Correction: The Preferred Treatment of Sternoclavicular Joint Infections: A Systematic Review.

[This corrects the article DOI: 10.7759/cureus.9963.].

Muscle flaps for sternoclavicular joint septic arthritis.

Septic arthritis of the sternoclavicular joint (SC) is rare. The most accepted technique for reconstruction of the defect after SC joint resection is the use of muscle flaps. We hypothesized that resection of ribs with the SC joint impacts timing, type and outcomes of reconstruction. This is a retrospective review of 44 patients who underwent wound closure with muscle flap following resection of the SC joint for septic arthritis over 14 years period from a single institution. Patients were divided into two groups based on the resection of the adjacent ribs with the SC joint. We found 18 (40.9%) patients with SC joint resection only and 26 (59.1%) with concomitant resection of the adjacent ribs. Patients in the rib resection group were younger, did not need SC joint fluid aspiration, and had higher tissue culture positivity (p < .05). Rib resection with the SC joint was found to be associated with delayed reconstruction (57.7% vs 22.2%, p = .030), need for serial debridement's (2 vs 1, p = .009), increased days from debridement to reconstruction for a subset of patients (75% percentile of 8 days vs. 0 days, p = .024), and longer hospital stay (18 vs 9, p = .006). Flap complications were higher in rib resection group (26.9% vs 5.6%, p = .67). Reconstruction following resection of the SC joint for septic arthritis is guided by the surgeon's impression regarding source control of infection. Rib resection concomitantly with joint resection appears to be a useful indicator of disease extent and may help guide clinical decision making in this challenging scenario.

Zinc shapes the folding landscape of p53 and establishes a pathway for reactivating structurally diverse cancer mutants.

Missense mutations in the p53 DNA-binding domain (DBD) contribute to half of new cancer cases annually. Here we present a thermodynamic model that quantifies and links the major pathways by which mutations inactivate p53. We find that DBD possesses two unusual properties-one of the highest zinc affinities of any eukaryotic protein and extreme instability in the absence of zinc-which are predicted to poise p53 on the cusp of folding/unfolding in the cell, with a major determinant being available zinc concentration. We analyze the 20 most common tumorigenic p53 mutations and find that 80% impair zinc affinity, thermodynamic stability, or both. Biophysical, cell-based, and murine xenograft experiments demonstrate that a synthetic zinc metallochaperone rescues not only mutations that decrease zinc affinity, but also mutations that destabilize DBD without impairing zinc binding. The results suggest that zinc metallochaperones have the capability to treat 120,500 patients annually in the U.S.

The Preferred Treatment of Sternoclavicular Joint Infections: A Systematic Review.

The treatment of sternoclavicular joint infection is a topic of controversy. This systematic review aims to evaluate the preferred treatment of sternoclavicular joint infections. A literature search using PubMed/MEDLINE®/Embase databases was conducted to identify publications on the surgical management of sternoclavicular joint infections. Case reports and studies without surgical management were excluded. The outcomes of interest included patient demographics, comorbidities, infectious etiologies, radiographic features, surgical management, and complications. Sixteen articles met the inclusion criteria. The mean age of the subjects was 53.4 years; there was a predominance of males (65%), and a minority of the subjects were obese (15%). The most common infectious etiology was methicillin-susceptible Staphylococcus aureus (MSSA) (48%). CT scan was reported in 46% of cases. The most common treatment was surgical resection of the joints (85%), followed by muscle flap closure of the wounds (54.2%). The complication rate ranged from 0-40%. Specifically, recurrence of infection was low with resection of the joint, followed by muscle flap closure. Given the heterogeneity of the methodology and inconsistency in the outcomes, a meta-analysis could not be performed. Overall, the current literature favors the resection of the sternoclavicular joint as the gold standard treatment. Closure of the wound using muscle flap seems to adequately treat this problem without any major untoward events.

Successful management of sternomanubrial joint septic arthritis with pectoralis muscle flap closure: a case series.

Primary infection of the sternomanubrial joint (SMJ) is extremely rare. We present four consecutive cases who were all treated with SMJ resection (partial sternectomy), bilateral partial 2nd rib resection and immediate placement of temporary wound vacuum therapy followed by pectoralis major muscle flap closure. Average patient age was 35.5 years with male predominance (75%). All patients had intravenous drug use as underlying risk factor along with concomitant viral infections Hep C (75%) and HIV (25%). MSSA was identified in resection cultures in 75% of the patients. Delayed bilateral PMFC was achieved in all patients (average post-resection day 5). Response to treatment was excellent with no recurrent infections, no complications and zero 30-day mortalities. Our experience represents the largest reported case series in adults and would suggest that aggressive surgical resection followed by PMFC would appear to be the preferred treatment for all patients with SMJ infection.

