Plastic Surgery and the Management of Surgical Infections.

ABSTRACT: Plastic surgeons bring wide anatomic competence and reconstructive surgical capacities to the management of surgical infections. Their anatomical expertise allows them to definitively explore and treat acute infections. Reconstructive options allow for the eradication of chronic infections with salvage of the infected body part. Hand infections illustrate the plastic surgeon's anatomic approach to acute infections. The management of distal tibial osteomyelitis illustrates how plastic surgeons can introduce techniques developed for other body regions in the treatment of a chronic infection.

Pulmonary mucormycosis eroding the chest wall: challenges in the management.

Pulmonary mucormycosis is a rare, life-threatening fungal infection usually seen in immunocompromised patients. Mortality in such patients is high due to underlying immunosuppression and poor general condition of the patients. Invasion of the adjacent structures is known but, to the best of our knowledge, pulmonary mucormycosis presenting with a full thickness chest wall erosion has not been reported. We report such a case with chest wall destruction with superadded bacterial infection. The use of prosthetic materials for chest wall reconstruction was not possible due to the presence of infection. In addition, there were other intra-operative and post-operative challenges which we managed using a multidisciplinary approach. This report highlights the successful outcome of this complex situation using pre-operative optimisation, adequate surgical debridement and effective management of post-operative complications with patience and perseverance.

Management of calcific myonecrosis using vacuum sealing drainage: A rare case report and 5-year follow-up.

 Calcific myonecrosis (CM), a rare post-traumatic sequel of the lower limb, is characterized by calcified lesions. A diagnosis of CM can be difficult owing to the longtime span from the emergence of the original trauma to the onset of the symptoms of CM. This case report aimed to feature a case of a 55-year-old gentleman who presented with a progressive painful swelling in the anterolateral aspect of the right lower leg with the initial trauma arising 11 years ago. In the conservative treatment, a fluid-filled mass was formed. The histological examination of the biopsy suggested a diagnosis of CM. The patient underwent a complete debridement operation, after which vacuum sealing drainage was used to manage the space left. Three weeks later, direct wound closure was achieved. Five-year follow-ups showed an excellent outcome without recurrence. Complete surgical debridement combined with primary closure is recommended to manage CM. Cite this article as: Wang C, Hao D, Wang S. Management of calcific myonecrosis using vacuum sealing drainage: A rare case report and 5-year follow-up. Acta Orthop Traumatol Turc., 2024;58(2):135-139.

Comparison of the efficacy of seven non-surgical methods combined with mechanical debridement in peri-implantitis and peri-implant mucositis: A network meta-analysis.

This network meta-analysis aims to compare the clinical efficacy of seven non-surgical therapies for peri-implant disease, including laser treatment, photobiomodulation therapy (PBMT), photodynamic therapy (PDT), systemic antibiotics (SA), probiotics, local antimicrobials (LA), and air-powder polishing (APP) combined with mechanical debridement (MD). We conducted searches in four electronic databases, namely PubMed, Embase, Web of Science, and The Cochrane Library, to identify randomized controlled trials of non-surgical treatments combined with MD for individuals (aged at least 18 years) diagnosed with peri-implantitis or peri-implant mucositis with a minimum of 3 months follow-up. The outcomes of the study were the reduction in pocket probing depth (PPD) and bleeding on probing (BoP), plaque index (PLI), clinical attachment level (CAL), and marginal bone loss (MBL). We employed a frequency random effects network meta-analysis model to combine the effect sizes of the trials using standardized mean difference (SMD) and 95% confidence intervals (CIs). Network meta-analyses include network plots, paired comparison forest plots, league tables, funnel plots, surface under the cumulative ranking area (SUCRA) plots, and sensitivity analysis plots. The results showed that, for peri-implantitis, PBMT +MD demonstrated the highest effect in improving PPD (SUCRA = 75.3%), SA +MD showed the highest effect in improving CAL (SUCRA = 87.4%, SMD = 2.20, and 95% CI: 0.38 to 4.02) and MBL (SUCRA = 99.9%, SMD = 3.92, and 95% CI. 2.90 to 4.93), compared to MD alone. For peri-implant mucositis, probiotics +MD demonstrated the highest effect in improving PPD (SUCRA = 100%) and PLI (SUCRA = 83.2%), SA +MD showed the highest effect in improving BoP (SUCRA = 88.1%, SMD = 0.77, and 95% CI: 0.27 to 1.28), compared to MD alone. Despite the ranking established by our study in the treatment of peri-implant disease, decisions should still be made with reference to the latest treatment guidelines. There is still a need for more high-quality studies to provide conclusive evidence and especially a need for studies regarding direct comparisons between multiple treatment options.

