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Chronic wounds are debilitating complications of diabetes mellitus. The present study was conducted to investigate the effect of the hair follicle stem cells (HFSCs) by polycaprolactone scaffold on the healing of incisional cutaneous wounds on streptozotocin-induced diabetic male rats.The wound model was obtained by a biopsy punch of the skin of the animals' back. The animals were randomly divided into five groups as follows: (1) Sham (nondiabetic, not treated), (2) Control (diabetic, not treated), (3) Scaffold (diabetic, treated with polycaprolactone nanofiber scaffold), (4) HFSCs (diabetic, treated with HFSCs), and (5) Scaffold + HFSCs (diabetic, treated with combination of Scaffold and HFSCs). The wounds were photographed in the course of the treatment and their healing rate was assessed. The samples were collected from the wound sites 7, 14, and 28 d after their development. Angiogenesis was surveyed by examining messenger RNA expression and the protein synthesis levels of vascular endothelial growth factor receptor 2 (VEGFR2) and platelet/endothelial cell adhesion molecule-1/cluster of differentiation 31. The histological changes were investigated using hematoxylin and eosin and Masson's trichrome staining. Furthermore, the wound breaking strength was measured on the 28th day by tensiometry.The application of the VEGFR2 as a substrate promotes the expression of CD31 in HFSCs and Scaffold + HFSCs groups compared to controls (P 0.0001). HFSCs and scaffold also rescue the diabetes-induced dysfunction as assessed based on the parameters, such as viability, proliferation, colony formation, cellular adhesion, and chemotactic migration. HFSCs augment the levels of VEGFR2 and promote the restoration of the wound healing in diabetic groups. Furthermore, the maximum biomechanical stress significantly increased in the experimental diabetic groups (Scaffold: 1.38 ± 0.09, HFSCs: 2.13 ± 0.8, Scaffold + HFSCs: 2.38 ± 0.11) compared to the diabetes control group (1.16 ± 0.12). Using of HFSCs and scaffold on diabetic wounds leads to an accelerated wound closure, notably.Thus, the current data showed that HFSCs and scaffold form excellent biomaterial in the treatment of diabetic wounds.

To compare the clinical outcomes of Peyronie's disease (PD) patients who were treated by plaque incision and grafting either with tunica vaginalis (TV) or buccal mucosa (BM) grafts.PD patients in BM (n=20) and TV group (n = 20) were recruited between 2013 and 2020. Erectile dysfunction was assessed by short form of International Index of Erectile Function Questionnaire (IIEF-5). Technical success was defined as residual curvature ≤15°. Penile Doppler ultrasound was performed at baseline evaluation, 3-, and 24 months. Peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistance index were measured in erect penis. Erect penile length and curvature angle were measured at baseline and at 3, 12, and 24 months.Mean age of the groups was comparable (47.2 ± 10.8 years in TV vs 46.5 ± 9.9 years in BM groups). Baseline mean penile curvature was 48.0 ± 6.6° (TV) and 50.3±11.6° (BM) (P.001). Mean residual curvature at 24-month visits was 12.4 ± 4.9° (TV) and 7.9 ± 3.7° (BM), not significantly different. Technical success rate was 90% for both groups at 24 months. Surgery significantly increased erect penile length in both groups. Mean preoperative IIEF-5 scores were 18.4 ± 2.5 and 17.5 ± 2.2 in TV and BM groups, respectively. In both groups, IIEF-5 scores significantly improved after surgery with no intergroup IIEF-5 difference (20.6 ± 2.6 in TV and 21.3 ± 2.2 in BM). Mean postoperative PSV significantly increased, EDV significantly decreased in both groups, however, there was no significant intergroup difference.Both grafting materials provided similar beneficial effects regarding technical success, erectile dysfunction, and penile length.

The most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function.We prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic footankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis.The median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12-16 months), the median American orthopaedic footankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p0.05).The three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.

Surgical wound excision is a necessary procedure for burn patients that require the removal of eschar. The extent of excision is currently guided by clinical judgement, with excessinto healthy tissue potentially leading to excessive scar, or inadequate debridement increasing risk of infection. Thus, an objective real-time measure to facilitate accurate excision could support clinical judgement and improve this surgical procedure. This study was designed to investigate the potential use of Rapid evaporative ionisation mass spectrometry (REIMS) as a tool to support data-driven objective tissue excision.Data were acquired using a multi-platform approach that consisted of both Rapid Evaporative Ionisation Mass Spectrometry (REIMS) performed on intact skin, and comprehensive liquid chromatography-mass spectrometry (LC-MS/MS) lipidomics performed on homogenised skin tissue extracts. Data were analysed using principal components analysis (PCA) and multivariate orthogonal projections to latent squares discriminant analysis (OPLS-DA) and logistic regression to determine the predictability of the models.PCA and OPLS-DA models of the REIMS and LC-MS/MS lipidomics data reported separation of excised and healthy tissue. Molecular fingerprints generated from REIMS analysis of healthy skin tissue revealed a high degree of heterogeneity, however, intra-individual variance was smaller than inter-individual variance. Both platforms indicated high levels of skin classification accuracy. In addition, OPLS-DA of the LC-MS/MS lipidomic data revealed significant differences in specific lipid classes between healthy control and excised skin samples; including lower free fatty acids (FFA), monoacylglycerols (MAG), lysophosphatidylglycerol (LPG) and lysophosphatidylethanolamines (LPE) in excised tissue and higher lactosylceramides (LCER) and cholesterol esters (CE) compared to healthy control tissue.Having established the heterogeneity in the biochemical composition of healthy skin using REIMS and LC-MS/MS, our data show that REIMS has the potential to distinguish between excied and healthy skin tissue samples. This pilot study suggests that REIMS may be an effective tool to support accurate tissue excision during burn surgery.

The ideal timing of tranexamic acid administration in total knee arthroplasty with tourniquet remains unclear. Our primary objective was to prove if administering it before surgical incision, instead of before releasing the tourniquet, reduces postoperative bleeding. A second objective was to determine whether a second dose reduces post-operative bleeding.A prospective, double-blind clinical trial was performed on 212 patients scheduled for total knee arthroplasty. They were randomised into 4 groups. Tranexamic acid was administered before the surgical incision in "pre-induction groups" (1 and 2), and just before the tourniquet release in "pre-release groups" (3 and 4). Groups 2 and 4 received a second dose 3h post-surgery. Main outcome was postoperative bleeding (visible blood loss and calculated total bleeding). Secondary outcomes were haemoglobin variations, complications and transfusion rate.The mean calculated total bleeding was 1563ml (95%CI: 1445-1681) in preinduction groups versus 1576ml (95%CI: 1439-1713) in pre-release groups (P=0.9); 1579ml (95%CI: 1452-1706) in single-dose groups versus 1559ml (95%CI: 1431-1686) in double-dose groups (P=0.82). One patient was transfused. The mean haemoglobin at discharge was 10.4g/dl (95%CI: 10.2-10.7) in singledose groups versus 10.8 (95%CI: 10.6-11.1) in double-dose groups (P=0.06).There were no differences in bleeding or transfusion regarding the time of tranexamic acid administration. The second dose had not impact on outcomes.EudraCT 2016-000071-24.

Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse.We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed.Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient.Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi.

The traditional approach in combined liver-kidney transplantation involves 2 separate and sequential incisions. We describe a modification of the standard Mercedes incision that allows a single-incision operation while providing and maintaining adequate exposure to enable safe dual-allograft transplantation.Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4 fingerbreadths below the rib edge with a midline, cephalad incision and inferior ± medial ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis.Five consecutive patients (3 women/2 men; mean age, 49 years; median body mass index, 29.8 kg/mThe modified Mercedes single-incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation. Further studies are needed to prove the theoretical benefits of this technique.

Surgical delay is one of the risk factors for mortality and morbidity in patients with HF. One of the causes of delay is due to admission on Thursday-Friday, weekends, holidays or previous periods. The final objective of this study is to analyze administrative-organizational delay in complication and mortality rates.A total of 607 cases of surgically operated hip fractures were analyzed. Two groups were established, one of them operated on in48 h (ND group) and the other surgically delayed for administrative organizational reasons (AA group). Demographic variables related to treatment and fracture were analyzed in both groups, as well as the rates of surgical wound complications, general complications and mortality rate in the first 30 days, in the first year and more than one year after surgery.We observed a surgical wound seroma and staining rate of 15.7% in the AA group and 9.6% in the ND group; and a surgical wound surface infection rate of 1.9% in the AA group and 0.8% in the ND group (p = 0.275). General complications occurred in 34.4% (AA group) and 29% (ND group). The 30-day mortality rate was 4.8% in the AA group and 1.9% in the ND group (p = 0.081).We found no statistically significant differences in patients delayed for administrative reasons in terms of mortality and surgical wound and general complication rates. Although the proportion of surgical wound complications and 30-day mortality was higher in the AA group versus the ND group.

Continuous injection of local anesthetics by using surgical wound catheters for postoperative pain relief has gained acceptance in recent years. However, whether this method can be alternatively used instead of systemic opioids in different surgical procedures has not yet been elucidated.The aim was to investigate the effect of continuous injection of bupivacaine through a catheter inside the surgical wound on reducing the postoperative pain of lumbar spine fusion surgeries.In this clinical trial, 31 patients undergoing non-traumatic lumbar spine stabilization surgery were randomly assigned to receive (n = 15) or do not receive (n = 16) bupivacaine through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), dose of required morphine, and drug-related complications within 24 hours of intervention were assessed and compared by the Mann-Whitney and independent t-test.Mean pain intensity was significantly lower in the case group over the first postoperative hour in the recovery room (p0.001), which continued for the first 2 hours after entering the ward. The mean morphine intake was lower in the bupivacaine group during the first postoperative 24 hours (16 ± 0.88 vs. 7.33 ± 0.93 mg, p0.001). The two groups were not significantly different regarding drug-related complications.Continuous intra-incisional infusion of bupivacaine helped better pain reduction during the early postoperative hours while sparing morphine consumption in the first postoperative day.

Lateral dog ear after mastectomy in overweight or large breasted patients is a source for patient discomfort and is aesthetically unpleasing. Although many different techniques have been proposed, none of them have emerged as standard. In 2012, the authors published their mastectomy technique based on an inverted L-scar incision and closure with a lateral skin flap advanced supero-medially onto the chest wall. Authors sought to report their experience with this technique in patients with wide or large breasts operated with mastectomy without immediate breast reconstruction. As a refinement to their initial technique, they added lipoaspiration to the lateral chest wall.A retrospective study identified 43 patients operated on using the L incision and lipoaspiration from January 2015 to January 2021. Patient and tumor characteristics, operative details, post-operative results, and complications were recorded. Patients were followed-up and assessed for arm motion restriction, lymphedema, and recurrence.The mean age was 68 years; the mean BMI was 29 kg/m 2. The mean follow-up was 32 months. The mean weight of the mastectomy specimen was 1009 g and the mean aspirated volume in the lateral chest wall was 450 mL. One patient had a hematoma, four patients had seroma, and one patient developed a minor wound dehiscence. No skin necrosis or arm movement restriction was observed. Two patients developed mild lymphedema. Three patients underwent delayed breast reconstruction.The proposed technique is a safe and effective method to avoid lateral dog deformity after mastectomy, achieving both functional and cosmetic outcomes.

A very small aortic root and annulus (≤17 mm) needs extensive aortic annular enlargement in adult patients. This report describes a technique that enlarged the aortic annulus by 5 valve sizes from 16 to 17 mm to size 27 bovine pericardial valve, as well as a modification of the aortotomy with the roof technique to make the aortotomy closure easier and more hemostatic while enlarging the sinotubular junction and proximal ascending aorta effectively for future valve-in-valve transcatheter aortic valve replacement.

The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA.This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI)30 kg/mOne hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χAmong patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

We aim to present a perforator flap-based technique that is useful in the resection and reconstruction of the palmar fascia for the treatment of Dupuytren's contracture with primary closure. A curve incision through the palmar skin radial to the hypothenar area was made. The ulnar side of the palmar skin and the subcutaneous fat was raised to the ulnar side, exposing the palmar fascia. The ulnar palmar digital artery extending from the superficial palmar arch curves distally towards the little finger at a point perpendicular to the fourth interdigital space with parting branches into the subcutaneous fat radial of the flap was carefully identified and preserved, and the Dupuytren's cords were excised. Depending on contracture involvement, additional incision extending from the arc of the palmar incision to the proximal interphalangeal joint is made to raise the digital flap similar to that of the palmar incision. The perforator flap was raised along the hypothenar region in 53 hands of 48 patients, nine women and 39 men, and their age at the time of surgery averaged 56 years. Two patients complained of paresthesia in the ring and little fingers after surgery in 2015, and the symptom had disappeared without further intervention before the latest follow-up in 2017. There was no incidence of skin necrosis, delayed healing, and no recurrence within the follow-up period. This perforator flap-based technique is technically reliable and straightforward with better exposure and easier removal of all the diseased fascia, making it possible for primary healing without skin necrosis and acceptable for the treatment of patients at all stages of the disease.

This study was performed to compare the effects on facial nerve (FN) function of the deep supra-temporalis muscle subfascial approach (DSFA) and traditional fascial approach (TFA) for access to the temporomandibular joint (TMJ), via qualitative and quantitative evaluations. Thirty patients requiring open TMJ surgery were randomly allocated to one of two groups: group A patients underwent the DSFA approach, while group B patients underwent the TFA approach. The TMJ was accessed via modified endaural incision with temporal extension. Clinical examinations, FN conduction tests, and electromyography (EMG) of the frontalis and orbicularis oculi muscles were used to assess FN function. A FN function deficit was noted in 50% of the whole sample population immediately after surgery, with no statistically significant difference between the groups (P = 0.082). Overall, 37.5% of the total study population experienced temporary loss of frontalis muscle activity, while zygomatic nerve injury was seen only in 25% of group A. Within 2-6 months, normal function returned in both groups. Nerve conduction studies showed no statistically significant difference between the groups in terms of nerve amplitude or latency after surgery. However, EMG of orbicularis oculi activity showed a significant difference between the groups after 6 months (P = 0.010). The results suggest that the traditional dissection approach is more protective of the FN, especially the zygomatic branch, than the deeper dissection technique.

