Management of open wounds: lessons from orthopedic oncology

A Prospective Evaluation of Intraoperative Indocyanine Green Fluorescence Angiography for Soft Tissue Sarcomas

INTRODUCTION

Postoperative wound complications after resection of soft-tissue sarcomas are challenging. Indocyanine green (ICG) angiography has previously been used to predict wound complications, but not for soft-tissue sarcomas. We aimed to evaluate whether this technology could help lower wound complications after soft-tissue sarcoma resections.

MATERIALS AND METHODS

We conducted a prospective study from 10/2017 to 9/2019 using ICG angiography during sarcoma resection surgery. Rates of wound complications were compared with a historical control consisting of surgeries before utilization of ICG angiography.

RESULTS

A total of 88 patients were included in the study. We found significantly lower rates of infection (11.8% versus 38%; P = 0.03) and wound dehiscence (11.8% versus 42.3%; P = 0.02) in the ICG angiography cohort compared with the historical controls.

CONCLUSION

ICG angiography use during soft-tissue sarcoma resections is promising technology and warrants further investigation to help reduce postoperative complications.

Cost Variance in Patients With Soft Tissue Sarcoma Who Develop Postoperative Wound Complications

Background:

Wound complications after a soft-tissue sarcoma surgery are common, occurring in up to 30% to 40% of patients who undergo preoperative radiation therapy. Although risk factors for developing complications are well-known, there is a paucity of literature on the increased healthcare costs after a wound complication. The purpose of this study was to detail these additional costs after a soft-tissue sarcoma surgery.

Methods:

A retrospective review of 99 patients from January 2013 to October 2019 was performed. Hospital and professional charges for the primary surgical procedure and any subsequent hospitalization or procedure related to a wound complication were compiled. Costs were inflated to 2019 dollars.

Results:

Total costs were 21.3% higher for patients who developed a wound complication (P = 0.006). Most patients (32 of 42; 76.2%) who developed a complication required a return trip to the operating room. The average number of return trips was 1.2 (range 0 to 5). For each return trip to the operating room because of a wound complication, an associated increased overall cost of 13.2% was noted (P < 0.001).

Conclusion:

Wound complications after a soft-tissue sarcoma resection are common and add considerable expense to the episode of care. A reduction in wound complications may markedly decrease the cost of treating soft-tissue sarcomas and continues to be an opportunity for improvement.

Intraoperative Indocyanine Green Fluorescence Angiography Is Sensitive for Predicting Postoperative Wound Complications in Soft-Tissue Sarcoma Surgery

INTRODUCTION

Indocyanine green (ICG) angiography is a novel technology that has been predictive of postoperative wound complications. It is unknown whether this technology can successfully predict complications after sarcoma resection. In this study, we aimed to evaluate the sensitivity and specificity of ICG angiography in predicting postoperative wound complications after soft-tissue sarcoma resection.

METHODS

A prospective cohort study of 23 patients was performed beginning October 2017 at our institution. Patients who underwent soft-tissue sarcoma resection were included. After tumor resection and wound closure, evaluation of tissue perfusion in skin edges was performed with ICG angiography. Wound complications were recorded in the postoperative follow-up.

RESULTS

Eight patients developed postoperative wound complications. Six patients were predicted to have wound complications on the final ICG scans. The accuracy of ICG angiography was dependent on the anatomic location, with improved accuracy in the lower extremity. ICG angiography had a sensitivity of 50%, a specificity and a positive predictive value of 100%, and a negative predictive value of 70% for wound complications after soft-tissue sarcoma resections located in the lower extremity.

CONCLUSION

ICG angiography has a high predictive value in the lower extremity for postoperative wound complications.

LEVEL OF EVIDENCE

Level III, Diagnostic.

Rigenera protocol in the treatment of surgical wound dehiscence

The effective management of post-operative wounds is important to prevent potential complications such as surgical-site infections and wound dehiscence. The purpose of this study was to treat wound dehiscence in elderly patients who were subjected to orthopaedic surgical interventions. The dehisced wounds were treated with autologous micro-grafts obtained using a promising CE-certified medical device called Rigeneracons. This instrument is a biological disruptor of human tissues able to specifically select progenitor cells that, as already reported in previous studies, maintain high cell viability but mainly have a high regenerative potential, allowing the repair of damaged tissues. Autologous micro-grafts obtained by Rigeneracons are ready to use and can be applied alone or in combination with biological scaffolds directly on the injured area. We observed in our patients a complete remission of dehisced wounds, on average, after 30 days from micro-grafts application and a total wound re-epithelialisation after 1 year from the surgical intervention. In conclusion, although we reported only three patients, autologous micro-grafts can be considered a promising approach for the treatment of dehisced wounds, improving the wound-healing process and in general the patient's quality of life without using other dressings.

A Therapeutic Role for Survivin in Mitigating the Harmful Effects of Ionizing Radiation

Background. Radiation therapy is a form of adjuvant care used in many oncological treatment protocols. However, nonmalignant neighboring tissues are harmed as a result of this treatment. Therefore, the goal of this study was to induce the production of survivin, an antiapoptotic protein, to determine if this protein could provide protection to noncancerous cells during radiation exposure. Methods. Using a murine model, a recombinant adenoassociated virus (rAAV) was used to deliver survivin to the treatment group and yellow fluorescence protein (YFP) to the control group. Both groups received targeted radiation. Visual inspection, gait analysis, and tissue histology were used to determine the extent of damage caused by the radiation. Results. The YFP group demonstrated ulceration of the irradiated area while the survivin treated mice exhibited only hair loss. Histology showed that the YFP treated mice experienced dermal thickening, as well as an increase in collagen that was not present in the survivin treated mice. Gait analysis demonstrated a difference between the two groups, with the YFP mice averaging a lower speed. Conclusions. The use of gene-modification to induce survivin expression in normal tissues allows for the protection of nontarget areas from the negative side effects normally associated with ionizing radiation.