Wound Healing Issues Research Articles

Fibular Allograft and Demineralized Bone Matrix for the Treatment of Slipped Capital Femoral Epiphysis.

Previous studies documented the use of fibular allograft in the treatment of slipped capital femoral epiphysis (SCFE) with bone graft epiphysiodesis (BGE). This study describes the results of using a 10-mm diameter premilled fibular allograft packed with demineralized bone matrix placed across the physis in an open surgical approach under image intensification. A review identified 45 cases of BGE using fibular allograft and demineralized bone matrix in 34 patients with a diagnosis of SCFE performed by a single surgeon during an 8-year period. Thirty-four cases (25 patients) had at least 1 year of follow-up and were included in the study. Medical records were reviewed for complications, subsequent surgeries, and time to physeal closure. Of the 34 cases included, there were no cases of acute chondrolysis. Complications included 1 case of bone graft extrusion that required surgical replacement and 1 re-slip requiring surgical stabilization. Five cases of avascular necrosis (AVN) were encountered (1 unstable slip with total head AVN, and 4 stable slips with 3 total head and 1 partial head AVN). In 1 patient, small loose bony fragments were noted on postoperative radiographs that appeared outside of the articular surface of the hip and were asymptomatic. Two patients encountered wound healing issues that resolved with appropriate wound care. In light of the occurrence of AVN in stable cases, BGE with autogenous corticocancellous graft is preferable to BGE with autologous fibular graft for the treatment of SCFE. [Orthopedics. 2016; 39(3):e519-e525.].

Surgical Timing and the Menstrual Cycle Affect Wound Healing in Young Breast Reduction Patients.

Young female subjects are known to have the highest baseline menstrual hormone levels of any female age group. Studies have found an association between hormone levels and wound healing. This has been researched in the orthopedic, gynecologic, and dermatologic literature, and more recently, in young patients undergoing augmentation mammaplasty. The purpose of this study was to determine whether the timing of surgery relative to the menstrual cycle plays a role in surgical complications following bilateral reduction mammaplasty. All female patients aged 25 years or younger with a documented last menstrual cycle undergoing a bilateral reduction mammaplasty from 2005 to 2013 were reviewed. Surgical timing and postoperative complications relative to the last menstrual cycle were recorded. The preovulatory phase referred to days 1 to 14 after the patient's last menstrual cycle, whereas the postovulatory phase referred to days 15 to 28. Forty-nine patients met inclusion criteria. Undergoing bilateral reduction mammaplasty during the postovulatory phase was associated with development of wound dehiscence and hypertrophic scarring (p < 0.005), which were the most common postoperative complications. Surgery in the preovulatory or postovulatory phase did not affect hematoma, seroma, wound infection, or nipple-areolar complex necrosis rates (p > 0.05). Age, race/ethnicity, body mass index, large resection mass, and medical comorbidities did not affect wound dehiscence or scar hypertrophy rates (p > 0.05). Young patients undergoing bilateral reduction mammaplasty during the postovulatory phase of the menstrual cycle have an increased risk of wound healing issues and poor scarring. This may be attributable to hormonal fluxes occurring during this phase and the already high hormone levels in this population.

Tibial Inlay Posterior Cruciate Ligament Reconstruction: Advances to a New Technique

Graft instability can be a long-term concern for orthopaedic surgeons who arthroscopically reconstruct the posterior cruciate ligament (PCL). Dissatisfaction over reconstruction methods led the senior author to develop a new method that combined both a tibial inlay and the double-bundle techniques. Long-term results over 15 years were satisfactory but there were still several disadvantages—pain, the risk of wound healing issues in patients with severely injured knee dislocation, and the potential for vascular injury. Recent advances in technology have the potential to address these disadvantages and further improve clinical outcomes. The authors developed a new arthroscopic all-inside transtibial PCL double-bundle allograft reconstruction technique using cortical-button suspensory fixation of a soft tissue graft in sockets. This technique yields a tibial location identical to that of the tibial inlay and functions in a very similar manner. This article shows the PCL graft preparation and technique used in this surgery. Early results have provided clinical support for its safety and efficacy but more long-term follow-up is necessary to validate the relative efficacy of this technique.

