Complex periprosthetic wound coverage in patients undergoing revision total knee arthroplasty: a single plastic surgeon study.

INTRODUCTION: Options for soft tissue coverage in revision total knee arthroplasty (rTKA) range from primary wound closure to complex muscle flap reconstructions. The purpose of this study was to investigate the institutional experience of wound coverage options for complex soft tissue defects in rTKA. MATERIALS AND METHODS: 77 patients undergoing rTKA with complex wound closure by a single plastic surgeon were retrospectively reviewed. The average follow-up was 30.1 months. In 18 (23.4%) patients, an intraoperative decision for primary closure was made. Fifty-nine patients (76.6%) received either a local fasciocutaneous (N = 18), a medial gastrocnemius (N = 37), a free latissimus dorsi (N = 3) or a lateral gastrocnemius flap (N = 1). Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis. RESULTS: Medial gastrocnemius flaps had significant lower cumulative revision-free survival rates than local fasciocutaneous flaps (P = 0.021) and primary closures (P < 0.001) (42.5% vs. 71.5% vs. 100%,respectively). Comparing the most common complex closure procedures medial gastrocnemius flaps had the highest rate of prolonged wound healing (29.7%) and infection/reinfection (40.5%). Infection-associated flap procedures had significant lower cumulative revision-free survival rates (30.5%) than non-infection associated flap procedures (62.8%,P = 0.047). A history of more than two prior surgeries (HR = 6.11,P < 0.001) and an age ≥ 65 years (HR = 0.30,P = 0.018) significantly increased the risk of revision. CONCLUSIONS: The results of this study indicate that primary closure -if possible- should be preferred to early proactive muscle flap coverage. Even in the hands of an experienced plastic surgeon muscle flaps have high revision and complication rates. The study highlights the need to clarify flap indications and to investigate alternative approaches.

Gluteus maximus transfer for wound closure and treatment of abductor deficiency: a single-plastic surgeon series.

INTRODUCTION: Due to the increasing number of total hip arthroplasties (THA), the number and complexity of revision procedures are also on the rise. For complex cases such as periprosthetic joint infections with soft tissue compromise or for abductor muscle deficiencies, one of the treatment options is a gluteus maximus flap (GMF) that covers dead space and can help restore the failed abductor mechanism. The purpose of this study is to investigate the outcomes of a single-plastic surgeon's series of GMF procedures. MATERIALS AND METHODS: This retrospective review reports on 57 patients (mean follow-up 39.2 months) undergoing GMF transfers for abductor insufficiency on native hip (N = 16), for abductor insufficiency in aseptic revision THA (rTHA) (N = 16), for soft tissue defects in aseptic rTHA (N = 8) and for soft tissue defects in septic rTHA (N = 17) by a single plastic surgeon over a 10-year period. Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis. RESULTS: The reoperation-free survival rate of GMF for abductor insufficiency in native hips was 100%. GMF procedures for soft tissue defects in septic rTHA had the lowest cumulative revision-free survival (34.3%) and highest reinfection rates (53.9%). More than three prior surgeries (HR = 2.9, p = 0.020), presence of infection (HR = 3.2, p = 0.010) and resistant organisms (HR = 3.1, p = 0.022) significantly increased the risk of revision. CONCLUSIONS: GMF is a viable option for addressing abductor insufficiency in native hip joints. However, high revision and complication rates are reported for GMF in septic rTHA. This study highlights the need to clarify the circumstances for which the flap reconstruction will be indicated.

Gluteus Maximus Advancement Flap Procedure for Reconstruction of Posterior Soft Tissue Deficiency in Revision Total Hip Arthroplasty.

