Severe Wound Complications Research Articles

In Vitro Comparison of Wire and Plate Fixation for Midline Sternotomies

The incidence of severe sternal wound complications in high-risk cardiac patients presents a significant need for more stabile sternal fixation techniques after median sternotomy procedures. Rigid metal plates, a potential alternative to wire fixation, are thought to promote faster sternal healing by reducing motion at the wound site. The goal of this study was to compare the stability provided by commercially available sternal plates with standard wires using an in vitro model. Lateral distraction tests were conducted on bisected polyurethane sternal models fixed with either a standard 7 wire configuration (n = 5) or a 3 plate configuration (n = 3). To assure controlled loading, the sternal models were attached to a computer-controlled test machine by a novel tethering system that distributes the total force (180N) equally to eight locations on the sternum. Stability was defined as the ability to restrict sternal separation at seven locations along the midline quantified using digital image analysis. Our results indicate that rigid plate fixation significantly reduced lateral motion relative to wire fixation. The lower sternal region most noticeably benefited from plate fixation as the splaying observed for wire fixation was reduced. Under these loading conditions, plating increased stability at the midline compared to wires; this increased stability may facilitate the recovery of high-risk patients undergoing cardiac operation. To enhance in vitro testing methods, future studies should incorporate additional in vivo loading conditions applied to the sternum. Alternate plating configurations should also be examined to further increase stability.

A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications.

Forty-eight patients who suffered sternal wound infections following coronary artery bypass grafting were retrospectively reviewed over a 5-year period. All patients in this study had clinical signs of major infection including redness, pain, and purulence at the time of mediastinal drainage and debridement. One patient died 11 days postoperatively because of heart failure, leaving 47 patients available for long-term follow-up. All muscle flaps (pectoralis and rectus abdominis) survived completely. All wound complications were related to chest wall skin flap dehiscence or continued infection. Seventeen of 22 patients (77 percent) undergoing flap closure 4 days or less after sternal debridement and irrigation suffered wound complications. Five of these 22 patients (23 percent) had major wound complications, meaning that the wound required more than 2 months of care before healing was complete. No major wound complications and only three minor complications (12 percent) occurred in 25 patients undergoing sternal flap closure 5 days or more after mediastinal debridement and irrigation. The frequency and severity of wound complications were significantly decreased in the group of patients undergoing sternal flap closure 5 or more days after sternal drainage and debridement (p < 0.00005). In the majority of cases [29 of 47 (62 percent)], secure sternal wound closure was obtained with a single, split, medially based, right pectoralis major muscle flap.

Endoscopic vs. Conventional Vein Harvesting:First Results with a New, Non-Disposable System

Most of the grafts used in coronary bypass surgery are still venous grafts. The preferred vein for bypass surgery is the long saphenous vein. Severe wound complications caused by saphenous vein harvesting occur in 1 % to 3 % of cases. Minor complications that do not need surgical revision occur in up to 43 % of cases. We developed an endoscopic harvesting technique using non-disposable instruments to reduce wound complications caused by vein harvesting. In a retrospective study, the occurrence of wound complications, haematoma, postoperative pain, ambulation, sensory disturbances and patient satisfaction were studied (n = 182). Patients who had either endoscopically harvested (n = 91) or conventionally harvested (n = 91) saphenous vein grafts were reviewed. Results were collected for 173 patients. The overall prevalence of wound complications was 18.7 %. The incidence of wound healing complications could be reduced significantly (p = 0.015) from 15.3 % to 3.4 % using the endoscopic technique. In the endoscopic group, postoperative ambulation was significantly (p = 0.002) easier, patient satisfaction was significantly (p = 0.007) higher, and postoperative leg swelling (p = 0.003) and haematoma (p = 0.004) could be reduced significantly. The occurrence of postoperative pain and sensory disturbances did not differ significantly. We conclude that the used endoscopic vein harvesting is a safe and cost effective method that can significantly reduce wound complications. An ongoing prospective study should establish our demonstrated data.

