproducible technique with better outcomes in terms of surgical wound healing and final toe length, after excision of distal infected toes. Level of Evidence: Diagnostic level 5—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Focused Perioperative Nutritional Supplementation Reduces Wound Complications in Patients Undergoing Spinal Fusion Surgery.

Retrospective cohort study. To evaluate intensive postoperative nutritional supplementation on wound healing complications and outcomes after spinal fusion surgery. Poor nutritional status leads to inferior postoperative outcomes by increasing mortality and predisposing patients to infection and wound healing complications. While perioperative nutritional supplementation has shown promise in mitigating these risks, there is a paucity of literature regarding specific nutritional routines in spinal fusion surgery. A retrospective analysis was conducted on patients who underwent spinal fusion surgery between 2019 and 2022. Demographic and nutritional data, including preoperative prealbumin levels (PAB) and postoperative supplemental diet, were examined. Primary endpoints included wound complications, with secondary outcomes assessing Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Health (PH) scores. Statistical analyses included unpaired t-tests and Chi-squared/Fischer's exact tests with significance set at P<0.05. Patients receiving the supplemental diet (n=229) demonstrated fewer wound complications (7% vs. 21%, P=0.004) and reoperations (3% vs. 11%, P=0.016) compared to those without supplementation (n=56). No significant differences were observed in preoperative or postoperative PROMIS PH or ODI scores. Patients with normal preoperative PAB had more wound complications without the supplemental diet (5% vs. 18%, P=0.025). A similar trend was seen in the patients with low preoperative PAB (12% vs. 26%, P=0.12). Postoperative nutritional supplementation significantly reduces wound complications after spinal fusion surgery in a cost-effective manner. This study underscores the modifiability of certain perioperative risk factors and suggests that nutritional strategies can mitigate potential complications.

Racial and ethnic disparities in reception of muscle flap closure during oncologic spinal surgery

BackgroundRacial disparities persist in surgical outcomes after spine surgery for primary and metastatic cancers. Muscle flap closure of spinal defects after oncologic resection has been shown to reduce wound complication rate with favorable cost-effectiveness. It is currently unknown whether racial disparities may affect the reception of this treatment. MethodsSpinal surgery procedures for tumor resection and subsequent reconstruction were identified in the 2011-2022 National Surgical Quality Improvement Program databases. Cases were propensity score matched for covariates like age, comorbidities, number of vertebral levels reconstructed, and length of stay to isolate the predictive impact of race on reception of muscle flap closure (p<0.05). Results9,467 patients that underwent oncologic spine surgery and had known race and ethnicity were identified in the final cohort. Two hundred thirty-two (2.5%) cases included muscle flap closure during the index surgery. After matching (n=4,196), minority race/ethnicity was associated with lower rates of muscle flap closure (2.2%) than non-Hispanic White race/ethnicity (3.8%) (p=0.0037). Upon weighted univariate logistic regression, minority racial and ethnic identification also predicted lower likelihood of muscle flap closure (OR: 0.57, 95% CI: 0.52-0.63, p<0.001). Among patients who received muscle flap closure, overall rate of all, major, or minor thirty-day postoperative complications were not different depending on race and ethnicity (p>0.05). ConclusionThere are evident racial disparities in the reception of muscle flap closure after oncologic spine surgery. Further work may investigate the role of intersecting socioeconomic factors like insurance status and hospital characteristics. LAY SUMMARYMuscle flap closure is a surgical technique within plastic surgery that has been associated with lower rates of complications after spine surgery to remove tumors. Our study shows that minority racial and ethnic groups are less likely on average to receive muscle flap closure. Data availability statementThe data that support the findings of this study are publicly available.

LONG-TERM OUTCOMES OF A RANDOMIZED CONTROLLED TRIAL COMPARING FIBULAR NAIL WITH OPEN REDUCTION AND INTERNAL FIXATION IN PATIENTS WITH UNSTABLE ANKLE FRACTURES

BackgroundStudies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up.MethodsPatients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years.ResultsNinety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859).ConclusionThe current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered.

