Negative Pressure Wound Therapy for Closed Surgical Wounds in Musculoskeletal Oncology Patients - A Case-Control Trial

Development and validation of a nomogram to predict surgical site infection after soft-tissue sarcoma resection

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.

Methods

A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients.

Results

LASSO regression analysis selected possible risk factors for SSI, including age, diabetes, operating time, skin graft or flap, resected tumour size, smoking, and radiation therapy. Multivariate analysis revealed that age, diabetes, smoking during the previous year, operating time, and radiation therapy were independent risk factors for SSI. A nomogram was developed based on the results of multivariate logistic regression analysis. In the development cohort, the incidence of SSI was 4.5% in the low-risk group (risk score < 6.89) and 26.6% in the high-risk group (risk score ≥ 6.89; p < 0.001). In the validation cohort, the incidence of SSI was 2.0% in the low-risk group and 15.9% in the high-risk group (p = 0.004).

Conclusion

Our nomogram will enable surgeons to assess the risk of SSI in patients with STS. In patients with high risk of SSI, frequent monitoring and aggressive interventions should be considered to prevent this.

Closed-Incision Negative-Pressure Wound Therapy after Resection of Soft-Tissue Tumors Reduces Wound Complications: Results of a Randomized Trial

BACKGROUND

Wound healing after resection of large soft-tissue tumors is often impaired by large dead space and fluid collection. Recently, the authors were able to show an association of wound complications with worse oncologic outcome in soft-tissue sarcomas. The aim of the study was to examine the value of closed-incision negative pressure wound therapy on postoperative wound drainage and wound complications after soft-tissue tumor resection.

METHODS

Patients for whom resection is planned of a soft-tissue tumor larger than 10 cm in diameter of the extremities or the trunk were allocated randomly to one of two groups. After wound closure, patients in the study group received closed-incision negative-pressure wound therapy for a duration of 5 days, whereas those in the control group received regular dressings. The amount of drainage fluid, course of wound healing, length of hospital stay, and wound edge perfusion at postoperative day 5 measured by white-light infrared spectroscopy were compared.

RESULTS

Sixty patients could be included in the study with even distribution to both study arms, meeting the goal. The postoperative course of wound drainage volume was significantly lower in the study group, and hospital stay was significantly shorter, with 9.1 ± 3.8 days versus 13.9 ± 11.8 days. The occurrence of wound complications was significantly lower in the study group on time-to-event analysis (one versus six). Tissue spectroscopy revealed a significantly higher oxygen saturation increase in the wound edge for the study group versus the control group.

CONCLUSION

Closed-incision negative-pressure wound therapy should be considered for patients undergoing resection of large soft-tissue tumors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Utility of Negative Pressure Wound Therapy: Raising the Bar in Chest Masculinization Surgery

BACKGROUND

Prophylactic use of negative pressure wound therapy (NPWT) has been shown to decrease the incidence of postoperative complications. This study aimed to evaluate the utility of NPWT in chest masculinization with free nipple graft (FNG).

METHODS

All consecutive male patients undergoing chest masculinization with FNG by a single provider at a single center were reviewed. Postoperative treatment with either NPWT or standard wound care (SWC) defined this study's cohorts. Patient characteristics and postoperative complications were compared between patients receiving NPWT versus SWC.

RESULTS

One hundred thirty-one patients with 262 closed breast incisions (NPWT=72, SWC=190) met inclusion criteria. Overall complications were higher in the SWC cohort (n=80/190, 42%) compared to the NPWT cohort (n = 13/72, 18%, p < 0.001). The NPWT group had significantly lower rates of partial nipple graft loss (9/72, 12.5% versus 47/190, 24.7%, p = 0.031), seroma formation (1/72, 1.4% versus 15/190, 7.9%, p = 0.037), and nipple hypopigmentation (6/72, 8.3% versus 36/190, 18.9%, p = 0.024) when compared to the SWC cohort. Time to drain removal was significantly faster in the NPWT group (NPWT 7 days versus SWC 9 days, p ≤ 0.001).

