Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon

Redesigning to V-Y Fasciocutaneous Flaps: Optimizing Outcomes in Patients With Pressure Injuries and Spinal Cord Injuries

Surgical treatment for patients with stage 4 pressure injury and spinal cord injury can be difficult because the complication rates are high. Several flaps have been described, but there is no consensus in favor of any flap. The V-Y fasciocutaneous flap, although commonly used, lacks a simple, standardized, step-by-step description. This study introduces a novel, simplified approach to the design and execution of the V-Y flap to improve the outcomes for these patients. This study aimed to evaluate the efficacy of 57 newly planned V-Y fasciocutaneous flaps for achieving predictable and improved outcomes in 40 patients with stage 4 pressure injury and spinal cord injury. Our technique demonstrated notable efficacy in terms of defect coverage (maximum of 196.35 cm²) and linear advancement (maximum of 12 cm). Interestingly, our approach records complication and recurrence rates equal to those of other flap types reported in the literature, with the advantage of not having full or partial necrosis. We describe an easy, highly reproducible, new technique of marking, tracing, dissecting, and advancing the V-Y fasciocutaneous flap so that its simplicity makes it the preferred choice of local flaps for this type of lesion; additionally, this technique is applicable to defects of varying sizes in any anatomical region.

Outcomes of Pressure Sore Surgery in Patients with Spinal Cord Injury and Spasticity

Background

Spasticity is a serious complication of spinal cord injury/disease (SCI/D) that affects 60%-80% of patients with this condition. The presence of spasticity can have a significant impact on the outcomes of reconstructive surgical interventions, such as those on pressure sores (PSs). Moreover, in the conservative treatment of PSs, spasticity may prevent maintaining adequate postures to avoid skin friction or traction. The aim of this study is to describe the PS reconstruction outcomes in a cohort of patients with SCI/D affected by spasticity.

Methods

In this retrospective study of patients with SCI/D consecutively admitted to Montecatone Rehabilitation Institute between October 2013 and March 2022, 54 PSs were treated in 46 people with spasticity.

Results

Postsurgery complications occurred in 26 of 54 treated PS, of which seven were major. Eleven patients experienced more than one complication. The overall incidence of postsurgical complications was 48.1%, and the incidence of major complications was 13%. Median length of hospital stay was 3.8 versus 1.8 months. Compared with other reports in the literature of PS reconstruction in patients with SCI/D, we found higher rates of overall, minor, and major complications.

Conclusions

Spasticity proved to be an important condition to consider, and its treatment requires specialized physicians. The collaboration between plastic surgeons and spasticity specialists is crucial to define the best treatment to reduce postoperative complications.

Reconstructive Surgery of Pressure Injuries in Spinal Cord Injury/Disorder Patients: Retrospective Observational Study and Proposal of an Algorithm for the Flap Choice

Pressure injuries (PIs) are a common complication in patients with spinal cord injury/disorder (SCI/D), and deep PIs require surgical treatment consisting of wide debridement and adequate reconstruction. We conducted a retrospective observational study at a tertiary rehabilitation hospital for SCI/D in Italy with the aim of describing the incidence and associated risk factors of postoperative complications in individuals with SCI/D presenting with chronic deep PIs, treated with a specific flap selection algorithm based on the site of the defect, the presence of scars from previous surgeries, and the need to spare reconstructive options for possible future recurrences. Medical records of surgical procedures performed on SCI/D patients with fourth-degree PIs, according to NPUAP classification (National Pressure Ulcer Advisory Panel), between July 2011 and January 2018 were reviewed. A total of 434 surgical procedures for fourth-degree PIs in 375 SCI/D patients were analyzed. After a mean follow-up of 21 months (range 12-36), 59 PIs (13.6%) had minor complications, and 17 (3.9%) had major complications requiring reoperation. The sacral site and muscular and musculocutaneous flaps were significant risk factors for postoperative complications. Six patients (1.4%) had a recurrence. The choice of flap correlates with the outcome of decubitus reconstruction. Therefore, reconstructive planning should be based on established principles.

Multidisciplinary treatment protocol for ischiatic, sacral, trochanteric or other pressure injuries in people with spinal cord injury: a retrospective cohort study

STUDY DESIGN

Retrospective cohort study Objectives: to describe the incidence and the associated risk factors of post-surgical complications and recurrence in individuals with spinal cord injury/disorder (SCI/D) presenting deep pressure injuries (PIs), treated with a specific surgical and rehabilitation treatment protocol.

SETTING

Tertiary Rehabilitation Hospital for SCI/D in Italy.

METHODS

Retrospective analysis of the medical records of adult individuals with SCI/D, who developed a PI after the first discharge from a Spinal Unit, underwent flap surgery for PI between July 2011 and January 2018. The statistical unit of analysis was the surgical intervention. Logistic regression analysis with robust standard errors was performed to assess risk factors of post-surgical complications.

RESULTS

434 surgical intervention records were included, for a total of 378 patients. The treated PIs were ischiatic in 56.2% of the cases, sacral in 32.5%, trochanteric in 15.7%, and 5.8% were in other sites. In 239 cases (55.1%) a histological diagnosis of osteomyelitis was confirmed. Minor complications occurred in 13.6% of interventions, while major complications were 3.9%. Sacral PI (OR = 2.55, 95%CI: 1.50-4.35) and muscular/musculocutaneous flap (OR = 2.12, 95%CI: 1.05-4.28) were significant factors associated with risk of post-surgical complications. After a mean follow-up of 21 months (range 12-36), six people (1.4%) had a recurrence. Patients with a recurrence had at least one comorbidity compared to 57% of people without recurrences (p = 0.036).

CONCLUSION

Our results demonstrate that complication and recurrence rates can be minimized when an established interdisciplinary and rehabilitation protocol is integrated in the clinical management.

Risk Factors for Venous Thrombosis after Spinal Surgery: A Systematic Review and Meta-analysis

Background. Venous thrombosis, comprising DVT and PE, is an orthopedic condition that may be fatal after surgery. This study’s purpose was to analyze risk factors for venous thrombosis following spine surgery to help guide treatment prophylaxis. Methods. A computer searched English databases such as PubMed, Web of Science, Embase, Cochrane Library, and Google Academic for relevant publications after spinal surgery. Preoperative walking difficulties, hypertension, diabetes, heart disease, preoperative bleeding volume, etc., were all examined using the NOS scale. Data were analyzed using Review Manager 5.3 software. An analysis was done. Due to the study’s differences, the data was compiled using fixed effects or random effects models. Results. A total of 25 studies were considered, with a total of 1,927,781 individuals after spine surgery, including 7843 patients with venous thrombosis. The included literatures had NOS scores ranging from 5 to 8. According to the findings of the meta-analysis, the age of patients with venous thrombosis after spinal surgery ( $\text{OR}=7.53$ , 95% CI (6.73, 8.33)), blood loss ( $\text{OR}=-141.79$ , 95% CI (-154.68, -128.9), $P=0.00001$ ), and operation time ( $\text{OR}=76.93$ , 95% CI (73.17, 80.86), $P=0.00001$ ) were higher than those without; diabetes mellitus (OR =1.23, 95% CI (1.12, 1.34), $P=0.00001$ ) and walking disability history ( $\text{OR}=2.97$ , 95% CL (1.77, 4.98), $P=0.0001$ ) increased the incidence of postoperative venous thrombosis. Conclusion. High age, female, spinal fusion, big volume blood loss patients, operation time, and hypertension, diabetes, and walking issue are all risk factors for venous thrombosis following surgery.