1
|
Awad SS, Stern JD, Milne CT, Dowling SG, Sotomayor R, Ayello EA, Feo Aguirre LJ, Khalaf BZ, Gould LJ, Desvigne MN, Chaffin AE. Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group. Adv Skin Wound Care 2023; 36:249-258. [PMID: 37079788 PMCID: PMC10144322 DOI: 10.1097/01.asw.0000922708.95424.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/07/2022] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction. METHODS An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds. RESULTS Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention. CONCLUSIONS The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.
Collapse
Affiliation(s)
- Samir S Awad
- Samir S. Awad, MD, MPH, FACS, is Professor of Surgery, Baylor College of Medicine and Chief of Surgery, Michael E. DeBakey VA Medical Center, Houston, Texas, USA. James D. Stern, MD, FACS, is Plastic Surgeon, Memorial Regional Hospital, Hollywood, Florida. Cathy T. Milne, APRN, MSN, ANP/ACNS-BC, CWOCN-AP, is Co-owner, Connecticut Clinical Nursing Associates, Bristol, Connecticut. Shane G. Dowling, MSPAS, PA-C, CWS, is Medical Science Liaison, Aroa Biosurgery Limited, Auckland, New Zealand. Ron Sotomayor, BA, RN, CWOCN, is a wound, ostomy, and continence nurse, Advent Health, Orlando, Florida. Elizabeth A. Ayello, PhD, MS, RN, ETN, CWON, FAAN, is Editor-in-Chief, Advances in Skin & Wound Care and President, Ayello, Harris and Associates Incorporated, Copake, New York. Leandro J. Feo Aguirre, MD, FACS, is Colorectal Surgeon, Palm Beach Health Network, Del Ray Beach, Florida. Basil Z. Khalaf, MD, is Wound Care Physician, The MEDIKAL Group, Houston, Texas. Lisa J. Gould, MD, is Plastic Surgeon, South Shore Health, Weymouth, Massachusetts. Michael N. Desvigne, MD, FACS, CWS, is Plastic Surgeon, Desvigne Plastic Surgery and Abrazo Health, Scottsdale, Arizona. Abigail E. Chaffin, MD, FACS, CWSP, is Associate Professor of Surgery and Chief, Division of Plastic Surgery, Tulane University and Medical Director, MedCentris Wound Healing Institute, New Orleans, Louisiana
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Tøstesen SK, Stilling M, Hanberg P, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen M, Petersen ET, Bue M. High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace—A Microdialysis Porcine Study. Antibiotics (Basel) 2022; 11:antibiotics11020208. [PMID: 35203810 PMCID: PMC8868149 DOI: 10.3390/antibiotics11020208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 μg/mL)). During the two dosing intervals, mean fT > MIC (4 μg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 μg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 μg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI.
Collapse
Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- Correspondence:
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9640 Farsoe, Denmark;
| | - Martin Knudsen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Emil Toft Petersen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| |
Collapse
|
3
|
Kim DG, Park ES, Nam SM, Cha HG, Choi CY. Volumetric Evaluation of Dead Space in Ischial Pressure Injuries Using Magnetic Resonance Imaging: A Case Series. Adv Skin Wound Care 2021; 34:668-673. [PMID: 34807898 DOI: 10.1097/01.asw.0000797960.52759.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To establish a preoperative evaluation procedure by measuring the volume of dead space using MRI in patients with ischial pressure injuries. METHODS Patients with spinal cord injury and ischial pressure injuries who underwent treatment between August 2016 and November 2019 were included in the study. Preoperative MRI scan was conducted on all patients. The volume estimation and three-dimensional (3D) reconstruction were performed based on MRI data using a 3D Slicer. Based on the resulting volume, a muscle flap that could fit the dead space was selected. Surgery was performed with the selected muscle flap, and a fasciocutaneous flap was added, if necessary. RESULTS A total of eight patients with ischial pressure injuries were included in the study. The mean patient age was 59.0 ± 11.0 years. The mean body mass index was 26.62 ± 3.89 kg/m2. The mean volume of dead space was 104.75 ± 81.05 cm3. The gracilis muscle was the most selected muscle flap and was used in four patients. In five of eight cases, a fasciocutaneous flap was used as well. The mean follow-up period was 16 months, and by that point, none of the patients evinced complications that required surgery. CONCLUSIONS To the authors' knowledge, this is the first report on volumetric evaluation of dead space in ischial pressure injuries. The authors believe that the 3D reconstruction process would enable adequate dead space obliteration in ischial pressure injuries. The authors propose that preoperative MRI scans in patients with ischial pressure injury should become an essential part of the process.