Results from the ASPIRE study for breast reconstruction utilizing the AeroForm™ patient controlled carbon dioxide-inflated tissue expanders

Therapeutic or prophylactic mastectomy is often indicated for women with breast cancer, or for those at a high risk of developing cancer due to familial history or genetic mutations. Favorable aesthetic and psychological results make prosthetic reconstruction of the breast with placement of tissue expanders followed by permanent implant a popular choice for women diagnosed with breast cancer. This study describes the results of the ASPIRE trial, the objective of which was to provide supportive data to demonstrate the performance and safety of the AeroForm™ System in a population with broader selection criteria than previous studies. Results of the earlier PACE clinical studies (PACE 1 and 2) demonstrated that the AeroForm™ System could be used safely and effectively to achieve the desired expansion necessary for successful breast reconstruction. In the current ASPIRE trial described in the paper, performance of the device was evaluated by successful tissue expansion and exchange to breast implant(s) unless precluded by a non-device related event. Safety data was evaluated based on reported adverse events. A prospective, single center, open-label study in which subjects who met the inclusion criteria and agreed to participate were enrolled and implanted with the AeroForm expander either at the time of mastectomy (immediate) or sometime after mastectomy (delayed). In the event of a bilateral procedure, the expander was implanted in each side. Subjects were followed until the explant of the tissue expander(s) and exchange for silicone or saline breast implant(s). Thirty-four expanders were placed in 21 subjects in the clinical trial; the average age of subjects was 49.7 ± 8.6 years with average BMI of 26.1 ± 4.7. Bilateral procedures accounted for 62% of the total and 88% of the reconstructions were completed with a latissimus dorsi flap (anterior approach) per the investigators standard procedure. Four (12%) of the cases (12%) were completed in two subjects using an inferior dermal flap. Overall success rate was 94% (32/34 breasts) with no device related reconstruction failures. Two subjects failed reconstruction, one due to infection and one due to wound healing issues, both requiring unilateral expander removal and revision surgery. However, successful second stage reconstruction was completed in both subjects in a delayed procedure. The ASPIRE trial reports confirmatory data in a more inclusive patient population than the previous PACE 1 and 2 trials, indicating that the AeroForm Expander, provides a time-saving, needle-free, safe and effective method of tissue expansion for breast reconstruction. There were no device related complications that precluded the subjects from achieving the study goal of a permanent implant exchange. Reported complications are similar to those reported in the literature for tissue expansion procedures. Further development may enable a single dose controller to operate both expanders in a bilateral patient and increase the size range offered with this promising technology.

Elective hand surgery after axillary lymph node dissection for cancer.

After axillary lymph node dissection (ALND), patients are cautioned against ipsilateral interventional procedures to avoid the theoretical increased risk of postoperative complications, particularly lymphedema. The authors' goal was to evaluate the complications of elective hand surgery after ALND. The authors reviewed patients presenting to their hand clinic from 1998 to 2011, selecting those with a diagnosis of breast cancer or melanoma and a history of previous ALND; the authors excluded those treated nonoperatively and those treated with elective surgery in the contralateral hand. Average age of the 22 patients meeting the criteria (20 with a history of breast cancer, 6 with preexisting lymphedema) was 53.9 years (range, 26.7 to 73.6 years) at the time of ALND and 63.1 years (range, 31.7 to 83.5 years) at the time of hand surgery. Average interval between surgeries was 9.2 years (range, 8 days to 37.3 years). Follow-up averaged 9.2 months (range, 8 days to 41.7 months). Fifteen patients were surveyed for long-term postoperative results (average surgery-to-survey interval, 4.3 years [range, 1 to 11.9 years]). Fifteen patients had uneventful postoperative recoveries, 4 had peri-incisional erythema requiring oral antibiotics, 1 had incisional pain and scarring, 1 had chronic wound-healing issues, and 1 had a dehiscence requiring a return to the operating room. In the 15 patients who completed the follow-up survey, there was no disease exacerbation in the 3 patients with preexisting lymphedema, and there were no new cases of lymphedema. Routine minor hand surgery did not result in lymphedema and did not increase existing lymphedema in these patients with previous ipsilateral ALND, but almost one-third of them had short-term complications in the postoperative recovery period.

