Wound Healing Issues Research Articles

Analysis of the Factors of Wound Healing Problems After Transtibial Amputation in Diabetic Patients.

Diabetes mellitus has a global impact, necessitating surgical intervention when conservative methods fail. Transtibial amputation (TTA) is commonly performed on diabetic patients, yet surgical site complications can lead to more procedures. This study aimed to identify factors linked to wound healing issues post-TTA in diabetics.A total of 181 patients who underwent TTA between 2004 and 2021 at a single hospital were included in the study. Exclusion criteria comprised trauma, non-diabetic mellitus, follow-up duration of less than 1 year, incomplete medical records, and surgeries performed by different surgeons. The comparison focused on underlying diseases other than diabetes between the group with wound problems and the group without. Additionally, factors impacting blood flow, such as presurgery hemoglobin levels, intraoperative blood transfusion, the use of antithrombotic or anticoagulant drugs, and the presence of procedures like percutaneous transluminal angioplasty (PTA) and bypass surgery, were analyzed.Among the 181 cases, 22.1% experienced problems at the surgical site while 77.9% did not. Statistical analysis revealed that age was a significant variable affecting wound healing problems after TTA in diabetic patients (p = .007). However, there were no significant differences in wound problems based on comorbidities other than diabetes (p = .209), gender (p = .677), preoperative anemia (p = .102), intraoperative blood transfusion (p = .633), the use of antithrombotic or anticoagulant medications (p = .556), and the performance of PTA or bypass surgery (p = .6).In conclusion, this study found that age was a significant variable affecting wound healing problems after TTA in diabetic patients. Although no association was observed between underlying diseases and wound healing problems, further investigation and cautious management of factors such as preoperative anemia, intraoperative blood transfusion, the use of antithrombotic or anticoagulant drugs, and the performance of PTA or bypass surgery are warranted to prevent complications and optimize wound healing outcomes in diabetic patients undergoing TTA.

Experience to date with elective transfemoral amputations incorporating agonist-antagonist myoneural interface (AMI) design

IntroductionThe agonist-antagonist myoneural interface (AMI) is a surgical construct that, when incorporated into limb amputation, offers to potential to preserve or restore proprioception, augment functionality, reduce neuropathic pain and enhance overall limb stability. We here present our experience to date with AMI construction in the context of transfemoral amputation (TFA). MethodsPatients were recruited for TFA with AMI construction at Brigham & Women’s and Brigham & Women’s Faulkner Hospital between June 2018 and June 2023. Data collection included demographic information, intraoperative parameters, clinical recovery metrics and complications. All data was then collated and analyzed. ResultsSeven TFA procedures were performed on seven patients during the study period. The operative technique employed evolved significantly over time, and included the development of both native and regenerative AMI models. Four patients were biological males (57%), and mean patient age was 42.0 ± 14.6 years. The etiology of conditions necessitating amputation included traumatic (43%), oncologic (29%), iatrogenic (14%) and congenital (14%). Mean operative time was 566 ± 97 min and average length of stay was 11.7 ± 8.4 days. Average postoperative follow-up was 2.19 ± 1.57 years (range 0.81–4.30 years). Postoperative imaging of AMI constructs demonstrated average muscle excursions of 6±3 mm, and total average limb volume preservation over time was 102 ± 14%. All patients demonstrated a complete wean from narcotic pain medications, with a mean time to wean of 86 ± 79 days. Minimal neuropathic pain was reported after the acute postoperative period. All seven (100%) of the subjects reported functional phantom limb sensation over the same time. Complications included significant soft tissue necrosis in two (29%) patients and minor wound healing issues in one (14%) patient. ConclusionsTFA incorporating AMI construction appears to offer promising benefits similar to those previously reported in patients undergoing similar interventions at the transtibial level.

A 10-Year Single-Burn Center Review of Free Tissue Transfer for Burn-Related Injuries.

