Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients

Effects of postoperative hand therapy in patients with Dupuytren's disease : A prospective hyperspectral imaging study

BACKGROUND

Hyperspectral imaging enables noninvasive evaluation of the microcirculation, which affects wound healing. In patients with Dupuytren's disease the microcirculation should be improved in order to achieve good clinical results and reduce the risk of recurrence. The aim of the study was to evaluate the microcirculatory effectiveness of postoperative hand therapy in patients with Dupuytren's disease after partial fasciectomy.

METHODS

In an inpatient hospital setting 35 patients with Dupuytren's disease were investigated before and after partial fasciectomy. Standardized hand therapy was performed after surgery. Its effects on superficial and deep oxygenation, tissue hemoglobin index and tissue water index were assessed using hyperspectral imaging at 3 regions of interest (ROI) within the first 2 postoperative days. For image evaluation, three ROIs were placed manually within the palm, the fingertip of the affected digit (fourth or fifth digit) and a fingertip of a control digit (unaffected, second digit of the same hand) using the vendor's software (TivitaTM Tissue Suite, Diaspective Vision, Germany).

RESULTS

Superficial oxygenation increased 1 day after surgery and after hand therapy. The tissue water index decreased on the second postoperative day.

CONCLUSION

Hyperspectral Imaging demonstrates that postoperative hand therapy effectively improves perfusion and oxygenation in the hands of patients with Dupuytren's disease and additionally reduces edema.

Prognostic Impact of Anemia and Blood Transfusions on Cardiovascular Outcomes in Patients Undergoing Vascular Surgery: A Scoping Review

OBJECTIVE

Prior studies suggest an association of anemia and blood transfusion with increased morbidity and mortality in patients undergoing cardiac surgery. However, the impact of perioperative anemia and blood transfusion on clinical outcomes in patients undergoing major vascular surgery has been poorly defined yet. The primary objectives of this scoping review were to determine the extent of the evidence base that links anemia and blood transfusions to mortality and cardiovascular outcomes in patients undergoing major vascular surgery, and identify recurring themes or gaps in the literature to guide future research.

METHODS

A scoping review of the literature from PubMed, Cochrane, and EMBASE databases was conducted up to December 2023 to identify articles related to the impact of anemia and blood transfusions on postoperative cardiovascular outcomes on patients undergoing vascular surgery. Methodology followed the PRISMA Protocols Extension for Scoping Reviews.

RESULTS

Twenty-two articles met the inclusion criteria, including 15 retrospective and 6 observational prospective studies. Anemia definition varied across studies, mainly based on hemoglobin cut-off levels. An association with older age, coronary artery disease, hypertension, diabetes, and other comorbidities was reported. Particularly in peripheral and endovascular aortic surgery, anemia was linked consistently with higher mortality, major adverse cardiac events, and other postoperative complications, such as respiratory and renal issues, surgical site infections, and longer hospital stays, depending on hemoglobin levels. Anemia itself is an important predictor of transfusions. Transfusions in anemic patients were associated with increased mortality, postoperative complications, and increased need for major amputation.

CONCLUSIONS

The weight of the evidence suggests that anemia carries a substantial burden of cardiovascular complications, mortality, and multiorgan complications, resulting in increased health care costs. Peripheral and endovascular aortic surgery are affected deeply by the impact of anemia. Anemia itself stands out as a crucial predictor for requiring transfusions. In turn, the effect of transfusion of blood products is associated with worse outcomes and complications.

Safety of open airway reconstruction in high-risk post-COVID patients: A case-matched control study

OBJECTIVES

COVID-19 pneumonia patients may have high rates of intubation and reduced pulmonary function once recovered. Poor pulmonary function is a relative contraindication to open airway reconstruction, post-COVID patients may extrapolate as high-risk for open airway reconstruction. This presents challenges in airway stenosis management of post-COVID pneumonia patients. This study reports the safety and outcomes of open airway reconstruction in carefully selected post-COVID patients.

METHODS

A retrospective case-matched control study of six post-COVID tracheal stenosis cases treated with tracheal resection and six matched controls. Controls were matched based on age, length of stenosis, and comorbidities. Primary outcomes are peri-operative safety events and need for future airway interventions.

RESULTS

Post-COVID cases and non-COVID controls were closely matched on age, length of stenosis, and comorbidities (p > 0.05). Duration of follow-up was not significantly different (p = 0.1894). No patients required reintubation, tracheostomy, ICU admission, or ventilator placement in the peri-operative period. There was one allergic reaction to antibiotics in a case and one aspiration pneumonia in a control. One case required in-office steroid injection and injection augmentation post-operatively, but no patients from either group required future operative airway intervention during the follow-up period.

CONCLUSION

Post-COVID tracheal stenosis cases had comparably excellent outcomes with matched controls after open tracheal construction, with few peri-operative safety events and minimal need for future interventions. These data indicate open airway reconstruction is a safe and effective option for the treatment of tracheal stenosis in carefully selected post-COVID patients.

LEVEL OF EVIDENCE: 4

Higher BMI Is Associated With Wound Breakdown Following Resection of Haglund Deformity

BACKGROUND

Haglund deformity is characterized by an enlarged posterosuperior calcaneus, often with inflammation of the retrocalcaneal bursa and Achilles tendon. This study aims to determine if obesity is associated with an increased rate of complications after Haglund resection.

METHODS

A retrospective review was conducted on patients who underwent surgical resection for Haglund deformity from January 2015 to December 2023 at a single academic center. The patient cohort was initially stratified by body mass index (BMI) into normal (BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30). For those classified as obese, further subclassification was performed using the standard system: obesity class I (mild obesity) = BMI 30.0-34.9; obesity class II (moderate obesity) = BMI 35.0-39.9; and obesity class III (severe obesity) = BMI ≥40.0. Data on demographics, surgical techniques, and weightbearing were collected and analyzed. Postoperative complications were compared between groups.

RESULTS

Of the 370 patients included in this study, 20 (5.4%) were classified as normal, 77 (20.8%) were overweight, and 273 (73.8%) were obese. Within the cohort of patients with obesity, 96 (35.2%) were classified as obesity class I, 96 (35.2%) as obesity class II, and 81 (29.7%) as obesity class III.The obese group had a higher proportion of females (70.0%) and Black/African American race (24.5%), and a higher prevalence of diabetes mellitus (22.0%) and American Society of Anesthesiologists scores compared with other groups. Additionally, analysis within the obesity subclassifications revealed significant differences in smoking status, with a higher proportion of nonsmokers as obesity class increased (58.3% in class I, 76.0% in class II, and 79.0% in class III; P = .01). Follow-up duration averaged 10.5 months, with wound breakdown rates significantly higher in the obese group vs the overweight or normal groups (11.0% vs 2.6% vs 0.0%, P = .02). No significant differences in wound complications or outcomes were observed between patients based on different obesity subclassifications.

CONCLUSION

Our findings demonstrate that after Haglund resection, obese patients have a higher risk of complications, particularly wound breakdown. This underscores the necessity of careful patient selection and perioperative optimization.

Super-Obesity is Associated With an Increased Risk of Complications Following Primary Total Knee Arthroplasty

BACKGROUND

Obesity, defined as a body mass index (BMI) ≥ 30, is an ever-growing epidemic, with > 35% of adults in the United States currently classified as obese. Super-obese individuals, defined as those who have a BMI ≥ 50, are the fastest-growing portion of this group. This study sought to quantify the infection risk as well as the incidence of surgical, medical, and thromboembolic complications among super-obese patients undergoing total knee arthroplasty (TKA).

METHODS

An all-payer claims database was used to identify patients who underwent elective, primary TKA between 2016 and 2021. Patients who had a BMI ≥ 50 were compared to those who had a normal BMI of 18 to 25. Demographics and the incidence of 90-days postoperative complications were compared between the 2 groups. Univariate analysis and multivariable regression were used to assess differences between groups.

