Development of a risk score to predict occurrence of deep sternal dehiscence requiring operative debridement

OBJECTIVE

Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence.

METHODS

A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates.

RESULTS

One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score.

CONCLUSIONS

This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.

Incidence and Risk Factors for Wound Revision after Surgical Treatment of Spinal Metastasis: A National Population-Based Study in South Korea

Wound complications are commonly seen after surgeries for metastatic spine tumors. While numerous studies have pinpointed various risk factors, there is ongoing debate. Therefore, this study aimed to verify various factors that are still under debate utilizing the comprehensive Korean National Health Insurance Service database. We identified and retrospectively reviewed a cohort of 3001 patients who underwent one of five surgical treatments (corpectomy, decompression and instrumentation, instrumentation only, decompression only, and vertebroplasty) for newly diagnosed spinal metastasis between 2009 and 2017. A Cox regression analysis was performed to determine the risk factors. A total of 197 cases (6.6%) of wound revision were found. Only the surgical method and Charlson comorbidity index were significantly different between the group that underwent wound revision and the group that did not. Regarding surgical methods, the adjusted hazard ratios for decompression only, corpectomy, instrumentation and decompression, and instrumentation only were 1.3, 2.2, 2.2, and 2.4, with these ratios being compared to the vertebroplasty group (p for trend = 0.02). In this regard, based on a sizable South Korean cohort, both surgical methods and medical comorbidity were found to be associated with the wound revision rate among spinal surgery patients for spinal metastasis.

Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction

BACKGROUND

To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d).

METHODS

Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula.

RESULTS

Median values of l2 , l1 , and b were 3.0, 6.0, and 6.0 cm, respectively. When l2  = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1 /l2  < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation.

CONCLUSION

Careful patient selection, adequate proximal SP, and l2  = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.

Postoperative wound dehiscence in mandibular fractures

OBJECTIVE

To clarify the occurrence and causes of non-infection-related surgical wound dehiscence (SWD) in intraorally treated mandibular fractures.

MATERIAL AND METHODS

Patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach were included in this retrospective study. The primary outcome variable was SWD. Associations between patient-, fracture- and surgery-related variables and SWD were evaluated.

RESULTS

Altogether 232 patients with 270 mandibular angle, body, symphysis and/or parasymphysis fractures were included in the analysis. In all, 22 SWDs were detected. These occurred in 9.5% of patients and in 8.1% of fractures. Surgery performed at night-time showed a significantly higher SWD rate than daytime surgeries (p = .012). Additionally, a significantly greater SWD rate was found among smokers (p = .041). Other studied variables remained statistically non-significant for SWD. In a multivariate analysis, night-time was the only significant independent variable with an odds ratio of 3.297 (95% CI 1.238 - 8.780, p = .017) for SWD.

CONCLUSION

The approach or closure technique used and the fracture type had only a minor effect on non-infection-related SWD in patients with mandibular fractures. To avoid SWDs, mandibular fracture surgeries should be conducted during the daytime with adequate support from an experienced surgeon.

Comparison of complications after closure of totally implantable venous access devices with non-absorbable suture and n-butyl-2-cyanoacrylate (NBCA) skin adhesive: Propensity score matching analysis

PURPOSE

This study aimed to compare the complication rates of non-absorbable suture (NAS) and n-butyl-2-cyanoacrylate (NBCA) skin adhesive for skin closure during totally implantable venous access devices (TIVADs) implantation.

METHODS

Between March 2020 and February 2021, 586 consecutive patients who underwent TIVAD implantation were retrospectively analyzed. Two groups of patients suture with NAS (n = 299) or NBCA (n = 287) were followed up for 18 months to compare the occurrence of infection, thrombosis, and non-thrombotic malfunction. A total of 364 cases were extracted using propensity score matching in a 1:1 ratio. Mean TIVADs maintenance days were analyzed using Kaplan-Meier survival analysis.

RESULTS

Nineteen cases of complications occurred (0.294/1000 catheter-days) in the NAS group and 17 cases (0.210/1000 catheter-days) in the NBCA group. The difference in the complication rates between the two groups was not statistically significant (p = 0.725) after propensity score matching. Mean TIVADs maintenance days were 627.3 days in NAS group and 697.6 days in NBCA group. There was no statistically significant difference in the number of TIVADs maintenance days between the two groups (p = 0.081).

CONCLUSION

In TIVADs implantation, skin closure using NBCA showed no difference in the occurrence of infectious complications compared with conventional non-absorbable skin suture.

Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review

OBJECTIVE

Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes.