The Commando procedure for mechanical double valve prosthesis endocarditis with destruction of the aortomitral continuity.

Infective endocarditis, particularly after implanting valve prostheses, poses significant surgical challenges, often requiring complex interventions. We describe a case of a 37-year-old male with Staphylococcus aureus endocarditis, unsuccessfully treated with mechanical valve prostheses. Continued infection led to the destruction of the intervalvular fibrous body, necessitating a Commando procedure involving radical debridement and replacement of both aortic and mitral valves with complex patch reconstruction. Prosthesis selection remains contentious, considering recurrence risk and long-term prognosis. Our case underscores timely intervention and meticulous technique in managing such complex situations. It highlights successful strategies for treating infective endocarditis with destruction of aortomitral continuity, emphasizing the pivotal role of the Commando procedure.

Standardized pilonidal protocol as rescue therapy for excision-refractory pilonidal disease.

PURPOSE: Severe pilonidal diseases have refractory symptoms despite multiple surgeries and optimal therapy remains unclear. We hypothesized that standardized minimally invasive protocol could be an effective rescue treatment. METHODS: We prospectively collected data from symptomatic patients who underwent ≥ 1 pilonidal excision prior to presentation at our clinic 2019-2023. We treated these patients with standardized protocol incorporating local wound care, regular manual/laser epilation, and selective debridement/pit trephination. RESULTS: We treated 34 refractory patients (23 males) with median follow-up 405 days. Median age of first symptoms was 17.1 years; presentation to our clinic 20.0 years. Prior to our clinic, 27 received one surgery (cleft lift-2, excision no closure-1, excision primary closure-18, wound vac after excision-3, excision flap closure-3); 7 had two surgeries (excision without closure + cleft lift-1, primary closure after excision twice-3, flap closure after excision twice-2, excision primary closure + excision without closure-1). We treated all patients with regular epilation ± local wound care. 14 (41%) underwent trephination ± debridement. All patients achieved complete resolution after median 52 days. Five (14.7%) recurred and were treated with trephination + debridement-2 or wound care alone-3. Symptom length had no correlation with resolution time, skin type, hair amount. CONCLUSIONS: Standardized minimally invasive protocol requiring only selective surgical intervention can treat refractory pilonidal disease with low recurrence rate.

Factors influencing nurses' use of maggot debridement therapy.

Management of hard-to-heal wounds remains a significant challenge for healthcare systems, with substantial economic burdens. Maggot debridement therapy, using sterile larvae of Lucilia sericata, effectively debrides necrotic tissue and promotes healing, yet its use is limited. This narrative review examines the influences on the use of this form of debridement by registered nurses, focusing on knowledge and attitudes, treatment-related pain, and practical issues. Findings indicate that wound specialist nurses are more knowledgeable and supportive of maggot debridement therapy compared with non-wound specialists, underscoring the need for targeted educational interventions. Pain management is critical, with mixed reports on pain levels, highlighting the necessity for tailored pain-relief strategies. Practical challenges include procurement difficulties and cost, suggesting a need for streamlined processes and clear clinical guidelines. Addressing these barriers through education, research, and improved logistics could enhance the acceptance and use of maggot debridement therapy, improving patient outcomes in wound management.

The use of acellular products in venous leg ulcers: a narrative review.

BACKGROUND: Venous leg ulcers (VLUs) are the most common type of chronic wound in the lower extremity and are often associated with redness, swelling, and pain at the site of the wound. The primary focus of VLU treatment is the promotion of wound healing through compression therapy, wound debridement, and elevation of the affected limb. Acellular matrices have gained traction as a potential adjunct to wound healing in diabetic foot ulcers. However, the clinical effect of acellular products in the setting of VLUs has not been well reported. OBJECTIVE: To review the published evidence on the use of acellular products in the management of VLUs. METHODS: PubMed, Embase, Cochrane, and Google Scholar databases were initially searched on March 2, 2023, for literature on VLU and acellular dermal matrix. Later, the search was broadened to include any and all acellular matrices, and a secondary search of the same databases was conducted on February 20, 2024. Articles obtained through collateral methods were also included. RESULTS: A total of 27 articles were identified for review. All studies were human studies. Four articles had level I evidence and 7 articles had level II evidence, while the remaining articles had level III or IV evidence. Studies included both large and small wound sizes ranging from 0.5 cm² to 100 cm2. Product application occurred once to twice weekly for 4 weeks to up to 36 months. Overall, regardless of ulcer size, the majority of studies reported favorable wound healing outcomes with the use of a variety of acellular skin coverage products with few complications. Some studies also reported pain reduction with the use of acellular skin substitutes in a small cohort of patients. CONCLUSION: Acellular products appear to have the potential to support healing in VLUs. However, more large-scale randomized controlled trials that provide level I evidence are needed.

