Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020

INTRODUCTION

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.

METHODS

A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.

RESULTS

A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05).

CONCLUSIONS

Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

Closure-related complications after median sternotomy in cats: 26 cases (2010-2020)

OBJECTIVES

The aim of this study was to determine closure-related complications and outcome after median sternotomy (MS) in cats.

METHODS

This was a retrospective, multicentric study. The medical records of cats undergoing MS from six referral hospitals were reviewed (2010-2020). Data retrieved included signalment, history, presenting complaints, surgery, patient outcomes and complications. Follow-up was performed via patient records and email/telephone contact with both owners and referring veterinarians. Descriptive statistics were performed.

RESULTS

Data on 36 cats were collected; four were excluded due to insufficient follow-up and six died less than 5 days after surgery. Twenty-six cats survived to discharge (survival rate 81%). Three cats had a full sternotomy (FS) performed and 23 cats a partial sternotomy (PS). Of the cats that underwent a PS, six included the manubrium (PSM) and three included the xyphoid process. For 14 cats, the length of sternotomy was unknown. Sternotomy closure was performed with suture in all cats. Two cats (7.7%) developed closure-related complications, both after PSM, during the long-term follow-up, one mild, slightly displaced sternal fracture and one severe, sternal dehiscence (without skin wound dehiscence) requiring revision surgery. No seroma, surgical site infection or wound dehiscence occurred. The most common reason for MS was the presence of a thoracic mass (17/26; 65%), with thymoma being the most common (11/17; 65%).

CONCLUSIONS AND RELEVANCE

MS has a low closure-related complication risk in cats when compared with dogs. Complications in cats present differently to what has been previously described in dogs.

Management and outcome of spinal implant-associated surgical site infections in patients with posterior instrumentation: analysis of 176 cases

PURPOSE

The management of implant-associated surgical site infections (SSI) in patients with posterior instrumentation is challenging. Evidence regarding the most appropriate treatment and the need for removal of implants is equivocal. We sought to evaluate the management and outcome of such patients at our institution.

METHODS

We searched our prospectively documented databases for eligible patients with posterior spinal instrumentation, excluding the cervical spine (January 2008-June 2018). Patient files were reviewed, demographic data and treatment details were recorded. Patient-reported outcome (PRO) was assessed with the Core Outcome Measures Index (COMI) preoperatively and postoperatively at 3 and 12 months.

RESULTS

A total of 170 patients underwent 210 revisions for 176 SSIs. Two-thirds presented within four weeks (105/176, 59.7%, median 22.5d, 7d-11.1y). The most common pathogens were Staphylococcus aureus (n = 79/210, 37.6%) and Staphylococcus epidermidis (n = 56/210, 26.7%). Debridement and implant retention was performed in 135/210 (64.3%) revisions and partial replacement in 62/210 (29.5%). In 28/176 SSI (15.9%), persistent infection required multiple revisions (≤ 4). Surgery was followed by intravenous and oral antimicrobial treatment (10-12w). In 139/176 SSIs (79%) with ≥ 1y follow-up, infection was cured in 115/139 (82.7%); relapse occurred in 9 (relapse rate: 5.1%). Two patients (1.4%) died. COMI decreased significantly (8.2 ± 1.5 vs. 4.8 ± 2.9, p < 0.0001) over 12 months. 72.7% of patients were (very) satisfied with their care.

CONCLUSION

Patients with SSI after posterior (thoraco-)lumbo(-sacral) instrumentation can be successfully treated in most cases with surgical and specific antibiotic treatment. An interdisciplinary approach is recommended. Loose implants should be replaced. In some cases, multiple revisions may be necessary. Patient outcomes were satisfactory.

Early-experience with a novel suture device for sternal closure in pediatric cardiac surgery

BACKGROUND

Sternal closure by absorbable suture material is an established method for chest closure in pediatric cardiac surgery. However, the formation of granuloma around knotted suture material is frequently observed and has potential for prolonged wound healing and infection, particularly in newborns and infants. This retrospective study analyses the suitability and reliability of a novel absorbable, self-locking, multi-anchor knotless suture with antibacterial technology for sternal closure in pediatric cardiac surgery.