RESULTS

In total, 3,376 super-obese TKA patients were identified and compared to 17,659 patients who had a normal BMI. Multivariable analysis indicated that the super-obese cohort was at an increased postoperative risk of periprosthetic joint infection (adjusted odds ratio [aOR] 3.7, 95% confidence interval [CI]: 2.1 to 6.4, P < .001), pulmonary embolism (aOR 2.2, 95%-CI: 1.0 to 5.0, P = .047), acute respiratory failure (aOR 4.1, 95%-CI: 2.7 to 6.1, P < .001), myocardial infarction (aOR 2.5, 95%-CI: 1.1 to 5.8, P = .026), wound dehiscence (aOR 2.3, 95%-CI: 1.4 to 3.8, P = .001), and acute renal failure (aOR 3.2, 95%-CI: 2.4 to 4.2, P < .001) relative to patients who have normal BMI.

CONCLUSIONS

Super-obese TKA patients are at an elevated risk of postoperative infectious, surgical, medical, and thromboembolic complications. As such, risk stratification, as well as appropriate medical management and optimization, is of utmost importance for this high-risk group.

Diagnosis and Treatment of Iron Deficiency and Iron Deficiency Anemia in Children and Adolescents: Recommendations of the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Society of Neonatology, and the Polish Society of Family Medicine

Background/Objectives. Iron deficiency is one of the most common nutritional deficiencies worldwide and is the leading cause of anemia in the pediatric population (microcytic, hypochromic anemia due to iron deficiency). Moreover, untreated iron deficiency can lead to various systemic consequences and can disrupt the child's development. Methods/Results. Therefore, a team of experts from the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Neonatology Society, and the Polish Society of Family Medicine, based on a review of the current literature, their own clinical experience, and critical discussion, has developed updated guidelines for the diagnosis, prevention, and treatment of iron deficiency in children from birth to 18 years of age. These recommendations apply to the general population and do not take into account the specifics of individual conditions and diseases.

The effect of Traumeel LT ad us. vet. on the perioperative inflammatory response after castration of stallions: a prospective, randomized, double-blinded study

Introduction

Stallion castration is a standard procedure with a risk of post-surgical complications. Castration induces an acute phase response (APR). Serum Amyloid-A (SAA) is a well-studied major acute phase protein (APP), that has been shown to be a good marker for the development of post-surgical complications. The current gold standard for reducing the APR after castration is Flunixin-Meglumin, which is a non-steroidal anti-inflammatory drug (NSAID) inhibiting COX1/2. In contrast, Traumeel LT ad us. vet. can modulate the APR by induction of the inflammation resolution. The aim of this study was to compare the effect of Flunixin-Meglumin and Traumeel LT ad us. vet. on the acute phase response.

Material and methods

A total of 60 stallions were recruited and 54 stallions entered the study with 27 stallions in each treatment group. The stallions were treated pre- and postoperatively with either Flunixin-Meglumin (FL) or with Traumeel LT ad us. vet. (TR). Blood was taken before and 24 h, 48 h and 72 h after castration. The following main parameters were assessed: SAA, fibrinogen, iron, white blood cells, neutrophils, Interleukin1ß, and cortisol. Wound healing and pain were assessed at 8 time points.

Results

The main variable SAA was increased after surgery reaching a mean value of 122 µg/ml in the FL group and a mean SAA of 226 µg/ml in the TR group 48 h after surgery, reaching a significant difference only at the 24 h timepoint (p = 0.03). All stallions had the highest pain summary score 8 hours after surgery, with decreasing values thereafter. The pain scores were not statistically different at any time point. In the FL group five stallions developed a suture dehiscence compared to only one stallion in the TR group (p = 0.001).

Discussion

Within the limitations of this study, Traumeel LT ad us. vet. seems to have proresolving effects on the inflammation induced by surgery making it a valuable treatment to reduce the APR induced by castration. Due to its different mode of action, Traumeel LT ad us. vet. might be an alternative treatment option if gastrointestinal side effects or renal side effects of NSAIDs should be avoided. Further studies are needed combining Traumeel LT ad us. vet. and Flunixin.

Inhaled nitric oxide as a salvage therapy for refractory hypoxemia in the post-transplantation period of hepatopulmonary syndrome: An explorative report of three cases

Liver transplantation (LT) is the only effective treatment for hepatopulmonary syndrome (HPS). Moreover, perioperative refractory hypoxemia (pRH) is a prevalent life-threatening condition and has extremely limited treatment options. Here, we report three patients with HPS who experienced pRH after LT and were consecutively treated with different salvage therapies, ephedrine inhalation, intravenous use of methylene blue with nitric oxide (NO) inhalation, and NO inhalation alone. The results showed that unresolved severe hypoxia may induce fatal morbidity such as early biliary leakage and acute kidney injury. Early initiation of NO inhalation, rather than ephedrine, can significantly improve oxygenation in patients with pRH and may help prevent hypoxia-related complications. Therefore, based on the response to these exploratory salvage treatments, we further demonstrate the unique ventilation-perfusion mismatch pathophysiology in specific lung regions during pRH in HPS. We propose that early inhalation of NO is an important treatment option to rescue severe hypoxia in patients with HPS during the perioperative period of LT.

Smoking status predicts anastomotic leak after esophagectomy: a systematic review & meta-analysis

BACKGROUND

Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication.

METHODS

A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test.

RESULTS

A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95% CI 1.18-1.76, I2 = 44%, p < 0.001. Meta-analysis of six studies comparing active smokers alone to never smokers identified a significant increased odds of anastomotic leak (OR 1.80, 95% CI 1.25-2.59, p = 0.002, I2 = 0%). Meta-analysis of five studies comparing ex-smokers to never smokers identified a significant increased odds of anastomotic leak (OR 1.36, 95% CI 1.02-1.82, p = 0.04, I2 = 0%). The odds of anastomotic leak decreased among ex-smokers compared to active smokers.

CONCLUSION

The findings of this systematic review and meta-analysis support the association between positive-smoking status and the risk of anastomotic leak after esophagectomy. Results further emphasize the importance of preoperative smoking cessation to reduce post-operative morbidity.

Reduction Mammoplasty in the Pediatric Population: An Analysis of Pediatric NSQIP Data From 2012 to 2019

Introduction: Reduction mammoplasty is becoming more commonly performed in the pediatric population yet the risk factors for complications have not been well-studied. The purpose of this study was to assess the relationship between preoperative patient characteristics and postoperative complications in a large population of pediatric patients undergoing reduction mammoplasty. Methods: Pediatric patients undergoing reduction mammoplasty were identified within the 2012 to 2019 National Surgical Quality Improvement Program database for cross-sectional study. The predictor variables were age, body mass index (BMI), diabetes, chronic steroid use, time under anesthesia, and operative time, and the primary outcome was a 30-day postoperative surgical site-related complication. Multivariate logistic regression was performed to identify a relationship between predictor variable and primary outcome. Results: A total of 1216 pediatric patients were identified with a mean age of 16.6 years and mean BMI of 30.8 kg/m2. The incidence of overall postoperative complications was 4.6%. Superficial surgical site infection (SSI) was the most common complication (29/1216; 2.4%). BMI was significantly associated with superficial SSI (odds ratio: 1.03, 95% confidence interval: 1.00-1.05, P = .02). Sixteen patients (1.32%) underwent a second operation, most commonly to address hematoma/seroma (7/16; 43.8%). Conclusion: In a large series of patients, pediatric reduction mammoplasty is a safe procedure with a low complication rate. BMI was significantly associated with the incidence of superficial SSIs with the most common cause for reoperation being a hematoma/seroma. This study can help guide the discussion between physicians and patients regarding potential risks associated with pediatric reduction mammoplasty.