Introduction Scalds from hot tap water can have devastating consequences and lifelong impact on survivors. The aims of this study were to (i) describe the frequency, demographic profile, injury event characteristics, and in-hospital outcomes for people with tap water scalds admitted to Australian and New Zealand burn centres; and (ii) determine whether there was variation in the frequency and epidemiological characteristics of tap water scalds between jurisdictions. Methods Data were extracted from the Burns Registry of Australia and New Zealand for people with tap water scalds admitted to Australian or New Zealand burn centres between January 1, 2010 and December 31, 2018. Demographic, injury severity and event characteristics, surgical intervention, and in-hospital outcomes were investigated. Results There were 650 people with tap water scalds admitted to Australian and New Zealand burn centres during the study period. Australians with tap water scalds (median [IQR] 29 [1–69] years) were older than New Zealanders (2 [1–36] years). Most tap water scalds occurred in the home, and 92% of these occurred in the bathroom. More than 55% of injuries occurred due to the accidental alteration of water temperature at the tap fixture. Two thirds of patients underwent a surgical wound procedure. The overall mortality rate was 3.7%, and the median hospital length of stay was 8.8 days. Conclusion Tap water scalds remain a public health problem in Australia and New Zealand. Our research highlights where gaps in current heated water regulations in residential homes perpetuate risks of tap water scalds, particularly in high-risk groups at the extremes of age. Extending current heated water regulations to include all Australia and New Zealand homes is required urgently, in conjunction with design safety improvements, and ongoing education of key stakeholders.

This study aimed to provide preliminary evidence on feasibility of the inaugural use of teleconsultation between acute hospitals and primary care for acute wound management in Singapore. Post-surgical patients with carbuncle wounds, perianal abscess wounds or surgical abdominal dehiscence wounds were recruited from an acute hospital. Instead of receiving their follow up care at the acute care tertiary hospital, patients were given the option to receive their care at primary care facilities instead, supported by teleconsultation wound services provided by wound care nurses from the hospital. The following outcome measures were collected: number of care sessions required (until wound healed), readmissions or referrals back to hospital, cost (patient's and healthcare provider's perspective), patients' and nurses' satisfaction. In total, 18 patients were recruited and completed the study (teleconsult group = 5; tertiary care clinic group = 13). The mean age (SD) of patients were 63.2 (SD 11.5) years old in the teleconsult group and 47.9 years old (SD 11.5) in the tertiary care clinic group. There were 7 female (54%), and 6 male (46%) in the tertiary care clinic group whereas teleconsult group consisted of male only (n = 5). Most had carbuncle wounds (teleconsult group: n = 4; 80%); tertiary care clinic group: (n = 10; 77%). For patients with carbuncle wounds, the average number of care sessions required were 21 and 33 for the tertiary care clinic and teleconsult respectively. None of the patients in the teleconsult group were referred back to the tertiary care hospital. All 16 nurses (n = 6 from acute care hospital, n = 10 from polyclinics) who participated in the feedback survey cited convenience, ease of tracking wound sizes, and closer collaboration between the acute care and primary care nurses as advantages of the service. Wound teleconsultation is feasible and potentially cost savings for patients with acute complex wounds.

Background Little data supports the optimal distance of cuticular suture placement from the wound edge to achieve the most cosmetically appealing scar. Objective To compare POSAS scores for cutaneous sutures spaced 2 versus 5 mm from the wound edge in head and neck defects repaired via linear closure. Methods Fifty patients were enrolled in this randomized, evaluator blinded, split-scar study. Surgical wounds were repaired with cuticular sutures 2 mm from the wound edge on one side and 5 mm on the other side. POSAS scores and scar width was compared three-months post-operatively. Results This study in sum observer POSAS score, with a mean (SD) of 16.06 (6.49) on the 2-mm side and 15.82 (6.83) on the 5-mm side (p=0.807). Similarly, no difference was seen in scar width, with a mean (SD) of 0.100 (0.058) cm on the 2-mm side and 0.100 (0.076) cm on the 5-mm side (p=0.967). Limitations Linear repairs were studied on head and neck defects after extirpation of cutaneous malignancies, resulting in a homogeneous elderly white patient population. Conclusion Cuticular sutures placed 2 or 5 mm from the wound edge did not result in different cosmetic outcomes in linear closures on the head and neck.

Objectives Chronic limb-threatening ischemia (CLTI) is frequently due to multilevel, heavily calcified lesions, and it is often associated with desert foot. Effective revascularization currently presents an additional challenge due to the increasing age, comorbidities, and frailty related to these patients. Pure endovascular treatment often fails to achieve effective and durable revascularization and it is associated with still high amputation rates. We present a novel hybrid approach and discuss its usefulness for limb salvage in complex infrainguinal lesions. Methods Two no-option patients for both anatomical and medical-comorbidity reasons, were treated consecutively for CLTI. Both of them had prior failed percutaneous endovascular treatment, and bypass revascularization had been ruled out. We describe the technical details of an aggressive, but still less invasive hybrid approach, consisting of open distal popliteal artery (PA) and tibial trifurcation endarterectomy plus patch angioplasty, associated with proximal endovascular treatment with inter-woven nitinol stent from the superficial femoral artery (SFA) to the endarterectomized area. Results Technical success and salvage of the affected limb were achieved in both cases, presenting significant postoperative clinical and hemodynamic improvement and allowing early discharge hospital at home. There was no surgical wound infection or other complications. Conclusions This hybrid approach through a single incision is safe and effective in the short term and can be used with excellent results for CLTI in high-risk and /or no-option patients.

The purpose of this study was aimed to compare the efficiency and safety of retromandibular versus modified Risdon approach using periangular incision for open reduction and internal fixation of low subcondylar mandibular fracture. Open reduction and internal fixation with different plating systems were utilized via retromandibular approach (group I) and via modified Risdon approach with periangular incision (group II). Twenty four (n= 24) condylar fractures in 21 adult patients were divided randomly into two equal groups (12 each) according to the cutaneous incision (approach) utilized. The evaluation score for scarring in group I it was excellent in 9 patients, good in 2 patients and acceptable in only one patient (Mean 2.4 ± SD 3.38). While in group II was excellent in 10 patients and good in 2 patients (Mean 2.4 ± SD 3.87) and the p value was 0.591. Symptoms of transient facial nerve weakness were noted in only 3 patients in group I with slight to moderate dysfunction (Mean 2 ± SD 3.21), while only one patient had facial nerve weakness in group II with House - Brackman score of 2 immediate postoperatively and this got resolved in 6 weeks (Mean 2 ± SD 4.04) and the p value was 0.00022. Within the limitations of the study it seems that a modified Risdon approach using periangular incision for reduction and fixation of low subcondylar fracture should be preferred whenever possible because it yields better outcomes.

