Superficial Wound Breakdown Research Articles

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias.

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias. Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS). Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100). ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Unstable Rotational Ankle Fractures Treated With Anatomic Mortise Repair and Direct Posterior Malleolus Fixation.

Introduction: The purpose of this study was to evaluate patient outcomes following a standardized algorithmic approach to ankle mortise stabilization, following rotational fracture, utilizing direct repair of the posterior malleolus in the prone position. Methods: Eighty consecutive patients with unstable rotational ankle fractures that involved the posterior malleolus were analyzed. All underwent direct repair of the posterior malleolus regardless of size through a posterolateral approach. Electronic records were retrospectively reviewed for demographic information, initial injury and operation details, healing status, and complications. Preoperative and postoperative radiographs were obtained to assess the initial injury and healing was determined both by radiographic and clinical progress at follow-up visits. Results: Average posterior malleolus fragment width was 8.1 ± 3.7 mm (range = 2.1-19.9 mm) and percentage of the articular surface was 23.6% (range = 7.1%-56.7%) on the lateral radiograph. Overall, 80/80 (100%) patients healed their ankle fractures by a mean 2.9 ± 1.1 months. Only 1 (1.3%) patient required transsyndesmotic fixation following posterior malleolus repair. Mean range of ankle motion was as follows: dorsiflexion 20° ± 10°, plantarflexion 34° ± 10°, inversion 8° ± 4°, and eversion 7° ± 4°. Seventy-nine patients (98.8%) had an anatomic mortise reduction. Nine patients (11.3%) had a superficial wound complication, 3 patients (3.8%) had dysesthesia in the sural nerve distribution, and 1 patient (1.3%) lost reduction of the medial malleolus. Conclusion: Patients who undergo direct repair of the posterior malleolus in the prone position can expect a high rate of healing with superficial wound breakdown being the biggest problem, which was associated with an ankle fracture dislocation. Posterior malleolus fixation may obviate the need of transsyndesmotic stabilization.Levels of Evidence: Retrospective Level IV.

Excisional Debridement for Chronic Achilles Insertional Tendinosis: A Novel Technique and Case Review.

Operative treatment of chronic Achilles insertional tendinosis (AIT) involves tendon debridement, removal of the retrocalcaneal bursitis, and excision of the calcaneal exostosis, often followed by repair of the Achilles tendon and deep tendon transfer. The literature describes a variety of techniques without a single standard of care. This is a retrospective review of 57 patients treated with an excisional debridement of the central portion of the Achilles tendon. The novelty of this technique is that instead of complete detachment of the tendon from its insertion, only the central portion is debrided and excised. This allows for enhanced visibility of the calcaneal exostosis and increased healing with apposition of viable tendon during side-to-side repair. Patient-reported outcome scores and pain significantly improved from preoperatively to a minimum of 2 years postoperatively. Complications were similar to those previously reported, with superficial wound breakdown being the most common. In conclusion, the use of this reliable, reproducible, and effective technique for the treatment of patients with chronic AIT is encouraged because it provides both enhanced visibility and allows complete resection of all pathological tissue. Level IV: Retrospective case series.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy.

Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP. Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used. In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02). In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Excisional Debridement for Chronic Achilles Insertional Tendinosis: Technique and Case Series

Category:Sports; AnkleIntroduction/Purpose:Operative treatment of chronic Achilles insertional tendinosis (AIT) involves tendon debridement, removal of the retrocalcaneal bursitis, and excision of the calcaneal exostosis, often followed by repair of the Achilles tendon and deep tendon transfer. The literature describes a variety of techniques without a single standard of care. The purpose of this study is to describe a novel approach for the treatment of chronic AIT and report clinical outcomes and complications of this technique.Methods:A retrospective review was performed of 57 patients with chronic AIT who were treated with the proposed surgical technique by a single surgeon from January 2015 through January 2019. Patient demographics, pain scores, functional outcome scores, and complications were reviewed. A telephone survey was also utilized to assess patient satisfaction. Following the breakdown of the data, comparisons of the preoperative scores were compared to the postoperative outcomes using Mann- Whitney U testing.Results:Preoperative VAS pain scores and VR-12 Physical scores were significantly improved at two year follow up. Additionally, patients described the outcome of their surgery as, ‘very good.’ Complications were also few and minimal. Three (5.3%) patients experienced superficial skin breakdown requiring return to the operating room and three (5.3%) developed postoperative cellulitis which responded to local care and oral antibiotics. There were no ruptures or record of recurrence of disease or pain.Conclusion:The technique described in this paper utilizes an excisional debridement of the central portion of the Achilles tendon in the shape of an apex superior triangle and therefore, does not require detachment of the tendon from its insertion on the calcaneus (Image 1). Functional outcome scores and pain significantly improved at two years follow up. Postoperative complications were similar to those previously reported with superficial wound breakdown being the most common. In conclusion, the authors encourage the use of this reliable, reproducible, and effective technique for the treatment of patients with chronic AIT.