Sternoclavicular Joint Infections: Improved Outcomes With Myocutaneous Flaps.

Sternoclavicular joint (SCJ) infection is a rare disease and its management remains controversial. Our institution has adopted an aggressive surgical approach of radical SCJ resection combined with myocutaneous flap (MCF) closure whenever possible. We reviewed our experience with this approach in the management of this condition. From July 2004 to June 2018, 50 consecutive patients were treated surgically for SCJ infections. Patient demographics, imaging studies, microbiology, and operative variables were analyzed. All patients underwent ipsilateral SCJ resection. Wound closure was performed with primary pectoralis advancement MCF closure at the initial operation in 25 patients, delayed MCF closure following temporary wound vacuum therapy and redebridement in 19 patients, and definitive wound vacuum therapy (DWVT) in 6 patients. End points were recurrence of infection, perioperative morbidity, and mortality. Localized swelling (100%) and pain (100%) were the most common presenting symptoms. MSSA was isolated in 50% of tissue cultures. Comorbidities included tobacco smoking 52%, diabetes mellitus 50%, intravenous drug use 34%, poor dental hygiene 32%, and obesity 28%. We had no deaths within 90 days of operation. Complications; seroma in 1 patient (2%), chest wall hernia in 1 patient (2%), retained drains in 1 patient (2%), recurrent osteomyelitis infection in 3 patients (6%), and hematomas in 5 patients (10%). Patients treated with primary MCF closure at the initial operation had a 0% (0/25) rate of recurrence compared to 5.26% (1/19) in delayed MCF closure. Overall, there was only a 2.27% (1/44) recurrence of infection in primary and delayed MCF closure combined, compared to 33.33% (2/6) in patients treated with DWVT closure. SCJ infections require an aggressive approach. Wound closure with an MCF (primary or delayed) is associated with less recurrence of infections compared with DWVT closure. Radical resection of the entire SCJ with MCF (primary or delayed) should be considered the preferred management strategy in patients with SCJ infections.

A Single Center Retrospective Evaluation of a Surgical Strategy to Combat Persistent Soft Tissue Wounds Utilizing Absorbable Antibiotic Beads.

Objective: To determine whether use of absorbable antibiotic-imbued beads in chronic soft tissue wounds presents a viable therapeutic modality. Approach: Retrospective analysis of all cases utilizing calcium sulfate antibiotic beads was conducted. Cases comprised complex wound and breast reconstruction performed by the senior author (C.P.D.) over 4 years at the University of New Mexico Hospital. All-cause need for reoperation and reoperation for infection in the 90 days following bead-assisted surgery were compared to traditional surgical intervention in the 90-day period preceding bead-assisted surgery. Paired-samples t-test and corrected Cohen's d were calculated for outcome significance and effect size. Results: A total of 60 patients underwent 84 bead-assisted surgeries. There was a significant decrease in rate of reoperation following bead surgery (M = 0.32) compared with prebead surgery (M = 2.2), p < 0.001. Rate of reoperation for infection significantly decreased from 1.7 before bead surgery to 0.05 following bead surgery, p < 0.001. Results remained significant when stratified by complex wound or breast reconstruction, p < 0.01. Cohen's d ranged from 1.25 to 2.13, with probability of superiority between 80% and 93%. Innovation: Use of antibiotic-laden materials is well established in the orthopedic literature, but poorly characterized in soft tissue applications. Biofilms are increasingly implicated as a unifying pathologic foe underlying chronic wound infection and nonhealing. Antibiotic beads have demonstrated activity against biofilm in vitro. This study demonstrates diminished reoperative burden for these wounds following antibiotic bead surgery, possibly as a result of in vivo biofilm antagonism. Conclusion: Antibiotic bead-assisted surgery was associated with significantly decreased infectious and all-cause reoperations for chronic and infected wounds.

Off-label Usage of Absorbable Beads Containing Antibiotics for Prevention of Surgical Site Infections.

Surgical site infections account for about 17% of all nosocomial infections, second only to urinary tract infections. Antibiotic beads deliver high local antibiotic concentrations and maintain low systemic levels. The authors assessed the efficacy of calcium sulfate absorbable antibiotic beads (CSAAB) in the prevention of surgical site infections (SSIs) for complex wound closures. Patient records from the University of New Mexico Hospital (UNMH; Albuquerque, NM) and Dartmouth-Hitchcock Medical Center (DHMC; Lebanon, NH) were retrospectively analyzed from 2004 to 2015. Each patient received CSAAB prophylaxis during operations performed by the principle investigator. Charts were grouped by wound location and category. Outcomes were defined solely by readmission within 30 days for repeat intervention. Zero of the 38 UNMH and 15 of the 104 DHMC patients were readmitted. Data reached statistical significance based on 95% confidence intervals using the binomial distribution. This brief retrospective chart review shows promising use for CSAAB in the prevention of soft tissue SSIs.