METHODS

The applied material (STRATAFIX^TMSymmetric PDS Plus, Ethicon) presents a poly-dioxanon PDS suture with a self-locking, multi anchor design, which enables a sternal closure in a continuous knotless suture technique. All children undergoing knotless closure after standard median sternotomy were examined for the occurrence of sternal wound infection or sternal instability by applying the screening criteria of the Centers for Disease Control and Prevention at hospital discharge, at 30 and 60 days.

RESULTS

In 130 cases, the new knotless sternal closure was used. Patients` mean age was 19.0±31.9 months (range: 0 to 142 months), mean bodyweight 7.8±6.6 kg (range: 2.4 to 35 kg). Delayed sternal closure occurred in 23 cases with a mean closure time after 2.9±2.6 days. One superficial incisional sternal site infection but no cases of deep sternal site infection or sternal instability were observed.

CONCLUSIONS

The application of the absorbable, knotless suture technique provides excellent results regarding the rate of sternal wound infection and improved healing after median sternotomy in pediatric patients.

Delayed debridement of open tibia fractures beyond 24 and 48 h does not appear to increase infection and reoperation risk

PURPOSE

Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures.

METHODS

All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early (< 24 h), delayed (24-48 h), and late (> 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation.

RESULTS

In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01).

CONCLUSION

Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

Mucormycosis after Coronavirus disease 2019 infection in a heart transplant recipient - Case report and review of literature

Mucormycosis is an invasive fungal infection (IFI) due to several species of saprophytic fungi, occurring in patients with underlying co-morbidities (including organ transplantation). During the ongoing Coronavirus disease 2019 (COVID-19) pandemic, there have been increasing reports of bacterial and fungal co-infections occurring in COVID-19 patients, including COVID-19 associated pulmonary aspergillosis (CAPA). We describe a case of mucormycosis occurring after COVID-19, in an individual who received a recent heart transplant for severe heart failure. Two months after heart transplant, our patient developed upper respiratory and systemic symptoms and was diagnosed with COVID-19. He was managed with convalescent plasma therapy and supportive care. Approximately three months after COVID-19 diagnosis, he developed cutaneous mucormycosis at an old intravascular device site. He underwent extensive surgical interventions, combined with broad-spectrum antifungal therapy. Despite the aggressive therapeutic measures, he died after a prolonged hospital stay. In this case report, we also review the prior well-reported cases of mucormycosis occurring in COVID-19 patients and discuss potential mechanisms by which COVID-19 may predispose to IFIs. Similar to CAPA, mucormycosis with COVID-19 may need to be evaluated as an emerging disease association. Clinicians should be vigilant to evaluate for invasive fungal infections such as mucormycosis in patients with COVID-19 infection.

Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: A single-center experience in 696 patients

There are 3 main types of incisions in major open, elective abdominal surgery: the midline incision (MI), the transverse incision (TI) and the modified Makuuchi incision (MMI). This study aimed to compare these approaches regarding wound complications and hernias, with a special focus on suture material and previous laparotomies.Patients who underwent elective abdominal surgery between 2015 and 2016 were retrospectively analyzed. Uni- and multivariate analyses were computed using stepwise binary and multifactorial regression models.In total, 696 patients (406 MI, 137 TI and 153 MMI) were included. No relevant differences were observed for patient characteristics (e.g., sex, age, body mass index [BMI], American Society of Anesthesiologists [ASA] score). Fewer wound complications (TI 22.6% vs MI 33.5% vs MMI 32.7%, P = .04) occurred in the TI group. However, regarding the endpoints surgical site infection (SSI), fascial dehiscence and incisional hernia, no risk factor after MI, TI, and MMI could be detected in statistical analysis. There was no difference regarding the occurrence of fascial dehiscence (P = .58) or incisional hernia (P = .97) between MI, TI, and MMI. In cases of relaparotomies, the incidence of fascial dehiscence (P = .2) or incisional hernia (P = .58) did not significantly differ between the MI, TI, or MMI as well as between primary and reincision of each type. On the other hand, the time to first appearance of a hernia after MMI is significantly shorter (P = .03) than after MI or TI, even after previous laparotomy (P = .003).In comparing the 3 most common types of abdominal incisions and ignoring the type of operative procedure performed, TI seems to be the least complicated approach. However, because the incidence of fascial dehiscence and incisional hernia is not relevantly increased, the stability of the abdominal wall is apparently not affected by relaparotomy, even by repeated MIs, TIs, and MMIs. Therefore, the type of laparotomy, especially a relaparotomy, can be chosen based on the surgeon's preference and planned procedure without worrying about increased wound complications.