Skin grafting is the mainstay treatment in burn patients. However, in the scenario of soft tissue deficit along with exposure of critical structures, free flap is the only reconstructive option to provide adequate coverage. The aim of the study is to review indications and surgical outcomes of burn patients requiring free tissue transfer. A retrospective cohort study was conducted to review all patients who underwent free tissue transfer for burn-related injuries between March 2012 and June 2023. A total of 13 patients required a free flap for their reconstruction. Eleven flaps were performed during the acute care and 2 were performed for delayed reconstruction. Patients were 69% males and 31% females, with a mean age of 45.5 ± 16 years and a mean BMI of 25.4 ± 6.5. The mean follow-up was 13.5 ± 13.9 months. Indications for free tissue transfer were bone exposure (92%) and severe neck burn contracture (8%). Overall complications rate was 54%. Complications included free flap loss (15%), hematoma (15%), vein thrombosis of the anastomosis (15%), infection (8%), amputation (8%), and wound healing issues (23%). Overall, 38% of the patients required re-operations including venous anastomosis revision, hematoma evacuation, debridement, skin grafting, and debulking. Although sometimes free flap remains the only reconstructive option in severe burn-related injuries, it is only rarely used. However, they carry a high risk of complications and should be considered only as the last resort for limb or life-threatening situations.

WTP8.11 Late Implant Loss Following Implant-based Immediate Reconstruction of the Breast

Abstract Aims Implant-based reconstruction is the most popular reconstruction in patients undergoing mastectomy for carcinoma or risk reduction. Postoperative complications such as infection are well known to result in implant loss, but the incidence and causes of late implant loss are not well studied. Methods We reviewed patients who underwent an implant-based reconstruction over a 5 year period (2018-2022) and identified those who had an unplanned implant removal 3 months after reconstruction. We looked at the comorbidities, method of reconstruction, exposure to radiotherapy and reasons for removal. Results Amongst 196 reconstructions there were 17 (8.7%) unplanned late removals, average time to removal 11.4 months. The reasons are infection or wound healing issues (8), rupture (3), cancer recurrence (3), deflation during port removal (2) and migration (1). Radiotherapy exposure was 41% vs. 18% in non-removal group. Conclusions A significant number of implants continued to be lost after the immediate postoperative period. Patients should be aware of that possibility. Radiotherapy appears to increase this risk.

Poster 181: Dual plating as a Cost-Effective Treatment Option for Operatively Indicated Midshaft Clavicle Fractures

Objectives: Many studies have highlighted lower rates of secondary operations with dual-plating compared to single-plating. Despite higher upfront costs associated with the dual-plating construct, the observed reduction in secondary operations compared to single-plating may make it a more cost- effective treatment option. The objective of this study was to assess the cost-effectiveness of dual-plate fixation compared to single-plate fixation in patients with operatively indicated displaced midshaft clavicle fractures. We hypothesized dual-plating would be a more cost-effective surgical option than single-plating, given its lower rates of postoperative complications. Methods: We developed a decision tree to model the occurrence of postoperative complications (hardware issues, wound healing issues, deep infection, non-union, and symptomatic hardware) associated with secondary surgeries. Complication-specific risk estimates were summarized for both plating techniques. The time horizon was two years, and the analysis was conducted from the healthcare payer’s perspective. The costs included direct medical costs, while the benefits were measured in quality-adjusted life-years (QALYs). We assumed that dual-plating would be $300 more expensive than single-plating upfront. We conducted probabilistic and one-way sensitivity analyses. Results: The model predicted reoperation in 6% of patients in the dual-plating arm compared to 14% of patients in the single-plating arm. In the base case analysis, the dual-plating increased QALYs by 0.007 and costs by $70 per patient yielding an incremental cost-effectiveness ratio (ICER) of $10,600 per QALY gained. The sensitivity analysis demonstrated that the cost-effectiveness of dual plating is driven by the cost of index surgery, risk of non-union, and symptomatic hardware complications in single- and dual- plating. At a willingness to pay threshold of $100,000 per QALY gained, 92% of simulations suggested dual-plating is cost-effective compared to single-plating (Figure 1). Conclusions: When indicated, operative management of displaced midshaft clavicle fractures with dual- plating is cost-effective compared to single-plating. Despite its higher initial upfront hardware costs, dual plating appears to offset added costs via lower rates of reoperations and improved patient quality of life.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