Incision and drainage (ID) of abscesses is one of the most painful procedures performed in emergency departments (EDs).We tested the following hypothesis: The addition of intranasal fentanyl to the standard practice of local infiltration with lidocaine would provide better pain control than lidocaine alone for adult ED patients undergoing ID.This was a randomized, double-blind study. Participants received 2 μg/kg of intranasal fentanyl or a comparable amount of intranasal water in addition to local lidocaine infiltration. The primary outcome, which we assessed immediately after the ID was completed, was a summary 0-10 pain score for which we asked study subjects to provide a number depicting their entire experience with the procedure.During a 19-month enrollment period, we screened 176 patients for eligibility and enrolled 49; 25 received placebo and 24 received fentanyl. Baseline characteristics were comparable. Mean (standard deviation) summary pain scores were as follows: fentanyl 6.2 (3.3) and placebo 7.0 (3.2). The 95% confidence interval for a rounded between-group difference of 0.9 was -1.1 to 2.6.In this small study, the addition of intranasal fentanyl did not substantially impact the pain scores of ED patients undergoing ID.

Summary Background The coronal incision represents the cornerstone for the treatment of upper-third maxillofacial pathologies. However, this approach leaves long scars that in numerous patients, it can cause extensive surrounding alopecia and sensory skin deficits. This clinical evidence prompted the authors to propose a full pretrichial incision, the crown incision, in order to overcome these drawbacks. Methods A retrospective study was performed to investigate and report the aesthetic and functional outcomes of 15 patients treated with this new approach. Results In the postoperative period, no major or minor complications were detected. The aesthetic evaluation of the scar by the operator and the patient showed overlapping results. The overall rating was 2.93 for the patient and 2.87 for the surgeon, on a scale from 0 (as normal skin) to 10 (very different from normal skin). The recovery of sensitivity in the innervation territories of the supratrochlear and supraorbital nerves was found to be complete in 14 patients. In one case, the sharp/blunt discriminative sensitivity was absent in all three points assessed. Conclusions This study showed the crown incision to be a safe approach with an optimal recovery of scalp sensitivity and excellent aesthetic results even in bald patients. Therefore, it can be considered a valid aesthetic and effective alternative to the classic coronal approach and should form part of the craniomaxillofacial surgical armamentarium.

Background Deep-space surgical site infections carry significant morbidity and mortality. The evidence for gentamicin-containing collagen implants at reducing surgical site infections in open infrainguinal arterial surgery is limited. This study examined whether gentamicin-containing collagen implants reduces 30-day surgical site infections and their severity following open infrainguinal arterial surgery. Methods A retrospective observational cohort study that included all patients undergoing infrainguinal arterial bypass or endarterectomy between November 2015 and March 2019 at a single tertiary vascular unit. Patients with contaminated/infected surgical fields, surgical wounds treated with negative pressure therapy, or the usage of antimicrobial implants and dressings other than Collatamp GⓇ (Aralez Pharmaceuticals, Canada) were excluded. Patients with gentamicin-containing collagen implants placed abutting vasculature were compared against patients without gentamicin-containing collagen implants. Outcomes included the rate of surgical site infections and their severity within 30 days after the operation. Results In 159 procedures (mean age 67.7 years, 74.8% male, 33.3% diabetic, 16.4% chronic renal failure, 25.2% anticoagulated postoperatively, 32.7% with prosthetic implants), 55 (34.6%) procedures received gentamicin-containing collagen implants. There were significantly more males (85.5% vs. 69.2%; P = 0.025), higher rates of obesity (41.8% vs. 26.0%; P = 0.041), and hyperlipidemia (65.5% vs. 49.0%; P = 0.048) in the gentamicin-containing collagen implant group. In total, 6 (3.8%) procedures developed deep-space surgical site infections (1 with gentamicin-containing collagen implant, 5 without) and 13 (8.2%) had severe surgical site infections that required re-intervention (1 with gentamicin-containing collagen implant, 12 without). On logistic regression analysis, the absence of gentamicin-containing collagen implants statistically significantly increased the odds of overall surgical site infections (OR = 2.50; 95% CI 1.01 – 6.19; P = 0.047). There was no statistically significant difference in the odds of deep-space surgical site infections or the severity and need for reintervention of surgical site infections. Conclusions This is the first study that examined the effect of gentamicin-containing collagen implants on the severity of surgical site infections in vascular surgery. Gentamicin-containing collagen implants may reduce the odds of overall surgical site infections. It did not reduce the odds of deep-space surgical site infections or the severity and reintervention rate of surgical site infections following infrainguinal arterial revascularization. Larger studies are required to achieve adequate power to assess for these outcomes.

Background Vascular surgery, especially lower limb revascularization surgery, has one of the highest rates of surgical complications, predominantly surgical site infections (SSI). Resulting in a significant burden of additional costs due to longer hospital stays, re-admissions and re-interventions, mainly attributable to deep incisional SSIs. Closed incisional negative pressure therapy (ciNPT) is a relatively new strategy in the postoperative management surgical wounds, aiming to reduce surgical wound complications. When discussing the clinical relevance of ciNPT, it is crucial to take into account the outcome of therapy as well as the additional costs related to ciNPT. Since, the additional costs must be justified by an associated decrease in the morbidity and costs associated with groin wound complications, which are particularly attributable to deep incisional SSIs. The current literature evaluating the beneficial effect of ciNPT in groin incisional vascular surgery, predominantly focusses on the decrease in superficial SSIs. Whereas this study aims to address and discuss the clinical relevance of ciNPT over conventional wound dressings, by separately evaluating and comparing the incidence of superficial and deep SSIs and their related re-admissions and re-interventions. Methods In this single center prospective cohort study performed in a non-academic hospital in The Netherlands, 59 consecutive patients (67 incisions) were included between January and October 2019. All underwent elective vascular surgery with groin (access) incisions for either lower limb revascularization surgery or abdominal aortic aneurysm surgery. The study group was treated with six days ciNPT (PREVENA Incision Management System; KCI/3M, San Antonio, TX, USA) and matched for equal comparison to a historical retrospectively analysed cohort of 54 consecutive patients (60 incisions), all of whom have undergone elective vascular surgery for equal indications with groin (access) incisions in our center between January and October 2018. The standard-care group was treated following standard surgical wound care protocol with conventional surgical self-adhesive plaster (10 × 15cm, Mepore, Molnlycke Health Care AB, Gothenburg, Sweden). Results Study groups were comparable at baseline, except for Body Mass Index (BMI), which was significantly higher in the ciNPT-group (P =.021). No significant differences for formation of seroma, hematoma, as well as wound dehiscence and SSIs were found between both groups. Groin SSIs were seen in 12.1% of the patients in the ciNPT-group and in 13.0% in the Standard-care group (OR 0.80, CI ((0.26, 2.48)), deep SSI contributed for 4 out of 7 patients of total SSIs in the ciNPT-group and for 2 out of 7 patients in the standard of care group (P-value >0.05). Analysis for incidence of hospital re-admission and re-intervention in both study groups showed no significant difference. Subset analysis in both study groups for SSIs differentiated in superficial and deep SSIs showed that only deep SSIs resulted in re-interventions. Conclusions Based on the findings in the population of our single center study, we conclude that routine use of ciNPT was not effective in reducing groin wound complications, and therefore could not replicate the promising findings from some previous studies. Furthermore, we did not find a reduction in the incidence of deep SSIs, which comprise the highest morbidity and costs. Considering our findings as well as the associated additional expenses related to ciNPT, it might be superfluous at this stage to use ciNPT as the new standard of post-operative groin incision care for all lower limb revascularization and abdominal aortic aneurysm surgeries. In our opinion further research is warranted for establishing a risk-factor based model for determination of the indication of ciNPT. To be able to achieve a more substantiated decision for utilizing ciNPT compared to standard surgical wound care in groin incisional vascular surgical interventions.