Salvage of avascular necrosis of the talus by combined ankle and hindfoot arthrodesis without structural bone graft.

Osteonecrosis of the talus is a well-recognized pathology, which can result in significant hindfoot collapse resulting in poor function and pain. Treatment with intramedullary tibiotalocalcaneal arthrodesis (IMTCA) using a retrograde intramedullary nail is widely utilized for severe concomitant tibiotalar and subtalar pathologies. This study reports the results of ankle and hindfoot arthrodesis in patients with arthritis and deformity caused specifically by talar osteonecrosis. Fourteen ankle and hindfoot arthrodeses with retrograde intramedullary nail were studied, with a mean follow-up of 26 months. Medical records were reviewed for operative technique, concomitant procedures, bone graft used, and postoperative complications including nonunion, infection, nerve injury, wound healing issues, and the need for additional surgeries. Clinical outcomes included Visual Analogue Scale for pain, the AOFAS Ankle/Hindfoot Score, and the SF-36 questionnaire. Over 80% of cases had osteonecrosis involving the entire body of the talus. In 4 cases tibiocalcaneal arthrodesis was performed, with the remaining talar head-neck portion fused to anterior aspect of tibia. Union was achieved in all cases. The mean preoperative VAS score was 6.9 (range 5 to 9, SD ± 1.5) decreasing to 1.7 (range 0 to 6, SD ± 2.2) postoperatively (P = .00008). The mean preoperative AOFAS score was 32.7 (range 20 to 46, SD ± 8.7), increasing to 72.1 (range 46 to 86, SD ± 10.1, P = .00003). The mean preoperative SF-36 physical component score was 30.5 (range 21 to 42, SD ± 6.9) increasing to 42.8 (range 20 to 60, SD ± 11.4) postoperatively (P = .02). Complications included 1 stress fracture, 4 hardware removals, and 1 superficial infection. Ankle and hindfoot arthrosis due to extensive talar AVN can be successfully treated with IMTCA.

Intraoperative Laser-Assisted Indocyanine Green Imaging for Objective Measurement of the Vascular Delay Technique in Locoregional Head and Neck Flaps

Reconstruction of oncologic or traumatic head and neck defects often requires complex planning of locoregional, pedicled, or interpolated flaps. In cases with a higher risk of flap failure, vascular delay with staged reconstruction can help improve tissue perfusion and increase chances of flap survival. An objective tool is needed to help guide reconstructive surgeons with the intraoperative decision to pursue vascular delay. To describe a pilot study using a novel application of a technique that quantifies and validates the benefit of the vascular delay procedure in locoregional flaps and to demonstrate a practical and broadly applicable technology that can be easily incorporated into intraoperative decision making and improve outcomes for high-risk flaps. A pilot study using intraoperative laser-assisted indocyanine green imaging measurements and fluorescence videos to objectively measure the benefit of vascular delay procedures in patients with head and neck defects and wound healing risk factors requiring locoregional flap reconstruction at an academic tertiary care center. Intraoperative laser-assisted indocyanine green imaging with video documentation and quantitative measurements was used to evaluate flap perfusion before a vascular delay procedure. Measurements were repeated after a 3-week vascular delay procedure. Two patients were identified based on comorbid conditions that resulted in a higher risk of flap failure, as well as the need for a locoregional flap for reconstruction. At the initial elevation of the flap, quantitative results from flap imaging demonstrated low perfusion numbers and minimal fluorescence, suggesting poor tissue perfusion and increased likelihood of postoperative flap compromise or failure. Following a vascular delay of 3 weeks, repeat measurements were substantially improved. No wound healing issues were observed. This is the first study to date to quantitatively demonstrate the benefit of the vascular delay technique in patients with potential vascular compromise in locoregional head and neck flap reconstruction. Data obtained suggest that this technology can be used to guide intraoperative decision making in complicated reconstructions and help optimize patient outcomes. NA.

Gluteal reshaping in the massive weight loss patient.

Gluteal reshaping in the massive weight loss patient.