The Use of Hindfoot Nails for Elderly Complex Distal Tibial and Ankle Fractures

Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weight bearing. We performed a retrospective observational review of patients >65years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, post operative mortality, complications and further treatment. The primary outcome was re-operation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty three out of 70 patients were female. The average age of those who died within 1year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days post-surgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.

Flexible adhesive GelMA/SF-based patch embedded with polydopamine N-halamine nanoparticles for repair of infected wounds

Complex bacterial infection and inevitable movement are the two most concerning issues in joint wound healing. In this work, N-halamine structure was introduced into polydopamine nanoparticles (PDNPs) and encapsulated in a gelatin methacryloyl (GelMA)/silk fibroin (SF) matrix to endow the patches with efficient and broad-spectrum antibacterial activity. Zone of inhibition and in vivo antibacterial tests confirm that the addition of N-halamine containing organic nanoparticles as antibacterial components is a convenient and feasible strategy in the development of wound healing antibacterial materials. Here, dopamine methacrylamide (DMA) was synthesized and grafted onto the gelatin methacryloyl in patches with UV irradiation to get a reasonable adhesion. The liver prick injury model showed that the flexible adhesive GelMA/SF-based patch could be fixed on the wound area with rapid hemostatic effect. Furthermore, the resultant patches possess good flexibility, breathability and excellent biocompatibility. The histology analysis indicated the designed patches demonstrated less inflammatory response, significantly enhanced vascularization and the regeneration of dermis and epidermis. In summary, these N-halamine hemostatic GelMA/SF patches hold a promise for diverse practical acute trauma treatments.

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic.

Vaginoplasty is a relatively common gender-affirmingsurgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery. To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic. A retrospective chart review of the first 80 patients presenting to a gender-affirmingsurgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables. The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%). Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

Comparison of sinus tarsi approach versus extensile lateral approach in the management of displaced intra-articular calcaneal fractures: A single-center study.

Controversy still exists for optimal treatment for displaced intra-articular calcaneal fractures (DIACFs). Conven-tionally, the extensile lateral approach (ELA) has been the most preferred approach. Although ELA provides excellent fracture access and direct evaluation of the depressed posterior facet, this approach has a high rate of serious complications, such as hematoma, superficial/deep infection, and wound healing issues. To overcome such complications, more minimally invasive techniques including external fixation, percutaneous fixation, arthroscopic assisted fixation, and sinus tarsi approach (STA) have been recently described. The primary aim of this study was to compare STA and LEA in the treatment of DIACFs. Patients who were operated for DIACFs in our clinic were included in the study. Patients with closed DIACFs of Sanders Type II, III, IV, and over 18 years of age were identified. Physical examinations and radiological evaluations of the patients were per-formed, and clinical scores were filled. Patients were divided into subgroups according to the Sander's classification and comparisons were made again according to these subgroups. There were 37 patients (four female and 33 male) in STA group and 44 patients in LEA group (six female and 38 male). The mean age was 44.42±13.57 years (range, 18-61) for STA group and 37.32±11.09 years (range, 18-56) for the LEA group. In clinical outcomes, except for short-form survey (SF-12)/MCS-12 (Mental Score) and visual analog scale score, all the parameters were signifi-cantly better in STA group compared to LEA group. No significant difference was observed between the two groups in radiographic results, except for the Böhler angle. Significantly less infection occurred in the STA group compared to LEA group (P=0.021). According to Sander's classification, American Orthopedic Foot and Ankle Society, foot and ankle disability index, and SF-12/PCS-12 and foot function index scores, no significant differences were determined between STA and LEA groups for Sanders Type 2, whereas the values were considerably higher in STA group than in LEA group for Sanders Type 3 and 4. In DIACFs, STA is considered a safe and effective method for restoring the width, height, and length of the calca-neus and reconstruction of joint alignment and has now become our standard technique for all calcaneal fractures requiring operative treatment.