A Pilot Study Using Intraoperative Placement of Cesium-131 Permanent Interstitial Brachytherapy in Resectable High Risk Recurrent Head and Neck Cancer

To determine the feasibility and safety of Cesium-131 implant in the management of recurrent head and neck cancer (HNC). This is a prospective trial approved by institutional IRB. Eligibility includes patients with resectable, recurrent failures who had a prior history of radiation to the head and neck deemed high risk for a second failure by our multidisciplinary tumor board. The strength and numbers of the Cesium 131 seeds were estimated based on a preoperative treatment plan with diagnostic CT images. Immediately after tumor extirpation, the seeds were implanted in the surgical bed based on the preoperative treatment plan with intraoperative adjustment. The surgical bed and the seeds were covered with a regional flap or microvascular free flap. A CT of neck was obtained on postoperative day 1 to confirm the dose distribution of the implant. The patient followed up at 1 month and 3 months after surgery, then every 3 months in the first two years. PET/CT scans or CT neck and chest with contrast was obtained at 3 months and one year after surgery. From November 2016 to September 2018, 15 patients were recruited, and 12 patients received protocol treatment. Of the three patients who did not receive protocol treatment, one had disease progression before surgery and went hospice, and two were determined to be low risk intraoperatively. Ninety-two percent (n=11) of the patients were male with a median age of 74.5 years old (range: 52-86). Primary sites included 5 oropharynx, 3 larynx, 3 skin, and 1 oral cavity. Recurrent sites included 10 neck alone, 1 neck and larynx, and 1 neck/peristomal. The interval between recurrence and previous radiation ranged from 3.7 – 103.8 months. Cesium implant dose ranged from 60 to 70 Gy. After surgery, patients remained in the hospital 3 to 9 days (median 6 days). There were no significant toxicities, and only one patient developed superficial wound breakdown requiring local wound care. The median follow-up was 10.1 months (range: 2.6 to 23.9) after implant. At last follow up, 5 patients had recurrence: 1 local, 2 distant, and 2 with both local and distant recurrences. Of the 3 local recurrences, only 1 had in-field failure. One patient failed in the contralateral neck and one in ipsilateral neck distant from the implant. Three patients had died, 2 with recurrences and 1 died of other cause with no recurrence. Intraoperative Cesium 131 implantation after surgical resection in recurrent HNC is feasible and safe. There were no unexpected severe toxicities. Most failures were out-of-field and distant failures. Future clinical trial with combination of cesium 131 implant and immunotherapy is under development.

Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation.

There is a growing trend toward early weightbearing as tolerated (WBAT) after open reduction and internal fixation (ORIF) of ankle fractures. To date, studies have excluded fractures with associated syndesmotic injuries from their cohorts. In this retrospective cohort study, a chart review was performed at a single level 1 trauma center, identifying all unstable ankle fractures that underwent operative fixation between July 2016 and July 2017. After exclusion criteria, 63 patients were identified and 31 were included in the final analysis, with 14 undergoing syndesmotic fixation. WBAT was initiated after suture removal, between 2 and 4 weeks postoperatively. Outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, and the need for repeat surgery. Weightbearing was initiated at an average of 17.8 days. All 31 patients progressed toward fracture union, with no hardware failures. Three patients developed superficial wound breakdown, which was treated with protected weightbearing in all cases and oral antibiotics in 1 case. All 3 went on to heal from their incisions. One patient had delayed wound breakdown and required a split-thickness skin graft that subsequently healed without complication. One patient underwent hardware removal 6 months postoperatively. There were no revision ORIF procedures. There is literature supporting early WBAT after ORIF of unstable ankle fractures in patients without major comorbidities. This article supports this trend, demonstrating that a group of ankle fractures requiring syndesmotic fixation were included in the early weightbearing cohort without a higher rate of catastrophic failure or increased wound problems. Level IV, retrospective cohort study.

