Wound Revision Research Articles

Hypofractionated Radiotherapy in Locally Advanced Myxoid Liposarcomas of Extremities or Trunk Wall: Results of a Single Arm Prospective Clinical Trial

Preoperative hypofractionated radiotherapy 5x5 Gy for five consecutive days, and then immediate surgery in patients with locally advanced soft tissue sarcomas (STS) showed a good local control rate and treatment tolerance. Myxoid liposarcoma (MLPS) is highly radiosensitive as compared with other STS, thus a longer gap between the end of RT and surgery may increase the local efficacy and allow to obtain better pathological response rate. The main objective of the study was to assess the safety of 5x5 Gy hypofractionated preoperative RT with prolonged gap (6-8 weeks) to surgery in patients with locally advanced primary MLPS. In this single-arm prospective clinical trial. Patients with locally advanced MLPS underwent preoperative 5x5 Gy RT with 6-8 weeks gap between RT end and surgery from April 2015 to January 2019. The primary endpoint of the study was the rate of perioperative wound healing complications. The secondary endpoints were the pathological response according to the European Organization for Research and Treatment of Cancer - Soft Tissue and Bone Sarcoma Group recommendations (EORTC-STSBG) and local control rate at 5 years. From April 2015 until February 2019 29 patients with primary MLPS finished the whole planned protocol treatment. All of the patients had the tumors located in the lower limb. The median tumor size was 16 cm. The median follow-up time was 13 months. Perioperative wound complications occurred in 9 patients (31%). 6 patients (21%) required medical intervention (antibiotics or wound revision, grade 2 or higher according to Common Terminology Criteria for Adverse Events version 4.03). These results are similar (32.4%) to our historical controls of 272 patients with advanced STS who were treated with 5x5 Gy RT and immediate surgery. R0 margins were achieved in all but two patients (7%) who had R1 resection margin. None of the patients had local recurrence and four patients (14%) developed distant metastases at the moment of analysis (February 2019). The pathological response category according to the EORTC-STSBG recommendations were B (3.5%), C (20.7%), D (34.5%) and E (41.38%). Preoperative hypofractionated RT with the prolonged gap between the RT and surgery is a reasonable approach to MLPS treatment providing a low rate of perioperative complications and good local control.

S1-16 JOURNEY THROUGH REPAIR OF FRONTAL SKULL BASE ENCEPHALOCELES IN AFRICA

Introduction: The authors present the experiences of treating 10 consecutive cases of frontobasal encephaloceles in sub-saharan Africa on a floating hospital ship. To see the sustainability and feasibility of treating complex craniofacial anomolies through teamwork and mentoring of local expertise. Emphasis on telecommunications and telemedicine and radiology in the process is highlighted. Methods: 10 out of 12 encephaloceles presented were fronto-basal; male to female ratio was 7 to 3. All cases were operated by the same team of 3 surgeons - neuro, plastic and max-fac, along with an even more international team of anesthesiologist and OR personnel. Age varied from 3months to 19 yrs. Pre-operative planning was done with the help of CT with contrast and 3D recontruction to help the planning of repair and to see the associated brain anomalies. Results: All cases were operated successfully via a combined craniofacial and direct approach to repair the herniated brain and correct the cosmetic deformity with no mortality. The most common morbidity was CSF leaks ~ 70%, this was managed successfully with conservative methods which will be discussed in the presentation. we did not have established cases of post of meningitis or vranial wound infection. All patient were prophylactically given antibiotics during their hospital stay. Local wound breakdown and revision was required in two cases. Only one patient needed permanent VP shunt. There were no short to medium term neurological sequelae due to the intervention. Conclusion: It is feasible to treat complex frontal encephaloceles via a combined craniofacial approach in countries with very poor access to safe surgical care. The involvement of local expertise which included max-fac and neurosurgeon during the 4 consecutive field services helps to dissociate knowledge and skills. The model of care is one of the alternatives to manage difficult craniofacial anomalies and could be applied to other areas of complex conditions.