Comparison of Ankle Fracture Fixation Using Intramedullary Fibular Nailing Versus Plate Fixation

Ankle fracture fixation using intramedullary fibular (IMF) nails has been shown to allow for earlier weightbearing, reduced wound complications, better union rates, and the absence of prominent hardware, compared to plates/screw (PS) constructs. The purpose of present retrospective cohort study was to compare outcomes of patients who underwent ankle fracture fixation using an IMF nail versus PS. Demographic, clinical, and radiographic data were recorded for patients who underwent ankle fracture fixation between May 2020 and May 2022, and who were at least 1 year postoperative. Toe-touch weightbearing was permitted immediately after surgery, protected weightbearing (PWB) at postoperative week 2, and weightbearing as tolerated in a brace at week 6. Radiographs were assessed preoperatively, and at 2, 6, 12, 24, and 48 weeks postoperative. Sixty-one ankle fractures (30 IMF, 31 PS) with a mean follow up of 14.7 and 18 (range, 12 to 23) months were included. Overall, the IMF nail cohort had less pain, faster time to union (11.4 vs 13.2 weeks), and less complications (23% vs 45%), reoperations (10% vs 16%), and surgical failures (9% vs 9.7%), compared to the PS cohort. The differences were not statistically significant. The PS cohort had a higher rate of symptomatic hardware irritation (p=<0.001). Tobacco use adversely effected direct osseous healing (p<0.001) and increased postoperative complications (p=0.050). The present study lends credence to the previously reported advantages of IMF nailing over PS fixation for ankle fractures. Ankle fracture fixation using a 4th generation, IMF nail is a viable alternative to traditional PS fixation.

How I do it: Endoscope-assisted in situ arterial reconstruction of the lower limb

Arterial reconstruction with the great saphenous vein is a frequently performed vascular surgery technique for revascularization of chronic limb threatening ischemia. Surgeon variations of the procedure are common and aim to balance patency, limb salvage, complications, hospital resources, and technical feasibility. We describe a minimally invasive revascularization option using endoscope assistance for in situ great saphenous vein–arterial bypass to treat infrainguinal occlusive disease. We highlight patient selection, operating room setup, instrument details, and procedure strategies that facilitate the use of this technique. The development and refinement of minimally invasive techniques for lower extremity arterial bypass are critical to reduce wound complications and improve limb salvage outcomes in patients.

Phase II Clinical Trial of Intravenous Levothyroxine to Mitigate Pharyngocutaneous Fistula in Euthyroid Patients Undergoing Salvage Laryngectomy.

Patients undergoing head and neck cancer surgery after prior radiation or chemoradiation are at high risk for wound complications. Hypothyroidism is a known risk factor for wound complications, especially fistulae after salvage total laryngectomy. The purpose of this phase II clinical trial is to investigate the effect of perioperative intravenous levothyroxine supplementation on wound complications in patients undergoing salvage total laryngectomy. Euthyroid patients previously treated with radiation/chemoradiation undergoing total laryngectomy were prospectively recruited (n = 72). Postoperatively, intravenous levothyroxine was administered at a weight-based dose (1.3 mcg/kg/d) and transitioned to enteral dosing on day 7. Free T3, T4, and thyroid-stimulating hormones were collected, and dosing was adjusted accordingly. The primary endpoints were rates of fistula formation and fistula requiring reoperation, compared with matched historic controls. All patients were monitored for adverse effects. The rate of postoperative hypothyroidism was 21% compared with 49% in a matched historic cohort. The rate of fistula formation was 18.1%, whereas the rate of fistula requiring reoperation was 4.2%, significantly lower than rates in our historic cohort (34.6% and 14.8%, respectively; P = 0.02 and 0.01). Postoperative hypothyroidism and recurrent clinical stage predicted fistula requiring reoperation in multivariate analysis; other acute phase reactants were not predictive. There were no observed adverse events related to levothyroxine supplementation. Postoperative intravenous levothyroxine supplementation reduced rates of acute hypothyroidism, fistula formation, and fistula requiring reoperation in patients undergoing salvage total laryngectomy without adverse effects. Intravenous levothyroxine is a viable strategy to reduce wound complications in this high-risk patient population.