METHOD

A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'.

RESULTS

A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery.

CONCLUSION

The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

"/" wiring (Durukan weave) to prevent sternal cutting by wires: a propensity score matched comparison with Robicsek weave

Introduction

Sternal closure still causes morbidity/mortality following sternotomy. Robicsek weave, cable systems, rigid plates and nitinol clips are systems employed to prevent sternal dehiscence.

Aim

The aim was to document the effectiveness of a novel method using standard sternal wires decreasing load on wires and spreading load on the lateral sternum to prevent sternal cutting by wires and thus sternal dehiscence.

Material and methods

756 patients who underwent coronary revascularization with sternotomy between July 2018 and November 2022 were retrospectively analyzed. Fifty patients with "/"wiring were compared with 50 patients with Robicsek weave by propensity score matching. "/" wiring (Durukan weave) spreads load laterally on the sternum by lateral sequential knotting of wires instead of midline knotting. Outcomes were superficial and deep sternal wound infection and non-infectious sternal dehiscence.

Results

There were 50 patients in each group. Mean age of the patients was 65.74 ±7.47 in Robicsek weave and 66.12 ±7.23 in Durukan weave. The perioperative characteristics of patients were comparable as propensity score matching was performed. None developed superficial sternal wound infection in Robicsek weave, whereas 2% (1) in "/"wiring. There was no deep sternal wound infection in each group. Non-infectious sternal dehiscence did not occur in either group.

Conclusions

"/" wiring seems to be a safe and cost-effective method for sternal closure for preventing sternal cutting by wires, therefore preventing sternal wound related problems and dehiscence. The method is cheap, easily applicable and less time consuming than Robicsek weave, which was proven to be the safest method for sternal wire closure.

Vaginal Cuff Dehiscence and a Guideline to Determine Treatment Strategy

In this retrospective study, our aim was to investigate a novel treatment strategy guideline for vaginal cuff dehiscence after hysterectomy based on the mode of operation and time of occurrence in patients who underwent hysterectomy at Severance Hospital between July 2013 and February 2019. We analyzed the characteristics of 53 cases of vaginal cuff dehiscence according to the mode of hysterectomy and time of occurrence. Out of a total of 6530 hysterectomy cases, 53 were identified as vaginal cuff dehiscence (0.81%; 95% confidence interval: 0.4-1.6%). The incidence of dehiscence after minimally invasive hysterectomy was significantly higher in patients with benign diseases, while malignant disease was associated with a higher risk of dehiscence after transabdominal hysterectomy (p = 0.011). The time of occurrence varied significantly based on menopausal status, with dehiscence occurring relatively earlier in pre-menopausal women compared to post-menopausal women (93.1% vs. 33.3%, respectively; p = 0.031). Surgical repair was more frequently required in cases of late-onset vaginal cuff dehiscence (≥8 weeks) compared to those with early-onset dehiscence (95.8% vs. 51.7%, respectively; p < 0.001). Patient-specific factors, such as age, menopausal status, and cause of operation, may influence the timing and severity of vaginal cuff dehiscence and evisceration. Therefore, a guideline may be indicated for the treatment of potentially emergent complications after hysterectomy.

Infection foretold?]

INTRODUCTION

surgical wound dehiscence with exposure of internal fixation material is a serious problem in orthopedic surgery and an important factor for infection.

OBJECTIVE

presentation of an unusual case of an adult patient with surgical wound dehiscence and complete exposure of 20 cm of the ulnar plate after six years of surgery, without infection signs, with bone healing and skin behind the plate.

CASE PRESENTATION

39-year-old man with an open Gustilo II Monteggia fracture-dislocation multifracture. The patient had a history of drug dependence. He had an open reduction and internal fixation with an ulnar reconstruction plate. The patient did not have any follow-up. After six years of the surgery, there was a complete exposure of the plate (20 cm) without infection and healing of the fracture with misalignment. After removing the plate, we observed spontaneous epithelialization attached to the bone bed. Skin coverage was complete at two months.

CONCLUSION

although unusual, bone consolidation without infection is possible in an open fracture with long-standing exposure to a forearm plate in the adult.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020

INTRODUCTION

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.

METHODS

A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.

RESULTS

A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05).

CONCLUSIONS

Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

Is air an issue? A severe case of subcutaneous emphysema in an immunocompromised patient

Abdominal crepitus and air in the subcutaneous tissue should be recognized early, as the most common etiologies for subcutaneous emphysema are fatal if not treated acutely. We present the case of a patient who developed subcutaneous emphysema as a consequence of the dehiscence of a previously closed gastrocutaneous fistula.