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Skull Base Osteomyelitis: A 5-Year Review and Prognostic Outcome in a Single Tertiary Institution

Objective

The primary objective of this study is to review the clinical parameters associated with skull base osteomyelitis (SBO), with a secondary aim of studying their association with patient outcomes 1 and 6 months after treatment initiation.

Study Design

This is a single-center restrospective observational study.

Setting

The study was conducted from January 2018 to December 2022 at the University Malaya Medical Center in Kuala Lumpur.

Methods

Patients aged over 15 years with a diagnosis of SBO were included in the study. Clinical parameters, investigations, and follow-up records were recorded. The disease outcomes were analyzed at 1 and 6 months after treatment initiation using multivariable analyses.

Results

The study identified 31 patients with SBO, the majority of whom were elderly males with comorbidities such as diabetes and hypertension. Otalgia and otorrhea were the most common symptoms, and computed tomography scans were used for diagnosis. Pseudomonas aeruginosa was the most commonly identified pathogen, and intravenous broad-spectrum antimicrobials were used to treat all patients. Surgical intervention was required for 25% of patients, and underlying ischemic heart disease, anemia, and single nerve palsy were significantly associated with an unfavorable prognosis. Patients with higher body mass index and elevated C-reactive protein showed poorer outcomes after 1 and 6 months of treatment, respectively.

Conclusion

Early recognition, prompt treatment, better control of comorbidities, nutrition, and monitoring can improve SBO outcomes and reduce complications. Therefore, as the prevalence of SBO increases, diagnostic criteria or management guidelines should be established to guide the best clinical practice.

Acellular Dermal Matrix-Assisted, Prosthesis-Based Breast Reconstruction: A Comparison of SurgiMend PRS, AlloDerm, and DermACELL

BACKGROUND

Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution.

METHODS

A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine-derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development.

RESULTS

A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications.

CONCLUSION

Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.

Melt electrowritten poly-lactic acid /nanodiamond scaffolds towards wound-healing patches

Multifunctional wound dressings, enriched with biologically active agents for preventing or treating infections and promoting wound healing, along with cell delivery capability, are highly needed. To address this issue, composite scaffolds with potential in wound dressing applications were fabricated in this study. The poly-lactic acid/nanodiamonds (PLA/ND) scaffolds were first printed using melt electrowriting (MEW) and then coated with quaternized β-chitin (QβC). The NDs were well-dispersed in the printed filaments and worked as fillers and bioactive additions to PLA material. Additionally, they improved coating effectiveness due to the interaction between their negative charges (from NDs) and positive charges (from QβC). NDs not only increased the thermal stability of PLA but also benefitted cellular behavior and inhibited the growth of bacteria. Scaffolds coated with QβC increased the effect of bacteria growth inhibition and facilitated the proliferation of human dermal fibroblasts. Additionally, we have observed rapid extracellular matrix (ECM) remodeling on QβC-coated PLA/NDs scaffolds. The scaffolds provided support for cell adhesion and could serve as a valuable tool for delivering cells to chronic wound sites. The proposed PLA/ND scaffold coated with QβC holds great potential for achieving fast healing in various types of wounds.

Strikingly High Rates of Periprosthetic Joint Infection Following Revision Surgery for Periprosthetic Fractures Regardless of Surgery Timing

BACKGROUND

Periprosthetic fractures following total hip arthroplasty (THA) often occur in the early postoperative period. Recent data has indicated that early revisions are associated with higher complication rates, particularly periprosthetic joint infection (PJI). The purpose of this study was to assess the effect of timing of periprosthetic fracture surgery on complication rates. We hypothesized that complication rates would be significantly higher in revision surgeries performed within 3 months of the index THA.

METHODS

The Medicare Part A claims database was queried from 2010 to 2017 to identify patients who underwent surgery for a periprosthetic fracture following primary THA. Patients were divided based on time between index and revision surgeries: <1, 1 to 2, 2 to 3, 3 to 6, 6 to 9, 9 to 12, and >12 months. Complication rates were compared between groups using multivariate analyses to adjust for demographics, comorbidities, and types of revision surgery.

RESULTS

Of 492,340 THAs identified, 4,368 (0.9%) had a subsequent periprosthetic fracture requiring surgery: 1,725 (39.4%) at <1 month, 693 (15.9%) at 1 to 2 months, 202 (4.6%) at 2 to 3 months, 250 (5.7%) at 3 to 6 months, 134 (3.1%) at 6 to 9 months, 85 (19.4%) at 9 to12 months, and 1,279 (29.3%) at >12 months. The risk of PJI was 11.0% in the <1 month group, 11.1% at 1 to 2 months, 7.9% at 2 to 3 months, 6.8% at 3 to 6 months, 8.2% at 6 to 9 months, 9.4% at 9 to 12 months, and 8.5% at >12 months (P = .12). Adjusting for confounding factors, risk of PJI following periprosthetic fracture surgery was similar regardless of timing (P > .05). Rates of subsequent dislocation and aseptic loosening were also similar regardless of timing.

CONCLUSIONS

The risk of PJI following repeat surgery for a periprosthetic fracture was strikingly high regardless of timing (6.8 to 11.1%), underscoring the high-risk of complications.

Investigating the risk factors for isthmocele development after cesarean delivery

BACKGROUND

Cesarean delivery rates are increasing globally, raising concerns about associated complications such as isthmocele. Isthmoceles are pouch-like defects in the anterior uterine wall at the site of a prior cesarean delivery scar.

OBJECTIVE

This study aimed to determine isthmocele prevalence, associated symptoms, and risk factors among women with a history of cesarean delivery.

STUDY DESIGN

This cross-sectional study evaluated 297 women with prior cesarean delivery using transvaginal ultrasound to screen for isthmocele. Data on demographics, pregnancy details, comorbidities, and indications for cesarean delivery were collected. Isthmocele was defined sonographically as any niche or defect at the hysterotomy site. Descriptive and comparative analyses identified factors associated with isthmocele.

RESULTS

Isthmocele prevalence was 65.3% (n=194). Abnormal vaginal bleeding was reported in 21.1% of participants, pelvic pain by 4.1% of participants, and both by 4.1% of participants. Compared to women without isthmocele, those with isthmocele were older (35.9 vs 31.6 years), had higher body mass index (26.8 vs 25.5 kg/m2), gravidity (1.8 vs 1.3), and parity (1.7 vs 1.2). Repeat cesarean delivery was more common (30.4% vs 12.6%) and elective cesarean delivery less common (33.5% vs 67.9%) among those with isthmocele.

CONCLUSION

Over half of the women with history of cesarean delivery had an isthmocele. Abnormal bleeding was common. Advanced maternal age, obesity, repeat procedures, and certain comorbidities appear to increase risk. Further research on prevention and treatment is warranted given the high prevalence.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation

BACKGROUND

Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late.

METHODS

We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation.

RESULTS

Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union).

CONCLUSIONS

There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Oxygenated Hydrogel Promotes Re-Epithelialization and Reduces Inflammation in a Perturbed Wound Model in Rat

Chronic wounds can take months or even years to heal and require proper medical intervention. Normal wound healing processes require adequate oxygen supply. Accordingly, destroyed or inefficient vasculature leads to insufficient delivery to peripheral tissues and impair healing. Oxygen is critical for vital processes such as proliferation, collagen synthesis and antibacterial defense. Hyperbaric oxygen therapy (HBOT) is commonly used to accelerate healing however, this can be costly and requires specialized training and equipment. Efforts have turned to the development of topical oxygen delivery systems. Oxysolutions has developed oxygenated gels (P407, P407/P188, nanocellulose based gel (NCG)) with high levels of dissolved oxygen. This study aims to evaluate the efficacy of these newly developed oxygenated products by assessing their impact on healing rates in a rat perturbed wound model. Here, P407/P188 oxygenated gels demonstrated greater re-epithelialization distances compared to its controls at Day 3. In addition, all oxygenated gels had a higher proportion of wounds with complete wound closure. All three oxygenated gels also minimized further escalation in inflammation from Day 3 to Day 10. This highlights the potential of this newly-developed oxygenated gels as an alternative to existing oxygen therapies.