261-LB: Robotic Pancreas Kidney Transplantation for Type 1 Diabetic Patient with End-Stage Renal Disease: First Year Experience in Single Institute

Background: Simultaneous pancreas kidney transplantation for type 1 diabetic patients with ESRD is a highly successful, but also very invasive surgery. Robotic assistance facilitates a minimally invasiveness approach to this technically intricate surgery. The present study aims to evaluate the feasibility and outcomes of the first year`s experience in robotic pancreas kidney transplantation (RPKT) for type 1 diabetic patients with ESRD. Patients and Methods: From October 2017 to October 2018, we enrolled consecutive cases of RPKT at the University of Virginia. Operative and clinical features including graft and patient survivals were retrospectively analyzed. The organs were introduced via 6 cm Pfannenstil incision. Results: Six patients (3 male/3 female) successfully underwent RPKT. Median age was 32 years old (range: 30-46years). Median pre-transplant body mass index (BMI) was 25.5 mg/kg2 (Range: 20.6-33.4 mg/kg2). Operative time and estimated blood loss were 593 min (473-733) and 300cc (150-400), respectively. Total cold and warm ischemic time were 436 min (242-585) for pancreas/725min (403-835) for kidney and 43 min (34-60) for pancreas/56min (44-69) for kidney, respectively. We created 5 enteric and 1 bladder drainage for transplant pancreas. There were no conversions to open. No major complications during surgery were observed. We reported one case of delayed graft function of kidney and two cases of rejection with complete recovery. We found one patient with a minor trocar wound dehiscence and revision of ureterocystostomy for stricture. There was one pancreas graft loss at postoperative 7 days due to graft vein thrombosis. No patient death was noted. Conclusion: RPKT for type 1 diabetic patients with ESRD appears to be a safe and effective surgical procedure with potential advantages of wound complication, quality of vascular anastomosis, and shorter recovery with minimal incision compared to conventional open surgery. Disclosure S. Lee: None. L.A. Cantrell: None. J. Oberholzer: Employee; Self; CellTrans. Research Support; Self; JDRF. Stock/Shareholder; Self; Sigilon Therapeutics.

Fast and slow myosin as markers of muscle regeneration in mangled extremities: a pilot study.

Mangled extremities were classically managed by amputation. But over the past few decades, with the advancement in surgical techniques, an increased number of limb salvages have been possible. As muscles usually get damaged in such grievous injuries, a thorough understanding of muscle regeneration may give a better insight into muscle healing in these injuries. Muscles are composed of slow and fast fibers which can be represented by slow and fast myosin, respectively. There are some animal studies which reported differential regeneration of slow and fast muscle fibers during muscle healing. We conducted this pilot study to find out whether the same holds true for muscle healing in mangled extremities also. This pilot study is designed in 15 patients with lower limb mangled extremities presenting to trauma center of PGIMER, Chandigarh, who were operated within 24h of injury to see whether muscle healing in mangled extremities follows the same pattern. Biopsies were taken during initial surgery conducted within 24h of injury and on the 7th day of injury when patient was posted again for secondary wound closure procedure or revision amputation. The biopsy samples were subjected to histopathological and immunohistochemistry examination using antibodies against fast and slow myosin. We found that the regenerating muscle fibers in the biopsy sample taken on the 7th day of injury showed only slow muscle fibers with the absence of fast muscle fibers when compared with the initial biopsy results showing differential regeneration of slow muscle fibers.

Total arterial myocardial revascularization using bilateral internal mammary arteries and the role of postoperative sternal stabilization to reduce wound infections in a large cohort study.

Total arterial myocardial revascularization using bilateral internal mammary arteries shows improved results for mortality, long-term survival and superior graft patency. It has become the standard technique according to recent guidelines. However, these patients may have an increased risk of developing sternal wound infections, especially obese patients or those with diabetes. One reason for the wound complications may be early sternum instability. This situation could be avoided by using a thorax support vest (e.g. Posthorax® vest). This retrospective study compared the wound complications after bilateral internal mammary artery grafting including the use of a Posthorax vest. Between April 2015 and May 2017, 1613 patients received total arterial myocardial revascularization using bilateral internal mammary artery via a median sternotomy. The Posthorax support vest was used from the second postoperative day. We compared those patients with 1667 patients operated on via the same access in the preceding 26 months. The end points were the incidence of wound infections, when the wound infection occurred and how many wound revisions were needed until wound closure. The demographic data of both groups were similar. A significant advantage for the use of a thorax support vest could be seen regarding the incidence of wound infections (P = 0.036) and the length of hospital stay when a wound complication did occur (P = 0.018). As seen in this retrospective study, the early perioperative use of a thorax stabilization vest, such as the Posthorax vest, can reduce the incidence of sternal wound complications significantly. Furthermore, when a wound infection occurred, and the patient returned to the hospital for wound revision, patients who were given the Posthorax vest postoperatively had a significantly shorter length of stay until wound closure.