[Postoperative sternomediastinitis: morphology of lesion, treatment strategy]. / Posleoperatsionnyi sternomediastinit: morfologiya porazheniya, taktika lecheniya.

OBJECTIVE: To analyze bone tissue damage at different stages of disease (El Oakley classification), treatment options for each clinical situation and results after each approach. MATERIAL AND METHODS: There were 45 patients with wound complications after cardiac surgery between October 2022 and September 2023. Thirty-eight (84.4%) patients underwent CABG, 7 (15.6%) patients - heart valve or aortic surgery. Mean age of patients was 68.1±10.3 years. There were 35 men (77.8%) and 10 women (22.2%). The first type was found in 11 (24.5%) patients, type 2-3 - 19 (42.2%), type 4 - 4 (8.8%), type 5 - 11 (24.5%) patients. RESULTS: Systemic inflammatory response syndrome was observed in 7 (36.8%) persons of the 1st group, 14 (73.7%) ones of the 2nd group, 4 (100%) patients of the 3rd group and 2 (18.2%) patients of the 4th group. C-reactive protein and procalcitonin increased in all patients with the highest values in groups 2 and 3. Redo soft tissue inflammation occurred in all groups after treatment. Mean incidence was 25%. Two (10.5%) patients died in the 2nd group and 1 (25%) patient in the 3rd group. CONCLUSION: The modern classification of sternomediastinitis does not fully characterize severity of disease in a particular patient. Simultaneous debridement with wound closure demonstrates acceptable mortality (within 10%). The highest mortality rate was observed in patients with diffuse lesions of the sternum. Less aggressive treatment approaches are possible for stable anterior chest wall.

Mixed burn injury to thigh secondary to D-cell lithium battery explosion.

There is an increasing trend globally of fire incidents as a direct consequence of battery failures[1-6], but a dearth of reporting in medical literature regarding injuries associated with primary lithium cell explosions. We present the case of an electrical engineer referred to the burns team as a chemical burn secondary to a D-cell lithium battery explosion. Initial assessment revealed an entry wound on the anteromedial thigh leaking contaminated fluid. Orthogonal X-rays demonstrated the battery casing lodged within the posterior thigh compartment. The wound was managed similar to that of a ballistic injury with staged debridement, washout and delayed primary closure. This is the first reported case of a lithium-thionyl chloride battery explosion causing injury. The case highlights various issues for attending teams, including appropriate first aid for chemical burns, consideration of significant soft tissue trauma deep to seemingly innocuous wounds and safeguarding concerns surrounding domestic explosive devices.

Outcomes of Arthroscopic Debridement of the First Carpometacarpal Joint: A Systematic Review.

Background: Arthroscopic debridement is increasingly being utilised in patients with early-stage first carpometacarpal joint (FCMCJ) arthritis but has limited supportive evidence. This systematic review evaluates the literature, and reports on outcomes and adverse events following this procedure. Methods: An electronic literature search of PubMed, Embase, Medline and Cochrane Central, looking for studies describing outcomes following arthroscopic debridement in FCMCJ arthritis, was performed in November 2022. Studies where bony resection or interposition was performed as adjuncts were excluded. Reported outcomes included visual analogue scores (VAS) for pain; Disabilities of Arm, Shoulder and Hand (DASH) scores; pinch and grip strength; complications and re-operations. Results: Out of a total of 90 studies revealed from the search, only two studies were eligible for inclusion, with a cohort of 34 patients. Following arthroscopic debridement for FCMCJ osteoarthritis, the mean VAS improved by four units, mean DASH by 22 points, grip strength by 4.5 kg and pinch strength by 2 kg at mean follow-up of 18 months. The pooled complication and re-operation rates were 8.8% and 23.5%, respectively. Conclusions: There is a lack of evidence supporting the utility of FCMCJ arthroscopy and debridement in the management of patients with early arthritis. Although the limited evidence suggests that there may be some therapeutic benefit, further large-scale prospective studies need to be performed before making conclusive recommendations. Level of Evidence: Level III (Therapeutic).