A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision

Background: Although studies in animals demonstrated a better wound healing after abdominal incision with cold scalpel than with electrocautery, clinical experiences did not confirm these findings. The purpose of this study was to compare early and late wound complications between diathermy and scalpel in gynecologic oncologic patients undergoing midline abdominal incision. Methods: Patients undergoing midline abdominal incision for uterine malignancies were divided into two groups according to the method used to perform the abdominal midline incision: cold scalpel and diathermy in coagulation mode. Early and late complications were compared. Logistic regressions were used for statistical analysis. Results: Nine hundred sixty-four patients were included, of whom 531 were in the scalpel group and 433 in the electrocautery group. Both groups were similar with respect to demographic, operative, and postoperative characteristics. Univariate analysis revealed a higher incidence of severe wound complications in the scalpel group than in the electrocautery group (8 of 531 versus 1 of 433, P <0.05). After adjustment for confounding variables (eg, age, body mass index) no differences were found between groups. Conclusions: Scalpel and diathermy are similar in terms of early and late wound complications when used to perform midline abdominal incisions. Therefore the choice of which method to use remains only a matter of surgeon preference.

Wound complications after left ventricular assist device implantation

Background. Wound necrosis and infection pose a tremendous risk for patients with left ventricular assist devices. Methods. We analyzed our database of patients with left ventricular assist devices for those who developed wound dehiscence and concomitant infection after left ventricular assist device implantation. Results. Three of our 66 patients (4.5%) with implantable ventricular assist devices had had severe wound complications with necrosis of the abdominal or thoracic wall uncovering part of the device. The predominant impact on the development of these complications was presumably related to multiple surgical interventions on the same site. Conclusions. Nevertheless, these patients can recover and undergo successful heart transplantation if adequately managed.

Pilon Fractures

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.

Metronidazole in head and neck surgery—The effect of lengthened prophylaxis

Previous studies of antibiotic prophylaxis have shown that treatment for 24 hours has been beneficial for head and neck surgery and that longer periods of antibiotic therapy have not improved results. Metronidazole (Flagyl), unlike other antibiotics tested, has been shown to be effective in an experimental abscess, even if treatment is begun up to 120 hours after administration of inoculum. This article presents a prospective, randomized, multifactorial study comparing a brief vs. a prolonged duration of metronidazole and cefazolin prophylaxis in 50 consecutive patients with a head and neck cancer undergoing operation. Patients receiving 2 days vs. 7 or more days of antibiotic prophylaxis were compared. Statistical analysis of data demonstrated a striking reduction in severity of wound complications and a reduced incidence of wound infections in the group treated with 7 or more days of antibiotic prophylaxis.

Preoperative irradiation for soft tissue sarcomas of the trunk and extremities in adults

Between May 1978 and January 1987, 58 adult patients with previously untreated sarcomas of the trunk and extremities were treated with preoperative irradiation and surgery at the University of Florida. All patients had a minimum of 2 years of follow-up; 24 had a minimum of 5 years of follow-up. The preoperative dose was usually 5040 cGy, with 120–125 cGy per fraction delivered twice daily. Operations were performed 2 to 6 weeks after radiation therapy. Eight patients received adjuvant chemotherapy. The tumors were high grade in 52 (90%), measured >10 cm in 45 (78%), and were extracompartmental in 49 (84%). The surgical margins were wide in 17, marginal in 31, and intralesional in 10 patients. A functional extremity was preserved in 47 of 54 patients who would have required an amputation had they been treated by operation alone. Five of 58 patients (9%) developed local failure; in three, the failure occurred outside of the irradiated volume. Survival rates (product-limit method) at 5 years according to grade and size of lesion were as follows: low grade, 100%; high grade, 10 cm or less in largest diameter, 68%; high grade, 11–20 cm, 39%. Data are insufficient for a 5-year analysis of high-grade lesions > 20 cm; to date, there are no 5-year survivors in these patients. Moderate and severe wound complications occurred in 16%. There were four pathological fractures in 52 long bones at risk.