Bilateral Internal Thoracic Artery Grafting in Women: A Word of Caution.

Despite the superior hemodynamic performance of internal thoracic arteries, total arterial revascularization with exclusive bilateral internal thoracic arteries (BITA) is less frequently used especially in specific subsets of patients, including females. We report our experience with total arterial revascularization with exclusive BITA regardless of sex and analyze the impact of female sex on the early and midterm outcomes. Total arterial revascularization with exclusive BITA was performed with equal frequency in females (79/99, 80%) and males (392/477, 82%; P = .68) undergoing isolated CABG for 3-vessel disease. Pre, intra and postoperative data were compared between these two groups. Complete revascularization was achieved in 77% of females and 72% of males (P = .08). Early mortality did not differ between the groups (6.3% versus 4.6%, P = .7). The incidence of re-sternotomy for bleeding, postoperative stroke, myocardial infarction, new onset atrial fibrillation, and hemofiltration for renal failure did not differ between the two groups. However, there were significantly more wound revision for combined superficial and deep sternal wound infection in females (26.5% versus 5.1%, P = .0001). Nevertheless, midterm survival, freedom from repeat revascularization, myocardial infarction, stroke, and major adverse cardiovascular and cerebral events at five years were very good and compared favorably between females and males. Our findings suggest that total arterial myocardial revascularization with exclusive internal thoracic arteries in females carries the same midterm benefits as in males. Early outcomes are comparable except for a higher incidence of wound revision for combined superficial and deep sternal wound infections in females compared to males. Benefits of bilateral internal thoracic artery grafting in females should be weighed against increased risk of early wound revision.

Central neurocytomas: surgical treatment outcomes and new trends and approaches in the treatment

Central neurocytomas of the brain are rare benign tumors of the cerebral lateral ventricles. The main treatment for them is surgical resection. Resection provides a long-term relapse-free period, but surgical intervention is associated with a number of significant difficulties due to the location, size, and blood supply features of these tumors. The postoperative period is often accompanied by hemorrhagic complications, impaired cerebrospinal fluid circulation, and worsening of neurological symptoms. The study purpose was to evaluate the effectiveness of surgical treatment in neurocytoma patients, assess the risk of complications after neurocytoma resection, and develop techniques for their prevention. The paper presents surgical treatment outcomes in 115 patients with central neurocytomas for the period from 2008 to 2017. The choice of a surgical approach and the surgical features are described in detail, and the radicality is assessed with allowance for the location and size of tumors. The immediate clinical outcomes of treatment are evaluated, complications are analyzed, and methods for prevention and treatment of complications are described. Analysis of the data revealed that the tumor was resected totally in 41 (36%) patients, subtotally - in 37 (32%), and partially in 37 (32%). The most common and dangerous complications were as follows: CSF circulation occlusion with the development of hydrocephalus in 23 (20%) patients; hemorrhage into the residual tumor, which required immediate revision of the surgical wound in most cases, in 25 (22%) patients. In the early postoperative period after tumor resection, almost all patients developed deterioration of condition with transient worsening of cerebral and focal symptoms. The degree and duration of this worsening were different. In 50% of cases, the postoperative condition was characterized by reduced voluntary activity, drowsiness or jitteriness, and motor or speech anxiety. We consider resection of neurocytomas as the main treatment option, despite the potential complications and effects of the operation.

Vacuum-assisted therapy for wound closure acceleration in second intention healing and prophylaxis of pathological scarring