Healing complications and their detrimental effects on bone gain in vertical-guided bone regeneration: A systematic review and meta-analysis

PURPOSE

Guided bone regeneration (GBR) utilizes a barrier membrane to allow osteogenic cells to populate a space by excluding epithelial and connective tissue cells. The purpose of this systematic review was to investigate the ratio of means (RoM) of vertical bone gained (Outcome) in vertical GBR procedures with healing complications (Intervention) and in vertical GBR procedures without healing complications (Comparison) in patients with vertically resorbed edentulous ridges that require dental implant placement (Population). A further aim was to investigate the incidence of complications after vertical GBR, and the influence of the timing of implant placement and regenerative devices on complications.

MATERIALS AND METHODS

MEDLINE (through PubMed), EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched in duplicate up to, and including, November 2020 for randomized and controlled clinical trials and prospective and retrospective case series. Outcomes included patient-level and site-level RoM of vertical bone gain between healing complications and uneventful healing, and incidences of complications that occurred after vertical GBR. Random-effects and fixed-effects meta-analyses were performed where appropriate. This study was registered on PROSPERO (CRD42021226432).

RESULTS

A total of 31 publications were selected for the qualitative and quantitative analyses. The RoM of vertical bone gained was 0.65 [95% CI = 0.47, 0.91] and 0.62 [95% CI = 0.45, 0.85] when membrane exposure without suppuration and abscess formation without membrane exposure occurred respectively, in comparison to uneventful healing. The overall incidence proportion of healing complications occurring at the augmented site at a site- and patient-level was 11.0% [95% CI = 7.0, 15.6] and 10.8% [95% CI = 6.6, 15.7]. At a patient-level, there were no significant differences between a simultaneous or staged approach, or with the regenerative device used. The site-level incidence proportion of membrane exposure without suppuration, membrane exposure with suppuration, and with abscess formation without membrane exposure was 8.7% [95% CI = 4.2, 14.2], 0.7% [95% CI = 0.0, 2.9], and 0.5% [95% CI = 0.0, 1.7], respectively. The site-level weighted mean incidence proportion of neurologic complications occurring at the donor site was 0.8% [95% CI = 0.0, 5.3].

CONCLUSIONS

There is a significant reduction in bone gain when healing complications occur. However, healing complications are relatively uncommon surgical complications after vertical GBR.

Preoperative contaminated wound management using short-term negative pressure wound therapy with instillation

BACKGROUND

The short-term application of negative pressure wound therapy with instillation and dwell time (NPWTi-d) enables the delivery of topical wound solutions, the solubilisation of debris and cleansing of the wound bed. The application of NPWTi-d may support the transition of the wound to a more manageable state and minimises the use of more invasive techniques.

METHOD

In this case series, we describe the process of applying NPWTi-d early as part of a contaminated wound treatment plan.

RESULTS

The case series included 15 patients in the preoperative setting. Wound types included surgical dehiscence, hard-to-heal wounds, heel pressure ulcers, diabetic foot ulcers, a cat bite and an amputation left open. Normal saline or a 0.125% sodium hypochlorite solution were instilled and allowed to dwell for five minutes, followed by 15 minutes of continuous negative pressure at -125mmHg. NPWTi-d was continued for 4-36 hours, or until the operating room became available. After NPWTi-d, we observed a decreased amount of devitalised tissue in the wound bed and reduced oedema and erythema in the periwound area. Patient white blood cells also significantly decreased in all cases after NPWTi-d (p<0.001).

CONCLUSION

Short-term use of NPWTi-d may be a useful option for supporting the surgical treatment of contaminated lower extremity wounds.

Influence of Different Incision Designs on Flap Extension: A Cadaveric Animal Model

It is well known that wound dehiscence is one of the most frequent complications in guided bone regeneration. The main cause of this complication may be a lack of tension-free and primary wound closure. The aim of this study was to evaluate and compare the effect of periosteal releasing incisions (PRI) on the extension of 3 different flap designs: envelope, triangular, and trapezoidal. Twelve pig mandibles were used to quantify extension of the flap designs. The mandibles were equally and randomly distributed into the 3 flap groups. Each mandible was divided into 2 sides: 1 was subjected to a PRI and the other not. The flap was pulled with a force of 1.08 N, and the extension was recorded. The subgroups without PRI showed an average extension of 5.14 mm with no statistically significant differences among them (P = .165). The PRI provided an average extension of 7.37 mm with statistically significant differences among the subgroups (P < .001). The releasing incisions significantly increased flap extension in each flap design. The increase in extension of the trapezoidal flap with PRI was significantly greater than in the other subgroups. In cases where primary closure is required, surgeons should consider performing trapezoidal flaps with PRI in order to reduce tension.