The effect of Sildenafil, a phosphodiesterase-5 inhibitor, on tendon healing: an experimental study in rat model of achilles tendon injury

INTRODUCTION

Sildenafil Citrate has various effects on the body, including widening blood vessels, inhibiting platelet aggregation, promoting the growth of blood vessels, stimulating apoptosis and adhesion of fibroblasts, and reducing inflammation. This research aims to explore how Sildenafil Citrate affects surgically treated Achilles tendons, both in terms of tissue structure and mechanical properties.

MATERIALS AND METHODS

Forty-eight Wistar-albino rats weighing 350-400 g were randomly divided into groups, 6 in each group, as the study group was given Sildenafil Citrate and the control group given saline, respectively. The Achilles tendon rupture model was created under ketamine and xylazine anesthesia. During the entire experiment, rats were housed in eight separate cages, six of them each. The study group and control group of the first group were sacrificed at the end of 1 week, and Achilles tendon samples were taken. After that, Achilles tendon samples were taken after sacrificing the second group at 14 days, the third group at 21 days, and the fourth group at 28 days, respectively. Neovascularization, inflammation, fibrosis and fibroblastic activities of the harvested Achilles tendons were evaluated histopathologically. Biomechanically, stretching was applied to the Achilles tendons and continued until the tendon ruptured. the maximum force values at the moment of rupture were calculated.

RESULTS

The mean maximum strength value of group T21, which was given sildenafil citrate for 21 days, was 31.1 ± 4.36 N, and the mean maximum strength value of group C21, which was the control group, was 20.56 ± 6.92 N. A significant difference was observed between the groups (p: 0.008). Group T28 (45.17 ± 5.54 N) also demonstrated greater strength than group C28 (34.62 ± 3.21 N) in the comparison (p: 0.004). The study also noted significant differences between the groups in neovascularization, in the first week, 1 mild, 3 moderate and 2 prominent neovascularization was observed in group T7, in group T28, moderate neovascularization was observed in 4 specimens and prominent neovascularization was observed in 2 specimens (p: 0.001). Furthermore, the groups showed significant differences in their levels of fibrosis, inflammation and fibroblastic proliferation (p: 0.017, p: 0.036, (p: 0.035) respectively).

CONCLUSIONS

Study has demonstrated that sildenafil citrate can enhance the biomechanical and histopathological aspects of tendon healing, resulting in a stronger tendon.

Low-Cost Wound Healing Protocol Reduces Infection and Reoperation Rates After Cranioplasty: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Cranioplasty infections are a common and expensive problem associated with significant morbidity. Our objective was to determine whether a wound healing protocol after cranioplasty reduced the rate of infections and to determine the value of this intervention.

METHODS

This is a single-institution retrospective chart review of 2 cohorts of cranioplasty patients over 12 years. The wound healing protocol, consisting of vitamin and mineral supplementation, fluid supplementation, and oxygen support, was instituted for all patients aged older than 15 years undergoing cranioplasty. We retrospectively reviewed the charts of all patients over the study period and compared outcomes before and after protocol institution. Outcomes included surgical site infection, return to operating room within 30 days, and cranioplasty explant. Cost data were collected from the electronic medical record. We included 291 cranioplasties performed before the wound healing protocol and 68 postprotocol.

RESULTS

Baseline demographics and comorbidities were comparable between preprotocol and postprotocol groups. Odds of takeback to operating room within 30 days were the same before and after the wound healing protocol (odds ratio [OR] 2.21 [95% CI 0.76-6.47], P = .145). Odds of clinical concern for surgical site infection were significantly higher in the preprotocol group (OR 5.21 [95% CI 1.22-22.17], P = .025). Risk of washout was higher in the preprotocol group (HR 2.86 [95% CI 1.08-7.58], P = .035). Probability of cranioplasty flap explant was also significantly higher in the preprotocol group (OR 4.70 [95% CI 1.10-20.05], P = .036). The number needed to treat to prevent 1 cranioplasty infection was 24.

CONCLUSION

A low-cost wound healing protocol was associated with reduced rate of infections after cranioplasty with concomitant reduction in reoperations for washout, saving the health care system more than $50,000 per 24 patients. Prospective study is warranted.

Hypoxic Microenvironment Reconstruction with Synergistic Biofunctional Ions Promotes Diabetic Wound Healing

Chronic hypoxia and ischemia make diabetic wounds non-healing. Cellular functions of diabetic chronic wounds are inhibited under a pathological environment. Therefore, this work develops a composite hydrogel system to promote diabetic wound healing. The composite hydrogel system consists of ε-poly-lysine (EPL), calcium peroxide (CP), and borosilicate glass (BG). The hydrogel supplies continuous dissolved oxygen molecules to the wound that can penetrate the skin tissue to restore normal cellular function and promote vascular regeneration. Biofunctional ions released from BGs can recruit more macrophages through neovascularization and modulate macrophage phenotypic transformation. Combining oxygen-mediated vascular regeneration and ion-mediated inflammatory regulation significantly accelerated diabetic wound healing. These findings indicate that this composite hydrogel system holds promise as a novel tissue engineering material.

The Overweight and Obese Patient in Oculofacial Plastic Surgery: A Narrative Review

PURPOSE

The oculofacial plastic surgeon will more frequently encounter challenges related to overweight and obese patients as the incidence rises. There is a paucity of data in the oculofacial plastic surgical literature regarding this topic. The goal of this review is to detail the role obesity plays in the perioperative course and the considerations for a surgeon treating this patient population.

METHODS

The authors conducted a computerized search using PubMed, Embase, and Google Scholar. The search terms used were "(obesity OR overweight) AND surgery," "(obesity OR overweight) AND oculoplastic," "(obesity OR overweight) AND oculofacial," "(obesity OR overweight) AND 'facial plastic surgery', " "(obesity OR overweight) AND 'bariatric surgery', " "(obesity OR overweight) AND (pre-operative OR post-operative OR intraoperative," " (obesity OR overweight) AND complications," "(obesity OR overweight) AND (facial plastic surgery) AND complications)," "(obesity OR overweight) AND eyelid," "(obesity OR overweight) AND (nasolacrimal OR 'nasolacrimal duct')," "(obesity OR overweight) AND IIH," "(obesity OR overweight) AND exophthalmos."

RESULTS

A total of 127 articles, published from 1952 to 2022 in the English language or with English translations were included. Articles published earlier than 2000 were cited for foundational knowledge. References cited in the identified articles were also used to gather further data for the review.

CONCLUSIONS

Overweight and obese patients pose specific challenges that the oculofacial plastic surgeon should be aware of to better optimize patient outcomes. Multiple comorbidities, poor wound healing, and nutritional deficits all contribute to the complications experienced in this patient population. Further investigation on overweight and obese patients is needed.

Consenso de expertos sobre la eficacia clínica y directrices sobre la terapia de oxígeno transdérmico continuo para la cicatrización de las heridas complejas o difíciles de cicatrizar

INTRODUCTION

Oxygen is pivotal for wound healing. Its lack or hypoxia can delay this process, especially in individuals with comorbidities, potentially resulting in complex or hard-to-heal wounds. The Colombian Association of Diabetes (ACD) and the Colombian Association of Internal Medicine (ACMI) collaborated with a diverse group of experts to provide recommendations on the efficacy and best practices of continuous transdermal oxygen therapy (TOTc) in the care of such wounds.

METHOD

A modified Delphi technique was employed to obtain controlled feedback and responses. Experts from various disciplines engaged in reviewing and discussing numerous relevant scientific studies, focusing on the role of TOTc in treating chronic ulcers.