PS-07-002 Penile augmentation by Division of the Suspensory Ligament of the penis and autologous fat injection: A 72-patient experience

To evaluate the outcome of penile augmentation (PA) surgery at one center. This was a retrospective review of patient outcomes after surgical PA from January 2018 to October 2018 at one centre. All patients underwent division of the suspensory ligament of the penis, with insertion of silicon buffer, and autologous fat injection. 60 patients underwent a standard halfmoon incision above the base of the penis in the pubic hairline and 12 patients had a V-Y-plasty incision. The following data were collected; pre and post-operatively: flaccid penis length and girth; patient reported satisfaction rates and complications. 72 patients were included the study. The mean patient age was 38 (26-62) years; mean follow-up period was 5 (1-9) months; mean pre-operative flaccid length and girth was 9.2 (6-14) cm and 8.8 (7-11.5) cm respectively; and the mean increase in flaccid penile length and girth was 4.4 (2-8) cm and 4.1 (2.5- 7.5) cm respectively. In terms of patient-reported treatment outcome: 50 patients reported very high satisfaction; 15 patients reported high satisfaction; 5 patients reported moderate satisfaction; and 2 patients low satisfaction. No serious complications were encountered, with the majority being managed conservatively: 5 patients who underwent V-Y-plasty incision developed superficial wound breakdown and infection which was managed conservatively; 5 patients developed phimosis which resolved spontaneously except in 1 patient who needed a circumcision; 5 patients had partial fat absorption with 3 requiring fat top-up; and 7 patients experienced the formation of a hard fat lump which was managed by hyalase injections in an outpatient setting.

Predictors of Satisfaction in Men After Penile Implant Surgery

IntroductionDespite the high satisfaction with penile implant (PI) surgery reported in the literature, a significant proportion of patients remain dissatisfied. AimTo evaluate satisfaction after PI surgery, using a single question and a scoring system. Furthermore, we attempted to define factors that predicted high patient satisfaction. MethodsThe study population consisted of all patients undergoing PI surgery between 2009 and 2015. Comorbidity, demographic, and implant information were recorded. Complications recorded included: minor (requiring no re-operation) such as penile or scrotal hematoma, superficial wound breakdown; major (requiring hospitalization or re-operation) such as device infection, erosion, and mechanical malfunction. Patient satisfaction was defined using a single question posed to the patient 6 months after surgery using a 5-point Likert scale (5 being the most satisfied). Descriptive statistics were used to define complication rates and multivariable analysis (MVA) was performed to define predictors of high satisfaction (score ≥ 4), including presence and degree of complications, Peyronie's disease (PD), diabetes mellitus (DM), number of vascular comorbidities, body mass index (BMI) > 30, and patient age. Main Outcome MeasurePatients with a major complication, with or without an additional minor complication, had a higher likelihood of being dissatisfied (25%) compared to patients with no complication or only minor complication 1.9% (no complications) and 3.7% (only minor complications), P < .001. Results902 patients were analysed. Mean age was 56.6 ± 10.6 years. Mean BMI was 30 ± 5. Comorbidity profile was diabetes 75%, dyslipidaemia 44%, hypertension 33%, cigarette smoking 32%, and PD 34%. 76% had a malleable implant (MPP) and 24% an inflatable implant (IPP). 31% had a minor complication and 9% a major complication. 93% had high satisfaction (score ≥4). Patients with any complication had a reduced rate of high satisfaction (97.5% vs 87.7%; P < .001) and even more pronounced with a major complication (96.7% vs 64.2%; P < .001). On MVA, only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, P < .001). ConclusionA high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is linked to a lower likelihood of achieving high satisfaction.Habous M, Tal R, Tealab A, et al. Predictors of Satisfaction in Men After Penile Implant Surgery. J Sex Med 2018;15:1180–1186.

Outcomes of Primary Posterior Spinal Fusion for Scoliosis in Spinal Muscular Atrophy: Clinical, Radiographic, and Pulmonary Outcomes and Complications.

Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Therapeutic Level IV.

MP25-02 EXPLORING THE PREDICTORS OF LOW SATISFACTION AFTER PENILE PROSTHESIS IMPLANTATION

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy I1 Apr 2017MP25-02 EXPLORING THE PREDICTORS OF LOW SATISFACTION AFTER PENILE PROSTHESIS IMPLANTATION Mohamad Habous, Osama Abdelwahab, Osama Laban, Raanan Tal, Saad Mahmoud, Alaa Tealab, Saleh Binsaleh, and John Mulhall Mohamad HabousMohamad Habous More articles by this author , Osama AbdelwahabOsama Abdelwahab More articles by this author , Osama LabanOsama Laban More articles by this author , Raanan TalRaanan Tal More articles by this author , Saad MahmoudSaad Mahmoud More articles by this author , Alaa TealabAlaa Tealab More articles by this author , Saleh BinsalehSaleh Binsaleh More articles by this author , and John MulhallJohn Mulhall More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.752AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Despite reportedly high satisfaction with penile implant (PI) surgery, some patients remain dissatisfied. Complications such as infection, mechanical malfunction and erosion remain significant concerns and are major contributors to patient dissatisfaction and regret. We aimed to explore outcomes and complications after PI surgery and to search for predictors of patient satisfaction. METHODS All patients who underwent PI surgery were included in the analysis. Comorbidity, demographic and implant information were recorded. Complications recorded included: minor (requiring no re-operation) such as, penile edema, hematoma, superficial wound breakdown; major (requiring hospitalization or re-operation) such as device infection, erosion, mechanical malfunction. Patient satisfaction was defined using a single question posed to the patient 6 months after surgery with a 5-point Likert scale (1 dissatisfied, 2 somewhat dissatisfied, 3 neutral, 4 somewhat satisfied, 5 satisfied). Descriptive statistics were used to define complication rates and multivariable analysis (MVA) was performed to define predictors of high (satisfaction score =4), including degree of complication, Peyronie's disease (PD), diabetes (DM), number of vascular comorbidities, BMI >30 and patient age. RESULTS 901 patients were analyzed. Mean age 56.6±10.6 years. Mean BMI 30.2±5.1. Comorbidity profile was: diabetes 75%, dyslipidemia 44%, hypertension 33%, cigarette smoker 32%, PD 34%. 76% had a malleable implant and 24% an inflatable implant. 31% had a minor complication and 9% a major complication. 93% had high satisfaction (=4). Patients with any complication had a reduced rate of high satisfaction compared to those without (88% vs 98%; p<0.001) and likewise with a major complication (64% vs 98%; p<0.001). On MVA, BMI >30, number of vascular risk factors, type of implant and DM were not predictive of high satisfaction. Only the absence of a major complication was a significant predictor of high satisfaction (OR 20, 95% CI 9-50, p <0.001). The presence of PD was almost statistically significant. CONCLUSIONS A high percentage of men are satisfied after penile implant surgery. Only the presence of a major complication is robustly linked to a lower likelihood of achieving high satisfaction. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e310-e311 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Mohamad Habous More articles by this author Osama Abdelwahab More articles by this author Osama Laban More articles by this author Raanan Tal More articles by this author Saad Mahmoud More articles by this author Alaa Tealab More articles by this author Saleh Binsaleh More articles by this author John Mulhall More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of Tibiotalocalcaneal Arthrodesis Through a Posterior Achilles Tendon-Splitting Approach.