Saline Load Test and Quilting Sutures to Treat Intractable Lateral Malleolar Bursitis

The purpose of this study was to evaluate the clinical outcomes of patients with intractable lateral malleolar bursitis who were treated using the intraoperative saline load test to find communication between the bursal sac and the ankle joint and the quilting sutures after bursectomy to reduce the dead space. We reviewed a total of 28 patients who had been treated with quilting sutures after bursectomy between April 2014 and June 2017. When there was capsular opening detected with the saline load test, it was closed with sutures or augmented with periosteum. On the final follow-up office visit, the lateral malleolus was examined for the recurrence of bursitis. Patient medical records were reviewed for postoperative wound dehiscence, skin necrosis, infections, and nerve symptoms. The saline load test was positive in 11 (42%) cases. The mean foot function index improved from 25.94 ± 20.46 to 11.73 ± 5.27 (p = .003). Fourteen (54%) patients were very satisfied with the results, 9 (35%) were satisfied, 2 (8%) rated their satisfaction as fair, and 1 (4%) was dissatisfied. No cases required skin graft or flap surgery. Intractable lateral malleolar bursitis was successfully treated using the saline load test and quilting sutures after bursectomy. Closure of the capsular opening prevented fluid drainage around the wound. Quilting sutures after bursectomy reduced dead space underneath the wound to prevent fluid accumulation and promoted healing of the skin on the underlying soft tissue.

The Perth Surgical Wound Dehiscence Risk Assessment Tool (PSWDRAT): development and prospective validation in the clinical setting

OBJECTIVE

The worldwide volume of surgery today is considerable and postoperative wound healing plays a significant part in facilitating a patient's recovery and rehabilitation. While contemporary surgical procedures are relatively safe, complications such as surgical wound dehiscence (SWD) or breakdown of the incision site may occur despite advances in surgical techniques, infection control practices and wound care. SWD impacts on patient mortality and morbidity and significantly contributes to prolonged hospital stay. Preoperative identification of patients at risk of SWD may be valuable in reducing the risk of postoperative wound complications.

METHOD

A three-phase study was undertaken to determine risk factors associated with SWD, develop a preoperative patient risk assessment tool and to prospectively validate the tool in a clinical setting. Phases 1 and 2 were retrospective case control studies. Phase 1 determined variables associated with SWD and these informed the development of a risk assessment tool. Univariate analysis and multiple logistic regression were applied to identify predictors of surgical risk. Phase 2 used the receiver operator curve statistic to determine the predictive power of the tool. Phase 3 involved a prospective consecutive case series validation to test the inter-rater reliability and predictive power of the tool.

RESULTS

In addition to those already identified in the literature, one independent risk predictor for SWD was identified: previous surgery in the same anatomical location (p<0.001, odds ratio [OR] 4). Multiple combined factors were integrated into the tool and included: age (p<0.019, OR 3), diabetes (p<0.624, OR 2), obesity (p<0.94, OR 1.4), smoking (p<0.387, OR 2), cardiovascular disease (p<0.381 OR 3) and peripheral arterial disease (p<0.501, OR 3). The predictive power of the tool yielded 71% in a combined data sample.

CONCLUSION

Patients with previous surgery in the same anatomical location were four times more likely to incur a dehiscence. Identification of at-risk patients for complications postoperatively is integral to reducing SWD occurrence and improving health-related outcomes following surgery.

Comparison between noninvasive and conventional skin closure methods in off-pump coronary artery bypass grafting using bilateral internal thoracic artery

Background

Sternal wound complications could increase the hospital cost while decreasing the satisfaction of surgery. Furthermore, it can potentially also lead to life-threatening mediastinitis especially after coronary artery bypass grafting using bilateral internal thoracic artery (BITA). Skill levels of suture technique vary among surgeons and may contribute to an increased wound complication rate. Thus, standardization of surgical wound closure could potentially decrease the surgeon factor. The aim of the study is to compare the wound complication rate between non-invasive surgical skin closure devices (zip surgical skin closure device, Zipline Medical, Campbell, CA, USA) and conventional suture closure.

Methods

Three hundred seventy-nine patients who underwent off-pump coronary artery bypass grafting (OPCAB) using BITAs at our institution between 2016 and 2018 were included in this study. Patients were divided into two groups; the Zipline group (zip-group, N=100), and conventional group (con-group, N=279). Following propensity score matching, 95 con-group patients were matched to 169 zip-group patients.