Use of Antibiotic-Impregnated Absorbable Beads and Tissue Coverage of Complex Wounds.

The treatment of complex wounds is commonplace for plastic surgeons. Standard management is debridement of infected and devitalized tissue and systemic antibiotic therapy. In cases where vital structures are exposed within the wound, coverage is obtained with the use of vascularized tissue using both muscle and fasciocutaneous flaps. The use of nondissolving polymethylmethacrylate and absorbable antibiotic-impregnated beads has been shown to deliver high concentrations of antibiotics with low systemic levels of the same antibiotic. We present a multicenter retrospective review of all cases that used absorbable antibiotic-impregnated beads for complex wound management from 2003 to 2013. A total of 104 cases were investigated, flap coverage was used in 97 cases (93.3%). Overall, 15 patients (14.4%) required reoperation with the highest groups involving orthopedic wounds and sternal wounds. The advantages of using absorbable antibiotic-impregnated beads in complex infected wounds have been demonstrated with minimal disadvantages. The utilization of these beads is expanding to a variety of complex infectious wounds requiring high concentrations of local antibiotics.

Opportunity cost: a systematic application to surgery.

BACKGROUND: Opportunity cost is the potential gain or loss when a person chooses to perform an activity over its next best alternative. With respect to surgery, opportunity cost can occur if a less efficient technology uses more operating time than its next best alternative. This additional operating time could be used in a productive way that, when economically valued, adds a "cost" to the less efficient technology. Although fundamental to the economist's view of costs and widely used in economic assessments, opportunity cost analysis is infrequently used in economic evaluation of surgical technology. Previous cost comparison studies in the surgical literature have not addressed opportunity cost when estimating the efficiency of competing technologies. With increasing healthcare costs and new technologic advancements in surgery, a surgeon's ability to understand opportunity cost and apply it when choosing between two comparable technologies is essential. Our objective is to present a system to estimate the opportunity cost for given surgical specialties and present a model to demonstrate its principle. METHODS: To demonstrate the principle of opportunity cost, our model used a hypothetical scenario comparing two clinically equivalent technologies that differed in that the use of one device (Device A) extended operating time in a hypothetical procedure by 30 minutes compared to its competitor device (Device B). How this extra operating time could potentially be used was then valued using the opportunity cost calculated by our study design. Our study design included 5 surgical procedures from 5 surgical specialties that were elective, profitable, high-volume (performed more than 100 times per year), and had a duration of less than 240 minutes. The data were taken from a university hospital setting in 2007 and included procedure volume, profit margin, and duration. The outcome measure was opportunity cost, which was estimated by dividing the selected procedure's profit margin by its duration. RESULTS: Surgical specialty results are presented in the accompanying Tables. Otolaryngology has the highest opportunity cost at $38/min. This cost was calculated by using myringotomy as the procedure that was elective, short in duration, performed in high volume, and provided the highest profit margin. By applying our model, the otolaryngology surgeon using the less efficient Device A to perform a hypothetical procedure would incur an opportunity cost of $1,140 ($38/min x 30 min). This is because he could have performed additional myringotomy procedures in the time saved had he instead used the more efficient Device B in his hypothetical cases. General surgery has the lowest opportunity cost at $9/min; laparoscopic inguinal hernia repair was the procedure used for its calculation. Under the same model, the general surgeon using Device A would incur an opportunity cost of $270 ($9/min x 30 min). This is because the general surgeon could have performed additional laparoscopic femoral/hernia repairs had she used the more efficient Device B in her hypothetical cases. CONCLUSION: In acknowledging opportunity cost, a surgeon can more accurately compare the efficiency of competing surgical devices. This comparison is carried out by estimating and applying a dollar amount to the potential utility of time created by the use of the less efficient device.

Initial experience with laparoscopic inferior epigastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast reconstruction.

HYPOTHESIS: Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation. DESIGN: Prospective case series. SETTING: Tertiary academic center. PATIENTS: Female patients with breast cancer who chose pedicle TRAM reconstruction. INTERVENTIONS: Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin. MAIN OUTCOME MEASURES: Complications of surgery and subsequent flap viability. RESULTS: From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient. CONCLUSION: Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.