RESULTS

Continuous transdermal oxygen therapy has proven to be an effective and safe treatment for chronic and/or hard-to-heal ulcers. This therapy directly addresses the wound's oxygen deficiency, providing an environment conducive to healing. Significant benefits were observed, including the acceleration of the healing process, wound size reduction, and an enhancement in patient quality of life. Its efficacy was found across various ulcer etiologies, underscoring its therapeutic versatility.

CONCLUSIONS

Continuous transdermal oxygen therapy is effective and safe for treating chronic and hard-to-heal ulcers. It's crucial to address each case individually and through a multidisciplinary approach to maximize this therapy's benefits. Both evidence and clinical experience back its utility across a variety of ulcer etiologies.

Comparison of abdominal depth with subcutaneous fat thickness in predicting surgical site infection among patients undergoing hepatopancreatobiliary surgery: a prospective observational study

Introduction

Surgical site infection (SSI) is a significant cause of postoperative morbidity resulting in an increased hospital stay and cost. Various measures have been used to predict SSI such as subcutaneous fat thickness (SCFT) and abdominal depth (AD) in case of abdominal surgeries. The objective of the study was to compare SCFT with AD to predict SSI in HPB surgeries.

Methods

A prospective observational study was conducted from February 2020 to February 2021, which included 76 patients who underwent elective open hepatopancreatobiliary surgeries. SCFT and AD at the level of the umbilicus were measured preoperatively using the computed tomography abdomen. The occurrence of SSI was evaluated in correlation with SCFT and AD. SCFT and AD were compared using the receiver operating characteristic curve for prediction of SSI.

Results

Twenty-five (32.3%) patients who underwent elective HPB surgeries developed SSI. 72% of the SSI were superficial. In multivariate analysis, only SCFT was associated with SSI, which was statistically significant. It was compared with AD using the receiver operating characteristic curve where SCFT proved to be better at predicting SSI (AUC=0.884) with cut-off =2.13 cm, sensitivity 84%, and specificity 86%), compared to AD with an AUC of 0.449.

Conclusion

SSI is the common cause of increased morbidity following hepato-pancreato-biliary surgeries with risk factors including SCFT and AD. Approximately one-third of patient developed SSI, with most the common being superficial SSI. SCFT at the incision site was associated with an increased rate of SSI and the better predictor for SSI as compared with the AD.

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications

OBJECTIVE

To investigate whether the routine use of running subcuticular closures (RSC) in orthopaedic trauma patients increases the rate of wound complications and reoperations.

DESIGN

Retrospective comparative study.

SETTING

Urban Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred sixty-six patients undergoing orthopaedic trauma procedures between June 2020 and March 2022.

INTERVENTION

Adoption of an RSC protocol where any incision/wound that could be approximated with interrupted subcuticular 2-0 monofilament sutures was closed with a running subcuticular 3-0 monofilament suture.

MAIN OUTCOME MEASUREMENTS

Wound complications and subsequent reoperations.

RESULTS

With adoption of the RSC protocol, 91.0% of all orthopaedic trauma procedures were closed with RSC compared with 7.5% of the historical control group. There were no observed differences in the rate of wound complications (proportional difference (PD) 6.0%, confidence interval (CI) -2.3% to 14.1%; P = 0.15) or reoperations (PD 5.2%, CI -1.9% to 12.2%; P = 0.14) between the RSC and the control group. Wound complications were not associated with RSC on univariate analysis (PD 7.2%, CI -10.0% to 24.0%; P = 0.41). On multivariate analysis, an ASA>2 (odds ratio (OR) 2.4, CI 1.0 to 5.7; P = 0.03), lower extremity injuries (OR 4.9, CI 1.3 to 17.8; P = 0.01), and open reduction internal fixation procedures (OR 2.8, CI 1.1 to 7.2; P = 0.02) were found to be independently associated with wound complications.

CONCLUSION

RSC for orthopaedic trauma procedures was not associated with increased wound complications when compared a historical cohort.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postintervention monitoring of peripheral arterial disease wound healing using dynamic vascular optical spectroscopy

SIGNIFICANCE

Due to the persistence of chronic wounds, a second surgical intervention is often necessary for patients with peripheral arterial disease (PAD) within a year of the first intervention. The dynamic vascular optical spectroscopy system (DVOS) may assist physicians in determining patient prognosis only a month after the first surgical intervention.

AIM

We aim to assess the DVOS utility in characterizing wound healing in PAD patients after endovascular intervention.

APPROACH

The DVOS used near-infrared light ( 670 < λ < 850    nm ) to record hemodynamic response to a cuff inflation in 14 PAD patients with lower limb ulcers immediately before, immediately after, and at a first follow-up 3 to 4 weeks after intervention. Ankle-brachial index (ABI) and arterial duplex ultrasound (A-DUS) measurements were obtained when possible.

RESULTS

The total hemoglobin plateau time differed significantly between patients with ulcers that reduced in size ( N = 9 ) and patients with ulcers that did not ( N = 5 ) 3 to 4 weeks after intervention ( p  value < 0.001 ). Data correlated strongly (89% sensitivity, 100% specificity, and AUC = 0.96 ) with long-term wound healing. ABI and A-DUS measurements were not statistically associated with wound healing.

CONCLUSIONS

This pilot study demonstrates the potential of the DVOS to aid physicians in giving accurate long-term wound healing prognoses 1 month after intervention.

Optimization of the target strategy of perioperative infusion therapy based on monitoring data of central hemodynamics in order to prevent complications

Enhanced Recovery After Surgery (ERAS) protocols are increasingly used in the perioperative period around the world. The concept of goal-directed fluid therapy (GDT) is a key element of the ERAS protocols. Inadequate perioperative infusion therapy can lead to a number of complications, including the development of an infectious process, namely surgical site infections, pneumonia, urinary tract infections. Optimal infusion therapy is difficult to achieve with standard parameters (e.g., heart rate, blood pressure, central venous pressure), so there are various methods of monitoring central hemodynamics - from invasive, minimally invasive to non-invasive. The latter are increasingly used in clinical practice. The current evidence base shows that perioperative management, specifically the use of GDT guided by real-time, continuous hemodynamic monitoring, helps clinicians maintain a patient's optimal fluid balance. The manuscript presents the analytical data, which describe the benefits and basic principles of perioperative targeted infusion therapy based on central hemodynamic parameters to reduce the risk of complications.

Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive series of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteen patients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.

Managing Acute Ankle and Hindfoot Fracture in Diabetic Patients

The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes.

Strategies to Minimize Surgical Scarring: Translation of Lessons Learned from Bedside to Bench and Back

Significance: An understanding of the physiology of wound healing and scarring is necessary to minimize surgical scar formation. By reducing tension across the healing wound, eliminating excess inflammation and infection, and encouraging perfusion to healing areas, surgeons can support healing and minimize scarring. Recent Advances: Preoperatively, newer techniques focused on incision placement to minimize tension, skin sterilization to minimize infection and inflammation, and control of comorbid factors to promote a healing process with minimal scarring are constantly evolving. Intraoperatively, measures like layered closure, undermining, and tissue expansion can be taken to relieve tension across the healing wound. Appropriate suture technique and selection should be considered, and finally, there are new surgical technologies available to reduce tension across the closure. Postoperatively, the healing process can be supported as proliferation and remodeling take place within the wound. A balance of moisture control, tension reduction, and infection prevention can be achieved with dressings, ointments, and silicone. Vitamins and corticosteroids can also affect the scarring process by modulating the cellular factors involved in healing. Critical Issues: Healing with no or minimal scarring is the ultimate goal of wound healing research. Understanding how mechanical tension, inflammation and infection, and perfusion and hypoxia impact profibrotic pathways allows for the development of therapies that can modulate cytokine response and the wound extracellular microenvironment to reduce fibrosis and scarring. Future Directions: New tension-off loading topical treatments, laser, and dermabrasion devices are under development, and small molecule therapeutics have demonstrated scarless wound healing in animal models, providing a promising new direction for future research aimed to minimize surgical scarring.