How I do it:- Endoscopic Reverse Denker's Approach.

Introduction: Endoscopic Denker's approach involves complete exposure of the anterior, inferior and lateral walls of the maxillary sinus providing access to both infratemporal and pterygopalatine fossa. Open approaches to maxillary sinus may lead to a high chance of cranial nerve dysfunction, trismus and wound healing issues. Surgical methods differ based on pathology, exposure, visualization and extent of clearance of the pathology. Method: The technique and surgical steps of Endoscopic Reverse Denker's approach are presented. Results: Critical steps include inferior turbinectomy, uncinectomy, followed by mega middle meatal antrostomy. For exposure drilling is started from the anterior margin of middle meatal antrostomy up to the pyriform aperture anteriorly till the anterior wall of the maxilla is visualized and the nasolacrimal duct can be visualized and transected. This method preserves the pyriform aperture and anterior wall similar to inside-out mastoidectomy tracing the pathology with less bone removal, faster and less morbidity. Conclusion: Endoscopic Reverse Denker's is a 2-handed or 4-handed endoscopic technique for proper exposure, visualization and clearance of the maxillary pathology of the anterolateral and anterior wall. Olfaction is preserved and crusting is less as there is less bone removal with no atrophic nasal changes. It preserves the pyriform aperture thereby preventing alar collapse.

2022 Roger A. Mann Award Winner: Total Ankle Replacement vs Arthrodesis (TARVA) Randomized Controlled Trial: 2 Year Results

Category: Ankle Arthritis; Ankle; Hindfoot; Other Introduction/Purpose: End-stage ankle osteoarthritis (EOA) causes severe pain and chronic disability. Once non operative measures have been exhausted the two main surgical treatments include total ankle replacement (TAR) and ankle fusion (AF). Systematic reviews have confirmed that both procedures are effective but there has never been a robust randomised multicentre level I study comparing the two treatments. Our objective was to investigate and compare the clinical and cost effectiveness of TAR against AF in the treatment of end-stage ankle osteoarthritis in patients aged 50-85 years. Methods: TARVA is a multi-centre, parallel-group, open label randomised trial. Patients with EOA, aged 50-85, suitable for either procedure were recruited at 17 UK hospitals. Randomisation was carried out using a secure on-line service and was stratified by surgeon and the presence or absence of adjacent joint OA (based on an independently reviewed preoperative MRI scan). Participants were randomised 1:1 to either TAR or ankle arthrodesis. The primary outcome was the change in the Manchester Oxford Foot & Ankle Questionnaire (MOXFQ) walking/standing domain scores between pre-operation and 52 weeks post- operation. Secondary outcomes measures included FAAM; FAAM (ADL); and Sport subscale scores. Quality of life was measured using the EQ-5D-5L. Total range of tibia to floor motion was measured using a validated method. Health economic analysis used mean incremental cost per quality-adjusted life years (QALY) gained. Analysis was by intention to treat. The trial registration is ISRCTN60672307. Results: Of 933 eligible patients 303 were randomised. 282 underwent surgery. Mean age 68 (71% male). Aetiology was post- trauma in 55.3%, and inflammatory in 7.1%. Groups were well balanced at baseline on all parameters. 54% TARs were fixed bearing. 61% of fusions were performed arthroscopically. At 2 years the adjusted mean difference in the change in MOXFQ W/S between TAR & AF was -4.4(95% CI -11.38 to 2.68, p=0∙23). Post hoc analysis of the commonest implant type (fixed bearing TAR) did show a statistically significant improvement over AF (p=0∙04, -8.9, 95% CI -17.2 to -0.6). Secondary outcomes, EQ5D-VAS and FAAM were significant. Complications included wound healing issues (13.8% vs 5.5%); nerve injuries (4.3% vs 0.7%). 11.8% of AF patients had plain radiographic evidence of non-union but only 6.9% had symptoms. Reoperation rate was 7.2% for TAR vs 5.2% for AF; and revision rate was 0.7% for TAR vs 2.8% for AF. Conclusion: Patients improved in all outcomes in both arms. We did not show a significant difference in our primary outcome measure between TAR and AF overall(p=0.23), but did show significance when fixed bearing TAR alone was compared against AF(p=0.04). Secondary outcomes did show significance. Adjacent joint arthritis increases the size of effect noted between arms. There were more wound healing issues and nerve injuries in TAR group. The symptomatic non-union rate for AF is 6.9%. TAR is likely to be cost-effective compared to AF at the NICE cost-effectiveness threshold of £20,000 per Quality Adjusted Life Year gained over the patients' lifetime.