A ten-year review of myelodysplastic defect management and use of a novel closure technique with V-Y crescentic rotation advancement flaps

The reconstructive goals for myelodysplastic defects are to provide a multilayered, tension-free and well-vascularized closure to prevent cerebrospinal fluid leakage, wound infection or breakdown and to optimize neurologic outcomes. We reviewed our ten-year experience with myelodysplastic defects and our preferred technique for large defects utilizing paraspinous flaps followed by V-Y crescentic rotation advancement flaps. A retrospective chart review was performed on all myelodysplastic defects closed at the University of Chicago Medicine from 2002 to 2012. Twenty-three patients were treated: eight were closed using V-Y crescentic rotation advancement flaps, eight primarily, two with transposition flaps and five with bilateral latissimus dorsi and gluteus maximus myocutaneous flaps. Patient defect characteristics, reconstructive details, follow up time, and wound complications were analyzed. The primary closure group included eight patients. There was one minor complication and two major complications that required debridement and plastic surgery consultation in this group. The transposition group included two patients and had no wound healing issues. The latissimus and gluteus myocutaneous group included five patients and had one minor wound healing issues. The V-Y crescentic group included eight patients. There were four minor wound breakdowns in the lateral donor sites and one major wound complication involving a CSF leak, meningitis and wound breakdown that required debridement. The groups were stratified by size, <5 cm and >5 cm, and further analyzed. Bilateral V-Y crescentic rotation advancement flap is a useful option when confronted with large myelodysplastic defects. It provides a multilayer, tension-free wound closure and spares the gluteus maximus and latissimus dorsi muscle groups.

Mini-Open Tenorrhaphy of Acute Achilles Tendon Ruptures

Background: The high incidence of soft tissue complications related to open Achilles repair has driven enthusiasm for developing minimally invasive surgical procedures. The Dresden procedure, which reduces wound-healing issues and avoids sural nerve damage, has recently been published and shows good functional results. Objective: To evaluate medium-term clinical results of procedures using the Dresden mini-open technique on acute Achilles tendon ruptures. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was performed on 100 consecutive patients with a mean follow-up of 42.1 months. At follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) score, time to return to work and sports, subjective satisfaction, and complications were registered. An isokinetic test was performed on the first 21 patients of this series at 1 year postoperatively. Results: The mean time to return to work was 56.0 days, and the mean time to return to sports was 18.9 weeks. The mean AOFAS score was 97.7; 98% of patients were satisfied. No complications regarding soft tissues and sural nerve damage were reported. Two reruptures and 5 cases of deep venous thrombosis were observed. The isokinetic evaluation showed good recovery of the involved muscles. Conclusion: The excellent functional and satisfaction results, ease of the procedure, and avoidance of sural nerve damage make the mini-open technique a very attractive alternative for acute, spontaneous Achilles tendon ruptures.

Adverse Events Associated With Mohs Micrographic Surgery

Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. To quantify adverse events associated with MMS and detect differences relevant to safety. Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Percutaneous Aponeurotomy and Lipofilling

The application of a new approach is presented, percutaneous aponeurotomy and lipofilling, which is a minimally invasive, incisionless alternative to traditional flap reconstructions. The restrictive subdermal cicatrix and/or endogenous aponeurosis is punctured, producing staggered nicks. Expansion of the restriction reconstructs the defect and creates a vascularized scaffold with micro-openings that are seeded with lipografts. Wide subcutaneous cuts that lead to macrocavities and subsequent graft failure are avoided. Postoperatively, a splint to hold open the neomatrix/graft construct in its expansive state is applied until the grafts mature. Thirty-one patients underwent one to three operations (average, two) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (n=9), contour defects of the trunk and breast requiring large-volume fat grafts (n=8), burn contractures (n=5), radiation scars (n=6), and congenital constriction bands (n=3). The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range, 20 to 30 percent). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion. Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its three-dimensional expansion, a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts was developed. Grafting this scaffold applies tissue-engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery. Therapeutic, V.