Results

The average age and history of cancer were significantly higher in the zip-group (P=0.021 and P=0.023, respectively). However, after propensity score matching, no differences were observed in the demographic data between the groups. In total patients (unmatched), although there was no significant difference in the incidence of deep sternal wound infection (DSWI) between the two groups (zip vs. con, 0% vs. 1.1%, P=0.569), the incidence of post-operative superficial sternal wound infection (SSWI) or dehiscence was significantly higher in the con-group than in the zip-group (1.0% vs. 7.9%, P=0.013). The results were consistent in the matched patients. (DSWI: 0% vs. 0.6%, P>0.999; SSWI or dehiscence: 1.1% vs. 7.1%, P=0.036). Multivariable analysis revealed use of the zip surgical skin closure device showed a preventive effect against wound complications [odds ratio (OR): 0.128, 95% confidence interval (CI): 0.017-0.976, P=0.029].

Conclusions

Zip surgical skin closure devices could decrease superficial wound complication rates compared to conventional suture techniques in OPCAB using BITAs.

A cross-sectional survey of patients with open surgical wounds in Slovenia

Most surgical wounds heal by primary intention, that is, the wound is closed with sutures, clips, or glue. However, some surgical wounds are either left open to heal from the bottom up ("healing by secondary intention") or break open partially or fully after primary closure. There is little basic knowledge about the occurrence and natural history of surgical wounds healing by secondary intention (SWHSI); therefore, the aim of this survey was to estimate the number of people with SWHSI in Slovenia, the nature of these wounds, and to investigate how they are managed. A multiservice, cross-sectional survey was carried out over a 2-week period in the city of Ljubljana, Slovenia (population 288,919). Healthcare professionals across health and social care settings completed one anonymised form for each patient with a SWHSI. Forms were completed for 110 patients. The point prevalence of SWHSI was 0.38 per 1,000 of the population (95% CI: 0.33-0.44). Patients' mean age was 50.5 years. The majority of SWHSI were planned to heal by secondary intention before surgery (76/110, 69%). Of SWHSI, 83% (92/110) were treated with wound dressings, and 6% were treated with negative pressure wound therapy. Data were missing for 11 cases. This survey is the first to provide essential information about the extent, nature, and treatment of SWHSI in Slovenia. Furthermore, it is one of the latest of a very small number of studies to have contributed to knowledge about SWHSI globally. The results from the survey can be used for planning future research, health resources management, and policy development.

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.

Effect of membrane exposure on guided bone regeneration: A systematic review and meta-analysis

AIMS

This review aimed at investigating the effect of membrane exposure on guided bone regeneration (GBR) outcomes at peri-implant sites and edentulous ridges.

MATERIAL AND METHODS

Electronic and manual literature searches were conducted by two independent reviewers using four databases, including MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials, for articles up to February 2017. Articles were included if they were human clinical trials or case series reporting outcomes of GBR procedures with and without membrane exposure. A random-effects meta-analysis was conducted, and the weighted mean difference (WMD) between the two groups and 95% confidence interval (CI) were reported.

RESULTS

Overall, eight articles were included in the quantitative analysis. The WMD of the horizontal bone gain at edentulous ridges was -76.24% (95% CI = -137.52% to -14.97%, p = .01) between sites with membrane exposure and without exposure. In addition, the WMD of the dehiscence reduction at peri-implant sites was -27.27% (95% CI of -45.87% to -8.68%, p = .004). Both analyses showed significantly favorable outcomes at the sites without membrane exposure.

CONCLUSION

Based on the findings of this study, membrane exposure after GBR procedures has a significant detrimental influence on the outcome of bone augmentation. For the edentulous ridges, the sites without membrane exposure achieved 74% more horizontal bone gain than the sites with exposure. For peri-implant dehiscence defects, the sites without membrane exposure had 27% more defect reduction than the sites with exposure.

Prevention of postsurgical wound dehiscence after abdominal surgery with NPWT: a multicentre randomised controlled trial protocol

OBJECTIVE

The effectiveness of negative pressure wound therapy (NPWT) in the prevention of postoperative surgical wound dehiscence (SWD) is the subject of much debate and remains to be determined. This study will identify individuals at risk of postoperative SWD and trial the use of NPWT as a prophylactic measure against the occurrence of SWD, compared with a non-NPWT standard surgical dressing (SSD).

METHOD

A prospective multicentre randomised controlled trial comparing NPWT dressing against standard surgical dressings (SSD) will be conducted. An intention-to-treat (ITT) approach will be used for the trial.