Prognostic factors for surgical site infection in patients with spinal metastases and following surgical treatment.

There were few articles reviewed prognostic factors of surgical site infection (SSI) in patients with spinal metastases following surgery. The purpose of the present study was to systematically: (1) investigate the incidence rates of SSI following spinal metastases surgery; (2) identify the factors which were independently associated with postoperative wound infection. One hundred sixty-seven consecutive adult patients with spinal metastases and underwent surgical treatment were retrospectively enrolled from January 2011 to February 2022. Demographic data, disease and operation-related indicators were extracted and analyzed. Univariate and multivariate logistic analysis model were performed respectively to determine independent risk factors of SSI. 17 cases infection were collected in this study. The overall incidence of SSI after surgery of spinal metastases patients was 10.2%. Univariate regression analysis showed that age (P = .028), preoperative ALB level (P = .024), operation time (P = .041), intraoperative blood loss (P = .030), Karnofsky Performance Status score (P = .000), body mass index (P = .013), American Society of Anesthesiologists > 2 (P = .010), Tobacco consumption (P = .035), and number of spinal levels involved in surgical procedure (P = .007) were associated with wound infection. Finally, the multivariate logistic model demonstrated that body mass index (P = .043; OR = 1.038), preoperative ALB level (P = .018; OR = 1.124), and number of spinal levels (P = .003; OR = 1.753) were associated with SSI occurrence. Surgery on multiple vertebral levels for spinal metastases significantly increases the risk of SSI and weight management, nutritional support and palliative surgery have the positive significance in reducing wound complications. Orthopedist should focus on identifying such high-risk patients and decrease the incidence of wound infection by formulating comprehensive and multi-disciplinary care strategy.

Endoscopic Repair of Ischial Tuberosity Avulsion Fracture

Background: The ischial tuberosity apophysis serves as an attachment site for the hamstring muscle complex in the pediatric pelvis. Once the apophysis begins to ossify around age 13 to 15 years, decreasing elasticity makes the physis the weakest part of the hamstring attachment to the pelvis. An avulsion injury of the hamstring muscle group in the adolescent therefore results in a fracture in the adolescent and is the functional equivalent to a 3-tendon proximal hamstring injury in an adult. Ischial tuberosity fractures have a higher rate of non-union than other pelvic apophyseal injuries. Endoscopic surgery offers the advantage of smaller incisions, reduced wound complications, and expedited recovery compared with an open procedure. Indications: Controversy exists over which fractures benefit from surgical fixation. Patients with an ischial tuberosity avulsion fracture that is displaced more than 20 mm or that remains symptomatic despite at least 3 months of conservative management are common indications for surgery. Technique Description: The patient is positioned in the prone position and under fluoroscopic guidance 2 endoscopic portals are created. The sciatic nerve is visualized, neurolysis performed, and then protected throughout the remainder of the case. The ischial tuberosity is located along with the avulsed apophysis and hamstring tendon. The bony surfaces are prepared. The fracture fragment is reduced and 3 partially threaded cannulated screws are percutaneously passed across the fracture. The interval between the semimembranosus and conjoined tendons was closed with a suture. Results: There are no results published specific to this technique. Outcome papers are lacking, but cohort studies show significant displacement increases risk for non-union. Displaced ischial tuberosity fractures are also thought to risk sciatic nerve irritation and decreased hamstring strength. Discussion/Conclusion: Recent advancements in periarticular endoscopic surgery of the hip have enabled this historically open procedure to be performed in a minimally invasive fashion. This technique achieves robust fixation of the avulsed fragment and the benefits of anatomic repair of the hamstring origin while avoiding the larger incision and soft tissue dissection required for an open procedure. In time, this technique may become standard of care much like other sports medicine procedures which have transitioned from open to arthroscopic with the development of suitable tools and techniques. 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.

Prospective evaluation of a closed-incision negative pressure wound therapy system in kidney transplantation and its association with wound complications.