The aim — to evaluate the possibility to accelerate wound healing by second intention and prophylaxis of pathological scaring with vacuum‑assisted closure (VAC) therapy.Materials and methods. The 12 patients in control group were studied retrospectively. Twelve patients of the study group were evaluated prospectively during 2016 — 2018 years. The inclusion criteria were: age from 18 to 70 years, wound with granulation tissue, possibility to approximate wound’s margins mechanically even with the moderate tension, possibility to create negative pressure in the wound’s cavity. Control group’s patients were treated by the routine methods. Main group’s patients were treated with the use of original method of wound healing by second intention closure acceleration and prophylaxis of pathologic scaring. Planimetric study of wound and final scars were performed in all patients.Results and discussion. Initial linear dimensions and area of wound defect were not statistically different in control and study groups. In last one wound edge were somewhat brought together by sterile adhesive film. The drain with the side halls was introduced into the wound cavity. The film was covered by the transparent elastic plastic plate. Tightness of the construction and plate fixation were provided by additional layer of adhesive film. The drain was connected to the source of negative pressure. Wound revision was performed at the fifth day. In case when wound edges were not in contact, the same treatment was continued. To the second stage of treatment proceeded after complete approximation of the wound edges. Approximated edges were fixed by the same film with the perforations along the wound axis. The drain was set over the film along its perforations. It was fixed by additional layer of the film and connected to the source of negative pressure. Law pressure was maintained until fool fixation of wound edges. Comparison of the wound healing time demonstrated that it was statistically shorter in study group (26.7 ± 6.29 days vs 37.3 ± 78.33 days respectively, p = 0.0009). Planimetric study of the scars supported better cosmetic result of the treatment in study group.Conclusions. Law pressure inside the wound promotes progressive approximation of the edges with their subsequent fixation until the moment of sealing. This accelerated healing of wounds in patients of the main group compared with patients in the comparison group (26.7 ± 6.29 days versus 37.3 ± 7.33 days, respectively, p = 0.0009). Improved adaptation of wound edges without additional mechanical damage together with compensation by the vacuum forces that pull apart wound edges allowed to achieve wound healing in patients of main group with the formation of scars of a smaller width (12.0 ± 5.69 mm vs. 28.0 ± 10.95 mm, p = 0.0002) and the area (636.9 ± 536.41 mm2 versus 1150.9 ± 595.86 mm2, p = 0.0370) compared with the comparison group. In the main group normotrophic scars developed statistically significantly higher than in the comparison group (χ2 = 4.20, p = 0.04).

RF52 MITRAL VALVE SURGERY IN OBESES: MINIMALLY INVASIVE COULD BE BETTER

Objective: obesity is become an important health problem in the Western world. The feasibility and efficacy of mitral surgery in very obese patients are controversial especially because of high risk of respiratory, infectious and wond complications. Methods: Between 1/2006 and 2/2018, 106 patients with BMI≥30 underwent minimally invasive MV surgery (9.0% of 1175): male were 50%, mean age was 63.4 ± 11.3, mean Euroscore was 6.3 ± 3.5 and Logistic was 11.1 ± 17.0. Comorbidities included: diabetes (26.4%), COPD (19.8%), chronic renal failure (17.0%), peripheral vasculopathy (5.7%), previous AMI (7.5%) and AF (47.2%). The mean EF was 54.9 ± 11.4 and 15.1% had pulmonary hypertension. In 22.6% had undergone previous cardiac surgery, in 4.7% were urgiences. Results: In 39.6% were mitral repair, associated procedures were TV procedures (10.4%) and AF-crioablation (17.0%). Mean cardiopulmonary and cross clamp time were respectively 142.2 ± 53.3 and 96.3 ± 33.5 minutes. The most utilized aortic clamp technique was endoreturn (61.3%). Conversions to sternotomy were 3.8%. Operative mortality was 0%. Reoperation for bleeding occured in 8.5%. Postoperatively, in 5.7% was necessary CVVH, in 3.8% PM implantation and in 2.8% tracheostomy. Only one patient suffered from major neurologic complications. Groin wound infection/linfocele occurred in 5.7% and in 2.8% was necessary a wound revision. Mean, median intubation time, ICU and hospital stay were respectively 45.4 ± 151.1 h (11 h), 3.8 ± 7.4days (1 day) and 12.0 ± 12.5days (8.0 days). The 30-day mortality rate was 5.7%. Conclusions: Minimally invasive approach appears to be safe, feasible and reproducible with low peri-operative morbidity expecially in obeses.

Management of Reverse Pellucid Type Topography.

Evaluation of the etiopathogenesis and management of topographic reverse pellucid pattern after rigid intraocular lens (IOL) implantation with wide limbal clear corneal incision (CCI). Fifteen eyes with a history of gradual decrease in vision after IOL surgery with at least 6.5-mm CCI were diagnosed with wound dehiscence and were managed with tight resuturation, delayed, and selective suture removal. The improvement in uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively) and refractive errors were analyzed, at least 6 months postoperatively. Postoperatively, UDVA improved in 13/15 eyes (86.7%), whereas CDVA also improved for at least 2 Snellen lines in 11/15 eyes (73.3%) (P<0.01 for both). In all patients, against-the-rule astigmatism changed to with-the-rule astigmatism pattern and the amount of cylinder decreased as the sutures are removed progressively. Vector analysis of astigmatism showed an arithmetic mean of corrected amount of cylinder of 4.17±2.10 D using manifest refraction data and 4.90±2.83 D using keratometric data at the last follow-up. Low visual acuity together with high astigmatism after rigid IOL surgery should prompt the surgeon for considering wound dehiscence that could be managed by careful and deliberate wound revision.

