Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

Abstract Background A relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width. Methods We retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m2. Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m2) and overweight/obese (OB/OW; BMI > 25 kg/m2). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer’s exact test to compare categorical variables. Statistical significance was set at p < 0.05. Results The total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m2. Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m2, who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15). Conclusions We conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.

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Plantar forefoot reconstruction: proposal of a management algorithm based on a case series analysis.

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2021.08.010 ◽

2021 ◽

Author(s):

Seng-Feng Jeng ◽

Hsiang-Shun Shih ◽

Marios Papadakis

Keyword(s):

Case Series ◽

Series Analysis ◽

Management Algorithm ◽

Forefoot Reconstruction

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Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology

Foot & Ankle Orthopaedics ◽

10.1177/2473011419884269 ◽

2019 ◽

Vol 4 (4) ◽

pp. 247301141988426 ◽

Cited By ~ 1

Author(s):

John T. Stranix ◽

Merisa L. Piper ◽

Said C. Azoury ◽

Geoffrey Kozak ◽

Oded Ben-Amotz ◽

...

Keyword(s):

Free Flap ◽

Femoral Condyle ◽

Donor Site ◽

Case Series ◽

Medial Femoral Condyle ◽

Flap Reconstruction ◽

Foot And Ankle ◽

Osseous Union ◽

Vascularized Bone

Background: Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone. Methods: A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months). Results: The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 ( P = .017) and prior arthrodesis ( P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively ( P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 ( P < .001). Conclusion: The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes. Level of Evidence: Level IV, retrospective case series.

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Choice of Material for Nasofrontal Duct Obliteration in Frontal Sinus Fracture

FACE ◽

10.1177/27325016211050423 ◽

2021 ◽

pp. 273250162110504

Author(s):

John W. Rutland ◽

Christopher P. Bellaire ◽

Abigail Katz ◽

Helen Liu ◽

Annie Arrighi-Allisan ◽

...

Keyword(s):

Systematic Review ◽

Bone Graft ◽

Frontal Sinus ◽

Donor Site ◽

Bone Grafts ◽

Postoperative Outcomes ◽

Management Algorithm ◽

Sinus Infection ◽

Increased Risk ◽

Frontal Sinus Fracture

Introduction: Within the surgical management algorithm for frontal sinus fracture (FSF), the choice of material for nasofrontal duct (NFD) obliteration is controversial, and a multitude of materials have been described in the literature. The present study aims to perform a systematic review to determine postoperative outcomes associated with various NFD obliteration materials. Methods: Two independent reviewers identified studies to be included based on inclusion and exclusion criteria. Odds ratios and Fisher’s Exact Tests were then used to compare outcomes between cohorts based on the material used for NFD obliteration. Complications under review included donor site complications, reoperations, frontal sinus infections, cerebrospinal fluid leaks, cosmetic defects, persistent pain and/or headaches, and mucocele formation. Results: Twenty-nine studies met inclusion criteria. The use of a vascularized flap was associated with a reduced risk of reoperation and postoperative frontal sinus infection compared with non-flap materials (OR = 0.23 (CI: 0.05, 1.04), P = .05. The use of avascular bone graft was associated with an increased risk of reoperation (OR = 8.89 (CI: 2.24, 29.94), P < .001. Use of bone graft was associated with increased postoperative frontal sinus infection compared with non-bone materials (OR = 3.92 (CI: 1.28, 11.96)), P = .017 and postoperative mucocele formation, P = .0035. The use of bone graft was associated with increased risk of total postoperative complications (OR = 2.68 (CI: 1.41, 5.11), P < .01. Use of autologous materials was associated with decreased number of total complications when compared with non-autologous materials (OR = 0.13 (CI: 0.02, 0.99), P = .02. Conclusions: Avascular grafts, such as bone grafts, for NFD obliteration may be associated with an increased risk of reoperation. In particular, bone grafts are associated with higher rates of reoperation, postoperative infection and mucocele formation. Vascularized flaps appear to offer excellent postoperative outcomes with minimal operative morbidity. This systematic review may be useful in further refining the roles of certain materials in NFD obliteration for FSF surgery.

