Improved Short-Term Prognosis of Pediatric Partial-Thickness Burns: Emergency Conservative Debridement Under Topical Anesthesia.

OBJECTIVES: Early wound management for pediatric patients with partial-thickness burns in the emergency department remains debatable. This study aims to evaluate the value of emergency conservative debridement under topical anesthesia in improving short-term prognosis of pediatric partial-thickness burns. METHODS: This retrospective cohort study enrolled children with partial-thickness thermal burns presenting to the emergency department within 6 hours postburn. All the enrolled patients were divided into 2 groups: the debridement group and the dressing group. The associations between emergency conservative debridement and time to reepithelialization was analyzed by using Kaplan-Meier curves with log rank test and multivariate Cox regression analysis. Moreover, the associations between emergency conservative debridement and in-hospital cost and length of stay were also evaluated. RESULTS: All baseline characteristics between groups were comparable (all P > 0.05). Emergency conservative debridement under topical anesthesia significantly decreased the median value of time to reepithelialization (13 vs 14 days, P = 0.02). Cox regression analysis showed that emergency conservative debridement significantly improved wound reepithelialization after adjusting for burn size (odds ratio, 4.07; 95% confidence interval, 1.64-10.11; P < 0.01). The mean length of stay of patients receiving conservative wound debridement was lower than that of patients in the wound dressing group (14.3 ± 7.3 vs 18.8 ± 10.4 days, P < 0.01), but not in terms of mean in-hospital cost per 1% total body surface area (2.8 ± 1.9 vs 3.0 ± 2.1 × 103 RMB per 1% total body surface area, P = 0.58). CONCLUSIONS: Emergency conservative debridement of pediatric partial-thickness burns under topical anesthesia significantly improves the wound healing outcomes without increasing health care burden.

Comparison of wound surface area measurements obtained using clinically validated artificial intelligence-based technology versus manual methods and the effect of measurement method on debridement code reimbursement cost.

BACKGROUND: Evidence shows that ongoing accurate wound assessments using valid and reliable measurement methods is essential to effective wound monitoring and better wound care management. Relying on subjective interpretation in measuring wound dimensions and assuming a rectilinear shape of all wounds renders an inconsistent and inaccurate wound area measurement. OBJECTIVE: The authors investigated the discrepancy in wound area measurements using a DWMS versus TPR methods and compared debridement codes submitted for reimbursement by assessment method. METHODS: The width and length of 177 wounds in 56 patients were measured at an outpatient clinic in the United States using the TPR method (width × length formula) and a DWMS (traced wound dimensions). The maximal allowable payment for debridement was calculated for both methods using the reported CPT codes based on each 20-cm2 estimated surface area. RESULTS: The average wound surface area was significantly higher with the TPR method than with the DWMS (20.20 and 12.81, respectively; P = .025). For patients with dark skin tones, ill-defined wound edges, irregular wound shapes, unhealthy tissues, and the presence of necrotic tissues, the use of the DWMS resulted in significantly lower mean differences in wound area measurements of 14.4 cm2 (P < .008), 8.2 cm2 (P = .040), 6.8 cm2 (P = .045), 13.1 cm2 (P = .036), and 7.6 cm2 (P = .043), respectively, compared with the TPR method. Use of the DWMS for wound surface area measurement resulted in a 10.6% lower reimbursement amount for debridement, with 82 fewer submitted codes, compared with the TPR method. CONCLUSIONS: Compared with the DWMS, TPR measurements overestimated wound area more than 36.6%. This overestimation was associated with dark skin tones and wounds with irregular edges, irregular shapes, and necrotic tissue.

Defensins of Lucilia sericata Larvae and Their Influence on Wound Repair Processes in Practical Assessment-A Study of Three Cases.

Bacteria inhabiting chronic wounds form a biofilm that prolongs and slows down the healing process. Increasingly common antibiotic resistance requires clinicians to search for effective and alternative treatment methods. Defensins are the most common antimicrobial peptides capable of eradicating pathogens. Their discovery in maggot secretions allowed for a broader understanding of the healing mechanisms, and approving the use of Lucilia sericata fly larvae in the treatment of infected wounds resulted in an effective and safe procedure. The aim of the study was to present the possibility of biofilm elimination in a chronic wound by means of medical maggots (Lucilia sericata) with the example of three selected clinical cases. The observation included three women who met the inclusion criterion of having venous insufficiency ulcers with inhibited regeneration processes. Medical maggots were applied in a biobag for three days, and observation was conducted for 21 consecutive days. In 2 cases, a significant elimination of necrotic tissue from the wound bed with local granulation tissue was observed 72 h after application of a larvae colony on the wounds. In 1 case, the application of the larvae accelerated the repair process by reducing the wound area by approximately 40% at the time of observation. The formation of biofilm in a chronic wound is one of the main causes of disturbances in its effective healing. Combining procedures (scraping, antiseptic compresses, MDT, NPWT) related to wound debridement increases the effectiveness of biofilm elimination. The use of medical maggots is a safe and effective method of choice, and it enhances the processes of debridement. However, confirmed indisputable data on their effectiveness and frequency of use in the process of stimulating healing processes are still not available in the literature.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.