Wound complications in the multimodality treatment of extremity and superficial truncal sarcomas.

The incidence and severity of wound complications were examined in 105 patients with extremity and superficial truncal sarcomas who were eligible for wide local excision with or without adjuvant perioperative brachytherapy (BRT) and/or chemotherapy. Fifty-four cases from the eligible group were entered into a randomized prospective trial of the efficacy of BRT in decreasing local recurrence. In the eligible patients, major wound complications occurred in nine of 41 (22%) of the BRT cases, compared with two of 64 (3%) of the non-BRT patients, which was a significant increase (P = .002). The combined frequency of major and moderate wound complications was also significantly increased in the BRT (18 of 41, 44%) compared with the non-BRT (nine of 64, 14%) patients (P = .0006). The median duration to complete resolution of these complications was 189 days (14 to 597) in the BRT, compared with 49 (11 to 170) days in the non-BRT group (P = .0005); however, no amputations were required, and only 14% of the BRT-associated wound complications were of prolonged duration, ie, greater than 200 days. In the randomized study, both the total number of complications, and the combination of major and moderate complications were increased significantly in the BRT v the non-BRT patients. Adjuvant Adriamycin (Adria Laboratories, Columbus, OH) administered in 60 mg/m2 increments to a cumulative dose of 540 mg/m2 did not appear to impair wound healing even when administered within 15 days of operation. Significant wound complications occur in major resections of extremity and superficial truncal sarcomas. If the addition of adjuvant BRT produces a decrease in local recurrence, then either patient selection will have to be more rigidly applied, especially in wounds where skin flap blood supply is tenuous, or the technique will need to be modified to balance the short-term aim of reducing wound complications with the long-term goal of local tumor control.

Short course netilmicin prophylaxis in renal stone surgery.

Following surgery for the removal of intrarenal calculi 30% of patients will develop severe wound complications. This study assesses the role of a short course of netilmicin given over the operative period, in 20 consecutive patients. Preoperative studies demonstrated that whilst 20% of patients had bacterial growth in the urine, culture of the removed calculus demonstrated that 50% of the stones exhibited a significant bacterial growth. Of the 20 patients, only one developed a wound complication. Following the preoperative dose, satisfactory netilmicin levels were obtained and no patient had levels greater than 1 microgram ml-1 by 7 h. Despite some degree of renal impairment, serum urea and creatinine values were unaffected.

Ischaemic wound complications in above-knee amputations in relation to the skin perfusion pressure.

Healing of the stumps in 59 above-knee amputations was correlated with the local skin perfusion pressure (SPP) measured preoperatively as the external pressure required to stop isotope washout using 131I-(-) or 125I-(-) antipyrine mixed with histamine. Out of the 11 cases with an SPP below 30 mmHg no fewer than 9 (82 per cent) suffered wound complications. Out of the 48 cases with an SPP above 30 mmHg severe wound complications occurred in only 4 cases (8 per cent). The difference in wound complication rate is highly significant (P < 0.01). It is concluded that the SPP can be used to predict ischaemic wound complications in above-knee amputations as has previously been shown to be the case in below-knee amputations.

Wound Healing in Above-Knee Amputations in Relation to Skin Perfusion Pressure

In 59 above-knee amputations healing of the stumps was correlated with the local skin perfusion pressure (SPP) measured preoperatively as the external pressure required to stop isotope washout using 1318-- or 125I--antipyrine mixed with histamine. Out of the 11 cases with an SPP below 30 mmHg no less than nine (82 per cent) suffered severe wound complications. Out of the 48 cases with an SPP above 30 mmHg severe wound complications occurred in only four cases (8 per cent). The difference in wound complication rate is highly significant (P less than 0.01). The postoperative SPP measured on the stumps was on average only slightly and insignificantly higher than the preoperative values, explaining why the preoperative values related so closely to the postoperative clinical course. We conclude that the SPP can be used to predict ischaemic wound complications in above-knee amputations as has previously been shown to be the case in below-knee amputations.