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Faculty Opinions recommendation of Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30,000 patients.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1128843.585931 ◽

2008 ◽

Author(s):

Stefan De Hert

Keyword(s):

Cardiac Surgery ◽

Statin Therapy ◽

Meta Analysis ◽

Postoperative Outcomes

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The PAP Flap Breast Reconstruction: A Practical Option for Slim Patients

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1727200 ◽

2021 ◽

Author(s):

Taehee Jo ◽

Dong Nyeok Jeon ◽

Hyun Ho Han

Keyword(s):

Donor Site ◽

Wound Dehiscence ◽

Diep Flap ◽

Separate Analysis ◽

Flap Reconstruction ◽

Average Body Mass Index ◽

Deep Inferior Epigastric Perforator ◽

Average Body Mass ◽

Artery Perforator ◽

Average Body

Abstract Background The posterior thigh-based profunda artery perforator (PAP) flap has been an emerging option as a secondary choice in breast reconstructions. However, whether a PAP flap could consistently serve as the secondary option in slim patients has not been investigated. Methods Records of immediate unilateral breast reconstructions performed from May 2017 to June 2019 were reviewed. PAP flap breast reconstructions were compared with standard deep inferior epigastric perforator (DIEP) flap breast reconstructions, and were grouped into single or stacked PAP flaps for further analysis. Results Overall, 43 PAP flaps were performed to reconstruct 32 breasts. Eleven patients underwent stacked PAP flap reconstruction, while 17 patients underwent 21 single PAP flap reconstruction. The average body mass index (BMI) of the patients was 22.2 ± 0.5 kg/m2. The results were as follows: no total loss, one case of venous congestion (2.3%), two donor site wound dehiscence cases (4.7%), and one case of fat necrosis from partial flap loss (2.3%). When compared with 192 DIEP flap reconstructions, the final DIEP flap supplied 98.1 ± 1.7% of mastectomy weight, while the final PAP flap supplied 114.1 ± 6.2% of mastectomy weight (p < 0.005), demonstrating that PAP flaps can successfully supply final reconstruction volume. In a separate analysis, single PAP flaps successfully supplied 104.2% (84.2-144.4%) of mastectomy weights, while stacked PAP flaps supplied 103.7% (98.8-115.2%) of mastectomy weights. Conclusion In our series of PAP flap reconstructions performed in low-to-normal BMI patients, we found that PAP flaps, as single or stacked flaps, provide sufficient volume to reconstruct mastectomy defects.

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Punch Grafting for the Management of Hard-to-Heal Diabetic Foot Ulcers: A Prospective Case Series

The International Journal of Lower Extremity Wounds ◽

10.1177/15347346211031085 ◽

2021 ◽

pp. 153473462110310

Author(s):

Marta García-Madrid ◽

Irene Sanz-Corbalán ◽

Aroa Tardáguila-García ◽

Raúl J. Molines-Barroso ◽

Mateo López-Moral ◽

...

Keyword(s):

Wound Healing ◽

Clinical Outcomes ◽

Diabetic Foot ◽

Donor Site ◽

Case Series ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Wound Debridement ◽

Prospective Case Series

Punch grafting is an alternative treatment to enhance wound healing which has been associated with promising clinical outcomes in various leg and foot wound types. We aimed to evaluate the clinical outcomes of punch grafting as a treatment for hard-to-heal diabetic foot ulcers (DFUs). Six patients with chronic neuropathic or neuroischemic DFUs with more than 6 months of evolution not responding to conventional treatment were included in a prospective case series between May 2017 and December 2020. All patients were previously debrided using an ultrasound-assisted wound debridement and then, grafted with 4 to 6 mm punch from the donor site that was in all cases the anterolateral aspect of the thigh. All patients were followed up weekly until wound healing. Four (66.7%) DFUs were located in the heel, 1 (16.7%) in the dorsal aspect of the foot and 1 (16.7%) in the Achilles tendon. The median evolution time was 172 (interquartile range [IQR], 25th-75th; 44-276) weeks with a median area of 5.9 (IQR; 1.87-37.12) cm2 before grafting. Complete epithelization was achieved in 3 (50%) patients at 12 weeks follow-up period with a mean time of 5.67 ± 2.88 weeks. Two of the remaining patients achieved wound healing at 32 and 24 weeks, respectively, and 1 patient showed punch graft unsuccessful in adhering. The median time of wound healing of all patients included in the study was 9.00 (IQR; 4.00-28.00) weeks. The wound area reduction (WAR) at 4 weeks was 38.66% and WAR at 12 weeks was 88.56%. No adverse effects related to the ulcer were registered through the follow-up period. Autologous punch graft is an easy procedure that promotes healing, achieving wound closure in chronic DFUs representing an alternative of treatment for hard-to-heal DFUs in which conservative treatment has been unsuccessful.