Patient-Specific Titanium-Reinforced Calcium Phosphate Implant for the Repair and Healing of Complex Cranial Defects

The reconstruction of complex cranial defects is challenging and is associated with a high complication rate. The development of a patient-specific, titanium-reinforced, calcium phosphate-based (CaP-Ti) implant with bone regenerative properties has previously been described in 2 case studies with the hypothesis that the implant may improve clinical outcome. To identify whether the introduction of CaP-Ti implant has the potential to improve clinical outcome. A retrospective review of all patients having undergone CaP-Ti cranioplasty was conducted. Comprehensive clinical data were collected from the hospital computer database and patient records. Bone formation and osseointegration were analyzed in a single retrieval specimen. Fifty patients, with 52 cranial defects, met the inclusion criteria. The patient cohort displayed a previous failure rate of 64% (32/50) with autologous bone, alloplastic materials, or both. At a median follow-up time of 25 months, the explantation rate due to either early postoperative infection or persistent wound dehiscence was 1.9% (1/53) or 3.8% (2/53), respectively. Surgical intervention with local wound revision was required in 2 patients without the need of implant removal. One patient had a brain tumor recurrence, and the implant was explanted 31 months after implantation. Histologic examination showed that the entire implant was partly yet evenly transformed into vascularized compact bone. In the present study the CaP-Ti implant appears to have improved the clinical outcomes in a cohort of patients with a high rate of previous cranioplasty failures. The bone regenerative effect may in particular have an impact on the long-term success rate of the implant.

Fulminant wound infection with Clostridium perfringens and Bacillus cereus in a healthy five year old boy

Abstract Trauma related soft tissue infections with Clostridium perfringens and Bacillus cereus in children are rare. We report a case of a healthy five-year old boy with a posttraumatic fulminant localized necrotisizing facial soft tissue infection. A five-year old healthy boy was admitted after a sledging accident. He presented with a laceration of the right cheek. Within 12 h after rinsing and primarily closure under analgosedation he developed localized severe pain and fever. Immediate wound revision under general anesthesia revealed necrotic subcutaneous tissue with an abscess cavity. After surgical debridement the wound was initially left open. An empiric antibiotic therapy with amoxicillin/clavulanate was initiated. A facial bone fracture was excluded by computed tomography. C. perfringens., B. cereus, B. licheniformis and B. pumilus were recovered. A correct intravenous combination therapy was initiated followed by secondary wound closure. The local situation and general condition of the boy improved markedly and no further intervention was necessary.

Small-for-size Syndrome Does Not Occur in Intestinal Transplantation Without Liver Containing Grafts.

The ideal donor in intestinal transplantation (ITX) is generally considered to be 50% to 70% of recipient body weight. This may be due to concerns for "small for size" syndrome as seen in liver transplantation. We report our experience using smaller donors (donor-recipient weight ratio [DRWR], < 50%) in ITX recipients. We studied a group of ITX recipients with DRWR of 50% or less to unmatched controls who received intestinal allografts with DRWR greater than 50%. We examined patient and graft survival and enteral autonomy from parenteral nutrition as surrogate markers for safety of using smaller donors and ease of abdominal wall closure between groups to determine the value. There was no difference in overall patient and graft survival, time to enteral autonomy from parenteral nutrition, and weight gain after ITX over time between groups. The need for complicated abdominal closure techniques was significantly more frequent in the control group than in the study group (34.6% vs 6.9%, P = 0.01). Secondary abdominal closure occurred more frequently in the control group (15.4% vs 0%, P = 0.014). Wound revisions also occurred more frequently in the control group (15.4% vs 0%, P = 0.028). Our data suggest that ITX using smaller donors (DRWR ≤ 50%) seems to be an acceptable practice without adverse impact on surgical complications, nutritional autonomy, and patient and graft survival. Abdominal wall closure seems easier in recipients of smaller donors and "small for size" syndrome as described in liver transplantation does not occur with intestinal allografts.