Fever in a patient with osteomyelitis: the diagnosis could be serotonin syndrome

Awareness of rare differential diagnoses of common clinical presentations helps promote early detection and prompt management of serious conditions. A 54-year-old man, with an infected non-union following a high tibial osteotomy, presented with an acutely discharging abscess to his proximal tibia. He was generally unwell with a Staphylococcus aureus bacteraemia. The tibia was debrided, CERAMENT G used as dead space management and a spanning external fixator applied. Postoperatively, pregabalin and tapentadol were commenced in addition to amitriptyline and sertraline, which the patient was taking regularly. Overnight, the patient developed hyperthermia, inducible clonus, hyperreflexia, agitation, confusion and rigors. Prompt recognition of the possibility of serotonin syndrome resulted in early cessation of serotonergic medications and a positive outcome. From this case an important message is that fever in a patient taking serotonergic medications should prompt a screening neurological examination. Clinicians should also be wary when patients are commenced on multimodal analgesia, including tapentadol.

Surgical treatment of mediastinitis: The vertical bolstered Donati stitch

Deep sternal wound infection is a major complication of cardiac surgery, with a low incidence but with catastrophic consequences in terms of morbidity, mortality, and health-care costs. Negative pressure wound therapy and appropriately timed sternal revision, with or without muscle flap mobilization, can improve the outcomes. This video tutorial illustrates the technical aspects of the surgical treatment of mediastinitis with the Robicsek method for sternal closure and an original wound closure technique, very effective and much simpler than the pectoral muscle flap technique.

[Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection]

Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).

[Surgical treatment of sternal osteomyelitis and sternomediastinitis following cardiac surgery]

OBJECTIVE

To analyze the incidence of cardiac surgeries and postoperative sternal osteomyelitis/sternomediastinitis, as well as treatment outcomes in these patients.

MATERIAL AND METHODS

We summarized 171 patients with postoperative sternal osteomyelitis and sternomediastinitis.

RESULTS

Organization of the Khabarovsk center for cardiovascular surgery in the Far Eastern Federal District was followed by 7.9- and 24.9-fold increase of the number of cardiac surgeries and CABG in 2005-2019, respectively. As a result, the number of patients with sternal osteomyelitis and sternomediastinitis after cardiac surgery increased from 0.50±0.10 to 1.59±0.17 cases per 100.000 (t=3.01; p<0.01). CPB and aortic clamping time (t=3.97; p<0.01), as well as surgery time (t=2.4; p<0.05) were significant risk factors of early postoperative complications. Two-stage surgical treatment of postoperative sternal osteomyelitis and sternomediastinitis (removal of ligatures and foreign bodies, sternal curettage with removal of sequesters at the first stage; resection of sternum with chest wall repair at the second stage) reduced hospital-stay from 31.9±13.4 to 29.2±10.8 days.

Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania

BACKGROUND

Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures.

QUESTIONS/PURPOSES

(1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania?

METHODS

A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05.

RESULTS

After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001).

CONCLUSIONS

We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Deep surgical site infection after posterior instrumented fusion for rheumatoid upper cervical subluxation treated with antibiotic-loaded bone cement: Three case reports

INTRODUCTION

Patients with rheumatoid arthritis (RA) tend to be immunosuppressed due to RA itself and the therapeutic drugs administered. The management of surgical site infection (SSI) following upper cervical spinal instrumented fusion in RA patients is challenging; however, literature on the treatment for such conditions is scarce. We report 3 consecutive patients with RA, who developed deep SSI following upper cervical posterior fusion and were treated using antibiotic-loaded bone cement (ALBC).