Minimally Invasive versus Traditional Surgery: Efficacy of PELD and PLIF in Treating Pyogenic Spondylodiscitis.

BACKGROUND Pyogenic spondylodiscitis is infection of the intervertebral disc or discs and the adjacent vertebrae. This retrospective study aimed to compare the effectiveness of percutaneous endoscopic lumbar debridement (PELD) versus posterior lumbar interbody fusion (PLIF) in 40 patients with pyogenic spondylodiscitis (PSD). MATERIAL AND METHODS Medical records of patients who underwent PELD (n=18) or PLIF (n=22) for PSD between 2018 and 2023 were reviewed. The recorded outcomes encompassed surgical duration, intraoperative blood loss, Oswestry Disability Index (ODI) measurements, Visual Analog Scale (VAS) assessments, C-reactive protein (CRP) levels, duration of hospitalization, erythrocyte sedimentation rate (ESR), American Spinal Injury Association (ASIA) grading, lumbar sagittal parameters, and the incidence of complications. RESULTS The PELD group had shorter surgical duration, less intraoperative blood loss, and shorter length of hospital stay compared to the PLIF group (P<0.01). At the last follow-up, both groups had significant improvement in ESR, CRP levels, and ASIA classification (P<0.001), but there was no significant difference between the 2 groups (P>0.05). The PELD group had lower ODI and VAS ratings at 1 month and 3 months, respectively (P<0.01). The PLIF group had significant improvements in intervertebral space height and lumbar lordosis angle (P<0.01). CONCLUSIONS Both PLIF and PELD surgical approaches demonstrate adequate clinical efficacy in the treatment of monosegmental PSD. PLIF can better ensure more spinal stability than PELD, but PELD offers advantages such as reduced minimal surgical trauma, shorter operative duration, and faster recovery after surgery.

Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation.

BACKGROUND: To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique. METHODS: We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement-coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function. RESULTS: The median and quartiles of bone defect length was 7 (4.75-9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9-19) weeks. At a median follow-up of 22 (20-27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6-8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105-120.0)°. CONCLUSIONS: For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.

Effectiveness of antimicrobial photodynamic therapy in the treatment of peri-implantitis: systematic review and meta-analysis.

The purpose of this study was to evaluate the current scientific evidence on the effectiveness of antimicrobial photodynamic therapy (aPDT) as an adjunctive treatment to mechanical debridement in the treatment of peri-implantitis. The Preferred Reporting Items for Systematic Reviews and Meta-analyses was followed. A protocol was registered in the International Prospective Registry of Systematic Reviews (PROSPERO #CRD42022361684). The search was carried out in seven databases, with no restrictions regarding language or year of publication. Our work included studies that compared clinical periodontal parameters between individuals treated with mechanical debridement associated with aPDT and a control group of patients who had undergone mechanical debridement alone. Study selection, data extraction, and risk of bias assessment (RoB 2.0) were performed by two review authors. Meta-analysis was performed. The mean difference (MD) and a 95% confidence interval (CI) were provided. Four hundred and seven-four studies were identified, of which five studies were included. The meta-analysis demonstrated that aPDT adjunctive to mechanical debridement in subjects with peri-implantitis resulted in greater reduction in probing depth 3 months after treatment than among subjects receiving treatment with mechanical debridement. Most of the included studies exhibit a low risk of bias. Adjunctive aPDT to mechanical debridement contributes to the improvement of peri-implant clinical parameters in individuals with peri-implantitis, in particular probing depth.

Short-Term Outcomes of Arthroscopic Treatment of Freiberg Disease.