BACKGROUND Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. METHODS A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. RESULTS A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups. CONCLUSIONS In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Objectives There is increasing interest regarding the risks and benefits of intrawound antibiotics applied directly to surgical wounds for the prevention of infection following orthopaedic trauma surgery. The purpose of this study was to investigate the economic justifiability of vancomycin and tobramycin powders for infection prophylaxis in orthopaedic trauma surgery. Methods The cost of vancomycin and tobramycin powders, infection rates and costs of treating surgical site infections were obtained from our institution's records and existing literature. A break-even analysis was then performed using vancomycin powder only, tobramycin powder only and combined vancomycin and tobramycin powders to determine the respective absolute risk reduction (ARR) in infection rate needed to make the prophylactic application of each therapy type break-even. Results At our institutional pricing of $20.64 and $75.80 for 1g vancomycin and 1.2g tobramycin, respectively, use of each individually would be economically justified if it reduced an average infection rate of 4.3% by an ARR of 0.02% and 0.07%, respectively. Used in combination for $90.66, the ARR was 0.09%. Varying cost of treating infection from $5,000-$200,000 while maintaining cost of antibiotic powder at $90.66 demonstrated a range in ARR from 1.93% to 0.05%, respectively. At the same cost of $90.66 but varying infection rate from 1% to 25% did not affect ARR, which was constant at 0.09%. Conclusions Considering the cost of vancomycin and tobramycin powder at our institution, the application of these powders, whether independently or in combination, appear to be economically justifiable for infection prevention in orthopaedic trauma surgery.

Objective Wound drain used to be a routine procedure after craniotomy for aneurysm clipping, although this was not based on clinical evidence. The purpose of our study was to determine the necessity of wound drain placement after anterior circulation aneurysm surgery. Methods Retrospective analysis of patients with anterior circulation aneurysms treated by clipping in the Department of Neurosurgery, Wuhan University Zhongnan hospital from January 2019 to December 2019 was carried out. Demographic and clinical data, including age, sex, body mass index, disease history, results of the laboratory and imaging examinations, and surgical logs, were reviewed. Results A total of 236 patients (90 male and 146 female) were included in the analysis and were divided into a Drain group and a No Drain group according to whether postoperative wound drainage was applied. There was no statistical difference in the incidence of a postoperative extradural hematoma between patients in the 2 groups. However, the incidence of postoperative meningitis was higher in the Drain group than in the No Drain group (9.09% vs. 1.59%, P = 0.009), and the total length of stay and postoperative length of stay in the Drain group were also more extended than in the No Drain group (17.32 ± 6.45 vs. 14.43 ± 5.75, P = 0.005; 12.83 ± 5.07 vs. 9.82 ± 4.50, P = 0.007, respectively). Conclusions Postoperative wound drain did not significantly reduce the incidence of an extradural hematoma after anterior circulation aneurysm surgery. On the contrary, it may be associated with an increased incidence of postoperative meningitis and length of stay. Given these findings, the postoperative drain should be maintained cautiously and meet more rigorous application criteria.

Objective Uterine fibroids are one of the most common gynaecological tumours in premenopausal women. The conventional surgical treatments are myomectomy and hysterectomy, but high-intensity focused ultrasound (HIFU) is a new noninvasive treatment creating no surgical wound. The aim of this study was to evaluate the effectiveness and safety of HIFU treatment compared with conventional surgery for patients with uterine fibroids. Data sources PubMed, Embase, and the Cochrane Library were searched for studies published before January 2021. Methods of study selection Studies comparing the outcome of HIFU and conventional surgery-myomectomy and hysterectomy-for patients with uterine fibroids were included. We conducted meta-analyses by using a random effects model. Uterine fibroid symptom score and the quality of life score were analysed using the weighted mean difference (MD). The recovery time and frequency of major adverse events were also evaluated. Tabulation, integration, and results Ten studies were included. HIFU relieved uterine fibroid symptom significantly when compared to conventional surgery at 6 (MD: -1.61, 95% confidence interval [CI]: -2.88 to -0.33) and 12 (MD: -2.44, 95% CI: -3.68 to -1.20) months after treatment. Similarly, HIFU group improve the quality of life score significantly at 6 (MD: 2.14, 95% CI: 0.86 to 3.42) and 12 (MD: 2.34, 95% CI: 0.82 to 3.86) months after treatment when compared with surgery group. Conclusion HIFU could be an effective and safe treatment option for patients with uterine fibroids. However, one of its side effects, skin burns, requires further research and discussion. Additional studies involving more randomized controlled trials are warranted.

Objective Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood. Design An observational cohort study. Setting A tertiary care hospital. Participants Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair. Interventions A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated. Measurements and Main Results The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001). Conclusions The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy.

Background Liver resection involves surgical removal of a portion of the liver. It is used to treat liver tumors and liver injuries. The complexity and high-risk nature of this surgery prevents novice doctors from practicing it on real patients. Virtual surgery simulation was developed to simulate surgical procedures to enable medical professionals to be trained without requiring a patient, a cadaver, or an animal. Therefore, there is a strong need for the development of a liver resection surgery simulation system. We propose a real-time simulation system that provides realistic visual and tactile feedback for hepatic parenchymal transection. Methods The tetrahedron structure and cluster-based shape matching are used for physical model construction, topology update of a three-dimensional liver model soft deformation simulation, and haptic rendering acceleration. During the liver parenchyma separation simulation, a tetrahedral mesh is used for surface triangle subdivision and surface generation of the surgical wound. The shape-matching cluster is separated via component detection on an undirected graph constructed using the tetrahedral mesh. Results In our system, cluster-based shape matching is implemented on a GPU, whereas haptic rendering and topology updates are implemented on a CPU. Experimental results show that haptic rendering can be performed at a high frequency (> 900 Hz), whereas mesh skinning and graphics rendering can be performed at 45 fps. The topology update can be executed at an interactive rate (> 10 Hz) on a single CPU thread. Conclusion We propose an interactive hepatic parenchymal transection simulation method based on a tetrahedral structure. The tetrahedral mesh simultaneously supports physical model construction, topology update, and haptic rendering acceleration.

Preoperative skin antiseptic preparation is the gold standard for prevention of surgical infection. However, improper use of antiseptics may lead to severe ocular damage. Currently, the most common surgical antiseptics can be divided into aqueous-based and alcohol-based disinfectants, with chlorhexidine and iodine/iodophors being the two major components. Chlorhexidine has a persistent antimicrobial effect and is resistant to neutralization by blood or organic products in surgical wounds. Nevertheless, due to its toxicity to the ears, meninges, and eyes, application of chlorhexidine should be prohibited in these surgical fields. Iodine/iodophor is better tolerated by the ocular surface and is the recommended antiseptic for ophthalmic or head and neck surgeries close to the periocular area. Alcohol is less pricey and has a rapid antiseptic effect, though its desiccating effect and flammability restrict the use in mucosal or laser surgeries. The single or combined use of these antiseptics may inadvertently induce severe ocular damage, especially during time-consuming head and neck surgeries with prone, hyperextension, or lateral tilt positions, or surgeries under general anesthesia. Apart from the choice of antiseptics, appropriate selection and attachment of bio-occlusive dressings are key to avoiding antiseptic-related ocular injuries. In this review, we provided a comprehensive summary of the characteristics of antiseptics used in surgical settings and the possible mechanisms and outcomes of antiseptic-related ocular injuries. The prevention, diagnosis, and acute management of these complications were also discussed.