Orthotics and Prosthetics in Rehabilitation

This comprehensive text offers an up-to-date, evidence-based approach to rehabilitation for people with prosthetic and orthotic issues, with a focus on interdisciplinary model of care; it is a great resource for assessment, treatment planning, and outcome evaluations for prosthetic/orthotic students. For clinicians, the book reinforces the importance of ongoing evaluation of assessment tools and provides practical treatment strategies for orthotic and prosthetic rehabilitation. Orthotics and Prosthetics in Rehabilitation is a collaborative effort with knowledgeable contributors from orthotics, prosthetics, physical and occupational therapy, medicine, and surgery. Learning objectives for each chapter are clearly identified. The tables and illustrations are of good quality and add value to the text. A thorough and up-to-date reference list at the end of each chapter indicates that information is current. Each chapter ends with case studies that challenge the reader to critically problem-solve clinical scenarios and develop intervention strategies. The book is divided into three parts. Part 1 covers baseline knowledge of factors that can influence orthotic and prosthetic rehabilitation outcomes, such as multidisciplinary approach, ageing and activity tolerance, motor learning, gait assessment, and footwear. A chapter titled “Motor Control and Motor Learning” reviews the current understanding of human motor control and the process of motor learning. Concepts such as type of feedback, when and how feedback should be used, mental imagery and practice, the role of sleep in motor learning, and the importance of patient-centred goals will help practitioners to plan interventions that will enhance retention of motor learning for people with movement impairments. Part 2 outlines the principles of designing and fitting orthoses for individuals with musculoskeletal dysfunction and neurological impairments. Information on orthotic management of various conditions, from bracing options for people with knee dysfunction to splinting techniques for contracture management for people with burns, is useful. The text emphasizes the benefits of soliciting input from all rehabilitation team members in selecting the most appropriate orthotic device to maximizing a person's function. The chapter on lower-extremity orthosis reviews factors to consider when prescribing an orthotic device and clearly outlines the criteria for prescribing stance-control orthotic knee joints in the knee-ankle-foot orthosis (KAFO) and who will benefit from this orthosis. Part 3 is devoted to current rehabilitation prosthetics options. The chapter on wound healing and the high-risk foot discusses up-to-date options for managing wound-healing issues, from dressings to orthotics to the use of therapeutic modalities. The chapters that follow, which cover amputation surgery levels and pre-prosthetic/prosthetic management, are augmented with clear illustrations and provide a sound knowledge base on the rehabilitation process following amputation. The chapter dealing with early rehabilitation of lower-extremity dysvascular amputation includes a comprehensive, user-friendly table on common prosthetic gait deviations for the transfemoral and transtibial prosthetic user. The table separates possible causes of gait deviations into intrinsic (client-related) factors and extrinsic (prosthetic or environmental) factors, and will help guide therapists in their clinical decision-making for determining the possible reasons for gait deviations (i.e., client vs. prosthetic). The chapter focusing on advanced rehabilitation for people with microprocessor knees covers common mobility problems and provides prosthetic and practical training solutions to asymmetric step length, stairs and ramps, sitting and squatting, and fall protection. The accompanying photographs are helpful in demonstrating treatment techniques. This text is well written, covering the important aspects of orthotic and prosthetic care. It is a valuable clinical resource for practitioners involved in prosthetic and orthotic rehabilitation, and would be a well-used resource for both clinicians and students.

Evidence-Based Value of Subcutaneous Surgical Wound Drainage

The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery. An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection. Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage. Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon's choice and can be based on multiple factors beyond the type of procedure being performed or the patient's body habitus. Therapeutic, II.

Double-Barrel Bypass for Cerebral Ischemia

In selected patients, extracranial-intracranial bypass remains an important treatment for the prevention of stroke. Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass uses 1 STA branch. We have adopted a "double-barrel" technique in which both branches are joined with MCA recipients in distinct vascular territories. To assess the feasibility of routinely using both branches of the STA for cerebral revascularization. Ten consecutive patients underwent double-barrel bypass. Patients were selected if they demonstrated symptomatic MCA hypoperfusion resistant to medical therapy or had symptomatic moyamoya disease. Flow-directed bypass was performed to augment flow to the territories most at risk in each case, based on preoperative and intraoperative data. Computed tomography perfusion was routinely performed to evaluate baseline deficits and postoperative augmentation. Clinical data were analyzed to assess patient demographics and outcomes. The double-barrel bypass was no more difficult technically than the traditional approach, with the second branch harvested through a small satellite incision. By isolating temporary occlusion to each territory, there was no additional ischemia to each brain region. No intraoperative complications or wound-healing issues occurred. Postoperative computed tomography perfusion studies all showed improvement, and delayed vascular imaging demonstrated universal graft patency. Nine of 10 patients have been asymptomatic since surgery, whereas 1 patient demonstrated symptoms in a separate vascular distribution. Double-barrel STA-MCA bypass is both feasible and potentially advantageous. In our series, both bypass branches remained patent, augmenting flow to the territories most at need.