A multicenter clinical trial evaluating the durability of diabetic foot ulcer healing in ulcers treated with topical oxygen and standard of care versus standard of care alone 1 year post healing

Multiple clinical trials and real‐world studies have demonstrated accelerated healing in diabetic foot ulcers (DFU) treated with advanced modalities, such as topical oxygen therapy (TOT). In addition to healing, the durability of wound closure is a crucial long‐term endpoint for DFU clinical trials: an advanced treatment that does not confer a reasonable ulcer‐free period will have limited clinical benefit and modest economic value. Preclinical studies suggest that DFUs receiving topical oxygen therapy will experience improved quality of healing: increased collagen deposition and angiogenesis. It is postulated that these changes will translate into a more long‐lasting closure for ulcers treated with TOT and SOC compared to ulcers treated with SOC alone. At the conclusion of a recently completed randomised controlled DFU clinical trial evaluating the efficacy of TOT and SOC compared to SOC alone, patients with healed ulcers were asked to enrol in a long‐term follow‐up study. Healed patients completed four questionnaires through text messages or phone calls within 1‐year post completion of the trial. Twenty‐nine patients consented to participate in the long‐term follow‐up trial (17 TOT/SOC and 12 SOC). Only seven subjects were lost to follow up (5 TOT and 2 SOC). This is a surprisingly low number when factoring in the disruption caused by the COVID‐19 pandemic that continued throughout the entire follow‐up period. In the remaining patients, 85% of the TOT patients and 60% of the SOC remained healed at 1 year. There was one major amputation, which occurred in an SOC‐treated patient. The numbers in the long‐term follow‐up were too small to reach statistical significance; however, there is a strong trend toward more durable closure in ulcers treated with TOT.

Photoacoustic monitoring of angiogenesis predicts response to therapy in healing wounds

Chronic wounds are a major health problem that cause the medical infrastructure billions of dollars every year. Chronic wounds are often difficult to heal and cause significant discomfort. Although wound specialists have numerous therapeutic modalities at their disposal, tools that could three dimensional-map wound bed physiology and guide therapy do not exist. Visual cues are the current standard but are limited to surface assessment; clinicians rely on experience to predict response to therapy. Photoacoustic (PA) ultrasound (US) is a non-invasive, hybrid imaging modality that can solve these major limitations. PA relies on the contrast generated by haemoglobin in blood which allows it to map local angiogenesis, tissue perfusion and oxygen saturation-all critical parameters for wound healing. This work evaluates the use of PA-US to monitor angiogenesis and stratify patients responding versus not-responding to therapy. We imaged 19 patients with 22 wounds once a week for at least 3 weeks. Our findings suggest that PA imaging directly visualises angiogenesis. Patients responding to therapy showed clear signs of angiogenesis and an increased rate of PA increase (p = 0.002). These responders had a significant and negative correlation between PA intensity and wound size. Hypertension was correlated to impaired angiogenesis in non-responsive patients. The rate of PA increase and hence the rate of angiogenesis was able to predict healing times within 30 days from the start of monitoring (power = 88%, alpha = 0.05). This early response detection system could help inform management and treatment strategies while improving outcomes and reducing costs.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

[Management of fracture-related infections]

Fracture-related infections (FRI) are a major challenge in orthopedic trauma surgery. The problems in the treatment of such infections are manifold. Especially in cases with insufficient fracture consolidation the treatment not only focusses on the eradication of the infection but also on the restoration of the osseous continuity. The extent of the accompanying soft tissue damage is of particular importance as reduced vascularization leads to impairments in fracture healing. Although acute infections are frequently easy to recognize, the symptoms of chronic infections can be unspecific and evade the diagnostic procedures. This fact makes the treatment of such infections complicated and sometimes necessitates an interdisciplinary approach. For this reason, the Fracture-related Infection Consensus Group developed an algorithm, which was first published in 2017 and revised in 2018 and 2020. The FRIs are biofilm-associated infections, so that the current guidelines follow the previously established treatment algorithms for periprosthetic infections. Despite the analogies to periprosthetic infections there are also differences in the treatment as the aspects of fracture healing and bone defect restoration represent determining factors in the treatment of FRI. This article presents the special features of FRI and the classification and guidelines for the treatment are discussed.

Oxygen-Releasing Composites: A Promising Approach in the Management of Diabetic Foot Ulcers

In diabetes, lower extremity amputation (LEA) is an irreversible diabetic-related complication that easily occurs in patients with diabetic foot ulcers (DFUs). Because DFUs are a clinical outcome of different causes including peripheral hypoxia and diabetic foot infection (DFI), conventional wound dressing materials are often insufficient for supporting the normal wound healing potential in the ulcers. Advanced wound dressing development has recently focused on natural or biocompatible scaffolds or incorporating bioactive molecules. This review directs attention to the potential of oxygenation of diabetic wounds and highlights current fabrication techniques for oxygen-releasing composites and their medical applications. Based on different oxygen-releasable compounds such as liquid peroxides and solid peroxides, for example, a variety of oxygen-releasing composites have been fabricated and evaluated for medical applications. This review provides the challenges and limitations of utilizing current oxygen releasable compounds and provides perspectives on advancing oxygen releasing composites for diabetic-related wounds associated with DFUs.

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection

Background

Despite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.

Method

A retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.

Results

From 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%; P < .001) and RSA (3.08% vs. 0.73%; P < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19; P < .001) and RSA cohort (odds ratio, 8.38; P < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.

Conclusion

Aseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.

Dissolved oxygen technologies as a novel strategy for non-healing wounds: A critical review

Non-healing wounds are steadily becoming a global-health issue. Prolonged hypoxia propagates wound chronicity; yet, oxygenating treatments are considered inadequate to date. Dissolved oxygen (DO) in aqueous solutions introduces a novel approach to enhanced wound oxygenation, and is robustly evaluated for clinical applications. A systematic literature search was conducted, whereby experimental and clinical studies of DO technologies were categorized per engineering approach. Technical principles, methodology, endpoints and outcomes were analysed for both oxygenating and healing effects. Forty articles meeting our inclusion criteria were grouped as follows: DO solutions (17), oxygen (O₂ ) dressings (9), O₂ hydrogels (11) and O₂ emulsions (3). All technologies improved wound oxygenation, each to a variable degree. They also achieved at least one statistically significant outcome related to wound healing, mainly in epithelialization, angiogenesis and collagen synthesis. Scarcity in clinical data and methodological variability precluded quantitative comparisons among the biotechnologies studied. DO technologies warrantee further evaluation for wound oxygenation in the clinical setting. Standardised methodologies and targeted research questions are pivotal to facilitate global integration in healthcare.

A scoping review to inform a multi-disciplinary approach for nutrition therapy in critically ill children with pressure injuries

Nutrition status plays a critical role in pressure injury (PI) healing and yet the available literature, especially in pediatric patients, is limited. Critically ill pediatric patients are at an increased risk of skin integrity compromise and PI development. Adequate nutritional intake can often be challenging to achieve in this population and immobility and illness present additional obstacles to maintaining skin integrity in this vulnerable population. Despite the unique nutritional challenges and needs of this group, there is no standardized approach to macro- and micronutrient management and monitoring. Here, several key vitamins and minerals believed to play a role in PI healing are discussed and an approach to nutritional management and monitoring for PI healing in pediatric patients is proposed. Registered dietitians (RD) are essential to assess individual patient macro and micronutrient requirements, to identify gaps and make recommendations to optimize nutritional therapy that may exist and impact wound healing. We used a scoping review to focus on the interplay of nutrition and PI healing and inform a multidisciplinary approach to PI identification and management. Through this review, we propose a strategy for the nutritional management of pediatric patients <30 kg at risk for and who present with PI.