BACKGROUND: Surgical treatment for Freiberg disease (also known as avascular necrosis of the metatarsal head) has not been completely defined. This retrospective study evaluated short-term outcomes after arthroscopic treatment of Freiberg disease. METHODS: From 2015 to 2019, 13 patients (15 feet) diagnosed as having Freiberg disease were enrolled for arthroscopic surgery. Feet were divided based on the Smillie classification system (two with stage I, eight with stage II, three with stage III, one with stage IV, and one with stage V). Arthroscopic interventions, including synovectomy, debridement, chondroplasty, microfracture, and loose body removal, were performed without considering the Smillie classification stage. Radiologic outcomes were evaluated by radiography (preoperatively and 3, 6, and 12 months postoperatively) and magnetic resonance imaging (preoperatively and 12 months postoperatively). Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal (MTP)-interphalangeal score and the visual analog scale (VAS) score. The MTP joint range of motion was measured using a goniometer preoperatively and postoperatively. RESULTS: Radiologic studies showed no evidence of osteonecrosis progression in postoperative 12-month radiographs of any patients. Postoperative 12-month magnetic resonance images showed reduction of bone marrow edema, irregularity of subchondral bone, and cartilage defects in all patients. Significant improvements in AOFAS and VAS scores occurred at all postoperative time points compared with preoperative scores (P = .001). The MTP joint range of motion also showed improvement at last follow-up (P = .001). CONCLUSIONS: Arthroscopic surgery for Freiberg disease showed excellent clinical outcomes, MTP joint range of motion, and short-term outcomes regardless of stage (Smillie classification) in radiologic evaluation.

The Efficacy of LRINEC Scoring in Patients with Necrotizing Fasciitis and its Correlation with the Outcomes.

<b><br>Introduction:</b> Necrotizing fasciitis (NF) is an expeditiously escalating inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues. To aid diagnosis, the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was devised to stratify the likelihood of infection in patients on presentation.</br> <b><br>Aim:</b> The study aimed to investigate and quantify the relationships between the LRINEC scoring system and the outcomes such as the need for amputation, length of hospital stay, and mortality in patients with necrotizing fasciitis.</br> <b><br>Material and methods:</b> A total number of 90 patients were admitted with a provisional diagnosis of necrotizing fasciitis. LRINEC score was calculated for each case based on six laboratory variables at the time of presentation. Enrolled patients were divided into three groups on the basis of the LRINEC score. The differences in mortality, length of hospitalization, number of debridement procedures, and need for amputation between these groups were compared.</br> <b><br>Results:</b> Increasing age, male gender, and DM have a poor prognosis in necrotizing fasciitis patients. The amputation and mortality rates are better correlated with higher LRINEC scores.</br> <b><br>Conclusions:</b> The LRINEC score helps in stratifying the patients into three risk categories (low risk, moderate risk, and high risk) according to the severity in a much more organized way, and thus the appropriate management like surgical debridement can be introduced on time. LRINEC score is a robust index that is capable of detecting early cases of necrotizing fasciitis and is simple enough for routine use. It is a simplified bedside diagnostic tool for early diagnosis and prediction of outcomes in patients with necrotizing fasciitis.</br>.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach.

BACKGROUND: Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT). METHODS: A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications. RESULTS: Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria. CONCLUSIONS: For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Clinicopathological study of otomycosis in a tertiary hospital in South-west Nigeria.

Background: Otomycosis is common in environments with hot, humid weather, and it may be challenging to manage. Objectives: To profile common clinical presentations, the pathogenic fungi, the treatment modalities with responses, and explore clinical factors associated with having positive fungal culture in Otomycosis. Methods: Retrospective review of patients with Otomycosis. Demographic and clinical parameters, otoscopic findings and mycological study results were recorded. The treatment modalities used and treatment response were summarized. Comparative statistical analyses of associated factors to positive fungal culture were performed with Chi square test, and Student's t-test, using SPSS version 22.0. Results: Total of 71 patients with M: F=1:1.8, mean age 38.5±19.8 years. Average duration of symptoms was 5.4 ±4.6 weeks; common presenting complaint was itchy ear (33.8%). Majority of patients (85.9%) had unilateral ear involvement, 50.0% applied ototopic medications before presentation, 8.5% had multiple co-morbidities. 20 patients had positive fungal culture results; common fungal isolate was Aspergillus niger 9 (45.0%).Clinical factors associated with positive culture of fungus were age, non-previous use of ototopic drugs, and presence of co-morbidity. The most common treatment was local ear debridement and use of topical antifungal creams. Majority (91.5%) of the patients responded with resolution of fungal infection. Complications rate was 8.4%. Conclusions: Otomycosis commonly present with itchy ears, the pathogenic fungi commonly being Aspergillus species. The factors associated with positive fungal culture were age, non-usage of ototopic agents and presence of co-morbidity. Treatment modality used was local debridement and topical antifungal agents, which produced favourable response in most patients.