The current study describes the surgical technique and early outcomes of a gluteus maximus advancement flap procedure for the treatment of posterior soft tissue insufficiency among patients with complex revision total hip arthroplasty. This retrospective case series was conducted with a prospective, single-institution arthroplasty registry. Patients who underwent a gluteus maximus advancement flap procedure in the setting of revision total hip arthroplasty between January 2012 and January 2016 were eligible for inclusion (N=7). Primary indications for the gluteus maximus flap procedure included periprosthetic infection with persistent wound breakdown (n=4), persistent symptomatic aseptic pseudotumor in the setting of adverse local tissue reaction after unsuccessful operative debridement (n=2), and abductor insufficiency with recurrent hip instability after unsuccessful placement of a constrained liner (n=1). All patients who underwent a gluteus maximus advancement flap procedure for chronic periprosthetic infection or adverse local tissue reaction had healing of the wound and were infection-free at the last follow-up. In the early postoperative period, 2 patients had recurrent wound infection that required flap elevation. The patients remained infection-free after the subsequent procedure. No patient had repeat instability, and no complications of flap necrosis or nerve palsy occurred. The gluteus maximus advancement flap procedure provides a diverse range of soft tissue coverage options for patients with recalcitrant periprosthetic joint infection, adverse local tissue reaction with pseudotumor, or recurrent instability. [Orthopedics. 2017; 40(3):e495-e500.].

An Algorithm for Building an Electronic Database.

OBJECTIVE: We propose an algorithm on how to create a prospectively maintained database, which can then be used to analyze prospective data in a retrospective fashion. Our algorithm provides future researchers a road map on how to set up, maintain, and use an electronic database to improve evidence-based care and future clinical outcomes. METHODS: The database was created using Microsoft Access and included demographic information, socioeconomic information, and intraoperative and postoperative details via standardized drop-down menus. A printed out form from the Microsoft Access template was given to each surgeon to be completed after each case and a member of the health care team then entered the case information into the database. RESULTS: By utilizing straightforward, HIPAA-compliant data input fields, we permitted data collection and transcription to be easy and efficient. Collecting a wide variety of data allowed us the freedom to evolve our clinical interests, while the platform also permitted new categories to be added at will. CONCLUSION: We have proposed a reproducible method for institutions to create a database, which will then allow senior and junior surgeons to analyze their outcomes and compare them with others in an effort to improve patient care and outcomes. This is a cost-efficient way to create and maintain a database without additional software.

Horizontal or vertical? an evaluation of patient preferences for reduction mammaplasty scars.

BACKGROUND: In the United States, the inferior pedicle Wise pattern technique of reduction mammaplasty has been well established as a safe and reliable method of reducing breast size while maintaining nipple-areolar vascularity and sensation. Nonetheless, the typical inverted-T scar of the Wise pattern reduction is a consistent source of patient and surgeon dissatisfaction with the operation, which has led to the increased popularity of limited-incision techniques of breast reduction. OBJECTIVE: In this study, it was our goal to evaluate patient preferences for breast reduction scar location. METHODS: A retrospective chart review was undertaken that identified 121 patients who underwent bilateral Wise pattern reduction mammaplasty between July 1999 and June 2004. The patients were asked to rate their satisfaction with the surgery on a 1 to 10 scale and to rate the extent, if any, to which they were bothered by their scars. Those patients who were bothered by their scars were asked to delineate which part of the scar bothered them most--the horizontal component, the vertical component, or the areolar component. A statistical analysis of the results was performed with a standard two-tailed t test and a chi(2) analysis. RESULTS: Of the 121 surveys mailed out, 27 surveys were undeliverable. Fifty-seven of the remaining 94 surveys were returned, for a response rate of 61%. Although 49 of the respondents (86%) were highly satisfied with their surgery, 37 patients (65%) indicated dissatisfaction with their scars. Forty-one patients (72%) responded to the question asking which of the scars was most bothersome. Of these 41 respondents, 10 were bothered by all scars equally. Among the remaining 31 patients, 20 (65%) indicated that the horizontal component bothered them most--a statistically significant proportion (P < .001). Twenty-three of 46 patients (50%) who responded to the questions asking which scar they would erase if they were able to do so indicated that they would erase the vertical scar, which was also statistically significant (P < .001). CONCLUSIONS: Our survey confirms the widespread satisfaction reported by patients who have undergone Wise pattern breast reduction surgery. However, it also demonstrates that a statistically significant number of patients are bothered by their scars. These results underscore the importance of developing techniques that minimize breast reduction scars and suggest that short-scar options would be welcomed by women considering breast reduction surgery.