Collapse
Affiliation(s)
- Dong Gyu Kim
- In the Department of Plastic and Reconstructive Surgery at the Soonchunhyang University Bucheon Hospital in Bucheon, Republic of Korea, Dong Gyu Kim, MD, is Resident; Eun Soo Park, MD, PhD, is Professor and Chief of the Medical Department; Seung Min Nam, MD, PhD, and Chang Yong Choi, MD, PhD are Associate Professors; and Han Gyu Cha, MD, is Assistant Professor. Acknowledgments : This work was supported by the Soonchunhyang University Research Fund. The authors have disclosed no other financial relationships related to this article. Submitted October 16, 2020; accepted in revised form January 26, 2021
| | | | | | | | | |
Collapse
|
4
|
Oliver RA, Lovric V, Christou C, Walsh WR. Comparative osteoconductivity of bone void fillers with antibiotics in a critical size bone defect model. J Mater Sci Mater Med 2020; 31:80. [PMID: 32840717 PMCID: PMC7447650 DOI: 10.1007/s10856-020-06418-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 07/24/2020] [Indexed: 06/11/2023]
Abstract
The study aimed to evaluate the comparative osteoconductivity of three commercially available bone void fillers containing gentamicin with respect to new bone, growth, host tissue response and resorption of the implant material. Defects were created in the cancellous bone of the distal femur and proximal tibia of 12-skeletally mature sheep and filled with three commercially available bone void fillers containing gentamicin (Stimulan-G, Cerament-G, Herafill-G). Peripheral blood was taken pre-operatively and at the time of implantation, as well as at intermittent timepoints following surgery to determine systemic gentamicin levels (5-,15- and 30- minutes, 1, 2, 3, 6, 12, 24, 48- and 72-hours, 3-, 6- and 12-weeks). Decalcified, embedded samples were stained with haematoxylin and eosin (H&E) and used to assess the host tissue response and the formation of new bone in the presence of test implant materials. No adverse reactions were noted at harvest at any time points for any cancellous implantation sites with the various implant materials. Comparative microCT analysis of the Stimulan-G, Cerament-G and Herafill-G test materials revealed a similar increase in bone surface area and volume between animals implanted with Stimulan-G or Cerament-G test materials. Animals implanted with Herafill-G test materials demonstrated the lowest increases in bone volume and surface area of the test materials tested, at levels similar to the negative control sites. By 12-weeks, Stimulan-G defects were completely closed with mature bone and bone marrow whilst the Cerament-G material was still present after 12 weeks by histological examination. In conclusion, this study demonstrated differences in the bone regenerative capacity of a range of bone void fillers in an in vivo setting.
Collapse
Affiliation(s)
- Rema A Oliver
- Surgical and Orthopaedic Research Laboratories, UNSW Sydney, Prince of Wales Clinical School, Prince of Wales Hospital, Level 1 Clinical Sciences Building, Randwick, NSW, Australia.
| | - Vedran Lovric
- Surgical and Orthopaedic Research Laboratories, UNSW Sydney, Prince of Wales Clinical School, Prince of Wales Hospital, Level 1 Clinical Sciences Building, Randwick, NSW, Australia
| | - Chris Christou
- Surgical and Orthopaedic Research Laboratories, UNSW Sydney, Prince of Wales Clinical School, Prince of Wales Hospital, Level 1 Clinical Sciences Building, Randwick, NSW, Australia
| | - William R Walsh
- Surgical and Orthopaedic Research Laboratories, UNSW Sydney, Prince of Wales Clinical School, Prince of Wales Hospital, Level 1 Clinical Sciences Building, Randwick, NSW, Australia
| |
Collapse
|
5
|
Silk Z, Vris A. Novel method to create a bespoke cement spacer for use in the management of segmental long-bone defects. Ann R Coll Surg Engl 2019; 101:530-532. [PMID: 31155902 DOI: 10.1308/rcsann.2019.0074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Z Silk
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Vris
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| |
Collapse
|
6
|
Riechelmann F, Kaiser P, Arora R. [Primary soft tissue management in open fracture]. Oper Orthop Traumatol 2018; 30:294-308. [PMID: 30182178 DOI: 10.1007/s00064-018-0562-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/20/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Debridement of soft tissue and bone in an open fracture situation to minimize infection risk and achieve primary skin closure, or to provide conditions for early soft tissue coverage. INDICATIONS Indications are Gustilo-Anderson grade I-III A-C open fractures. CONTRAINDICATIONS Contraindications are injuries requiring amputation, burns, and life-threatening injuries which make appropriate treatment temporarily impossible. SURGICAL TECHNIQUE Removal of gross contamination and macroscopic contaminants; debridement of the wound; complete resection of contaminated and dirty tissue; sparse step-by-step resection of contaminated or non-vital wound and bone margins until vital, bleeding tissue begins; low-pressure irrigation with isotonic irrigation fluid; diagnostic biopsies for microbiological testing; reduction of dead space by interpositioning of muscle or cement spacers loaded with local antibiotics; primary wound closure if tension-free closure possible; otherwise, if resources and knowhow permit and satisfactory clean debridement was achieved, local flap; if flap impossible, debridement not satisfactory, secondary tissue necrosis likely, potential remaining contamination or contamination with fecal matter, then vacuum-assisted closure therapy. POSTOPERATIVE MANAGEMENT Wound inspection on the second postoperative day, generous indication for second-look surgery after 36-48 h, wound inspection on the second postoperative day, wound inspection every other day, primary antibiotic prophylaxis with a first- or second-generation cephalosporin (e. g., cefuroxime), and adaptation of antibiotic therapy according to susceptibility screening. RESULTS Infection rates of 2-4.7% are reported for immediate primary wound closure in Gustilo-Anderson grade I, II, and III A open fractures. For Gustilo-Anderson grade III B, good wound healing, bony consolidation, and no need for secondary surgery was reported in 86.7% when primary wound closure was achieved.
Collapse
|
7
|
Abstract
High-energy, open tibial shaft fractures may result in significant comminution, bone loss, and soft tissue injuries. Early, thorough debridement of all nonviable tissue is of critical importance in treating these fractures as an inadequate initial debridement increases the risk of infection and nonunion. Large iatrogenic bone and soft tissue defects can result from debridement and will require subsequent reconstruction by both orthopaedic and plastic surgeons. Although a variety of approaches exist to address these reconstructions, successful management of bone defects remains a considerable challenge. In this article, we detail our approach to debridement and reconstruction of segmental tibial defects and provide a review on the literature on this topic.
Collapse
|