Background Total Elbow Arthroplasty is becoming an increasingly popular and challenging reconstructive procedure due to improvements in surgical technique, implant design and good to excellent clinical outcomes reported. To our best knowledge, complication such as a brachial artery pseudoaneurysm after primary or revision surgery of total elbow arthroplasty hasn´t been described in the literature so far. Case presentation We present a case of an 81-year-old female patient who underwent elbow hemiarthroplasty in 2014 at our institution after suffering a comminuted intra-articular distal humerus fracture. In 2019 she presented at our emergency department after a fall from standing height. On the X-ray a periprosthetic fracture of the humerus was observed. The patient underwent a total elbow revision arthroplasty with bone stock augmentation. After 24 hour of an uncomplicated evolution she complained of a significant pain and progressive swelling on her right upper limb with persisting bleeding from the surgical wound. Ultrasound and Computed Tomography angiography confirmed the presence of a 7 × 8 mm brachial artery pseudoaneurysm. After considered different treatment options an emergent endovascular procedure was elected. Throughout femoral artery catheterization the brachial artery was explored and a large intimal flap and thrombus were retrieved with a catheter after which an immediate and excellent inflow was noted. Postoperatively, the patient reported significant improvement and complete resolution of upper limb symptoms. An arterial duplex and CT angiography demonstrated normal patterns of blood flow. Follow-up at 1 year showed normal elbow range of motion and no related pain. Conclusions This case highlights that a formation of brachial pseudoaneurysm is a potential life and limb-threatening complication, not previously described, after primary or revision total elbow arthroplasty and of which orthopedic surgeons should be aware. Level of evidence Level IV; Case report

Objective Nocardia can be introduced accidentally causing non-healing surgical wounds. Method From February 2017 to January 2021 samples from wounds were collected. Nocardia identification and susceptibility testing were carried out by standard procedure. Results Seventeen (35.4 %) Nocardia spp. and 20 other pathogens (41.7%) were recovered by culture. Drug susceptibility among Nocardia was >70% to amikacin, amoxicillin-clavulanic acid, levofloxacin, linezolid, and imipenem, 47% to cephalosporins and 41% to trimethoprim/sulfamethoxazole. Conclusions Infections with Nocardia spp. should be considered in non-healing surgical wounds.

Background Following a decompressive craniectomy (DC), the harvested bone flap is stored for future cranioplasty. There are two different methods proposed for bone banking, namely subcutaneous pocketing (SP) in the abdominal wall and cryopreservation (CP) in a refrigerator. This study was designed to evaluate the risk of developing infection in each study group. Methods In this randomized clinical trial design, a total of 143 patients underwent a primary decompressive craniectomy. Thereafter, they were randomly allocated into two groups, as SP and CP, and they were then scheduled for a future cranioplasty. Next, 108 patients underwent cranioplasty using an autologous bone flap and then followed-up for 18 months. Some variables, including demographic data, indications for primary DC, rate of post-operative clinical infection, bacterial culture results, the interval between craniectomy and cranioplasty, post-operative hospitalization duration, new morbidities, mortality rate, bone flap resorption rate, and several possible associated risk factors, were also recorded. The obtained data were analyzed by an expert bio-statistician using proper bio-statistical methods. A P value Results Four patients in the cryopreservation group (n = 50) indicated post-operative bone flap infection (8%), which was statistically significant (P = 0.041). Accordingly, all of them were resulted as positive for Methicillin-Resistant-Staphylococcus aureus (MRSA). Using the subcutaneous pocket method, no post-operative infection was observed after cranioplasty. The overall postoperative infection rate was estimated as 4%. The mean of age in the post-operative infection group’s participants was 50.25 years old, and in the non-infected, it was 34.93 years old, which was also significant (P = 0.048). Bone flap resorption (BFR) rate was found to be higher by the use of CP method in comparison to SP technique (p = 0.0001). Of note, no other risk factor was found attributable to a higher BFR rate (p-values > 0.05). Conclusions Older age and cryopreservation method at higher storage temperature (-18C˚) may be associated with infection’s development after performing cranioplasty. BFR is more prevalent in the use of CP method rather than SP preservation technique.

Objective To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties. Method A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. Results The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs. Conclusion Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

Objectives To examine how postoperative pain control after robotic thoracoscopic surgery varies with liposomal bupivacaine (LipoB) versus 0.5% bupivacaine/1:200,000 epinephrine (Bupi/Epi) intercostal nerve blocks within the context of an enhanced recovery after thoracic surgery (ERATS) protocol. Design A retrospective analysis of a prospectively maintained database of patients undergoing robotic thoracoscopic procedures between September 1, 2018 and October 31, 2019 was conducted. Setting University of Miami, single-institutional. Participants Patients. Interventions Two hundred fifty-two patients had either LipoB intercostal nerve blocks (n = 129) or Bupi/Epi intercostal nerve blocks (n = 123) when undergoing robotic thoracic surgery. Measurements and Main Results Comparative analysis of patient-reported pain levels, in-hospital and post-discharge opioid requirements, 90-day operative complications, length of hospital stay, and hospital costs was performed. Data were stratified to either anatomic lung resection or pulmonary wedge resection/mediastinal-pleural procedures. Bupi/Epi patients reported significantly more acute postoperative pain than LipoB patients, which correlated with higher in-hospital and post-discharge opioid requirements. There were no differences in postoperative complications, length of hospital stay, or hospital costs between the two groups. Conclusions As part of an ERATS protocol, infiltration of intercostal spaces and surgical wounds with LipoB for robotic thoracoscopic procedures afforded better postoperative subjective pain control and decreased opioid requirements without an increase in hospital costs as compared with use of Bupi/Epi.

Introduction : The incidence of hip periprosthetic fractures (PPF) has been increasing in recent years. In Vancouver type B1 there are several osteosynthesis options. The aim of this paper is to assess both the treatment and results of Vancouver type B1 PPF in patients operated at our centre. Material and Method : An observational retrospective study of patients operated at Hospital Universitario Miguel Servet for type B1 PPF via osteosynthesis with plate between January 2014 and March 2017. Such details were documented and analysed as type of implant used for fixation, patient demographics, complications, time to union and function score using the Harris Hip Score. The minimum follow up was 2 years. Results : Overall, 37 patients (21 women) were available for review with a mean age of 80.7 years (range 54–99). 8 of these patients died, with an average age of 85.6 (83–95). Out of these 8 dead patients, 4 died in the first year, with an average age of 87 (83–95). 19 fractures had cemented stems whereas 18 were uncemented. According to prosthesis type, 8 had a cemented partial arthroplasty, 11 a cemented total hip arthroplasty (THA), 18 a non-cemented THA; with an average period until PPF of 2.5 years (0.2–5.6), 7 years (0.09–18.1) and 8.1 years (2.6–12.7) respectively. Devises used for stabilisation of the fracture included 27 Cable-Ready® plates (Zimmer–Biomet), 5 Dall-Miles® plates (Stryker) and 5 femur NCB® plates (Zimmer-Biomet). Complications included 5 acute superficial infections of surgical wound, 1 chronic infection, 5 pressure ulcers (4 sacral, 1 heel), 7 patients required intra-operational blood transfusion. The mean time to union was 10.35 weeks (range 6–13). The mean Harris Hip Score postoperatively was 65 (44–95). Discussion : Treatment via open reduction and internal fixation with locked lateral plate covering most of the femur in elderly patients or those with poor bone quality, or a plate with proximal cerclages and distal screws in patients with better bone quality are appropriate treatment methods. To achieve good results using these techniques, we consider minimisation of soft tissue dissection highly important likewise using a meticulous osteosynthesis technique with special attention to biology and biomechanics.