A number of operative approaches have been described to perform a tibiotalocalcaneal (TTC) arthrodesis. Here we present the largest reported series of a posterior Achilles tendon-splitting approach for TTC fusion. With institutional review board approval, a retrospective review of the TTC fusions performed at a single academic institution was carried out. Orthopedic surgeons specializing in foot and ankle surgery performed all procedures. Eligible patients included all those who underwent a TTC fusion via a posterior approach and had at least a 2-year follow-up. Forty-one patients underwent TTC arthrodesis through a posterior Achilles tendon-splitting approach. Mean age at surgery was 56.9±15.0 years. There were 21 female and 20 male patients. Preoperative diagnoses included arthritis (n = 13 patients), failed total ankle arthroplasty (9), avascular necrosis of the talus (9), prior nonunion of the ankle and/or subtalar joint (6), Charcot neuro-arthropathy (2), and stage IV flatfoot deformity (2). In 37 patients (90.2%), a hindfoot intramedullary arthrodesis nail was used, with posterior plate or supplemental screw augmentation in 17 patients. Posterior plate stabilization alone was utilized in 4 cases (9.8%). The fusion rate was 80.4%. Eight patients developed a nonunion of the subtalar, tibiotalar, or both joints. Complications were observed in 17 patients (41.4%). Of these, ankle nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial wound breakdown (9.7%), subtalar nonunion (4.8%), and TTC malunion (2.4%) were the most frequently identified. One patient eventually underwent amputation (2.4%). We believe that posterior Achilles tendon-splitting approach for tibiotalocalcaneal arthrodesis was a safe and effective method, with similar union and complications rates to some previously described techniques. We believe the posterior approach is advantageous as it provides simultaneous access to both the ankle and subtalar joints and allows for dissection to occur between angiosomes, which may preserve blood supply to the skin. Level IV, retrospective case series.

Interval debulking surgery following neo-adjuvant chemotherapy for stage IVB ovarian cancer using neutral argon plasma (PlasmaJet™)

ObjectiveWe present a novel surgical approach to ovarian cancer debulking using neutral argon plasma (PlasmaJet™). Case historyA 48 year-old woman diagnosed with FIGO stage IVB grade 3 serous epithelial ovarian carcinoma received three cycles of neoadjuvant chemotherapy with carboplatin and paclitaxel. Operative techniqueDissection and radical debulking surgery were performed using PlasmaJet™ as previously described [1,2]. This included diaphragmatic and abdominal peritoneal stripping, supra-colic omentectomy, tumour ablation on the small and large intestines and mesentery, pelvic and para-aortic lymphadenectomy. ResultsThe only post-operative complication was a superficial wound breakdown, which healed by secondary intention. She remains well two years after surgery, with no sign of recurrence. ConclusionIn this case, PlasmaJet™ facilitated diaphragmatic peritoneal stripping as well as dissection of tissue close to bowel and major vessels. Further study is required to assess whether this device can reduce the need for bowel resection while achieving complete cytoreduction.

Vastus Lateralis Flap Reconstruction After Girdlestone Arthroplasty

Pressure ulcers are found in approximately 4.7% of hospitalized populations. Up to 12.3% of hospitalized populations are at risk for developing these wounds. Decubitus ulcers are more common among the inpatient spinal cord injury group, with prevalence rates up to 30%. Surgical intervention is required when bone or the hip joint becomes involved. Girdlestone arthroplasty is a procedure that excises affected proximal femur and acetabular tissues; however, this resection typically results in a sizeable defect. The vastus lateralis flap has been extensively reviewed as a soft tissue filler option for this deficit. Thirteen consecutive cases from a single institution using the vastus lateralis muscle flap reconstruction after Girdlestone arthroplasty were reviewed. A search of internal records identified 11 patients with 13 vastus lateralis flap reconstructions performed immediately after Girdlestone arthroplasty for stage 4 ulcers or chronic, infected wounds affecting the hip joint. All patients involved were subjected to a similar standardized post-procedure activity schedule. Complications were defined as minor (superficial wound breakdown) or major (requiring further operative procedures to close the wound). The majority of patients were male (91%) with a mean age of 43 years at the time of the procedure. All wounds involved the hip joint proper. Ninety-one percent of the patients had a history of spinal cord deficits. Thirty-one percent of the flaps had minor, superficial wound breakdown. Another 31% of the reconstructions required an additional operative procedure for major wound complications. One patient's wound was from multiple prior failed hip replacements. He eventually became ambulatory using a walker after reconstruction. Ultimately, 69% of the flaps healed satisfactorily without the need for further operative intervention. Surgical debridement is required for chronic wounds involving the proximal femur, acetabulum, and hip joint. This review demonstrates that the use of a single-stage procedure including Girdlestone arthroplasty with immediate vastus lateralis muscle flap reconstruction is a practical treatment option for chronic wounds involving the acetabular joint. The use of a postoperative protocol and subsequent sitting schedule contributed to the success of these reconstructions. Overall, this procedure is applicable to spinal cord injury/pathology patients and to failed total hip arthroplasty patients for future assisted ambulation.