Arm Composite Autogenous Vascular Access Using the Great Saphenous Vein and the Femoral Vein: Results from a Single-centre Study

The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery. Retrospective single-centre study. Prospectively collected clinical database. Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates. The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access. With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

Does Recent DVT and/or Pulmonary Embolus Preclude Complex Extremity Flap Reconstruction?

Introduction: Over the prior 10 years of our reconstructive surgery practice, a high volume of extremity reconstructions requiring flap coverage have been performed. Our poly-trauma cases often present with multi-extremity injuries, have high amputation rates, and are accompanied by pelvic and/or long-bone fractures with extensive soft tissue wounds. These patients have high Injury Severity Scores (ISS) with many independent risk factors for developing deep vein thromboses (DVTs) and pulmonary emboli (PEs). This study will determine the incidence of DVT/PE in our traumatic extremity cases that underwent flap procedures and will review the outcomes and complications within this high-risk cohort of patients. METHODS: A retrospective review of flap procedures for extremity injuries from 2003-2011 was completed. For those patients requiring flap coverage with known DVT/PE, therapeutic anticoagulation or IVC filters were provided per accepted guidelines or standards of care. Outcomes evaluated in the DVT/PE cohort included flap success rates, with complications such as partial/total flap failure, donor and/or recipient site hematomas, seromas, or wound healing issues assessed. RESULTS: A total of 137 extremity flap procedures were performed (76 pedicle; 61 free flaps), with 22 patients (16.1%) having radiographic evidence of preoperative DVT/PE (11 pedicle and 11 free flap cases, respectively). Upper extremity cases had an even higher rate of confirmed preoperative DVT/PE (22.4% of all extremity cases and 68.2% of DVT/PE cases). The ISS averaged 23.8 for the DVT/PE cohort (range 19-39). Anticoagulation therapy consisted predominantly of weight-based therapeutic LMWH in 15 cases (68.2%), IVC filter in 5 patients (22.7%), and heparin drip in 2 patients (8.9%). The average duration of anticoagulation therapy was 16 days (range 4-50days) prior to flap transfer. The most common complications were partial flap necrosis (4.5%) and hematoma (4.5%). There were no total flap failures, infections, or adverse outcomes related to progression of an existing DVT or PE in this series. CONCLUSION: DVT/PE rate in our trauma patients was 16.1% for all cases requiring extremity flap coverage and 22.4% for those cases within the upper extremity flap cohort. Despite these preoperative thrombotic events and risks, flap transfers were performed with high success rates and relatively low complication rates. Pedicle and/or free flaps for extremity injuries can be considered safe to perform in carefully selected and treated patients with known preoperative DVT/PE.

Subgroup Analyses: When Should We Believe Them?

You are an orthopaedic oncologist who has recently excised a high-grade soft-tissue sarcoma from the thigh of a fifty-year-old woman. This patient does not have metastatic disease, has had preoperative radiation, and is now in your clinic for her second postoperative visit. After some wound-healing issues, her wound is now healed and she would like to know if her chance of long-term survival would increase if she underwent adjuvant chemotherapy. Your sarcoma multidisciplinary team generally does not offer chemotherapy to patients with localized disease. However, you decide to consult the literature. You find a meta-analysis by the Sarcoma Meta-analysis Collaboration (SMAC) that was published in The Lancet in 1997 and by the Cochrane Collaboration in 20001. The meta-analysis includes data from fourteen trials involving 1568 patients with localized soft-tissue sarcoma who were randomized to chemotherapy or to no chemotherapy. The article concludes that “there is evidence that doxorubicin-based chemotherapy after initial treatment reduces recurrence, either at the original site or elsewhere in the body…[and] seems to increase the length of time patients live, but this is less certain.” Based on nine subgroup analyses of treatment effect, “greater benefit was seen in men and those whose tumor originated in a limb.” Given the conclusion of the meta-analysis, would you choose not to offer chemotherapy because of the fact that your patient is female? Information obtained from randomized controlled trials is considered the best available evidence for determining a therapeutic treatment effect. However, randomized trials assess a representative sample of patient populations. In order to provide data on individual subsets of patients, subgroup analyses are often done2-4. Information from subgroups is potentially helpful for making treatment decisions for individual patients. In fact, a large percentage of clinical trials include subgroup analyses with the goal of meeting …