BACKGROUND CONTEXT Infection around intervertebral fusion cages can be intractable because of the avascular nature of the intervertebral disc space. Intervertebral cages with antibacterial effects may be a method by which this complication can be prevented. PURPOSE To investigate the bacterial load on the antibacterial coating cages for spinal interbody fusion STUDY DESIGN An experimental in vitro and in vivo study. METHODS Based on the micro-computed tomography (CT) data of rat caudal discs, mesh-like titanium (Ti) cages that anatomically fit into the discs were fabricated by three-dimensional (3D) printing. Additionally, an antibacterial coating was applied with quaternized chitosan (hydroxypropyltrimethyl ammonium chloride chitosan, HACC). In vitro release kinetics of the HACC was performed, and the antibacterial performance of the HACC-coated (Ti-HACC) cages (via inhibition zone assay, bacterial adhesion assay, and biofilm formation assay) was evaluated. Then, Ti-HACC- or noncoated (Ti) cages were implanted in the caudal discs of rats with bioluminescent Staphylococcus aureus. Bacterial survival was investigated using an in vivo imaging system (IVIS) on postoperative days 1, 3, and 5. On day 5, the infection-related changes (bone destruction and migration of cages) were assessed using micro-CT, and the healing status of the surgical wounds was also assessed. After the removal of the cages, the quantification of bacteria attached to the cages was obtained by IVIS. Histological evaluation was performed by hematoxylin and eosin staining and TRAP (tartrate-resistant acid phosphatase) staining. RESULTS Release kinetic analysis showed the sustained release of HACC over 3 days from Ti-HACC cages. Antibacterial effects of Ti-HACC cages were demonstrated in all in vitro assays. IVIS evaluation indicated that the in vivo implantation of Ti-HACC cages with S. aureus exhibited better wound healing, less infection-related changes on micro-CT, and reduced bacterial quantity in the extracted cages compared to Ti cages. Histological evaluation demonstrated an increased number of TRAP-positive osteoclasts and severe bone destruction in the rats treated with Ti cages. CONCLUSIONS We developed a novel antibacterial HACC-coated intervertebral cage that exhibited prominent antibacterial efficacy and prevented the structural damage caused by the infection in rat caudal discs. Clinical Significance HACC-coated titanium intervertebral cages may be a promising option for preventing intractable postoperative infection in spinal interbody fusion surgery.

Persistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.SSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P.0001), especially causing wound blistering (RR 12.66, P.0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).ciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.

Background Although postoperative pancreatic fistula (POPF) is a common and critical complication of pancreatoduodenectomy (PD), effective strategies to prevent POPF have not yet been completely developed. Because appropriate management of POPF is important to reduce the mortality rate after PD, in this study we aimed to evaluate our approach for the management of POPF after PD, including the postoperative course. Methods This retrospective study included 605 consecutive patients who underwent PD at our hospital between 2010 and 2020. All patients who developed POPF were first managed conservatively, with drainage tubes placed during surgery retained to manage POPF. In cases wherein conservative treatment was unsuccessful, open drainage, followed by continuous negative pressure and continuous irrigation, was used. For open drainage, the surgical wound was opened bluntly (approximate length, 5 cm) under local anesthesia, and the fluid was directly and completely drained. Results The prevalence of POPF of grades B and C was 15.4% (n = 93) and 0.33% (n = 2), respectively. Of these patients, 1 required reoperation, 43 recovered with conservative management only, 47 required open drainage, and 4 required image-guided percutaneous drainage. Postoperative hemorrhage with a pseudoaneurysm was identified in 3 (0.66%) patients. The postoperative in-hospital mortality rate was low (n = 1, 0.16%). The rate of successful POPF management was 98.9%. Conclusion Based on our high success rate in POPF management, we consider open drainage to be a safe primary management method for POPF.

Summary Background Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients. It is unclear whether incisional negative pressure wound therapy (NPWT) can reduce the risk of SSIs in patients after open abdominal surgery. Methods A prospective, non-blinded multi-centre randomized controlled trial (RCT) was performed to evaluate the incidence of SSI post-laparotomy using incisional NPWT compared with a standard dressing. The primary outcome was the rate of superficial SSI. Results A total of 124 patients (61 patients in the NPWT arm and 63 patients in the control arm) were included. One hundred and nine (87.9%) patients underwent colorectal surgery; 61 patients (49.2%) had emergency surgery. There were more superficial SSIs in the control group than in the NPWT group, although not statistically significant (20.6% vs 9.8%, P=0.1). Upon multiple logistic regression analysis, control dressings were associated with increased risk of superficial SSI although again, not statistically significant (odds ratio (OR) 2.41, 95% confidence interval (CI) 0.81–7.17, P=0.11). There was no superficial non-SSI related wound dehiscence in the NPWT group compared with 9.5% in the control group (P=0.03). There was no difference in postoperative complications (P=0.15), nor in other wound complications (P=0.79). Conclusion NPWT was not associated with decreased superficial SSI in this RCT. However, there was a statistically significant reduction in superficial wound dehiscence with NWPT dressings. The results of this study should be included in meta-analyses for better evaluation of NPWT on closed abdominal incisions.

One of the most important complications associated with thyroid and parathyroid surgery is vocal cord paralysis due to a recurrent laryngeal nerve injury. Recurrent laryngeal nerve injury paralysis induced by local anesthetics is a rare complication with very few published cases. Various techniques are available for diagnosing vocal cord paralysis, including, flexible fiberoptic laryngoscopy, videostrobolaryngoscopy and indirect laryngoscopy. However, these techniques are expensive and are often associated with pain and discomfort among patients. Considering these disadvantages, transcutaneous laryngeal ultrasound is an alternative imaging tool for vocal cord examination in patients undergoing thyroid and parathyroid surgery. We describe a case which was sonographically diagnosed a transient bilateral vocal cord paralysis after the local infiltration of 10 mL of 2% mepivacaine administered for the revision of the surgical wound due to a subcutaneous hematoma that occurred after a subtotal parathyroidectomy.