Superficial Temporal Artery Dissection

Dissection of the superficial temporal artery (STA) is often required in preparation for a bypass procedure. Traditionally, dissection of the STA involves a direct cutdown on the artery after marking the course of the artery on the skin with the help of a Doppler ultrasound probe. We describe a method that takes advantage of the position of the STA superficial to the temporal fascia. The technique was used in a total of 38 procedures in 32 patients to create synangiosis or extracranial-intracranial STA bypasses. The STA was dissected using a blunt malleable brain retractor that was inserted into the subgaleal plane directly over the STA, allowing creation of a linear incision and concurrent protection of the STA in its bed. Either computed tomography- or catheter-based angiography was used to evaluate the patency postoperatively. All STA vessels were dissected without complications or injury to the graft vessel. The sole complication was a superficial wound breakdown in a synangiosis case. Postoperative angiography demonstrated patency in all but 1 of the 24 bypass cases (95.8%). We describe a method that takes advantage of the position of the STA superficial to the temporal fascia to allow rapid, safe, and efficacious dissection. The incision is linear and easier to manage and close. In our series, there were no technical complications related to the dissection of the STA.

Flexible intramedullary nailing in paediatric femoral shaft fractures

This retrospective study aims to evaluate the efficacy of flexible intramedullary (IM) nails as a fixation device of paediatric femoral shaft fractures. A total of 36 children with 37 closed fractures were treated by this method. The patients ranged in age from 7.2 to 13.5 years and the mean follow-up was 25.5 months. All patients had open femoral growth plates at the time of surgery. All fractures united and none of the patients needed re-operation. Complications included pain/irritation at the insertion site, 6 superficial wound breakdown 1 and one case of delayed union. No major complications were recorded. After nail removal, all children had full range of hip and knee motion. At final follow-up, although radiographs revealed that 44% of the children had malalignment at the fracture site in one or both planes, none of the children presented with clinical malalignment of the fractured limb. Maximum angulation that was calculated on the coronal plane was 5° into varus and on the sagittal plane 7° of anterior angulation (apex posteriorly). Leg-length discrepancy was assessed clinically and radiographically when needed. A total of 50% of the children had a leg-length inequality but none of them complained of a functional problem. Flexible nailing of diaphyseal fractures of the femur is a reliable method with a small learning curve and allows early mobilisation. Most of our minor complications were technique related and could be avoided.

Minimally invasive direct repair of lumbar spondylolysis with a pedicle screw and hook construct

Object Lumbar spondylolysis occurs in approximately 6% of the population and presents with localized mechanical back pain, often in young athletes. Surgical treatment may involve decompression, lumbar intersegmental fusion, or direct repair of pars defects. Although such open procedures may effectively resolve symptoms, minimal-access approaches may additionally decrease collateral damage to soft tissues, allowing young, active patients to resume athletic activities sooner. In this study, the authors review their experience repairing bilateral lumbar spondylolyses with screw and hook constructs placed via a minimal-access approach. Methods Five consecutive pediatric patients with bilateral L-5 spondylolysis were treated. Bilateral incisions (2.5 cm) were made over L-5. Exposure was maintained with bilateral expandable tubular retractor systems. Pedicle screws were placed in the L-5 pedicles and attached to hooks under the L-5 laminae. A direct repair was performed at the pars defect. Clinical characteristics, operative variables, and postoperative outcomes were collected. Results All 5 patients underwent surgery; 4 were male (80%) and 1 was female (20%), and the mean age was 15.8 years (range 15-17 years). The mean estimated blood loss and duration of surgery were 37 ml (range 15-75 ml) and 1.94 hours (range 1-3 hours), respectively. Postoperative hospital stays ranged from 1 to 3 days (mean 1.8 days). The only complication occurred in 1 patient who experienced minor superficial wound breakdown. All patients have experienced resolution of symptoms at this preliminary stage, which has continued over an 8-month follow-up period. Conclusions Lumbar spondylolysis can be adequately and safely treated via minimal-access surgical repair of the pars interarticularis by using pedicle screws and rod-hook constructs. This approach may decrease the collateral soft tissue damage common to open dissections, and may be ideal for young, active surgical candidates.