Bilateral Hindfoot Osteonecrosis Associated with Treatment for Cutaneous T-Cell Lymphoma

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: There are reports of bilateral atraumatic osteonecrosis of the talus associated with some chemotherapy agenst for cutaneous T-cell lymphomas (CTCL), and systemic glucocorticoid treatment is by far the most common. We report the case of a 63-year old woman with CTCL previously treated with a high-affinity folate analog, pralatrexate, and multiple short- courses of prednisone dose packs who developed bilateral ankle and hindfoot stress fractures which progressed to hindfoot necrosis involving the talus and calcaneus. Methods: Chart Review Results: MRI was used for the diagnosis of stress fractures and osteonecrosis. The right foot was most symptomatic at presentation and was treated with a 6-month period of protected weight bering in a CAM boot. Follow up imaging demonstrated complete collapse of the talar dome. The patient underwent tibiotalarcalcaneal fusion which was complicated by wound healing issues requiring a skin graft. During this time, left sided symptoms worsened, and MRI confirmed insufficiency fractures with adjacent areas of edema and necrosis about the calcaneus, talus, and lateral malleolus. Considering her recent wound healing difficulties, the left foot was definitively treated in a CAM walker boot with some improvement in symptoms. Conclusion: Insufficiency fractures of the hindfoot are known to progress to osteonecrosis and are typically associated with long- term or high dose systemic steroid administration. Cases presenting after short-courses of oral steroids are uncommon; those associated with methotrexate (a lower affinity folate analog) are rare, and cases associated with pralatrexate or CTCL outside osteonecrosis of the jaw were not found during literature review. Despite cessation of chemotherapy and CTCL remission and early institution of protected weight, this patient rapidly progressed to bilateral hindfoot collapse. Providers and patients should be aware of the associated risks and potential for less favorable outcomes.

236.8: Early Surgical Complications in Everolimus (EVR) Treated Renal Transplant Recipients

