Early Coagulopathy is Associated With Increased Incidence of Ventilator-Associated Events Among Burn Patients.

OBJECTIVE: Coagulopathy is known to be associated with burn injury. Our group has shown that, in spinal cord injury patients, coagulopathy is associated with an increase in ventilator-associated pneumonia (VAP). We hypothesized that the same association exists between coagulopathic burn patients and ventilator-associated events. METHODS: Patients admitted for burn care between January 1, 2011 and December 31, 2015 who required mechanical ventilation were included in the study. Ventilator-associated events (VAEs) as defined by the Center for Disease Control were categorized as no event, ventilator-associated condition, infection-related ventilator-associated complication, and possible VAP. Demographic, injury characteristics were compared among four international normalized ratio (INR) categories using analysis of variance and chi-square tests. RESULTS: Four hundred four patients were admitted for burn care, of whom 263 met the inclusion criteria. One hundred eleven had normal INR, 59 had a slightly elevated INR (1.2-1.4), 33 had a moderately elevated INR (1.4-1.6), and 60 had a severely elevated INR (>1.6). Those with moderately and severely elevated INR were ventilated for a longer period (P = 0.0034), had more days in the ICU (P = 0.0010), and had longer hospital stay (P = 0.0016). After adjusting for inhalation injury and total body surface area, patients with severely elevated INR were over four times as likely to have any VAE (OR: 4.16, 95% CI: 1.33-13.05) and 4.5 times as likely to develop infection-related ventilator-associated complication or possible ventilator-associated pneumonia combined (OR: 4.59, 1.35-15.67). CONCLUSIONS: Early coagulopathy is associated with a significantly increased incidence of VAEs in burn patients. While additional studies need to be conducted to verify these findings, early recognition and treatment could decrease VAEs.

Preserving the posttrapeziectomy space with a human acellular dermal matrix spacer: a pilot case series of patients with thumb carpometacarpal joint arthritis.

BACKGROUND: Advanced thumb carpometacarpal arthritis is widely treated with trapeziectomy and tendon interposition despite donor-site morbidities. Trapeziectomy alone leaves a postresection space, leading to proximal metacarpal migration and scaphoid/trapezoid impingement. Prosthetic implants have been unsuccessful due to particulate debris, silicone synovitis, osteolysis, and migration. Recent studies have shown successful use of allograft for interposition material in the posttrapeziectomy space both in animal and human models. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using a spacer constructed from human acellular dermal matrix (HADM). METHODS: Sixteen patients with Eaton stage III-IV thumb carpometacarpal osteoarthritis received the above procedure from the 2 senior authors. HADM was imbricated to fill the posttrapeziectomy space and secured to the volar capsule and metacarpal base. Pre- and postoperative trapezial space on radiograph, pain scores, and grip strength were recorded. RESULTS: Six months postoperatively, radiographs showed an average joint space loss of 11%. Heights postoperatively were not significantly different from immediate postoperative heights (P ≥ 0.01). At 6 months, patients had improved pain and grip strength (P ≤ 0.01). No infections, foreign body reactions, or other complications occurred. CONCLUSIONS: HADM has been used extensively in other forms of reconstruction and has been shown to incorporate into surrounding tissues through neovascularization. Our early results illustrate that HADM can safely fill the dead space left by trapeziectomy.

Metastasis of hepatocellular and renal cell carcinoma to the hand.

SUMMARY: Malignant carcinoma metastasis to the skeleton is the third most common site of metastasis after lung and liver, usually involving the axial skeleton and the proximal ends of long bones, ribs, and vertebrae. Acrometastasis, metastasis to hands or feet, comprises only 0.1% of all metastases. Here, we present 2 cases of acrometastasis, one from hepatocellular carcinoma and the other from renal cell carcinoma. We describe the presentation, radiographs, surgical treatment, and outcomes for each patient. Patients presented with swelling and pain at the tumor sites and were treated with amputations. The second patient's disease progressed resulting in death shortly after amputation indicating acrometastasis may be a poor prognostic indicator of survival. We review the literature and discuss the importance of disease process recognition and prognosis.

Acellular dermal matrices in hand reconstruction.

BACKGROUND: The goal of this article is to review the current literature on the use of acellular dermal matrix in forearm, wrist, and hand reconstruction. METHODS: A comprehensive literature search was performed using the Cochrane Database of Systematic Reviews, MEDLINE, PubMed, and Web of Knowledge. Articles were categorized as acellular dermal matrix used in soft-tissue repair and in ligament reconstruction. Search terms included "acellular dermal matrix," "biologic dressing," "skin replacement," "dermal allograft," "AlloDerm," "FlexHD," "Permacol," and "Strattice." These were all cross-referenced with "forearm," "wrist," and "hand." Data extraction focused on indications, surgical techniques, clinical outcomes, and complications. Exclusion criteria included regeneration templates, neonatal foreskin, and review articles. RESULTS: More than 100 articles published between 1994 and 2011 were identified. Upon final review, five prospective case-control studies, three retrospective case-control studies, four case reports, one cross-sectional cohort, one prospective consecutive series, and one study type unknown were evaluated. Matrix was most commonly used in burn reconstruction. It has also been used in ligament and joint reconstruction for first carpometacarpal arthritis. One article illustrated the use of porcine matrix in basal joint arthritis, a practice that was abruptly terminated because of a concern over increased infections. CONCLUSIONS: The clinical indications for acellular dermal matrix have increased throughout the last 15 years. Hand surgeons have been cautious but diligent in developing alternative treatment options in hand reconstruction, with a focused effort to reduce donor-site morbidity. Although acellular dermal matrices continue to find innovative uses to solve upper extremity surgical problems, more comparative prospective trials are needed.