Risk Factors for Plate Infection, Exposure, and Removal in Mandibular Reconstruction.

OBJECTIVE: Mandibular plate reconstruction (MPR) is often indicated after tumor ablation, osteoradionecrosis excision, and traumatic bone loss to restore oral functionality and facial cosmetics. There are limited analyses identifying risk factors that lead to plate infection (PIn), exposure, and removal ("plate complications"). STUDY DESIGN: Retrospective cohort study. SETTING: Academic tertiary medical center. METHODS: Patients who underwent MPR from 2013 to 2022 were identified. Risk factors for plate complications were analyzed based on demographic, clinical, intraoperative, and postoperative factors. Multivariable analysis was conducted with logistic regression. Survival analysis was conducted with a Cox model. RESULTS: Of the 188 patients analyzed, 48 (25.5%) had a plate complication [infection: 22 (11.7%); exposure: 23 (12.2%); removal: 35 (18.6%)]. Multivariate analysis revealed predictive associations between at least 1 plate complication and the following variables: smoking status, soft tissue defect size, number of plates, average screw length, and various postoperative complications. Other associations approached the threshold for significance. Prior and adjuvant radiation therapy, type of free flap, stock versus custom plates, and perioperative antibiotic prophylaxis regimens were not associated with plate complications. No plate complication was independently associated with lower overall survival. PIn (hazard ratio, HR: 7.99, confidence interval, CI [4.11, 15.54]) and exposure (HR: 3.56, CI [1.79, 7.08]) were independently associated with higher rates of plate removal. CONCLUSION: Plate complications are relatively common after MPR. Smoking history, specific disease characteristics, hardware used during surgery, and postoperative complications may help identify higher-risk patients, but additional larger-scale studies are needed to validate our findings and resolve discrepancies in the current literature.

Clinical application of posterior tibial artery or peroneal artery perforator flap in curing plate exposure after ankle fracture fixation.

The study aims to evaluate the clinical application of posterior tibial artery or peroneal artery perforator flap in the treatment of plate exposure after ankle fracture fixation. A posterior tibial artery or peroneal artery perforator flap was used on 16 patients with plate exposure after ankle fracture fixation in our hospital between July 2018 and July 2021. The time required to harvest the flap, the amount of intraoperative blood loss, the duration of postoperative drainage tube placement, the outcome of the flap and the healing observed at the donor site are reported. The sizes of the flaps were 2.5-7.0 cm × 5.0-18.0 cm and averaged 4.0 cm × 12.0 cm. The time required to harvest the posterior tibial artery or peroneal artery perforator flap ranged from 35 to 55 min and averaged 45 min. The amount of intraoperative blood loss ranged from 20 to 50 mL and averaged 35 mL. The duration of postoperative drainage tube placement ranged from 3 to 5 days and averaged 4 days. A total of 15 flaps survived and one flap had partial necrosis and survived after conservative treatment. All donor area defects were directly sewed and stitched without complications. There are multiple advantages of the posterior tibial artery or peroneal artery perforator flap, including simple preparation technique, reliable repair of the defects and without the need for performing microvascular anastomosis. It can be safely used in curing plate exposure after ankle fracture fixation and worth popularizing in grassroots hospitals.

Efficacy of Antibiotic Cement in Preserving Endoplants After Infection With Plate Exposure.

Background: To study the feasibility and efficacy of antibiotic cement in preserving endoplants after infection in patients with early tibial plateau fracture on plate exposure. Patients and Methods: A retrospective analysis of 23 patients treated for post-operative infection with plate exposure after tibial plateau fracture between 2017 and 2021. They were divided into the observation group (10 patients) and the control group (13 patients). Total operation time, length of hospitalization, hospitalization cost, the number of surgeries, white blood cell (WBC) count, neutrophil (NEUT) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the post-operative evaluation index, and complications were observed during the follow-up period. Results: All patients were followed up for 6 to 12 months; wound healing was observed in both groups. The total operation time for patients in the control group was longer compared with the observation group. However, the length of hospitalization, hospitalization cost, and number of surgeries in the observation group were less compared with the control group. No difference in WBC, NEUT, ESR, and CRP levels was observed one day after surgery. Furthermore, WBC, NEUT, ESR, and CRP levels were higher in patients in the control group compared with the observation group 72 hours after surgery. There were no differences in the post-operative evaluation index and complications in both groups. Conclusions: The antibiotic cement coating used for treating early post-operative infection in patients with tibial plateau fracture could effectively control infection while retaining endoplant, thereby promoting wound healing. It could also reduce pain and the medical burden on patients.

Management of failed stainless steel implants in the oromaxillofacial region of dogs.