Introduction: De novo use of low dose Everolimus in combination with reduced-exposure of Tacrolimus (EVR+rTAC) is still limited by lack of evidences from long term follow-up data and by the wound healing issues reported in the early clinical experiences. For these reasons the combination of tacrolimus and mycophenolatemofetil (TAC+MMF) is more frequently adopted as immunosuppressive treatment in renal transplantation. Aim of this study was to analyze clinical safety and efficacy of once a day combination of EVR+rTAC vs standard TAC+MMF in de novo Renal Transplant Recipients (RTR). Methodology: We are reporting our preliminary data of a prospective clinical study in RTR who completed their first 5 years follow-up after renal transplantation. After randomization RTR received once a day low dose EVR (blood levels: 3 - 5 ng/ml) plus TAC (blood levels: 3 – 5 ng/ml) or standard TAC plus once a day mycophenolate mofetil (MMF+TAC) immunosuppression. Results: One hundred two renal transplant recipients entered the study and completed the 5 years follow-up. No significant differences were found between the two recipients groups EVR+rTAC (51 pts) and MMF+TAC (51 pts) in the demographic data: age, sex, BMI, time on dialysis, transplant waiting time, native renal disease, pre-transplant diabetes, ischemic heart disease. All patients received as induction low fixed dose of Thymoglobuline (50mg IV x 4 days: pre-op and on day1, 2, 3). The incidence of acute rejection was not significantly different between the two groups (EVR+rTAC: Rey 7.2% vs MMF+TAC Rey 9.4%). One year estimated GFR also was not significantly different: EVR+rTAC: eGFR 50 ml/min vs MMF+TAC: eGFR 51 ml/min). Early surgical complications (within 30 days post-op) were also not significantly different in the two groups: EVR+rTAC: 20% vs MMF+TAC: 17%. The analysis of the severity of these surgical complications according with the Clavien-Dindo classification, also found no significant differences in the grade of complications: EVR+rTAC:class1 #5, class 2 #1, class 3 #4 vs MMF+TAC: class1 #4, class 2 #0, class 3 #5. Finally, we adopted the preemptive strategy to prevent CMV infection in our RTR, by monitoring PCR-CMV-DNA without pre-emptive pharmacologic antiviral prophylaxis, in both the study groups. Our data indicate that pre-emptive CMV prophylaxis with PCR-CMV-DNA monitoring in the presence of the combination of EVE+TAC is very effective in the diagnosis of CMV reactivation up to month 6 after transplantation: EVR+rTAC, PCR-CMV-DNA positive 36% vs MMF+TAC: PCR-CMV-DNA positive 65%, p 0.003. This preemptive strategy, showing the significant inhibition of CMV replication by the mTOR inhibitor Everolimus is effective in RTR, cheaper respect to antiviral drugs and avoiding emergent CMV resistance. Conclusion: In conclusion, the immunosuppressive combination of low dose Everolimus and low dose Tacrolimus allows the same excellent clinical results of standard Tacrolimus and MMF therapy, without increasing early surgical complications, with the significant advantages of less CMV infections.

Complications of Immediate versus Delayed DIEP Reconstruction: A Meta-Analysis of Comparative Studies.

Simple SummaryAlthough the deep inferior epigastric perforator flap (DIEP) has become the most frequent autologous flap in breast reconstruction, it remains unclear whether reconstruction should be performed at the same time as the mastectomy or delayed. Therefore, we conducted a meta-analysis to offer an overview of recipient site postoperative complications and help guide practicians toward the ideal timing for breast reconstruction. A pooled analysis using the Mantel and Haenszel methods with a fixed effect model provided results as an odd ratio with a 95% confidence interval. Among most complications including hematoma, infection, fat necrosis, and flap loss, no significant differences were observed. However, delayed wound healing was significantly higher for patients who underwent delayed breast reconstruction. This paper offers evidence that both surgical timings offer similar outcomes and are, therefore, valid surgical strategies. Purpose: The setting regarding the ideal timing for deep inferior epigastric perforator flap (DIEP) reconstruction remains unclear. Immediate breast reconstruction (IBR) is performed at the same time as mastectomy, while delayed breast reconstruction (DBR) is performed at any time after mastectomy except immediately. We compared both strategies to assess whether IBR or DBR should be performed to reduce postoperative adverse events. Methods: A systematic review of PubMed, Embase, Medline, Cochrane, and Web of Science was conducted, aiming at articles comparing the recipient site outcomes of IBR versus DBR with DIEP. We used the Mantel–Haenszel method with a fixed effects model. Results were expressed as the OR with a 95% CI. Results: Two retrospective and two prospective studies were identified involving 5784 DIEPs (1744 immediate and 4040 delayed). We showed a significant difference in favor of IBR for wound healing issues (OR = 0.57, 95% CI 0.41, 0.77; p = 0.0003). However, no significant differences for hematoma, infection, fat necrosis, partial flap loss, and total flap loss rate were seen. Conclusions: Despite variability in the choice of the ideal time for breast reconstruction and outcomes reported among studies, immediate DIEP surgery appears to be a reliable setting with less delayed healing issues.