AIMS

The primary outcome is the prevention of postoperative SWD up to and including day 30 postoperative. Secondary outcomes are: prevention of surgical site infection (SSI) and economic analysis of treatment groups.

CONCLUSION

This study will determine the effectiveness of NPWT in the prevention of postoperative abdominal SWD in a predefined level of risk population. This level 1 study will provide further data for abdominal SWD risk classification, which is anticipated to inform preventive postoperative management. The study design uses a prospective real-world scenario in order to identify clinically significant differences between the intervention and control groups.

TRIAL REGISTRATION

This trial was prospectively registered on 10 December 2012 with Australian and New Zealand Clinical Trials Network (ANZCTR): 12612001275853.

Impact of surgical wound dehiscence on health-related quality of life and mental health

OBJECTIVE

To assess the impact of surgical wound dehiscence on health-related quality of life and mental health. Dehiscence of surgical wounds is a serious postoperative complication associated with high morbidity and mortality.

METHOD

Sixty-one adult patients, who had undergone neurological, general, colorectal, orthopaedic, gynaecological, plastic, cardiovascular, urological or neurological surgery in a university hospital in Brazil, were assessed between 30 and 180 days after surgery. Twenty participants who achieved complete wound healing were allocated to the control group and 41 participants who developed surgical wound dehiscence were allocated to the dehiscence group. Patients unable to complete the questionnaires because of cognitive impairment and those who declined to participate or died were excluded from the study. Data were collected using a questionnaire assessing sociodemographic and clinical characteristics of participants; the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36); and the Beck Depression Inventory (BDI).

RESULTS

Surgical wound dehiscences were 0.5-30 cm in length, 0.5-7 cm in depth, and located in the arms, legs or trunk. There were significant between-group differences in mean scores on the physical functioning (p<0.01), role physical (p<0.01), social functioning (p=0.01), and bodily pain (p=0.01) dimensions of the SF-36. Participants with wound dehiscence reported significantly higher BDI scores (more depressive symptoms) than controls (p=0.01).

CONCLUSION

Surgical wound dehiscence had a negative impact on the physical functioning, role physical, social functioning, and bodily pain dimensions of health-related quality of life and on mental health.

DECLARATION OF INTEREST

No conflict of interest to declare.

Surgical wound dehiscence in an Australian community nursing service: time and cost to healing

OBJECTIVE

Surgical wound dehiscence (SWD) increases the length of hospital stay and impacts on patient wellbeing and health-care costs. Globally, the health-care costs associated with SWD are poorly reported and those reported are frequently associated with surgical site infection (SSI), rather than dehiscence of non-microbial cause. This retrospective study describes and reports on the costs and time to healing associated with a number of surgical patients who were referred to a community nursing service for treatment of an SWD following discharge from a metropolitan hospital, in Perth, Western Australia.

METHOD

Descriptive statistical analysis was carried out to describe the patient, wound and treatment characteristics. A costing analysis was conducted to investigate the cost of healing these wounds.

RESULTS

Among the 70 patients referred with a SWD, 55% were treated for an infected wound dehiscence which was a significant factor (p=0.001). Overall, the cost of treating the 70 patients with a SWD in a community nursing service was in excess of $56,000 Australian dollars (AUD) (£28,705) and did not include organisational overheads or travel costs for nurse visits. The management of infection contributed to 67% of the overall cost.

CONCLUSION

SWD remains an unquantified aspect of wound care from a prevalence and fiscal point of view. Further work needs to be done in the identification of SWD and which patients may be 'at risk'.

DECLARATION OF INTEREST

The authors declare they have no competing interests.

Evaluation of Risk Factors of Surgical Wound Dehiscence in Adults After Laparotomy

Objectives:

The percentage of patients with difficult and prolonged healing of the wound is still high, while the immediate complications such as wound dehiscence occurs in up to 3 % of all treated patients in abdominal surgery. The aim of study was to analyze the risk factors and comorbidities in the group patients undergoing laparotomy and associated with early postoperative wound dehiscence.

Methods:

The retrospective study included all patients treated surgically at Clinic of General and Abdominal surgery, Clinical Center of the University of Sarajevo in the period from January 1, 2013 until January 1, 2016, with clinically verified surgical wound dehiscence.