Plasma-Stimulated Wound Healing

Cold plasma treatment of wounds is gaining much interest, because it will offer a noncontact, painless, and harmless therapy to manage large-area lesions (burn wounds and chronic ulcerations). One of the important issues in plasma wound healing is the safety of the method. In this paper, we study in vitro the effects of plasma treatment on cell death, proliferation, and wound healing. We performed a parametric study of plasma-treated 3T3 fibroblast cells. For the treatment, a cold atmospheric plasma needle (13.56-MHz microjet in helium) was used. Cells were cultured in six well plates and subsequently deposited on the bottom of the well. As a wound model, a scratch was made in the cell culture. Then, the proliferation of the cells from the sidewalls into the scratch was observed by microscopy. It appeared that plasma treatment stimulates the proliferation of cells into the scratch. This suggests that plasma treatment could result in accelerated wound healing.

The effect on pCR of bevacizumab and/or antimetabolites added to standard neoadjuvant chemotherapy: NSABP protocol B-40.

LBA1005 Background: The addition of capecitabine (X), gemcitabine (G), and bevacizumab (B) to taxanes have each improved PFS in metastatic breast cancer. The primary aims of this trial were to determine if adding X or G to docetaxel (T) → AC will increase breast pathologic complete response (pCR) rates in operable, HER2-negative breast cancer and if adding B to T-based regimens →AC will increase pCR rates. Secondary aims included assessment of clinical complete response (cCR) rates. Methods: Pts received one of 3 T-based regimens, with or without B, 15mg/kg, q3wks x 4: T 100 mg/m2 day 1; T 75 mg/m2 day 1 and X 825 mg/m2 BID days 1-14; or T 75 mg/m2 day 1 and G 1000 mg/m2 days 1 and 8. Pts then received preoperative AC x 4, with or without B for the initial 2 cycles of AC. Pts randomized to B resumed B for 10 postop doses. The primary endpoint was pCR in the breast. The maximum of the standardized pairwise differences between pCR rate for the T → AC regimen and for the other 2 T-based regimens was used as the test statistic to adjust for multiple comparisons. Fisher’s exact test was used to compare the arms with and without B. Results: The groups were balanced, with 47% clinically node+, 56% poorly differentiated, and 59% HR+. Assessments for pCR were available from 1180 of 1206 randomized patients. pCR for TX and TG were 29.7% and 32% vs. 32.7% for T. Neither TX nor TG increased cCR rates relative to T (58.3% and 60.4% vs. 61.5%). TX and TG increased toxicity. Addition of B increased the pCR rate (28.4 vs. 34.5%, p=0.027) and the cCR rate (55.8 vs. 64.3%, p=0.007). The effect of B was predominantly in the HR+ subset (15.2 vs. 23.3%, p=0.008) with minimal effect in the HR- subset (47.3% vs. 51.3%, p=0.44). Grades 2/3/4 toxicities increased with B were HTN (1/&lt;1/0% vs. 13/9/&lt;1%), HFS (11/7/0% vs. 15/11/0%), and mucositis (10/3/0% vs. 20/5/0%). Conclusions: The addition of B to neoadjuvant chemotherapy improved pCR and cCR rates, but the addition of X or G to T did not improve outcomes. Follow-up for wound healing issues and DFS will help define the role of B in the treatment of early breast cancer. Funded by NCI PHS grants U10-CA-37377, U10-CA-69974, U10-CA-12027, U10-CA-69651, and U10-CA-44066, and F. Hoffmann La-Roche, Ltd., Genentech, USA, and Eli Lilly.