Radiation-induced angiosarcoma after mastectomy and TRAM flap breast reconstruction.

Radiation-induced angiosarcoma of the breast is being reported with increasing frequency as a result of the increased use of radiation therapy in conjunction with breast conservation surgery. However, this entity has not been well documented in patients undergoing mastectomy. The authors present a case of angiosarcoma occurring in a patient 6 years after undergoing mastectomy for invasive duct carcinoma with immediate transverse rectus abdominis musculocutaneous flap reconstruction followed by postoperative radiation therapy. The diagnosis of angiosarcoma was made by skin biopsy performed by the patient's reconstructive surgeon on routine follow-up examination. This is the first reported case of postradiation angiosarcoma occurring in a postmastectomy breast reconstructed with autogenous tissue and it is unusual in that the cancer invaded the musculocutaneous flap. Diagnosis and management recommendations for radiation-induced angiosarcoma are discussed.

A simple solution for management of the postpneumonectomy empyema cavity.

Postpneumonectomy bronchopleural fistula with empyema is a difficult problem. Once the fistula is healed, successful closure of the pleural space is associated with varying degrees of success, as well as the potential for major reconstructive surgery. My colleagues and I describe a simple approach for the definitive management of the open pleural space involving split-thickness skin grafts to marsupialize the pleural cavity.

Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction.

INTRODUCTION: Several studies have evaluated patient satisfaction following breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap and tissue expander/implant. However, the specific aesthetic determinants of patient satisfaction have not been determined. METHODS: Patients who had undergone tissue expander/implant or TRAM flap reconstruction were retrospectively polled on their age, type and timing of reconstruction, mastectomy type, laterality of reconstruction, adjuvant therapy, and symmetrizing and nipple-areolar procedures. Aesthetic satisfaction based on breast shape, symmetry of breast shape, breast size, symmetry of breast size, breast scarring, and breast sensation was assessed using a 5-point scale. RESULTS: Two hundred eleven patients with 105 TRAM flaps and 160 expander/implants responded. Unilateral TRAM recipients rated their breast shape, symmetry of breast shape, and symmetry of breast volume significantly higher than did implant patients. When bilateral reconstruction patients were evaluated, no significant differences were seen. The presence of nipple-areolar reconstruction positively influenced every parameter except breast sensation. Immediate reconstruction, skin-sparing mastectomy, and age >60 years at the time of reconstruction were also associated with higher scores, while postoperative radiation therapy resulted in lower satisfaction. Free flap reconstruction produced higher satisfaction in breast shape and breast scarring when compared with pedicle flap reconstruction. CONCLUSIONS: Aesthetic satisfaction after breast reconstruction is highly influenced by the presence of nipple-areolar reconstruction and less so by age, timing of reconstruction, adjuvant therapy, or free flap procedures. The type of reconstructive procedure is a significant variable only in unilateral reconstruction.

Recent advances in the reconstruction of complex Achilles tendon defects.

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.

Expression of cyclooxygenase-2 in the periprosthetic capsule surrounding a silicone shell implant in the rat.

Prosthetic breast implants are used frequently for both aesthetic and reconstructive purposes. Histologically, the normal tissue response to silicone implants typically involves an inflammatory infiltrate that consists initially of macrophages, and later consists of fibroblasts, myofibroblasts, and lymphocytes. To characterize further the nature of the inflammatory response to silicone breast implants, the authors evaluated the expression of the enzyme cyclooxygenase-2 (COX-2) by the tissues and cells of the breast capsule after silicone augmentation in an animal model. COX-2 is an inducible enzyme that is expressed primarily in response to inflammatory stimuli and mediates the production of prostaglandins that support the inflammatory process. Fifty-nine animals at five time points were evaluated. Specifically, on days 4, 7, 14, 28, and 80 the authors identified cytoplasmic COX-2 expression in each of the three cell types of interest, including endothelial cells, macrophages, and fibroblasts. Selective COX-2 inhibiting agents may be an appropriate pharmacological intervention for modulating the formation of periprosthetic capsules.