Trial in progress: Phase II activity trial of high-dose radiation and chemosensitization in patients with macrometastatic lymph node spread after sentinel node biopsy in vulvar cancer: Groningen International Study on Sentinel Nodes in Vulvar Cancer III (GROINSS-V III/NRG-GY024).

TPS5624 Background: Early stage invasive squamous cell carcinoma of the vulva is treated by radical excision of the primary tumor combined with a sentinel node (SN) procedure for the groins. GROINSS-VI and GOG-173 demonstrated that if there is no metastasis to the SN, then standard of care is observation. GROINSS-VII/GOG-270 demonstrated that micrometastatic disease (<2mm) to the SN requires standard radiotherapy (50 Gy) without the need for an inguinofemoral lymphadenectomy (IFL). This study also found that patients with macrometastasis ( > 2mm) required IFL in order to have an acceptably low groin recurrence rate. However, IFL is associated with significant morbidity such as lymphedema, wound healing issues, and recurrent infections. It is hypothesized that for those with macrometastasis ( > 2 mm) in the SN, the efficacy of treatment can be increased by giving a higher dose of radiotherapy along with chemosensitization. Methods: This is an international multicenter single-arm phase II prospective clinical trial. The primary objective is to investigate the safety of replacing IFL by chemoradiation in early-stage vulvar cancer patients with a macrometastasis ( > 2mm) and/or extracapsular extension in the SN. The primary endpoint is the groin recurrence rate in the first two years after primary treatment. Secondary endpoints are short and long-term morbidity associated with the SN procedure and chemoradiation and quality of life as measured by EORTC-QLQc30. Patients with invasive ( > 1mm) squamous cell carcinoma of the vulva, stage T1, tumor size < 4 cm diameter and no suspicious lymph nodes by imaging of the groins will proceed with SN detection. Institutions enrolling patients must demonstrate prior surgical experience with SN detection with the submission of at least 10 successfully completed cases in vulvar cancer. Patients with SN metastases > 2mm and/or with extracapsular extension or those with > 1 SN with micrometastases will be eligible for this study. Treatment will consist of chemoradiation with a dose of 56 Gy to the groin combined with weekly cisplatin 40 mg/m2 IV on days 1, 8, 15, 21 and 29 of radiotherapy. One hundred and fifty-seven patients in Europe, United States and Canada will be enrolled. The study includes continuous monitoring of groin recurrences with stopping rules. Results of this trial may be practice changing and eliminate the need for IFL in all women with clinically early stage vulvar cancer. The study is currently open for enrollment. Clinical trial information: NCT05076942.

Wound Dillemmas: Investigating the Effect of Barbed Knotless Suture Versus Smooth Suture for Subcuticular Tissue Closure During Knee Surgery in Youth Athletes

Background:Surgical procedures of the knee are commonly performed on youth athletes for a myriad of conditions. Restoration of motion is paramount following surgery and wound healing issues may arise. Studies have investigated wound closure technique and its’ effect on wound healing in arthroplasty, but there is a paucity of information in youth sports medicine.Purpose:To investigate wound healing following knee surgery as affected by smooth running monofilament versus barbed running knotless suture for subcuticular closure.Methods:A retrospective investigation was conducted of a single surgeon’s knee procedures between January 2013 to December 2020. Suture type for closure of the operative wound as well as any wound healing dilemmas (i.e., wound dehiscence and formal operative debridement) encountered during the post-operative period were recorded. The surgical procedure, perioperative antibiotics, wound lavage, dressing type and patient demographics were also recorded. Group 1 underwent subcuticular wound closure performed with a running smooth non-barbed monofilament suture and was compared to Group 2 where closure was performed with barbed monofilament suture. Exclusion criteria was a history of ipsilateral knee surgery and congenital syndromes. Statistical analysis was performed.Results:486 patients were identified of which 21 were excluded leaving 202 patients in Group 1 and 263 in Group 2. Average age was 15.8 years (range 10 to 25 years). 277 were female. Wound dehiscence occurred in 17 patients in Group 1 (8.42%) and 25 in Group 2 (9.51%) (p=0.684). Formal debridement was performed in 8 patients in Group 1 (3.96%) and 4 (1.52%) in Group 2 (p=0.100). There was a significantly higher tourniquet time (p<0.001), number of meniscus repairs (p<0.001) and trochleoplasties (P=0.011) in Group 2. There was no difference between groups regarding comorbidities, body mass index, and age. A power analysis yielded to reach 80% power (p<0.05) 12,405 patients per group would be needed for investigating the rate of dehiscence and 868 patients per group for formal debridement.Conclusion:Subcuticular suture type did not significantly affect the rate of wound healing dilemmas encountered following knee surgery in this young cohort. Formal debridement was required at a diminished rate in the barbed suture group but not significant enough to recommend routine use. Larger cohort studies are needed to further investigate this trend.Table 1.Patient characteristics