Wound complications can cause considerable morbidity in kidney transplantation. Closed-incision negative pressure wound therapy (ciNPWT) systems have been efficacious in reducing wound complications across surgical specialties. The aims of this study were to evaluate the use of ciNPWT, Prevena™, in kidney transplant recipients and to determine any association with wound complications. A single-center, prospective observational cohort study was performed in 2018. A total of 30 consecutive kidney transplant recipients deemed at high risk for wound complications received ciNPWT, and the results were compared to those of a historical cohort of subjects who received conventional dressings. Analysis for recipients with obesity and propensity score matching were performed. In total, 127 subjects were included in the analysis. Of these, 30 received a ciNPWT dressing and were compared with 97 subjects from a non-study historical control group who had conventional dressing. The overall wound complication rate was 21.3% (27/127). There was no reduction in the rate of wound complications with ciNPWT when compared with conventional dressing [23.3% (7/30) and 20.6% (20/97), respectively, p = 0.75]. In the obese subset (BMI ≥30 kg/m2), there was no significant reduction in wound complications [31.1% (5/16) and 36.8% (7/19), respectively, p = 0.73]. Propensity score matching yielded 26 matched pairs with equivalent rates of wound complications (23.1%, 6/26). This is the first reported cohort study evaluating the use of ciNPWT in kidney transplantation. While ciNPWT is safe and well tolerated, it is not associated with a statistically significant reduction in wound complications when compared to conventional dressing. The findings from this study will be used to inform future studies associated with ciNPWT in kidney transplantation.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

BackgroundNegative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life. MethodThis is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life. ConclusionPatients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Laparoscopic Cholecystectomy in Jos: Prospects and Perspectives.

Laparoscopic cholecystectomy is now done in a lot more private and public hospital settings presently in low-income countries, particularly sub-Saharan Africa. Though it is not routinely done in these centres, the percentage of cholecystectomies done laparoscopically has increased over the years. Laparoscopic surgery services were introduced at our hospital in 2011 and this retrospective study reviews our outcomes with the procedure over a 6-year period. A total of 87 cholecystectomies were done in the period under review. Forty-eight (55.2%) were laparoscopic cholecystectomies, 30 (44.8%) were open cholecystectomies, and 9 (10.3%) were mini-laparotomy cholecystectomies. There were 32 (66.7%) women and 16 (33.3%) men who had laparoscopic cholecystectomy giving a male-to-female ratio of 1:2. The mean age of the patients was 41.0 years (SD = 14.3 years). The most common indication for laparoscopic cholecystectomy was calculous cholecystitis. The most common co-morbidity was hypertension in 23 (47.9%) patients, followed by sickle cell anaemia in 10 (20.8%) patients. The operating time ranged from 70 min to 120 min with a mean of 86.6 (SD = 14.5). There were three conversions and two intra-operative complications. Twenty-five patients (52.1%) were discharged within 24 h, 16 (33.3%) within 48 h and the rest (14.6%) were discharged later. The duration of surgery had a significant association with duration of hospital stay. There was 1 mortality in our study. Laparoscopic cholecystectomy offers unique advantages over open such as decreased length of hospital stay and reduced wound complications. Most of the cholecystectomies in our setting are now performed laparoscopically with a low conversion rate and low incidence of bile duct injuries. Patients with sickle cell disease constitute a significant percentage of patients requiring this procedure.

Drain use can be avoided in reverse shoulder arthroplasty

BackgroundDrains have demonstrated no clear benefits and some potentially harmful effects in hip and knee replacements. There is little evidence about the effects of its use in shoulder arthroplasty. We hypothesized that drain use would increase postoperative blood loss without reducing wound complications. MethodsWe included 103 reverse shoulder arthroplasties (RSA), 71 were operated for degenerative pathology, 32 due to a fracture. All complications were recorded. Hemoglobin (Hb) and hematocrit (Htc.) level were collected and compared to postoperative data. Length of hospitalization and volume output were also noted. Results45 patients received a closed-suction drain. Patients with coagulopathy had significant higher bleeding and were excluded (p = 0.03). Patients operated for a fracture were older (80.1y.o vs 72.1 p < 0.01) and had higher blood drop (∆Hb p = 0.01; ∆Htc p = 0.03). There were neither differences between drain and control group in ∆Hb or ∆Htc in the degenerative RSA group (1.84+/-0.89 vs 1.68+/-0.84, p = 0.36; 5.78+/-2.89 vs 5.53+/-2.87 p = 0.50) nor in the fracture RSA group (2.65+/-0.94 vs 2.65+/-1.01, p = 0.90; 7.91+/-2.99 vs. 7.09+/-4.21, p = 0.56). There were neither differences in complications (degenerative p = 0.33; fracture p = 0.21). Drain use was related to a longer hospital stay in elective surgery (2.6 vs 1.8 days; p < 0.01). DiscussionThe rate of complication is similar between patients with and without drain use. Drain use after shoulder arthroplasty does not affect postoperative bleeding but increases the length of hospital stay. Drains seems to be an unnecessary intervention after RSA that may increase associated costs and can be safely abandoned. Level of evidenceLevel III retrospective comparative study.