PATIENT CONCERNS

All 3 patients reported in the current study experienced compression myelopathy with upper cervical spinal deformity and received prednisolone and methotrexate for controlling RA preoperatively. The patient in Case 1 underwent C1-2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 3 months postoperatively; the patient in Case 2 underwent occipito-C2 posterior fusion and developed deep SSI due to methicillin-sensitive Staphylococcus aureus at 2 weeks postoperatively; and the patient in Case 3 underwent occipito-C2 posterior instrumented fusion and laminoplasty at C3-7, and developed deep SSI due to methicillin-resistant coagulase negative staphylococci at 3 weeks postoperatively.

DIAGNOSIS

All patients developed deep staphylococcal SSI in the postoperative period.

INTERVENTIONS

All 3 patients were treated using ALBC placed on and around the instrumentation to cover them and occupy the dead space after radical open debridement.

OUTCOMES

The deep infection was resolved uneventfully after the single surgical intervention retaining spinal instrumentation. Good clinical outcomes of the initial surgery were maintained until the final follow-up without recurrence of SSI in all 3 cases.

CONCLUSION

ALBC embedding spinal instrumentation procedure can be a viable treatment for curing SSI in complex cases, such as patients with RA who undergo high cervical fusion surgeries without implant removal.

Outcome of rectus femoris muscle flaps for groin coverage after vascular surgery

OBJECTIVE

The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage.

METHODS

All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay.

RESULTS

A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%).

CONCLUSIONS

This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.

Haemophilus Parainfluenzae Septic Arthritis Following Primary All-Inside Meniscus Repair: A Case Report and Review of the Literature

Background: Haemophilus parainfluenzae (H. parainfluenzae) is a gram-negative rod that inhabits the oral cavity. It is a common cause of respiratory tract infections and rarely is responsible for musculoskeletal infections in immunocompetent hosts. We present a case of a 17-year-old male whose postoperative course following arthroscopic all-inside meniscus repair was complicated with H. parainfluenzae septic arthritis. The infection was successfully cleared with two arthroscopic irrigation and debridements and antibiotic therapy. The patient successfully returned to full-contact high school football at five months postoperatively. To our knowledge, this represents the first reported case of H. parainfluenzae infection following an orthopaedic procedure in an adolescent. Level of Evidence: IV.

Clostridium difficile Infection of a Total Hip Arthroplasty: Case Report and Review of the Literature

CASE

We describe the case of an 85-year-old woman who presented with worsening right hip pain after a conversion hip replacement. Subsequent imaging demonstrated a gas-containing collection in the lateral thigh. She was taken to the operating room for irrigation and debridement, where intraoperative cultures returned positive for Clostridium difficile. Surgical management was followed by a prolonged course of antibiotics.

CONCLUSIONS

Clostridium difficile as the etiology of infection in a conversion arthroplasty is exceedingly rare. Orthopaedic surgeons and infectious disease specialists should consider C. diff as a potential cause of infection in conversion hip arthroplasty because management options will need to be tailored.

Chronic mesh infection complicated by an enterocutaneous fistula successfully treated by infected mesh removal and negative pressure wound therapy: A case report

RATIONALE

Tension-free repair of inguinal hernia with prosthetic materials in adults has become a routine surgical procedure. However, serious complications may arise such as mesh displacement, infection, and even enterocutaneous fistula (EF). The management of chronic mesh infection (CMI) complicated by an EF is very challenging. A simple treatment of infected mesh removal and negative pressure wound therapy (NPWT) may cure the patients with EF with CMI.

PATIENT CONCERNS

A 75-year-old male patient underwent tension-free treatment for a bilateral inguinal hernia at a county hospital 10 years ago. Three months before admission, the right groin gradually formed a skin sinus with outflow of fetid thin pus, and it could not heal.

DIAGNOSES

The patient was diagnosed preoperatively with mesh plug adhesion to the intestine, which resulted in low-flow EF combined with CMI.

INTERVENTIONS

The patient received a simple treatment mode consisting of an incision made from the original incision, but the new incision did not penetrate the abdominal cavity; treatment included resection of the fistula, removal of the mesh, repair of the intestine and local tissue, and continuous irrigation of vacuum sealing drainage (VSD) devices for NPWT.

OUTCOMES

The infected mesh was completely removed. Five VSD devices were utilized to treat the EF and wound. The time from intervention to wound healing was 35 days, and follow-up for 6 months revealed no infection and no hernia recurrence in the right groin.