CONCLUSIONS

Patients receiving NPWT over their closed incisions following chest masculinization with FNG were found to have significantly lower rates of partial nipple graft necrosis, seroma formation, and time to drain removal compared to those receiving SWC. Future prospective, randomized studies to further elucidate the role of NPWT in top surgery are warranted.

Closed incision negative pressure wound therapy versus conventional dressings following soft-tissue sarcoma excision: a prospective, randomized controlled trial

Aims

The primary objective of this study was to compare the postoperative infection rate between negative pressure wound therapy (NPWT) and conventional dressings for closed incisions following soft-tissue sarcoma (STS) surgery. Secondary objectives were to compare rates of adverse wound events and functional scores.

Methods

In this prospective, single-centre, randomized controlled trial (RCT), patients were randomized to either NPWT or conventional sterile occlusive dressings. A total of 17 patients, with a mean age of 54 years (21 to 81), were successfully recruited and none were lost to follow-up. Wound reviews were undertaken to identify any surgical site infection (SSI) or adverse wound events within 30 days. The Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) score were recorded as patient-reported outcome measures (PROMs).

Results

There were two out of seven patients in the control group (28.6%), and two out of ten patients in the intervention group (20%) who were diagnosed with a SSI (p > 0.999), while one additional adverse wound event was identified in the control group (p = 0.593). No significant differences in PROMs were identified between the groups at either 30 days (TESS, p = 0.987; MSTS, p = 0.951) or six-month (TESS, p = 0.400) follow-up. However, neoadjuvant radiotherapy was significantly associated with a SSI within 30 days of surgery, across all patients (p = 0.029). The mean preoperative modified Glasgow Prognostic Score (mGPS) was also significantly higher among patients who developed a postoperative adverse wound event (p = 0.028), including a SSI (p = 0.008), across both groups.

Conclusion

This is the first RCT comparing NPWT with conventional dressings following musculoskeletal tumour surgery. Postoperative wound complications are common in this group of patients and we observed an overall SSI rate of 23.5%. We propose proceeding to a multicentre trial, which will help more clearly define the role of closed incision NPWT in STS surgery.

Cite this article: Bone Jt Open 2021;2(12):1049–1056.

Inflammatory prognostic scoring systems are risk factors for surgical site infection following wide local excision of soft tissue sarcoma

Introduction

Limb-sparing surgery with negative margins is possible in most soft tissue sarcoma (STS) resections and focuses on maximising function and minimising morbidity. Various risk factors for surgical site infections (SSIs) have been reported in the literature specific to sarcoma surgery. The aim of this study is to determine whether systemic inflammatory response prognostic scoring systems can predict post-operative SSI in patients undergoing potentially curative resection of STS.

Methods

Patients who had a planned curative resection of a primary STS at a single centre between January 2010 and December 2019 with a minimum follow-up of 6 months were included. Data were extracted on patient and tumour characteristics, and pre-operative blood results were used to calculate inflammatory prognostic scores based on published thresholds and correlated with risk of developing SSI or debridement procedures.

Results

A total of 187 cases were included. There were 60 SSIs. On univariate analysis, there was a statistically significant increased risk of SSI in patients who are diabetic, increasing specimen diameter, American Society of Anaesthesiology (ASA) grade 3, use of endoprosthetic replacement, blood loss greater than 1 L, and junctional tumour location. Modified Glasgow prognostic score, C-reactive protein/albumin ratio and neutrophil–platelet score (NPS) were statistically associated with the risk of SSI. On multivariate analysis, ASA grade 3, junctional tumour location and NPS were independently associated with the risk of developing a SSI.

Conclusion

This study supports the routine use of simple inflammation-based prognostic scores in identifying patients at increased risk of developing infectious complications in patients undergoing potentially curative resection of STS.

American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy

PURPOSE

Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.

METHODS AND MATERIALS

Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.

RESULTS

Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.

CONCLUSIONS

These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.