Management of complications of fracture fixation in the oromaxillofacial (OMF) region may present a diagnostic and therapeutic challenge. While titanium and stainless steel implants have been utilized in successful fracture fixation in the OMF region, the use of titanium implants is preferred due to the superior intrinsic properties of titanium. Nonetheless, stainless steel materials are still used due to their availability and familiarity. In the present methods report, we describe our approach to the management of failed stainless steel plates and screws used to treat traumatic injuries in the OMF region. Furthermore, we exemplify our approach with five dogs that exhibited complications of stainless steel implants in the OMF region and their subsequent management. In those cases, all failed implants were removed. Reconstruction with a combination of recombinant human bone morphogenetic protein-2 (rhBMP-2) and titanium implants was utilized in two cases while a mandibulectomy was performed in one case. Three cases required removal of the stainless-steel implant with no additional surgical therapy. We conclude that the success of treatment of failed stainless steel implants depends on the use of advanced imaging findings, appropriate antimicrobial therapy, as well as potentially regenerative reconstructive surgery.

Analysis of the therapeutic effect of artificial leather embedding combined with fascial sleeve flap transplantation on chronic wounds of lower limbs with bone and plate exposure.

BACKGROUND: After severe trauma of lower limbs, bone, tendon or plate graft exposure is common. The traditional repair method is to use a variety of skin flap transplantation to cover the exposed part, but the wound often can not heal after operation, or the wound is cracked, ulcer, sinus, bone and steel plate are exposed again after wound healing. The reason for this result is that when the flap is covered, the space around the bone plate is not well closed, forming a dead cavity, blood and exudate accumulation, hematoma formation or infection, and finally the wound ruptures again. In addition, due to the swelling and contracture of the flap after operation, the suture tension between the flap and the receiving area becomes larger, the skin becomes thinner and broken, and then the wound is formed. In order to solve the above problems, we carried out the study of artificial true skin embedding combined with fascial sleeve flap transplantation in the treatment of chronic bone plate exposed wounds of lower limbs. METHODS: In this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion, removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1-2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in nine cases and the lateral superior malleolar artery perforator flap in two case. RESULTS: The flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation. CONCLUSIONS: Artificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture. It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs.

Risk factors for reconstruction plate exposure after surgery in oral cancer patients. A retrospective cohort study.

OBJECTIVES: The aim of this study was to elaborate risk factors for reconstruction plate exposure after wide excision in oral cancer patients, and to find out the most effective treatment. MATERIALS AND METHODS: We include patients who underwent ablative surgery for oral cancer and reconstruction plate fixation from the year 2010 to 2016, separate them into two groups according to whether the hardware was exposed, compare risk factors including age, tumor site, staging, comorbidities, and previous treatment between the two groups. The treatment course and outcome were also recorded. RESULTS: In total, 75 patients received reconstruction plate fixation after ablative surgery. Bone plate exposure was found in 26 cases (34.6%). The size of the bone defect and the thickness of soft tissue covering the plate were significant risk factors for plate exposure. In 21 patients (72.4%), the bone plate was removed. Conservative treatment was not effective. Removal of bone plate and debridement in one single surgery had a success rate of 81%. CONCLUSION: In this study, skin thickness less than 1.5 mm over the reconstruction plate and bone defect size larger than 8.4 cm were the two significant risk factors for bone plate exposure. Although a standardized treatment algorithm is lacking, surgical debridement with removal of the bone plate result in complete soft tissue healing in most patients and should be the treatment of choice. CLINICAL RELEVANCE: Patients with larger bone defect and thinner covering soft tissue bear more risk for exposure. The most effective treatment is to remove the hardware.

Effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates after surgery for foot and ankle fractures.

BACKGROUND: Treatment of exposed steel plates after surgery for foot and ankle fractures is complicated. This study aims to analyze the effects of microsurgical repair treatment on the clinical efficacy, complications, and flap follow-up scores of patients with exposed steel plates following foot and ankle fracture surgery. METHODS: Eighty-two patients with exposure of steel plates after surgical treatment for foot and ankle fractures in our hospital from March 2017 to March 2018 were included in this study. The patients were divided into a study group (43 patients who received microsurgical repair) and a control group (39 patients who received conventional repair surgery). We compared the clinical efficacy, complication rate, flap followup score, recovery of ankle-hindfoot function and ankle function before treatment and at 3 and 6 months after treatment, and patient satisfaction between the two groups. RESULTS: The clinical effectiveness rate in the study group was 95.35%, which was higher than the control group (76.92%) (P<0.05). The flap appearance, texture, and elasticity scores in the study group were higher than those in the control group (P<0.05). After treatment, the American Orthopedic Foot and Ankle Society (AOFAS) score and Baird ankle score increased significantly in both groups, and reached a peak at 6 months after treatment. The peak scores of the study group were considerably higher than those of the control group at each period after treatment (P<0.05). The incidence of complications in the study group (6.98%) was lower than the control group (25.64%) (P<0.05). Patient satisfaction was higher in the study group (97.67%) than the control group (79.49%) (P<0.05). CONCLUSIONS: Microsurgical repair of exposed steel plates after surgery for foot and ankle fractures has a significant clinical effect. It can improve the flap follow-up scores, accelerate healing of the ankle, improve aesthetics, and reduce the incidence of complications. It is therefore worthy of widespread use in clinics.

Evaluation of alloplastic mandibular reconstruction combined with a radial forearm flap compared with a vastus lateralis myocutaneous flap as the first approach to two-stage rehabilitation in advanced oral cancer.