LESSONS

The NPWT is effective in treating CMI concomitant with EF and does not increase the risk of hernia recurrence.

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis

BACKGROUND

Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).

METHODS

Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.

RESULTS

Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).

CONCLUSION

Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.

A systematic review on the use of muscle flaps for deep groin infection following vascular surgery

OBJECTIVE

The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage.

METHODS

The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated.

RESULTS

A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences.

CONCLUSIONS

Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.

Post-operative Orthopedic Infection with Monomicrobial Leclercia adecarboxylata: A Case Report and Review of the Literature

CASE

An 65-year-old immunocompetent female developed a Leclercia adecarboxylata infection following the repair of closed olecranon fracture. L. adecarboxylata is associated with polymicrobial infections, infections in immunocompromised patients and penetrating or open wounds. Following speciation, intravenous ceftriaxone was started. Two weeks later, the patient presented with leukopenia and neutropenia. Per infectious disease recommendations, the patient was switched to intravenous ertapenem with resolution of both infection and neutropenia. The olecranon fracture went on to heal fully.

CONCLUSIONS

This case describes a rare postoperative monomicrobial infection with L. adecarboxylata in an immunocompetent host following musculoskeletal trauma and identifies L. adecarboxylata as a potential emerging hospital-acquired pathogen following orthopedic surgery.

Negative Pressure Wound Therapy Versus Closed Suction Irrigation System in the Treatment of Deep Surgical Site Infection After Lumbar Surgery

OBJECTIVE

We compared the efficacy of a closed suction irrigation system (CSIS) and negative pressure wound therapy (NPWT) for deep surgical site infection (SSI) after lumbar surgery with instrumentation.

METHODS

We included 31 patients (NPWT group, n =16; CSIS group, n = 15) with deep SSIs after lumbar surgery with instrumentation from 2007 to 2017. The medical records were reviewed and patient characteristics, laboratory results, infection details, and treatment interventions were recorded. The Japanese Orthopaedic Association score and Oswestry disability index were used to assess pain and functional outcomes preoperatively and 3 and 12 months postoperatively. The cost of SSIs were compared between the NPWT and CSIS groups.

RESULTS

No significant differences were found in the baseline characteristic data between the NPWT and CSIS groups. Implants were retained in all patients in the CSIS group, but required removal from 2 patients with late infections in the NPWT group. The average hospital stay was 36.8 ± 10.5 days and 33.4 ± 18.9 days in the NPWT and CSIS groups, respectively. The cost was greater in the NPWT group than in the CSIS group. Both NPWT and CSIS significantly reduced the Oswestry disability index and improved the Japanese Orthopaedic Association scores, but no significant difference was found between the 2 groups.

CONCLUSIONS

Our results have shown that both NPWT and CSIS are efficient techniques for the management of deep SSI after lumbar surgery with instrumentation. CSIS was more economical and the NPWT system was portable and easier for postoperative nursing care.

Incidence and risk of surgical site infection after adult femoral neck fractures treated by surgery: A retrospective case-control study

Surgical site infections (SSI) are devastating complications after surgery for femoral neck fractures. There are a lot of literature have shown a strong association between diabetic patients and SSI. This study aimed to identify diabetes as an independent risk factor of SSI, focusing on femoral neck fractures, and to investigate the other potential risk factors for SSI.We retrospectively collected data from patients who underwent surgery for femoral neck fractures through the medical record management system at a single level 1 hospital between January 2015 and June 2016. Demographic and clinical patient factors and characteristics of SSI were recorded. The case group was defined as patients with SSI and the control group was defined as patients without SSI. Univariate and multivariate analyses were performed to determine the risk factors for SSI.Data were provided for 692 patients, among whom 26 had SSI, representing an incidence rate of 3.67%. In the SSI group, 24 (3.47%) patients had superficial infection and 2 (0.29%) had deep infection. On multivariate analysis, diabetes (P < .001) was determined an independent risk factor of SSI, so were surgery performed between May and September (P = .04), body mass index (P = .031), corticosteroid therapy (P = .003), anemia (P = .041), and low preoperative hemoglobin levels.Our results suggest that clinicians should recognize patients with these factors, particularly diabetes. And taking management optimally in the preoperative period will prevent the SSI after femoral neck fracture.