Staple versus Suture Closure for Ankle Fracture Fixation

Category: Trauma Introduction/Purpose: Ankle fractures are commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. Metallic staples are a commonly accepted method of skin closure in other specialties, though the use of staples in orthopaedics, and more specifically in foot and ankle surgery, remains a topic of debate. Proponents of staples report several potential advantages to using staples instead of sutures, including reduced closure time, faster and less painful removal, or improved cosmetic appearance. This study aimed to compare outcomes of suture versus staple closure as well as to evaluate the safety of staple closure after open fixation of acute traumatic ankle fractures. Methods: The medical records of 94 patients treated at our institution with open fixation of an acute traumatic ankle fracture by a single surgeon between January 2011 and June 2017 were retrospectively reviewed. Demographics, preoperative characteristics, relevant comorbidities, operative characteristics, and postoperative outcomes were compared between patients who received superficial skin closure using staples versus suture techniques. Statistical analysis was performed using chi-squared test and Fisher’s exact test. Results: The staple and suture group patients were demographically similar at baseline. Of the 94 patients included in this study, 10 patients developed local wound related complications postoperatively, including 5 with wound dehiscence, 4 with superficial wound infections, and 1 deep infection . Eight patients required revision surgery due to infection or wound dehiscence. Four patients in the suture group developed superficial wound infections, compared with zero in the staple group. One patient in the staple group developed a deep infection. With the numbers available, no significant differences could be detected in the incidence of postoperative infections, local wound related complications and revision surgeries between two wound closure groups. Conclusion: Our data suggests that there is no statistical difference in outcomes between staple and suture closure after open fixation of acute ankle fractures. Because there was no difference in morbidity with possible benefits of reduced closure time, faster removal, and improved cosmetic appearance, we conclude that staple closure may be a safe alternative to sutures for superficial skin closure. This study adds evidence to a growing body of literature and suggests that staples can be used in some instances, clinical decision making, surgeon preference, and technique proficiency should remain the cornerstone of closure in ankle fracture surgery.

Intradermal Scalp Closure Using Barbed Suture in Cranial Tumor Surgeries: A Technical Note.

Traditional scalp closure technique following elective craniotomy involves placement of staples or a continuous running suture. Despite low complication rates, these techniques are often considered to be disfiguring by patients, contribute to the psychosocial trauma of brain surgery, and are associated with discomfort during postoperative staple or suture removal. Some authors have described scalp closure using intradermal absorbable suture, but this technique likely does not reach the tensile strength of closure using traditional methods, and requires knots at the apices of the incision, which can act as a nidus for infection. We employed a barbed intradermal closure method in supratentorial elective craniotomies for tumor resection. Complication rates were recorded, and cosmetic outcomes were informally assessed. Intradermal closure with barbed sutures was utilized in 76 patients. At the 2-wk postoperative clinic visit, cosmetic outcomes were excellent in all cases. There was 1 superficial wound infection that presented 6 wk after a pterional craniotomy for low-grade glioma. This resolved with superficial wound revision and oral antibiotic therapy. We present a novel scalp closure technique for craniotomies using intradermal barbed Monocryl suture. We have had excellent cosmetic outcomes, and the infection rate of 1.3% compares favorably to published rates. Further studies are required to quantify the improvement in patient satisfaction compared to conventional closure methods.

Posterior cranial fossa and spinal local infections

The aim of this paper is to review the current knowledge on the management of local infections in posterior cranial fossa (PCF) and spinal surgery; the center of our paper will be the diagnosis and management of infections of the wound, the subcutaneous tissue, and muscle strata. Very few papers address the problem of local infections in posterior cranial fossa and spinal surgery. The largest amount of the literature data is indeed centered on how to deal with deep infections, CSF leak, and secondary meningitis or hardware infection. Concerning PCF surgery, a higher rate of local infections has been reported, compared with supratentorial surgery. To prevent such complications, prophylaxis remains the most important tool in dealing with local infections; a careful surgical planning and patient selection are also important. On the other hand, in dealing with local infection in spinal setting, there are several evidences that local vancomycin might help reducing them in adults as well as in children. The treatment protocol consists in antibiotic therapy and, whenever needed, wound revision to remove infectious material or to obtain a microbiological diagnosis. Prognosis has overall to be considered favorable both in the short term as well as in the long term.