Electrospun nanofibers have been considered as relatively ideal material system for the design and construction of surgical wound dressings in the past few decades. Although there are lots of other biopolymers employed for electrospinning, chitosan is one of the most important biopolymers for the fabrication of electrospun nanofibers, due to its nontoxic, antibacterial, biocompatible as well as biodegradable properties. Electrospun chitosan nanofibers with random or aligned fiber structure can further be cross-linked by physical, chemical and ionic crosslinking methods. The as-crosslinked electrospun chitosan nanofibrous membranes possess enhanced wet stability, improved mechanical property and good biocompatibility, which are necessary for wound healing application. The present work reviews the recent studies on the design and development of electrospun chitosan nanofibers and their applications for wound healing, such as antibacterial materials, hemostatic dressings, angiogenesis and immune regulation.

Introduction The correct closure of the surgical wound is an important step in the procedure of a total hip prosthesis implantation, which aims to a correct healing of the wound and minimize the risk of complications. The objective of our study is to determine if the use of a bidirectional barbed suture decreases the closing time after PTC, in the fascial and subcutaneous plane, when compared to the conventional suture polyglactin 910. The hypothesis is that there is no difference in closing time when comparing both sutures. Material and method Prospective single blind randomized study comparing 2 groups: study group with the use of bidirectional continuous barbed suture (Quill®) (Gr.Q) and a control group (Gr.V) using discontinuous polyglactin 91 suture (Vicryl®). Closure was performed in 2 planes (fascia and subcutaneous) simultaneously by 2 surgeons. The exclusion criteria were: previous surgeries on the same hip, revision surgeries, major deformities and allergies to suture components. The variables under study were: 1) fascia closure time, subcutaneous and global, 2) surgical wound infection, and 3) dehiscence. Results 82 patients (39 GrQ, 43 GrV) were included. The global closing time was shorter in Gr.Q (5 min 59 s) compared to Gr.V (7.01 min); (p Superficial infection was observed in 1 GrQ patient and 1 in GrV; 1 case of deep infection in Gr.Q (p = 0.29). One patient presented dehiscence of the wound in Gr.Q (p = 0.3). However, these differences did not show statistical significance. Conclusions The use of a barbed suture allows a shorter closing time compared to the conventional one. However, despite this decrease in time, no differences were found in terms of the appearance of infection or wound dehiscence.

Summary Introduction Reconstruction of the crus of the antihelix after tumor resection is a significant surgical challenge and to date no ideal method has been described. The authors present a novel approach using a pedicled flap from preauricular excess skin, which is tunneled through the helix to the anterior auricular surface. Material and Methods The presented technique was successfully applied in a series of three patients requiring reconstruction of the superior and inferior crus of the antihelix after resection of skin malignancies. Technique and outcomes are described in detail. Results Postoperative course was uneventful in all patients and all flaps healed with excellent esthetic results. Initial flap edema was observed in two cases that resolved spontaneously. Conclusion The preauricular pull-through flap is a versatile, straightforward, and reliable method for reconstruction of auricular defects located at the superior and inferior crus of the antihelix, including the triangular fossa, using the natural preauricular skin excess.

Background Surgical site infection (SSI) and wound breakdown after emergency laparotomy are common. They incur significant patient morbidity and health care costs. Negative-pressure dressings (NPDs) applied over closed incisions may minimize wound complications. However, its utility in the emergency setting is unknown. Here, we examined whether prophylactic NPD reduces wound complications after emergency laparotomies. Methods This is a retrospective review of consecutive emergency laparotomies undertaken at a university hospital from January 2018 to October 2019. Outcomes included the rate of SSI, wound breakdown, hospital-outreach service utilization, wound-related readmissions, and length of stay. Propensity score matched analysis was used to assess bias. Results A total of 227 emergency laparotomies were reviewed, 70 received NPD and 157 had conventional dressings (controls). SSI was identified in 33 (21.0%) patients from the control group and six (8.6%) from the NPD group (odds ratio 0.35, 95% confidence interval: 0.15-0.85, P = 0.022). Wound breakdown was observed in 21 (13.4%) patients from the control group and three (4.3%) from the NPD group (odds ratio 0.29, 95% confidence interval: 0.09-0.91, P = 0.040). The prophylactic benefit of NPD was most evident in clean-contaminated, contaminated, and dirty wounds. The NPD group had comparatively shorter postoperative stay, less outreach service utilization, and lower rates of wound-related readmissions. Multivariate analysis demonstrated that increasing age, body weight >75 kg, and wound contamination are independent predictors of wound complications, whereas NPD prevented SSI and wound breakdown. Conclusions Prophylactic NPD significantly reduced wound complications after emergency laparotomy. This was associated with a substantial health resource saving. This study provides a strong rationale for randomized trials in this area.

Background Primary closure of the surgical wound during neurosurgical procedures is sometimes difficult because of limited ability to expand the scalp, or because the skin defect is large. Hence, our institution recently adopted the technique of intraoperative tissue expansion using a Foley catheter for these cases. We describe this easily accomplished, readily available, effective, economical technique and describe our experience performing the technique. Methods With this procedure, the subcutaneous tissue (usually the subperiosteal layer) surrounding the skin defect is dissected to make a subcutaneous pocket in which to place a 20-French Foley catheter. The standard expander is a 30-mL balloon. The catheter is inserted into the subcutaneous pocket, and the balloon is inflated with 10–30 mL of saline for 5 minutes, after which the balloon is deflated for 3 minutes in a cyclic loading manner. After sufficient expansion, the primary closure of the surgical wound is achieved with minimal tension on the surrounding skin. Results Between November 2018 and February 2020, we performed this technique in 5 patients, each with a large surgical defect in the scalp. Primary closure was achieved, and postoperative wound healing was excellent in all 5 patients. Conclusions Intraoperative skin expansion using a Foley catheter—which is easily performed, readily available, and economical—can be used to achieve surgical wound closure during various neurosurgical procedures.

Background Research nurse involvement in trials is crucial to successful conduct, however their feedback on trial design and conduct is not necessarily always collected and shared. This study was designed to explore research nurse feedback in relation to study and protocol design and implementation in the National Institute for Health Research Programme Grants for Applied Research funded Surgical Wounds Healing by Secondary Intention pilot and feasibility trial (SWHSI). The primary aim of this study was to inform the design and conduct of a proposed future, larger study in this area. Given the evidence gap, it was deemed prudent to share these findings for the benefit of others. Methods A sequential, dependent mixed methods study, comprising a Likert scale questionnaire and semi-structured interviews, explored the experiences, in relation to study design and conduct, of research nurses involved in the trial. Of the 10 research nurses involved in the trial, eight nurses completed a questionnaire and were interviewed. Questionnaire data was analysed using descriptive statistics and interview data using thematic analysis. Results A range of questionnaire responses were provided, however at least 50% (n = 4) of respondents indicated that they were happy with both the study design and conduct. Interview data identified key themes to consider when involving research nurses in the design, delivery and conduct of RCTs; removing barriers to recruitment, time management, engagement strategies and resource provision. Conclusion Engagement of research nurses is important to enable effective trial conduct. Research teams should therefore consider how best to obtain and include input from all members of the research team from the outset. Furthermore, the sharing of feedback on research design and conduct, from the perspective of research nurses delivering trial recruitment and retention, remains crucial to effective and efficient trial conduct. Trial registration Clinical Trial Registry: ISRCTN12761776. Date of registration: 10th December 2015.