Risk factors and management approach for deep sternal wound infection after cardiac surgery at a tertiary medical centre.

BACKGROUND: Deep sternal wound infection (DSWI) is a rare but severe complication following cardiac surgery. Our study investigated the risk factors and treatment options for patients who developed DSWI at our institution between May 1988 and April 2008. METHOD: Data was collected prospectively in a database and information on demographics reviewed retrospectively on 5649 patients who underwent cardiac surgery during this period. RESULTS: The incidence of DSWI was 34/5649 (0.6%). These patients were older (mean age 66.1 vs. 64.5), more likely to die (in hospital mortality 11.8% vs. non DSWI group 1.8%) and had longer hospital stays (DSWI group mean stay 25 days vs. non DSWI group 9 days). Using Fisher's exact test the risk predictors for DSWI determined at our institution included diabetes managed with oral medications (p=0.021), previous cardiac surgery (p=0.038), BMI≥30 (p=0.041), LVEF≤30 (p=0.010), IABP usage (p=0.028) and homologous blood usage (p<0.001). Most commonly bilateral pectoralis major muscle flap (BPMMF) was used for treatment of DSWI (11/30, 36.7%). CONCLUSION: Ultimately our data was comparable to published data in the literature on known risk predictors.

Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap.

OBJECTIVE: To report our experience using two staged bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. METHODS: A retrospective study of 9417 open-heart surgery cases performed between 1998 and 2003 at The Prince Charles Hospital. Sixty-eight patients were referred to the plastic surgical team for consideration of bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. RESULTS: There was a trend for early referral for flap operation (median 10 days) (p=0.49). The median postoperative ventilation time and ICU stay were 1 and 2 days, respectively. The median hospital stay after flap operation was 15.5 days. One-year overall survival was 91%. Ninety-five per cent healed stable sternum was achieved with 100% failure in patients with chronically unstable sternum. Early referral appears to be an important factor in preventing osteomyelitis formation (p=0.05) with the longest recurrence at 10 months postoperatively. CONCLUSIONS: The key to the successful management of deep sternal wound infection is early referral for pectoralis major flap operation. Our approach is safe with good long-term outcomes. We recommend this approach in all severe deep sternal wound infection but not in patients with chronic unstable sternum.

Soft tissue reconstruction after compound tibial fracture: 235 cases over 12 years.

BACKGROUND: Outcomes in management of compound tibial fractures are measured by the rate of infection and non-union. These are a function of many variables that interact in complex ways. Our aims are to describe changes in these injuries over the past decade, to determine which variables predict a poor outcome and to compare reconstructive options controlling for these variables. METHODS: All compound tibial fractures reconstructed at the Princess Alexandra Hospital from 1999 to early 2009 were reviewed retrospectively. The remainder of 2009 and 2010 were reviewed prospectively. Data were collected from departmental audits, medical records and imaging. RESULTS: 251 flaps were performed in 235 patients. Reconstructions within one week declined after 2000, which correlated with increasing Negative Pressure Dressings use (R = 0.77). Free flap use increased though the incidence of distal fractures did not (R = 0.29). Muscle flaps were consistently preferred. Injuries with a poor outcome had a greater delay or failed soft tissue reconstruction. A poor outcome was more likely in patients with a contaminated distal fracture (p = 0.0038). Outcomes in muscle and fasciocutaneous flaps were not significantly different. CONCLUSIONS: Compound tibial fracture management has evolved to temporary followed by definitive fixation. Free flap use has increased, particularly in diaphyseal injuries. Delays in reconstruction should prompt aggressive surgical management. Injuries at risk of a poor outcome can be further characterised as being distal and contaminated. Reconstructive surgeons should not be discouraged from using muscle flaps. A management algorithm based on the evidence provided is presented. LEVEL OF EVIDENCE: Therapeutic III.

Peripheral primitive neuroectodermal tumour - a rare cause of a popliteal fossa mass: A case report and review of the literature.

A literature review of peripheral primitive neuroectodermal tumours, illustrated with an index case report describing an 80-year-old woman who presented with a mass in the left popliteal fossa, is reported. An excision biopsy was performed, revealing a possible peripheral primitive neuroectodermal tumour as the primary pathology. Normally confined to the chest wall and axial soft tissues of children and young adults, reports of this tumour existing in other areas and in the elderly population are scarce.

Une analyse bibliographique des tumeurs neuroectodermiques primitives périphériques est présentée conjointement à un cas de référence décrivant une femme de 80 ans qui a consulté à cause d'une masse du creux poplité gauche. Une excision-biopsie a révélé la possibilité d'une tumeur neuroectrodermique primitive périphérique en pathologie primaire. Normalement, cette tumeur est confinée à la paroi thoracique et aux tissus mous axiaux des enfants et des jeunes adultes. Elle est rarement signalée dans d'autres foyers et au sein de la population âgée.

History of lower limb reconstruction after trauma.

BACKGROUND: The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important. METHODS: This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time. RESULTS: Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%. CONCLUSIONS: Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.