Obesity in Revision Total Knee Arthroplasty - a Systematic Review and Legal Assessment

In recent years, the incidence of overweight and obesity has increased in the German population. Thus the number of obese patients treated with primary total joint arthroplasty has also increased. It is therefore predicted that the number of obese patients undergoing revision total joint arthroplasty will also increase. Nevertheless almost every manufacturer of commercially available revision arthroplasty implants states in his product safety guarantee that obesity is a relative or absolute contraindication. Data on revision total joint arthroplasty in obese patients are sparse. The aim of this systematic review is to assess the current literature on re-revision rate, infection rate, postoperative clinical outcome, and implant survival rate in obese patients undergoing revision total knee arthroplasty. Moreover, potential legal consequences and aspects are discussed which are essential for the surgeon. We conducted a systematic review of the online databases PubMed and identified clinical studies on obesity and overweight in revision total knee arthroplasty. Study quality was assessed using levels of evidence and the modified Jadad score. We also included descriptive data on case numbers, age, gender, height, weight and follow-up time. Current legal aspects were also analysed. Five studies met the inclusion criteria and were included in the systematic review. The average Jadad score was 1, the average level of evidence 3. In two studies, infection and revision occured more often in obese patients. Patients with morbid obesity had a higher risk of wound revision and periprosthetic joint infections. Three studies showed that obese patients had significantly lower scores for clinical outcome measures in function and pain. The legal aspect was not discussed in any of the five studies. Overall, published data are sparse and very heterogeneous. Therefore comparing these five studies is difficult. However, the results of our review suggest that obesity in revision total knee arthroplasty may have a negative influence on reoperation rate, infection rate and postoperative functional outcome. From a legal point of view, potential weight limitations of the implants intented for use have to be part of the oral preoperative discussion. The patient's informed consent has to be received and documented prior to revision total joint arthroplasty.

Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome.

Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS). We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n= 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n= 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity. The diseases associated with leak formation included lipomyelomeningocele (n= 16), myelocystocele (n= 4), and myelomeningocele (n= 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n= 15), primary resuturing with local rotation flap of muscle (n= 3), external ventricular drain placement (n= 1), ventriculoperitoneal shunt (n= 3), external ventricular drainage (n= 1), and a combination of techniques (rotation flap with external drain; n= 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications. In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.

Robot-assisted Kidney Autotransplantation: A Minimally Invasive Way to Salvage Kidneys

BackgroundKidney autotransplantation (KAT) is the ultimate way to salvage kidneys with complex renovascular, ureteral, or malignant pathologies that are not amenable to in situ reconstruction. A minimally invasive approach could broaden its adoption. ObjectiveTo describe operative technique, perioperative complications, and early functional outcomes of robot-assisted kidney autotransplantation (RAKAT). Design, setting, and participantsRetrospective review of prospectively collected data regarding consecutive patients undergoing RAKAT between March 2017 and February 2018 at two university hospitals. InterventionRAKAT. Outcome measurements and statistical analysisTechnical feasibility, perioperative complications, and early functional results. Results and limitationsSeven patients underwent RAKAT (three male and four female; five left and two right; one totally intracorporeal) for complex ureteral strictures (n=5), severe left renal vein nutcracker (n=1), and loin pain hematuria syndrome (n=1). Two patients underwent bench vascular reconstruction and one patient underwent ex vivo flexible ureterorenoscopy. No patient needed open conversion. Median operative and console time was 370 and 255min, respectively, with median vascular and ureteral anastomosis time of 28 and 23min, respectively. Median warm, cold, and rewarming ischemia time was 2, 178, and 44min, respectively. One major postoperative complication occurred—wound dehiscence needing wound revision (grade 3b). Median hospital stay was 5 d. At 3 mo, all patients were free of indwelling stents, pain, or hematuria. Median serum creatinine at 3 mo was 0.80mg/dl and median calculated autotransplant glomerular filtration rate did not drop significantly. ConclusionsRAKAT is feasible, safe, and results in good functioning of the autotransplant in selected patients with complex ureteral strictures, loin pain hematuria, or severe nutcracker syndrome. Larger studies with longer follow-up are needed to confirm these findings and to test whether RAKAT is feasible for other KAT indications. Patient summaryWe describe the first series worldwide of a minimally invasive technique for kidney autotransplantation. Robot-assisted kidney autotransplantation is a safe and feasible approach to prevent nephrectomy for intractable symptoms in selected patients with complex ureteral or renal pathology.

A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. Level IV, retrospective case series.