After continuity resection of the mandible, reconstruction of continuity with a reconstruction plate and soft tissue can be an alternative to immediate osseous reconstruction in patients with advanced oral cancer. We evaluated exposure of the plate in such reconstructions by comparing the results of a radial forearm flap (RFF) with a vastus lateralis myocutaneous flap (VLMF). We also analysed the resection margins and the incidence of secondary osseous reconstructions after one year free from relapse. We retrospectively examined all 48 mandibular reconstructions in which a reconstruction plate and RFF or VLMF had been used between 2007 and 2016. Exposure rates of plates were assessed and local (size and site of resection) and systemic risk factors (age, sex, treatment with radiation, and smoking) evaluated. Reconstruction plates, together with a RFF, were significantly more likely to be exposed than those with a VLMF (p = 0.01). There was significantly more exposure in the RFF group in mandibular defects larger than 6 cm, in contrast to the VLMF group (p = 0.002). Younger age (p < 0.001), lower body mass index (BMI) (p = 0.05) and smoking (p = 0.011) led to more exposure. In seven cases a second operation was necessary due to macroscopically invaded or close margins. Thirty-one patients had no bony reconstruction because of local recurrence, distant metastases, inadequate resection margins, poor general condition, or a second (different) tumour. Exposure of the plate after mandibular reconstruction happens less often with the VLM flap than with the RFF. The two-step approach can be an option in the treatment of advanced oral cancer.

Successful management of an orocutaneous fistula and exposed mandibular plate with the vacuum-assisted closure system: A case report.

Orocutaneous fistulas are one of the most problematic postoperative complications after oral cancer surgery. Notably, in patients with mandibular plate exposure it is necessary to remove the plate. However, it takes longer for these patients to achieve complete fistula closure. The present report described an 84-year-old man with a postoperative orocutaneous fistula and exposed mandibular plate who was treated with the vacuum-assisted closure system. This system protects the wound from contamination while the negative pressure prevents tissue fluid retention, promotes blood flow, facilitates granulation tissue formation and decreases the bacterial cell count. Vacuum-assisted closure was successful in the present case, and complete fistula closure took 20 days. Additionally, there was no evidence of recurrence over the 11-month follow-up.

Surgical site infections following oral cavity cancer resection and reconstruction is a risk factor for plate exposure.

BACKGROUND: Plate-related complications following head and neck cancer ablation and reconstruction remains a challenging problem often requiring further management and reconstructive surgeries. We aim to identify an association between surgical site infections (SSI) and plate exposure. METHODS: A retrospective study between 1997 and 2014 was performed to study the association between postoperative SSI and plate exposures. Eligible patients included those with a history of oral squamous cell carcinoma who underwent surgical resection, neck dissection, and free tissue reconstruction. Demographic and treatment related information was collected. SSI were classified based on CDC definition and previously published literature. Univariable analysis on demographic factors, smoking history, diabetes, radiation, surgical and hardware related factors; while multivariable analysis on SSI, plate height, segmental mandibulectomy defects and radiation were conducted such as using cox proportional hazard models. RESULTS: Three hundred sixty-five patients were identified and included in our study. The mean age of the study group was 59.2 (+/-13.8), with a predominance of male patients (61.9%). 10.7% of our patient cohort had diabetes, and another 63.8% had post-operative radiation therapy. Patients with SSI were more likely to have plate exposure (25 vs. 6.4%, p <0.001). Post-operative SSI, mandibulectomy defects, and plate profile/thickness were associated with plate exposure on univariable analysis (OR = 5.72, p < 0.001; OR = 2.56, p = 0.014; OR = 1.44, p = 0.003 respectively) and multivariable analysis (OR = 5.13, p < 0.001; OR = 1.36, p = 0.017; OR = 2.58, p = 0.02 respectively). CONCLUSION: Surgical site infections are associated with higher rates of plate exposure. Plate exposure may require multiple procedures to manage and occasionally free flap reconstruction.

Minimizing osteoradionecrosis after mandibular reconstruction and radiation in advanced head and neck cancer patients.

BACKGROUND: Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap. METHODS: A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups. RESULTS: A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04). CONCLUSION: The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. 2016;114:399-404. © 2016 Wiley Periodicals, Inc.

Wound Dehiscence and Device Migration after Subconjunctival Bevacizumab Injection with Ahmed Glaucoma Valve Implantation.

PURPOSE: To report a complication pertaining to subconjunctival bevacizumab injection as an adjunct to Ahmed Glaucoma Valve (AGV) implantation. CASE REPORT: A 54-year-old woman with history of complicated cataract surgery was referred for advanced intractable glaucoma. AGV implantation with adjunctive subconjunctival bevacizumab (1.25 mg) was performed with satisfactory results during the first postoperative week. However, 10 days after surgery, she developed wound dehiscence and tube exposure. The second case was a 33-year-old man with history of congenital glaucoma and uncontrolled IOP who developed AGV exposure and wound dehiscence after surgery. In both cases, for prevention of endophthalmitis and corneal damage by the unstable tube, the shunt was removed and the conjunctiva was re-sutured. CONCLUSION: The potential adverse effect of subconjunctival bevacizumab injection on wound healing should be considered in AGV surgery.