806 Foot burns in diabetic patients: A systematic review

IntroductionPatients with diabetes are prone to foot injuries and burns. Managing burned feet in patients with diabetes can be difficult due to multiple concomitant patient comorbidities that delay wound healing. Burn surgeons tasked with treating these complex foot burns understand that these patients are at risk of developing significant complications, such as infections and non-healing diabetic foot ulcers, which may ultimately lead to amputation. Although there are many studies that examine the causes and outcomes of diabetic foot ulcers and their management, there is a lack of consensus on how to best manage lower extremity burns in patients with diabetes.MethodsA systematic review was performed according to PRISMA criteria and identified 18 articles addressing the management of burned feet in patients with diabetes. Means and standard deviations of scale variables and frequencies derived from nominal and ordinal variables abstracted from the literature were compared between each group. A meta-analysis was attempted but existing data was not of sufficient quality for meaningful analysis, and data aggregation was done where applicable.ResultsThe three-database search identified 726 articles, which yielded 18 full text articles that met inclusion criteria. mean age of patients was 54 years (SD 7), and 80% (n=203) were male. Most (90%, n=179) had type II diabetes, and 10% (n=20) had Type I diabetes. Mean duration of diabetic disease was 11 years (SD 4), and mean A1c at admission was 9% (SD 1). Peripheral neuropathy (64%, n=123) was the most common comorbidity. Median TBSA burned was 2% (IQR 2), and scald (56%, n=155) was the most common mechanism of injury. Full thickness burns (70%, n=102) were most common, followed by partial thickness (28%, n=41), and superficial thickness (2%, n=2). A majority (55%, n=88) had burn wound infection identified at admission. Patients had a median delay in presentation from time of injury to hospital admission of 4 days (IQR 4.5). Sixty percent of patients received surgical treatment via excision and grafting, had a median length-of-stay of 20.5 days despite a median total body surface area involvement of 2%, and experienced sequelae of impaired wound healing such as infections, graft loss, and need for further surgery. Ultimately, 23% of patients had significant wound healing issues that resulted in amputation.ConclusionsExcision and grafting may not be the optimal approach for managing foot burns in patients with diabetes, many of whom are at high risk of amputation. Non-operative management of foot burns in patients with diabetes should be explored as a method to decrease amputations in patients with foot burns.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

The Modified M-plasty Approach to Mastectomy: Avoiding the Lateral Dog-ear.

Summary:Postmastectomy “dog-ears” are cosmetically displeasing, can contribute to a poorly fitting bra, and may cause discomfort for patients. They occur most commonly in patients with high body mass index and/or large breasts and can be challenging to manage. To avoid the lateral dog-ear following simple mastectomy, we describe the M-plasty with the addition of a lipodermal flap. We demonstrate that the addition of a lipodermal flap not only flattens the lateral contour of the chest wall but also facilitates a tension-free closure. This helps reduce wound-healing issues in high-risk patients with multiple comorbidities, high body mass index, and large breast size.