Acute Achilles tendon rupture: modern management

Achilles tendon rupture is a common injury and its incidence is increasing. There is a large body of literature on the subject and much of it debates the influence of management on re-rupture rates. Operative treatment was thought to be superior in reducing the risk of re-rupture. However, it must be balanced against the risks, in particularly wound infection and breakdown, and sural nerve injury. Minimally invasive surgery aimed to reduce wound complications but has frequently been associated with a higher risk of sural nerve damage and irritation. The introduction of functional rehabilitation, which includes early weight bearing and range of motion within an orthosis, has been pivotal in improving outcomes particularly in non-operatively managed patients. More recent evidence suggests that re-rupture rates are now similar between operatively and non-operatively managed patients when incorporating a functional rehabilitation protocol. The publication of the Achilles Tendon Rupture Score, which has been validated specifically for this injury, has been helpful in providing a more detailed picture of post-injury symptoms and function. The studies which have included this as an outcome measure have also shown comparable results between operatively and non-operatively treated patients.

Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery.

Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery. This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice. Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit. Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

Optimizing the Approach to STA-MCA Bypass Surgery and Reducing Wound Complications

The treatment of complex intracranial aneurysms with bypass surgery using 2 branches of the superficial temporal artery (STA) proves to be an effective surgical option. However, the harvest of these 2 STA branches, combined with a pterional craniotomy, carries the potential risk of delayed wound healing of the skin flap. This study undertook a retrospective analysis to examine and identify the factors associated with this delayed wound healing. A total of 56 consecutive cases, including both ruptured and unruptured complex intracranial aneurysms, that underwent bypass surgery with 2 branches of the STA, were analyzed retrospectively. Major delayed wound healing was observed in 6 (10.7%) cases. Univariate analysis demonstrated significant associations with the following factors: rupture (P= 0.023), presence of diabetes mellitus (P= 0.028), large craniotomy size (P= 0.012), and the type of skin incision (P ≤ 0.001). Age (P= 0.283), sex (P= 0.558), body mass index (P= 0.221), and other blood test parameters did not demonstrate any statistical significance. Similarly, the presence of a dominant frontal branch (P= 0.515) or a low-positioned frontal branch (P= 0.622) did not reveal statistically significant results. In the treatment of complex intracranial aneurysms, where harvesting of the 2 STA branches is involved with a pterional craniotomy, producing a smaller skin flap (L- or T-shaped incision) is effective in minimizing the risk of delayed wound healing. The process of harvesting the STA and closing the wound demands meticulous care, taking into consideration the normal anatomical structures and the subdermal vascular plexus of the scalp.

The effect of postoperative immobilization in a plaster of Paris back-slab on the surgical wound-healing following the open reduction and plate and screw fixation of the closed calcaneal fractures: a randomised controlled study

Background: Intraarticular calcaneal fractures often need open reduction and internal fixation with plate osteosynthesis. Wound complication is one of the common problems encountered following this. It affects the outcome adversely. Our study was done to assess if a postoperative back-slab can offer any significant difference in the incidence of wound complications. Methods: Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were provided postoperative slab and continued for six weeks. The remaining 22 patients were not provided any plaster. All patients were followed-up for two years. Results: The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p=0.02). Also, significantly lower heel widening was reported in the plaster group (p=0.03). Although there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusions: Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures.