Wound complications

Management of complications after skin surgery relevant for melanoma in the trunk and extremities during the COVID-19 pandemic: a case series report

BACKGROUND

Patients with melanoma have been found to be at greater risk of adverse outcomes including mortality after contacting COVID-19. Management of postsurgical complications presented additional challenges by potentially increasing exposure to COVID-19 through repeated inpatient admissions to hospital during the pandemic. We report four cases for which skin flaps, lymph ligation, and split-thickness skin graft (STSG) were successfully used in the treatment of complications in the trunk and extremities after wide local excision (WLE). This study details the operative experience in management of postsurgical complications for melanoma in the trunk and extremities during a 6-month period at the height of the COVID-19 pandemic.

CASE PRESENTATION

We present 4 cases detailing management of complications that occurred after wide local excisions performed for melanoma during Feb. to Oct. 2020. Case 1: A 90-year-old man who experienced wound dehiscence and necrosis on the shoulder after non-radical excision for an aggressive melanoma and underwent the side-to-side closure after ellipse formed WLE with modified tangent-to-circle method. Case 2: An 80-year-old man who had undergone excision for melanoma in his left upper arm and histopathology did not show radically. Two weeks after the excision, he underwent a WLE and direct reconstruction with double rotation skin flap. Case 3: A 55-year-old man that experienced a large wound dehiscence on his back due to WLE. He underwent an advanced double skin flap operation. Case 4: A 36-year-old woman who had a lymphorrhea and graft necrosis after WLE and STSG on the right lower leg. A combination of micro lymph ligation and re-STSG was performed. One month after the operation, all wounds had healed. There was no clinical evidence of tumor recurrence after 8 months post procedure.

CONCLUSIONS

Severe complications (e.g., large wound dehiscence, necrosis, or lymphorrhea) following wide local excision of melanoma are infrequent but must be swiftly and appropriately managed, especially during the COVID-19 pandemic to decrease the likelihood of COVID-19 infection and impaired oncology outcomes from delaying systemic cancer therapy due to the complications in primary interventions.

Risk factors for explantation due to infection after sacral neuromodulation: a multicenter retrospective case-control study

BACKGROUND

Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden.

OBJECTIVE

We sought to identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens.

STUDY DESIGN

This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from Jan. 1, 2004, through Dec. 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants as well as explants due to infection at 8 participating institutions. Cases were patients who required implantable pulse generator explantation for infection during the review period. Cases were included if age ≥18 years old, follow-up data were available ≥30 days after implantable pulse generator implant, and the implant was performed at the institution performing the explant. Two controls were matched to each case. These controls were the patients who had an implantable pulse generator implanted by the same surgeon immediately preceding and immediately following the identified case who met inclusion criteria. Controls were included if age ≥18 years old, no infection after implantable pulse generator implant, follow-up data were available ≥180 days after implant, and no explant for any reason <180 days from implant. Controls may have had an explant for reasons other than infection at >180 days after implant. Fisher exact test (for categorical variables) and Student t test (for continuous variables) were used to test the strength of the association between infection and patient and surgery characteristics. Significant variables were then considered in a multivariable logistic regression model to determine risk factors independently associated with infection.

RESULTS

Over a 10-year period at 8 academic institutions, 1930 sacral neuromodulator implants were performed by 17 surgeons. In all, 38 cases requiring device explant for infection and 72 corresponding controls were identified. The incidence of infection requiring explant was 1.97%. Hematoma formation (13% cases, 0% controls; P = .004) and pocket depth of ≥3 cm (21% cases, 0% controls; P = .031) were independently associated with an increased risk of infection requiring explant. On multivariable regression analysis controlling for significant variables, both hematoma formation (P = .006) and pocket depth ≥3 cm (P = .020, odds ratio 3.26; 95% confidence interval, 1.20-8.89) remained significantly associated with infection requiring explant. Of the 38 cases requiring explant, 32 had cultures collected and 24 had positive cultures. All 5 cases with a hematoma had a positive culture (100%). Of the 4 cases with a pocket depth ≥3 cm, 2 had positive cultures, 1 had negative cultures, and 1 had a missing culture result. The most common organism identified was methicillin-resistant Staphylococcus aureus (38%).

CONCLUSION

Infection after sacral neuromodulation requiring device explant is low. The most common infectious pathogen identified was methicillin-resistant S aureus. Demographic and health characteristics did not predict risk of explant due to infection, however, having a postoperative hematoma or a deep pocket ≥3 cm significantly increased the risk of explant due to infection. These findings highlight the importance of meticulous hemostasis as well as ensuring the pocket depth is <3 cm at the time of device implant.

Management of extensive tibial osteolysis with the Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation

Although total ankle replacement has endured improvement in implant design since its conception, failure requiring revision remains a known endpoint. We describe a technique for management of extensive tibial osteolysis for failed Agility™ total ankle replacement systems using geometric metal-reinforced polymethylmethacrylate cement augmentation. This technique provides immediate component stability and is a cost-effective alternate to impaction bone grafting. With this technique, the complications we have experienced have been limited to minor delayed incisional healing, and all patients have resumed meaningful weightbearing activities with stable integration of the tibial component.

Preserving functional capacity as opposed to tissue preservation in the diabetic patient: a single institution experience

The authors performed a retrospective review of prospectively collected data of all diabetic patients who underwent transmetatarsal amputation (TMA) for toe gangrene or neuropathic ulceration from May 2006 to June 2009. Twenty-nine TMAs were performed in diabetic patients during the study period, including 24 men and 5 women with a mean +/- SD age of 66.3 +/- 7.5 years. The indications for TMA were gangrene of > or = 2 digits in 12 patients (41%) and neuropathic ulceration with underlying osteomyelitis or abscess and a concomitant dysfunctional forefoot in 17 patients (59%). Of the 12 patients who presented with toe gangrene, 7 (58%) underwent endovascular intervention and 5 (42%) underwent open vascular bypass. Equinus contracture was present in 27 patients (93%), and 26 (96%) of these patients underwent tendo-Achilles lengthening or gastrocnemius recession. Correction of equinus contracture was not performed in 1 patient as it was deemed not feasible. Forefoot varus deformity was present in 22 (76%) patients, and balancing was performed in 17 of these patients (77%) with skeletal stabilization or tendon transfer. Balancing was not performed in the remaining patients as it was not necessary or not feasible. Sixteen patients (55%) healed primarily and 5 patients (17%) developed minor wound separation that healed via secondary intention. An additional 4 patients were able to maintain functional revision procedures confined to the foot (1 TMA revision, 3 Chopart amputations). Three patients (10%) required below-knee amputation, and there were 2 deaths (7%) during the time period. Functional amputation confined to the foot was achieved in 86% of ambulatory diabetic patients. These results support a more aggressive initial approach in ambulatory diabetic patients with multiple digital ulcerations, allowing this patient population to remain functional and avoid multiple reoperations and ultimately major amputation.

Lesser toe salvage with external fixation and autogenous bone grafting: a case series

Lesser toe salvage secondary to soft tissue ulceration and underlying osteomyelitis is a challenge, and amputation is frequently the primary procedure recommended. The author presents an observational case series involving retrospective review of prospectively collected data of 4 lesser toe salvage procedures with external fixation and delayed autogenous bone grafting for the treatment of osteomyelitis in 4 consecutive patients. Each patient underwent initial resection of involved soft tissue ulceration and underlying osseous components of the lesser toe with application of external fixation and polymethylmethacrylate antibiotic-loaded bone cement spacer. Once eradication of osteomyelitis was confirmed clinically, the patient underwent delayed insertion of autogenous bone graft harvested from the ipsilateral calcaneus or osteocutaneous flap transfer from the fibular border of the ipsilateral great toe. There were 2 men and 2 women with a mean age of 56.5 years. Three patients had diabetes mellitus, and 1 had previous history of open fracture. There were 2 right feet and 2 left feet involved and 2 second, 1 third, and 1 fourth toe salvage procedures performed with a mean follow-up of 12 months. The external fixation device was maintained until complete osseous integration was verified, which occurred at a mean of 7.5 weeks. All procedures were deemed successful with complete osseous incorporation of the proximal and distal graft-host bone interfaces and no recurrent soft tissue ulcerations, osteomyelitis, toe deformity, or fracture about the bone graft sites.

Extra-articular ankle stabilization: a case series

Maintenance of the foot at 90 degrees to the lower leg following posterior calf lengthening or to prevent an equinus contracture in situations in which splint, cast, or external fixation is deemed inappropriate is a challenge. The author presents an observational case series involving 9 extra-articular ankle stabilizations performed in 9 consecutive patients. Each patient underwent his or her index surgery followed by percutaneous placement of 2 smooth 2.8-mm or larger diameter Steinmann pins extra-articular to the ankle joint. There were 6 men and 3 women with a mean age of 56.1 years (range, 31-73 years). Five patients had diabetes with peripheral neuropathy, 2 had critical limb ischemia, 1 had alcohol-induced neuropathy, 1 had lupus, and 1 was an active smoker. Eight patients had posterior calf lengthening, and 1 had open metatarsal fractures with severe soft-tissue disruption with an inability to use splint immobilization. Three patients had a transmetatarsal amputation, 2 patients had Chopart amputations, 2 patients had forefoot plastic surgery reconstructive procedures, 1 had a complex Charcot reconstruction, and 1 had a splittibialis anterior tendon transfer. Extra-articular ankle stabilization fixation was retained for a mean of 5.5 weeks (range, 2-10 weeks). Mean follow-up was 12 months (range, 1-17 months). All extra-articular stabilization procedures were deemed successful. When properly performed, extra-articular stabilization to maintain the foot at 90 degrees to the lower leg represents a safe, simple, reliable, and minimally invasive technique useful in situations in which traditional splint or cast immobilization is not possible and when external fixation is deemed inappropriate.

V-Y fasciocutaneous advancement flap coverage of soft tissue defects of the foot in the patient at high risk

This single-center, observational case series involved a review of prospectively collected data pertaining to 16 V-Y fasciocutaneous advancement flaps performed on 16 consecutive patients between August 2006 and December 2008. Each patient underwent primary excision of a foot ulcer with debridement of soft tissue and bone, insertion of polymethylmethacrylate antibiotic-loaded bone cement, and immobilization. At an average of 3 days after the index procedure, soft tissue and osseous deformities were corrected in 13 of the 16 patients, and a V-Y fasciocutaneous advancement flap was used for coverage of the soft tissue defect in all patients. Patients were kept nonweightbearing and were followed up until clinical healing occurred or failure was declared. There were 12 male and 4 female patients with a mean age of 64.0 +/- 7.4 years (range, 48-75 years). Fifteen patients had diabetes mellitus with a mean of 5.1 +/- 1.8 (range, 3-8) medical comorbidities. There were 10 medial forefoot, 3 central forefoot, 2 lateral forefoot, and 1 dorsal midfoot full-thickness soft tissue defects that displayed a mean diameter of 2.3 +/- 1.4 cm (range, 1.0-3.5 cm). All but 4 flaps healed primarily, with each developing marginal dehiscence that healed with local wound care measures. Two deep infections occurred despite healing of the flap, which necessitated transmetatarsal amputation with split-thickness skin graft coverage. When properly performed and after complete resolution of infection, V-Y fasciocutaneous advancement flap coverage of complex foot ulcerations represents a useful and reliable technique even in patients with multiple medical comorbidities.