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Repairing the injured bronchus in blunt chest trauma – A case series

Trauma ◽

10.1177/1460408620988116 ◽

2021 ◽

pp. 146040862098811

Author(s):

Anith Nadzira Riduan ◽

Narasimman Sathiamurthy ◽

Benedict Dharmaraj ◽

Diong Nguk Chai ◽

Narendran Balasubbiah

Keyword(s):

Blunt Trauma ◽

Chest Trauma ◽

Surgical Intervention ◽

Case Series ◽

Trauma Patients ◽

Lung Collapse ◽

Comprehensive Management ◽

Lung Capacity ◽

Management Algorithm ◽

Operative Outcomes

Introduction Traumatic bronchial injury (TBI) is uncommon, difficult to diagnose and often missed. The incidence of TBI among blunt trauma patients is estimated to be around 0.5–2%. Bronchoplastic surgery is indicated in most cases to repair the tracheobronchial airway and preserve lung capacity. There is limited existing literature addressing the management of this condition in view of its rarity. The comprehensive management and outcomes of these patients are discussed. Methods The case notes of all patients who presented with persistent lung collapse due to trauma since July 2017 were reviewed retrospectively. Those patients requiring surgical intervention were included in the review. The mode of injury, clinical, radiological and bronchoscopy findings, concurrent injuries, type of surgery, length of stay (LOS) and operative outcomes were reviewed. Results Out of 11 patients who presented with persistent lung collapse post-blunt trauma, four (36%) were found to have structural bronchial disruption. All of them underwent successful repair of the injured bronchus, without the need of a pneumonectomy. The other seven patients were successfully treated conservatively. Conclusion The repair of the injured bronchus is essential in improving respiratory function and to prevent a pneumonectomy. Routine bronchoscopic evaluation should be performed for all suspected airway injuries as recommended in our management algorithm. Delayed presentations should not hinder urgent referral to thoracic centers for tracheobronchial reconstruction.

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Ocular adverse events associated with immune checkpoint inhibitors: a novel multidisciplinary management algorithm

Therapeutic Advances in Medical Oncology ◽

10.1177/1758835921992989 ◽

2021 ◽

Vol 13 ◽

pp. 175883592199298

Author(s):

Orthi Shahzad ◽

Nicola Thompson ◽

Gerry Clare ◽

Sarah Welsh ◽

Erika Damato ◽

...

Keyword(s):

Adverse Events ◽

Checkpoint Inhibitors ◽

Case Reports ◽

Case Series ◽

Simple Algorithm ◽

Cancer Therapeutics ◽

Management Algorithm ◽

Ocular Symptoms ◽

Systemic Corticosteroids ◽

Permanent Loss

Ocular immune-related adverse events (IrAEs) associated with use of checkpoint inhibitors (CPIs) in cancer therapeutics are relatively rare, occurring in approximately 1% of treated patients. Recognition and early intervention are essential because the degree of tissue damage may be disproportionate to the symptoms, and lack of appropriate treatment risks permanent loss of vision. International guidelines on managing ocular IrAEs provide limited advice only. Importantly, local interventions can be effective and may avoid the need for systemic corticosteroids, thereby permitting the continuation of CPIs. We present a single institution case series of eight affected patients managed by our multidisciplinary team. Consistent with previously published series and case reports, we identified anterior uveitis as the most common ocular IrAE associated with CPIs requiring intervention. Based on our experience, as well as published guidance, we generated a simple algorithm to assist clinicians efficiently manage patients developing ocular symptoms during treatment with CPIs. In addition, we make recommendations for optimising treatment of uveitis and address implications for ongoing CPI therapy.

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