Enhanced perfusion of elliptical wound closures using a novel adhesive suture retention device

BACKGROUND AND AIMS

The purpose of this investigation was to test the hypothesis that a novel adhesive retention suture device (ARSD) can increase perfusion at elliptical wound closures by distributing stress away from the suture site.

METHODS

Stress in the skin around a suture both with and without support from an ARSD was evaluated using a finite element model. A single-center, randomized split-scar comparison trial using laser speckle contrast analysis was used to quantify the perfusion at elliptical wound closures in human patients both with and without an ARSD.

RESULTS

The finite element model revealed that the ARSD promoted load transfer to the skin over a larger area, thus reducing the local stress and deformation in the skin around the suture site. Results from the split-scar study showed a mean improvement of 25% perfusion units with the ARSD, and the improvement was statistically significant (p = 0.002).

CONCLUSION

The reduction in local stress and enhanced perfusion around the suture site reveals the potential benefit of using an ARSD to enable more efficient healing by avoiding complications associated with both low perfusion and skin tearing, such as dehiscence, infection, and cheese wiring.

The Ideal Time for Iron Administration in Anemia Secondary to Blood Loss-An Experimental Animal Model

BACKGROUND

Anemia and iron deficiency are two of the main public health problems worldwide, associated with negative outcomes in surgical patients. This experimental study aimed to create a model of acute iron deficiency with anemia through blood loss and extensive surgery. Afterwards, intravenous iron was administered to correct the iron deficiency and to improve the hematological parameters in distinct moments regarding the surgical time. To assess the optimum time for therapeutic intervention, experimental subjects were compared, performing clinical, paraclinical, and histological examinations, as well.

METHODS

Male rats (n = 35), aged 11-13 months, were randomly designated into six groups. Anemia and iron deficiency were obtained through a 15% blood volume loss, followed by major surgical intervention (femur fracture and osteosynthesis using Kirschner wire). Therapeutic intervention was obtained with an intravenous ferric carboxymaltose infusion, as follows: group II: intraoperative (n = 7), group III: 48 h after surgery (n = 7), group IV: 48 h before surgery (n = 5), and group V: seven days before surgery (n = 6). Group I (n = 5) was left anemic, while group 0 (n = 5) was nonanemic without therapeutic intervention.

RESULTS AND DISCUSSION

In group I, serum iron lower than in group 0 (27.04 ± 6.92 μg/dL versus 60.5 ± 2.34 μg/dL), as well as hemoglobin (10.4 ± 0.54 g/dL versus 14.32 ± 2.01 g/dL) and ferritin values (22.52 ± 0.53 ng/mL versus 29.86 ± 3.97 ng/mL), validated the experimental model. Regarding wound healing after surgical trauma, we observed that neovascularization was more significant in group III, followed by group V, with fewer neutrophils, a well-represented and rich in lymphomonocytes inflammatory infiltrate associated with the biggest collagen fiber dimensions. The periosteal reaction and callus area presented thicker trabeculae in groups II and III compared to the anemic group.

CONCLUSIONS

This original experimental study assessed the effect of perioperative intravenous iron administration at a specific time by comparing the weight, hematological, and iron status-defining parameters, as well as histological characteristics of the included subjects. The present findings highlight that correcting the iron deficiency in emergency settings through intravenous iron administration intraoperatively or 48 h postoperatively could determine the improved bioumoral parameters, as well as a better evolution of the postoperative wound and bone healing compared to the anemic group or subjects that received therapeutic intervention 48 h before surgery.

Multilayer Mattress Stitches for Complicated Wounds in Spine Surgery

Introduction

Local infection and prolonged fluid discharge account for most complications in lumbar spine surgery. This report is a brief description of a useful technique for revision of complicated, draining wounds with surprisingly positive results that otherwise frequently require multiple surgical interventions.

Technical Note

We describe the postoperative course of three patients, with prolonged and continuous serosanguineous discharge from the skin incision, who underwent wound revision with multilayered mattress stitches after open decompressive or instrumented spinal surgery. For this purpose, a thick monofilament suture is passed through the skin, subcutaneous fatty tissue, and paravertebral muscle in the fashion of a vertical mattress stitch while the loop above the skin level is augmented using a soft silicone capillary drainage to distribute tension along the wound margin.

Conclusions

None of the patients treated with the multilayered mattress stitches required further surgical intervention. In this small case series, the multilayered mattress stitches augmented with soft silicone tubing were a useful technique for treating complicated lumbar surgical wounds with prolonged serosanguineous discharge.

Surgical wounds in reduction mammoplasty: a comparison of Monocryl and Prolene sutures on scars

OBJECTIVE

The type of suture material affects the quality of scars. The aim of this study was to find the superior suture material for reduction mammoplasty between Prolene and Monocryl based on the comparison of scars.

METHOD

A prospective observational study was conducted at a university-based hospital in Mashhad, Iran between October 2015 and September 2017. Monocryl and Prolene suture materials, used for closing the outermost layer in mammoplasty, were compared. Patients' incision scars were assessed objectively according to the Patient and Observer Scar Assessment (POSAS) criteria. The relevant CONSORT guideline was used for reporting this study.

RESULTS

Seventy-eight women with a mean age of 36.8±9.5 years were entered into the study. The frequency of wound healing in both groups was 97.4% 1 month after surgery and by the third visit, 3 months after surgery, only one patient had a stretched scar. Moreover, wound inflammation in the first two visits was less frequent in the Prolene group that healed completely 3 months after surgery (after excluding the one patient with wide scar inflammation). The frequency of itching of the wound in the Monocryl group was 24.4%, 11.5% and 12.8% in the three follow-up visits, respectively, and the values for the Prolene group were 24.4%, 9.0% and 6.4%, respectively. No significant difference was seen between the two groups in terms of wound healing, inflammation and itching (p>0.05). Overall, 94.8% of patients were satisfied with the surgery.

CONCLUSIONS

Our study revealed that there was no significant difference between Monocryl and Prolene. Hence, either of the two suture materials can be used for wound closure in reduction mammoplasty.

Electric Factors in Wound Healing

Significance: Electric factors such as electric charges, electrodynamic field, skin battery, and interstitial exclusion permeate wound healing physiology and physiopathology from injury to re-epithelialization. The understanding of how electric factors contribute to wound healing and how treatments may interfere with them is fundamental for the development of better strategies for the management of pathological scarring and chronic wounds. Recent Advances: Angiogenesis, cell migration, macrophage activation hemorheology, and microcirculation can interfere and be interfered with electric factors. New treatments with various types of electric currents, laser, light emitting diode, acupuncture, and weak electric fields applied directly on the wound have been developed to improve wound healing. Critical Issues: Despite the basic and clinical development, pathological scars such as keloids and chronic wounds are still a challenge. Future Directions: New treatments can be developed to improve skin wound healing taking into account the influence of electrical charges. Monitoring electrical activity during skin healing and the influence of treatments on hemorheology and microcirculation are examples of how to use knowledge of electrical factors to increase their effectiveness.