Combination of Luque Instrumentation With Polyaxial Screws in the Treatment of Myelomeningocele Kyphosis

Rigid congenital kyphosis in myelomeningocele is associated with an important morbidity with skin breakdown, recurrent infection, and decreased function. Kyphectomy is the classic treatment to restore spinal alignment; however, surgery is associated with morbidity and long-term complications. The purpose of this retrospective study was to examine the authors' experience using combination of Luque instrumentation with posterolaterally placed polyaxial screws in the treatment of myelomeningocele kyphosis. From June 1999 to June 2003, 7 patients were treated and followed up for an average of 68.6 months. The average age at the time of the operation was 7 year and 1 month. All patients underwent vertebral excision from just above the apex of vertebral deformity to realign the sagittal deformity. Posterolaterally placed polyaxial screws were used in combination with segmental Luque instrumentation. Kyphotic deformity averaged 104 degrees before surgery, 15.2 degrees after surgery, and 18.5 degrees at the latest follow-up. The average loss of correction was 3.3 degrees. The average blood loss was 611 mL. Complications occurred in 2 of 7 patients were superficial wound breakdown and deep wound infection that required rotational flap closure. Kyphectomy with posterior instrumentation by using Luque technique in the combination with polyaxial screws is reliable method for correcting rigid kyphotic deformity in patients with myelomeningocele. Rigidity of the construct, greater correction capacity, and low profile instrumentation by the help of posterolateral insertion of the polyaxial screws and wiring were the distinct advantages of this technique.

KARYDAKIS FLAP REPAIR FOR SACROCOCCYGEAL PILONIDAL SINUS DISEASE: HOW IMPORTANT IS TECHNIQUE?

Numerous operative and conservative treatments have been described in the published work for the management of sacrococcygeal pilonidal sinus; yet there remains considerable debate over its ideal treatment. This report is an audit of our results using the Karydakis flap repair in the management of this condition. We analysed prospective data on 70 patients who had had a Karydakis procedure. The length of follow up ranged from 1 to 79 months (median 36 months). Seventy-one operations were carried out in 70 patients. This included 12 patients (17%) who had previously undergone between one and four procedures (median 2) for recurrent disease. Superficial wound breakdown occurred in 27 patients (38%) and complete wound breakdown occurred in six patients (8.4%). These wounds were allowed to heal by secondary intent. The median time to complete healing for superficial and complete wound breakdown was 80 and 84 days, respectively. Disease recurrence occurred in three patients (4.2%) -- two of whom had recurrent disease at the time of this presentation. Of the three patients who had a recurrence after our surgery, two had a superficial breakdown and one had a complete wound breakdown. Sacrococcygeal pilonidal disease has a low recurrence rate when treated by the Karydakis operation involving flattening of the midline cleft. This procedure avoids the need for more complicated flap repairs.

Mesh repair of parastomal hernias – a safety modification

Parastomal herniation is not uncommon and numerous surgical approaches to the problem have been employed including mesh reinforcement. Bowel wall erosion is a worrying potential complication of placing an edge of mesh around bowel. To reduce this possibility a simple modification is suggested. The polyproylene mesh repair is fashioned on the posterior rectus sheath. The required aperture for the bowel is marked appropriately on the mesh. Instead of simple removal of the marked circle, the aperture is fashioned by folding back and stitching in place the triangular flaps from the middle to form a rolled rather than sharp edge. Non-absorbable monofilament stitches reconstitute the mesh encirclement, and attach it laterally and medially to the aponeurotic tissue. A review of the case notes was conducted and each patient was contacted by a postal questionnaire. This technique has been used in 10 patients (7 end colostomies, 2 end ileostomies and 1 loop ileostomy) since 2000. Over a median follow-up period of 30 months (range 2 to 40 months) there have been no hernia recurrences, no infected meshes, no bowel damage attributable to the mesh and no troubles with stoma. The only complication encountered has been a segment of superficial wound breakdown in one patient. This technique appears to offer a safe and reliable modification for mesh repair of parastomal herniation, in being designed to obviate the possibility of erosion of the stomal bowel wall by a sharp mesh edge but at the same time providing a sound herniorrhaphy by complete encirclement.