Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study.

BACKGROUND: Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs. OBJECTIVE: The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults. METHODS: The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery. RESULTS: Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery. CONCLUSIONS: The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

Recurrent diabetic foot ulcers: Results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery.

The diabetic foot ulcer (DFU) and Charcot Neuroarthropathy (CN) are serious complications of diabetes mellitus in which wound closure is complex to achieve. Treating recurrent DFU in patients with a combination of infection, ischemia, and deformities is extremely challenging and this group of patients has a very poor outcome. This case series describes the outcomes of patients with a recurrent DFU and CN, with a mean SINBAD score of 4 and of which 40% had a TCS of D3, using a multidisciplinary protocol that includes reconstructive foot and ankle surgery. In 24/35 (69%) of patients, wound closure was achieved after a mean of 75 days postoperatively. The mean ulcer-free period was 358 days. The mean number of interventions was 6.7 (range 3-9). Post treatment 27/35 (77%) of patients was mobile, without additional amputation or ulcer recurrence. This study shows that wound closure and a long ulcer-free period can be achieved in patients with a DFU and CN and its multifactorial underlying diseases when treated in a multidisciplinary team, including reconstructive foot and ankle surgery.

Quality of Care and Cost-effectiveness: Optimizing Wound Care in the Netherlands.

OBJECTIVE: Previously, the authors implemented a "fast-track protocol" in the Netherlands to shorten the time to referral for patients when diagnostic testing was deemed necessary given suspicion of underlying pathology preventing wound healing. This subanalysis of the cross-sectional study presents the cost reduction of using that fast-track protocol. METHODS: The cross-sectional study data were collected at the Alrijne Wound Centre between January 2017 and January 2018 and included patients from two general practitioner practices and a large home-care organization who had a new occurrence of wounds. The cost-effectiveness analysis consisted of an analysis of the mean reduction in care, wound dressing materials, and reduction in unnecessary hospital referrals. RESULTS: In 2017, a total of 415 patients received wound care of the general practitioners or home-care organization. By using the "fast-track" protocol, costs were reduced in all areas. After extrapolation, the minimum mean cost reduction in wound care was €129,949,638; on wound dressings, it was €2,623,920, and on the reduction of unnecessary hospital referrals, the average recovery was €2,436,000. CONCLUSIONS: Prompt triage, analyses, and treatment of underlying causes by specialized doctors in a multidisciplinary setting offer enormous potential for cost savings. The conservative estimate is that approximately €135,000,000 to €293,000,000 can be saved in annual healthcare costs in the Netherlands using this protocol.

Optimization of Best Practice Wound Care in the Netherlands.

Estimates regarding the prevalence of chronic wounds in the Netherlands vary from 350 000 to 500 000. The cross-sectional multicenter study presented here provides evidence for the incidence and prevalence of wounds and chronic wounds. The primary aim of the present study was to provide evidence for incidence and prevalence of (chronic) wounds outside the hospital. The secondary aim was to optimize the organization for chronic wounds care within our region. From January 2017 until January 2018, information was prospectively collected of patients with new onset of wounds in 2 general practitioner practices to which 19 100 patients are enrolled. For the patients with new onset of wounds the "fast track protocol" was used and outcomes including etiology and wound healing were measured. This protocol included a structured treatment protocol and predetermined triage moments. The Alrijne Wound Centre database 2014 was used as a control group (469 records). The incidence of new onset of wounds was 364/19 100 (1.9%). The prevalence of wounds was 405/19 100 (2.1%). The prevalence of chronic wounds, that is, wounds that did not show a sufficient healing rate after 4 to 6 weeks, was 78/19 100 (0.4%). Time to referral to a wound physician (the triage moment) was 5 weeks versus 19 weeks in 2014 (P < .001). Unnecessary referrals to the hospital was reduced by 17.4% (P = .007). In conclusion, the prevalence of the chronic wounds was 4 per 1000 patients. The use of the "fast track" protocol optimizes wound care, wounds heal faster, and unnecessary referrals decrease significantly.

The Reverdin Graft: The Forgotten Skin Transplant.

ABSTRACT: This article describes a series of four patients for whom a Reverdin graft was performed. The Reverdin graft, also known as a pinch graft, is a method to promote epithelialization for superficial wounds. The intervention is minimally invasive with a short learning curve. The procedure and its advantages and disadvantages are discussed in this case series. This pinch graft is a widely accepted, minimally invasive intervention to accelerate the epithelialization of wounds.

Prevalence of foot ulcers in dialysis-dependent patients.

Hemodialysis patients are at high risk for foot ulceration. The aim of this prospective study was to describe the prevalence and risk factors for foot ulcers in hemodialysis-dependent patients. From 2012 until 2015, all hemodialysis patients (n = 66) above18 years of age, treated at the Alrijne Hospital (Leiderdorp, the Netherlands), were included. Demographics and medical history were collected and the quality of life was measured. Data were collected on common risk factors for foot ulceration: peripheral arterial disease, peripheral neuropathy with or without foot deformities, diabetes mellitus (DM), hypertension, smoking, previous foot ulcer, edema, pedicure attendance, and orthopedic footwear. Sixty-six hemodialysis patients were evaluated; the prevalence of foot ulcer was 21/66 (31.8%). Risk factors were history of foot ulceration in 27/66 (40.9%), ankle-brachial index (ABI) <0.9, and toe pressure < 80 mmHg in 38/66 (57.6%). The percentage of DM in the group of foot-ulcers was higher 13/21 (61.9%) vs. 20/45 (44.4%) in the non-ulcer group, this was not significant (p = 0.183). No differences were found in ABI, toe pressure, peripheral neuropathy and foot deformity, between the DM and non DM group. The mortality between ulcer vs. no ulcer was significant different: 13/21 (61.9%) vs. 11/45 (24.4%) (p = 0.003). Approximately, one-third of hemodialysis patient have a foot ulcer 21/66 (32%). Arterial insufficiency is associated with an increased risk of foot ulcers. In patients with a foot ulcer, survival is significantly lower than in patients without a foot ulcer; interventions to reduce foot ulceration should be implemented for all hemodialysis patients and include frequent inspection, and prompt treatment. Further research should focus on the prevention of foot ulcers in dialysis-dependent patients.

Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat Infected Orthopedic Implants: A 4-patient Case Series.

Infection following orthopedic implants for bone fixation or joint replacement is always serious and may require removal of the osteosynthetic material. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is an emerging therapy for the treatment of complex wounds, including infected wounds with osteosynthetic material. The purpose of this case study was to evaluate the outcomes of 4 patients (1 man, 3 women; age range 49 to 71 years) with a postoperative wound infection (POWI) following fracture repair and internal fixation. All patients were at high risk for surgical complications, including infections. Standard infection treatments (antibiotics) had been unsuccessful. Based on the available literature, a NPWTi-d protocol was developed. Following surgical debridement, wounds were instilled with polyhexanide biguanide with a set dwell time of 15 minutes, followed by continuous NPWTi-d of -125 mm Hg for 4 hours. The system was changed every 3 to 4 days until sufficient granulation tissue was evident and negative pressure without instillation could be used. Systemic antibiotics were continued in all patients. Granulation tissue was found to be sufficient in 12 to 35 days in the 4 cases, no recurrence of infection was noted, and the osteosynthesis material remained in place. No adverse events were observed. Research is needed to compare the safety and effectiveness of this adjunct treatment in the management of challenging wounds to other patient and wound management approaches.