Effect of Peri-Operative Hyperoxygenation on Surgical Site Infection in Patients Undergoing Emergency Abdominal Surgery: A Randomized Controlled Trial

Background: The rationale for hyperoxygenation in controlling surgical site infection (SSI) has been described in many studies yet has not been defined clearly. Some studies in colorectal surgery have reported beneficial effects, whereas studies in gynecologic surgery have reported either no effect or a deleterious effect. This study assessed the effectiveness of hyperoxygenation on the reduction of SSI in patients undergoing emergency abdominal surgery. Patients and Methods: Eligible patients were assigned randomly to two groups (study group, 80% oxygen or control group, 30% oxygen). The patients in the study group received 80% oxygen and the patients in the control group received 30% oxygen intra-operatively and for two hours after surgery. Arterial blood gas analysis was done after resuscitation, at the end of the surgery, and at two hours after extubation. All patients were assessed for SSI, post-operative nausea and vomiting, and respiratory complications. Patients were followed post-operatively for 14 days. Surgical site infection was diagnosed according to U.S. Centers for Disease Control and Infection (CDC) criteria and by aerobic wound cultures. Results: After exclusion, 85 patients in the control group and 93 patients in the study group were analyzed. There was no difference for baseline, intra-operative, and post-operative characteristics between the two groups, except for higher oxygen saturation at closure and two hours post-operatively, in the 80% group (p = 0.01). Surgical site infection occurred in 29 patients (34.11%) in 30% fraction of inspired oxygen (F_IO₂) group and in 19 patients (20.43%) in 80% F_IO₂ group (p = 0.04). The risk of SSI was 59% lower in the 80% F_IO₂ group (adjusted odds ratio, 0.41; 95% confidence interval [CI], 0.19-0.88 vs. the 30% F_IO₂ group). There were no differences in post-operative nausea and vomiting and respiratory complications between the two treatment groups. Conclusions: Administration of 80% peri-operative hyperoxygenation in emergency abdominal surgery reduces SSI and is a cost-effective method.

Effect of intra-operative high inspired fraction of oxygen on postoperative nausea and vomiting in children undergoing surgery: A prospective randomised double-blind study

BACKGROUND

Administration of high inspired fraction of oxygen (FiO2) during anaesthesia has been proposed to decrease postoperative nausea and vomiting (PONV) in adults but has not been extensively studied in children.

OBJECTIVES

The primary objective of this study was to evaluate the effect of 80% FiO2 on the incidence of PONV in children undergoing surgery.

DESIGN

Prospective, randomised, study.

SETTING

Single-centre, teaching hospital.

PATIENTS

Children of either gender in the age group of 5 to 15 years scheduled for elective surgeries were assessed for eligibility. In cases of emergency surgeries; patients receiving supplemental oxygen pre-operatively or on mechanical ventilation; sepsis; bowel obstruction or ischaemia; poor nutritional status; anaemia (Hb <8 g%) or surgeries lasting less than 1 h or greater than 4 h were excluded from the study.

INTERVENTIONS

After induction of anaesthesia, children were randomised to receive either 30 or 80% oxygen in air, till the end of surgery.

MAIN OUTCOME MEASURES

Incidence of PONV within 24 h; surgical site infections (SSI)s; serum serotonin and TNF-α levels and the incidence of postoperative pulmonary complications (PPC)s were studied.

RESULTS

The overall 24 h incidence of PONV was not different between the low and high FiO2 groups [24 vs. 23%; P = 0.84; odds ratio (OR) 0.92; 95% confidence interval (CI), 0.44 to 2.06]. The incidence of SSIs (15 vs. 12%; P = 0.61; OR 0.77; 95% CI, 0.28 to 2.10) and PPCs (12 vs. 8%; P = 0.38; OR 0.59; 95% CI, 0.18 to 1.92) were not significant between the low and high FiO2 groups, respectively. Intragroup and intergroup comparisons of serum serotonin and TNF-α showed no significant difference either at baseline or at the end of surgery.

CONCLUSION

High intra-operative FiO2 of 80% does not provide additional protection against PONV in children.

TRIAL REGISTRATION

The study was registered with Clinical Trials Registry of India (CTRI) with trial registration no: CTRI/2018/07/014974.

Proteomic signatures for perioperative oxygen delivery in skin after major elective surgery: mechanistic sub-study of a randomised controlled trial

BACKGROUND

Maintaining adequate oxygen delivery (DO₂) after major surgery is associated with minimising organ dysfunction. Skin is particularly vulnerable to reduced DO₂. We tested the hypothesis that reduced perioperative DO₂ fuels inflammation in metabolically compromised skin after major surgery.

METHODS

Participants undergoing elective oesophagectomy were randomised immediately after surgery to standard of care or haemodynamic therapy to achieve their individualised preoperative DO₂. Abdominal punch skin biopsies were snap-frozen before and 48 h after surgery. On-line two-dimensional liquid chromatography and ultra-high-definition label-free mass spectrometry was used to characterise the skin proteome. The primary outcome was proteomic changes compared between normal (≥preoperative value before induction of anaesthesia) and low DO₂ (<preoperative value before induction of anaesthesia) after surgery. Secondary outcomes were functional enrichment analysis of up/down-regulated proteins (Ingenuity pathway analysis; STRING Protein-Protein Interaction Networks). Immunohistochemistry and immunoblotting confirmed selected proteomic findings in skin biopsies obtained from patients after hepatic resection.

RESULTS

Paired punch skin biopsies were obtained from 35 participants (mean age: 68 yr; 31% female), of whom 17 underwent oesophagectomy. There were 14/2096 proteins associated with normal (n=10) vs low (n=7) DO₂ after oesophagectomy. Failure to maintain preoperative DO₂ was associated with upregulation of proteins counteracting oxidative stress. Normal DO₂ after surgery was associated with pathways involving leucocyte recruitment and upregulation of an antimicrobial peptidoglycan recognition protein. Immunohistochemistry (n=6 patients) and immunoblots after liver resection (n=12 patients) supported the proteomic findings.

CONCLUSIONS

Proteomic profiles in serial skin biopsies identified organ-protective mechanisms associated with normal DO₂ after major surgery.

CLINICAL TRIAL REGISTRATION

ISRCTN76894700.

Molecular Biomarkers of Oxygen Therapy in Patients with Diabetic Foot Ulcers

Hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT) including continuous diffuse oxygen therapy (CDOT) are often utilized to enhance wound healing in patients with diabetic foot ulcerations. High pressure pure oxygen assists in the oxygenation of hypoxic wounds to increase perfusion. Although oxygen therapy provides wound healing benefits to some patients with diabetic foot ulcers, it is currently performed from clinical examination and imaging. Data suggest that oxygen therapy promotes wound healing via angiogenesis, the creation of new blood vessels. Molecular biomarkers relating to tissue inflammation, repair, and healing have been identified. Predictive biomarkers can be used to identify patients who will most likely benefit from this specialized treatment. In diabetic foot ulcerations, specifically, certain biomarkers have been linked to factors involving angiogenesis and inflammation, two crucial aspects of wound healing. In this review, the mechanism of how oxygen works in wound healing on a physiological basis, such as cell metabolism and growth factor signaling transduction is detailed. Additionally, observable clinical outcomes such as collagen formation, angiogenesis, respiratory burst and cell proliferation are described. The scientific evidence for the impact of oxygen on biomolecular pathways and its relationship to the outcomes in clinical research is discussed in this narrative review.

Subcuticular sutures versus staples for skin closure after primary hip arthroplasty

High-quality and cost-effective health care are highly recommended especially in joint replacement surgeries, particularly in total hip arthroplasty. Therefore, it is indispensable for orthopaedic surgeons to spot the potential areas of quality improvement. Evaluating the efficacy of the different ways of skin closure is an unacknowledged topic. We performed this study following both the Preferred Reporting Items for Systematic Reviews and Meta- analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Articles were from any country, written in any language. We included all randomised control trials and retrospective cohort studies undergoing primary total hip arthroplasty who either received staples or subcuticular sutures for skin closure. The primary outcome was the incidence of wound infection. Secondary outcomes included length of stay (LOS), time to skin closure, total cost, and patient’s satisfaction. We included five studies in our cumulative meta- analysis. We conducted them using Review Manager V.5.0. We computed the risk ratio as a measure of the treatment effect, taking into account heterogeneity. We used Random-effect models. Primary skin closure with subcuticular sutures had insignificant marginal advantages for wound infections, LOS, and wound oozing. On the contrary, staples were more cost- effective and had less time for closure with higher patient’s satisfaction. Except for closure time and patient satisfaction , no significant difference between the two groups. The use of staples after THA may have several slight clinical advantages over the subcuticular sutures. However, owing to the complexities associated with wound closure, future clinical and laboratory studies assessing their complication outlines must be examined before an optimum technique can be determined.