Results:

The results showed statistically proportion of male patients (70%) compared to female (30%). The largest number of respondents were in age group 71-80. Surgical wound infection was evident in 61% of patients, malignant staining in 52%, hypoproteinemia was found in 50% of patients, anemia in 43%, peritonitis in 36% and diabetes in 14% of respondents. Of the total respondents with surgical wound dehiscence, 30 (68%) had comorbidities present. By analyzing the prevalence of comorbidity and risk factors recorded in relation to comorbidity, it was noted that hypertension is most often associated with hypoproteinemia (X²=4.399; p=0.036), wound infection (X²=4.112; p=0.043) and malignant diseases (X²=4.016; p=0.045). The frequency of the anemia, peritonitis and diabetes in the sample was not different in relation to the comorbidity conditions (p >0.05).

Conclusions:

The risk factors occurrence of surgical wound dehiscence in our study were identified as hypoproteinemia, malignant disease, anemia and peritonitis. The highest incidence of dehiscence was in patients operated on in medical emergencies, and in patients with malignant disease.

Role of soap and water in the treatment of wound dehiscence compared to normal saline plus povidone-iodine: A randomized clinical trial

BACKGROUND

The incidence of cesarean section is increased. About 3-30% of the women who undergo cesarean experience surgical site infections (SSIs). Many methods, have been used to decrease the incidence of SSIs, but despite much effort, no definite efficacious method has been suggested.

MATERIALS AND METHODS

In this parallel, single-blinded, randomized control trial, 56 women with post-surgical superficial wound dehiscence were divided into two groups in a 1:1 ratio. One group was irrigated with normal saline for irrigation and Firooz® baby soapand the other with normal saline for irrigation and povidone-iodine. Formation of granulation tissue was monitored in both groups. Also, the reason for surgery, length of wound dehiscence, and duration of hospitalization and wound union after were compared in both group's.

RESULTS

The soap group patients were irrigated for 4.18 ± 1.96 days compared to 5.36 ± 2.83 days for the patients in povidone-iodine group (P = 0.414). The granulation tissue was formed after 3.88 ± 1.94 days in the soap group compared to 4.48 ± 2.92 days in the other group (P = 0.391), and the duration of hospitalization was 5.48 ± 2.04 days in the soap group compared to 6.3 ± 2.95 days in the other group (P = 0.423). So, no differences were observed between the two groups.

CONCLUSION

It can be concluded since there is no difference between the results of two groups, irrigation with normal saline and soap is safe, easy and causes no harm or allergy compared with povidone iodine and normal saline.

Two questions on bilateral internal mammary artery usage

The use of a single internal mammary graft to the left anterior descending artery has been the gold standard in surgical coronary revascularization since its introduction. However, the take-up rate of use of bilateral internal mammary arteries has been slow despite emerging evidence. This has been partly due to the worry of postoperative complications, in particular, sternal wound complications. Skeletonization of the internal mammary has been proposed as a technique that can preserve the sternal microcirculation and therefore reduce this complication. In this article, we examine the evidence comparing the skeletonization technique versus the conventional pedicled technique for harvesting the internal mammary artery.

Sternal wrapping: developments and results

BACKGROUND

Postoperative sternal wound complications are infrequent events that negatively affect recovery and may have serious consequences. Sternal wrapping, a technique of sternal care, has hemostatic properties without bone wax, and offers mechanical and microbiologic protection.

METHODS

From February 1998 to December 2011, 258 patients in 2 Italian institutions underwent various cardiac surgery procedures with sternal wrapping in place, and were followed up for no less then 6 months.

RESULTS

Two (0.8%) extremely compromised patients with ischemic sternal osteonecrosis and deep sternal wound infection required a sternal stabilizing procedure. Four (2%) other patients developed sternal wound complications that were treated entirely medically; 3 of them were very trivial, and 1 was an atypical mediastinitis without sternal involvement. Overall, 46.1% of patients (45.3% of isolated coronary artery bypass, 49.3% of isolated on-pump coronary artery bypass, and 18.2% of off-pump coronary artery bypass patients) were transfused. None of the complications was related to sternal wrapping, bleeding from the sternal edge, or sternal wound problems.

CONCLUSIONS

Sternal wrapping showed a very low incidence and severity of sternal wound complications, with good prevention of sternal osteomyelitis. Hemostatic properties were satisfactory, with transfusion rates within an acceptable range.

Tests of experimental tissue adhesive sealants: analysis of strength effects in relation to tissue adhesive sealant standards

The sealing efficiencies (SE% = surfaces sealed/surfaces tested) of 2 experimental tissue adhesive sealants (TASs), L.C. TAS and glutaraldehyde TAS (GA TAS), were determined by applications in 12 mixed-breed pigs (weight range, 40-60 kg) that had been anticoagulated with heparin and divided into groups of 6: Group I, L.C. TAS; and Group II, GA TAS. Leaking tissue surfaces used were 5-mm aortic punch holes and lacerated splenic, hepatic, and lung surfaces (2 of each, in each pig). First-application SEs were as follows: for aortic punch holes, 91% in Group I and 16.6% in Group II (P <0.001; 95% confidence interval [CI], 49%-100%); for splenic leaking tissue surfaces, 83.3% in Group I and 0 in Group II (P < 0.001; 95% CI, 78%-88%); for hepatic leaking tissue surfaces, Group I, 83.3%; Group II, 16.6%; P <0.001 (95% CI, 37%-97%); and for lung leaking tissue surfaces, 75% in Group I and 0 in Group II (P <0.001; 95% CI, 50%-99%). For both 1st and 2nd applications on all leaking tissue surfaces, SEs were 98% in Group I and 29% in Group II (P <0.001; 95% CI, 37%-99%). These results are consistent with the hypothesis that a TAS with higher cohesive and adhesive strengths, such as L.C. TAS (cohesive strength, >6.5 kg/cm(2); adhesive strength, >1.5 kg/cm(2)), will have higher SEs for leaking tissue surfaces than will a TAS with lower cohesive and adhesive strength. An analysis of these data in relation to TAS standards is discussed.

Intracutaneous versus transcutaneous suture techniques: comparison of sternal wound infection rates in open-heart surgery patients

In open-heart surgery, sternal wound infection after median sternotomy is a critical complication. The intracutaneous suture is conventionally used in closing sternal incisions. In this prospective, randomized, controlled clinical trial, intracutaneous and transcutaneous suture techniques for closing the sternum were compared with respect to postoperative sternal wound infections and cosmetic results. In this study, we included 100 patients who had undergone open-heart surgery. Skin wounds were closed with intracutaneous suture in 50 patients and with transcutaneous suture in the remaining 50. Superficial or deep sternal infections that developed within 6 postoperative weeks were evaluated. Cosmetic results were similar in the 2 groups. Deep wound infections were not observed in either group. Superficial infection of postoperative sternal wounds occurred at rates of 2% (n=1) and 16% (n=8) for transcutaneous and intracutaneous techniques, respectively (P = 0.016). One patient in the transcutaneous group and 6 patients in the intracutaneous group who developed superficial sternal infections were diabetic. Although the use of the transcutaneous suture technique in closing sternal incisions of cardiac surgery patients provided no cosmetic improvement, it decreased the risk of superficial sternal infection and reduced the length of postoperative hospital stay, particularly in diabetic patients.

Routine application of the omental pedicle graft in 50 consecutive patients at risk for sternal wound infection

After cardiac surgery, healing can be delayed by sternal wound infection, particularly if mediastinitis develops. Because of the technical simplicity of omentopexy, we recommend the use during open-heart surgery of an omental pedicle graft in selected cases to prevent postoperative complications. This article describes our experience over a 4-month period (from 30 March 1989 through 2 August 1989) with this technique in 50 consecutive patients at moderate-to-high risk for postoperative sternal and mediastinal problems. The patients included 39 men (78%) and 11 women (22%), whose ages ranged from 22 to 83 years (mean, 55 years). Preoperative risk factors included extreme obesity, 13 patients (26%); chronic obstructive pulmonary disease, 13 patients (26%); diabetes mellitus, 6 patients (12%); obesity and diabetes, 8 patients (16%); and obesity, diabetes, and chronic obstructive pulmonary disease, 3 patients (6%). Operative risk factors included cardiac reoperation involving prolonged surgery, 6 patients (12%); bilateral mammary grafting, 17 patients (34%); and the need for prolonged (greater than 72-hour) mechanical respiratory assistance, 2 patients (4%). Three of the 50 patients (6%) were considered to be at moderate risk due to an increase in nosocomial infections at the time of their surgical procedures. Although the omentopexy itself caused no complications, 5 patients had major complications related to the cardiac procedure. Two of these patients died, for an operative mortality of 4%; death was caused by progressive peritonitis in 1 case and by cardiac tamponade in the other case. At least 2 of the remaining 3 patients withstood localized mediastinal infection and had thereafter an extremely benign postoperative course. We conclude that an omental pedicle graft, placed prophylactically in patients at risk for sternal wound infection, can serve as a valuable adjunct to healing after cardiac surgery.

Management of high-risk sternotomy wounds with retention sutures

The authors describe a technique for reinforcing sternal wound closure that is recommended for high-risk wounds and for use after sternal dehiscence.