Synchronous circular frame stabilisation and microsurgical soft tissue reconstruction for open lower limb fractures-A cost analysis and description of the surgical technique.

INTRODUCTION: Current surgical paradigms for ortho-plastic management of IIIB open tibial fractures make compromises. Often, definitive circular frame stabilisation is delayed until the soft tissue envelope is secure to allow access for further soft tissue reconstruction if required. This delay has potential clinical and cost implications. A previous study showed acute circular frame stabilisation performed concurrently or before soft tissue reconstruction was feasible without additional soft tissue reconstruction problems. This study examines potential resource savings using this approach. METHODS: All open tibial fractures managed by circular fixator and microsurgical soft tissue reconstruction between April 2015 and June 2019 were identified from a prospectively maintained database. Those receiving circular frame stabilisation with synchronous microsurgical soft tissue reconstruction were considered cases; those in whom the frame stabilisation was delayed were controls. Cost data were derived from the Patient Level Information and Costing System. Salvage cases and those with incomplete treatment were excluded. RESULTS: Nine cases and 25 controls were evaluated. No statistically significant difference was observed between groups in terms of age, sex, injury severity score, time to debridement, time to coverage, length of follow up, or time to union. Median length of stay was 13.3 and 19.7 days for cases and controls respectively (p<0.01). Cases required fewer procedures (2.3) compared to controls (4.5) (p<0.001). The cost of care was less for cases (£25,527) than controls (£32,952) (p <0.05). No cases returned to theatre with flap failure or flap compromise. Complications were similar between groups. CONCLUSION: In suitable patients, synchronous circular frame stabilisation and microsurgical soft tissue reconstruction is a safe, clinically effective, and cost-saving option.

Maggot Debridement Therapy for Chronic Leg and Foot Ulcers: A Review of Randomized Controlled Trials.

OBJECTIVE: To critically analyze the existing randomized controlled trials (RCTs) on the clinical, economic, and psychological implications of maggot debridement therapy (MDT). DATA SOURCES: An exhaustive literature search for English-language publications was conducted using MEDLINE, EMBASE, and PubMed. STUDY SELECTION: Keywords used for the search were based on the PICO (Population, Intervention, Comparison, Outcome) framework. The titles, abstracts, and relevant full-text articles were screened. Seven RCTs were selected after applying the inclusion and exclusion criteria. DATA EXTRACTION: Data pertaining to the primary and secondary outcomes of each study were extracted. DATA SYNTHESIS: The data extracted were evaluated and categorized into clinical, economic, and psychological outcomes pertaining to MDT. A judicious evaluation of these outcomes was made, and the following conclusions were drawn. CONCLUSIONS: There exists heterogeneity in the extant RCTs, but MDT appears to be effective for a quick early debridement. For diabetic foot ulcers, MDT improves debridement, controls infection, and enhances wound healing. In chronic peripheral vascular disease ulcers, it aids in early debridement, but the final outcome is equivocal. Further robust integrated health economic and parallel qualitative assessment studies are recommended to understand the cost-effectiveness and patient acceptability and experience.

Efficacy of Versajet hydrosurgery system in chronic wounds: A systematic review.

Studies demonstrating the effectiveness of hydrosurgery for chronic wounds are extremely limited. This systematic review aimed to evaluate the efficacy of hydrosurgery compared with conventional debridement in chronic wounds, skin ulcers, and non-acute wounds. This PROSPERO-registered review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases. Abstracts of all studies were screened independently by two reviewers. The bias of prospective randomised controlled studies was assessed using the Cochrane Collaboration's tool for assessing the risk of bias and RevMan 5.4 software, whereas the bias of retrospective comparative studies was evaluated using the Risk of Bias Assessment Tool for Non-randomised Studies. Two prospective randomised controlled trials, two retrospective comparative studies, and three prospective non-comparative studies were included. Hydrosurgery enabled rapid debridement. The Versajet Hydrosurgery System saved 8.87 minutes compared with the conventional methods. Similarly, the debridement quality was high with this system. The debridement number needed to achieve adequate wound beds was fewer in the hydrosurgery group than in the conventional group. These superiorities lead to subsequent success and cost-effectiveness. As there were only two prospective randomised controlled studies, and much information was missing, the risk of bias was unclear. This review confirmed that hydrosurgery is useful for the debridement of chronic wounds, considering the procedural speed and quality.

In-Hospital Complications following Arthrotomy versus Arthroscopy for Septic Knee Arthritis: A Cohort-Matched Comparison.

There is a paucity of literature comparing the relative merits of open arthrotomy versus arthroscopy for the surgical treatment of septic knee arthritis. The primary goal of this study is to compare the risk of perioperative complications between these two surgical techniques. To this end, 560 patients treated for septic arthritis of the native knee with arthroscopy were statistically matched 1:1 with 560 patients treated with open arthrotomy. The outcome measures included major complications, minor complications, mortality, inpatient hospital charges, and length of stay (LOS). Major complications were defined as myocardial infarction, cardiac arrest, stroke, deep vein thrombosis, pulmonary embolism, pneumonia, postoperative shock, unplanned ventilation, deep surgical site infection, wound dehiscence, infected postoperative seroma, hospital acquired urinary tract infection, and retained surgical item. Minor complications included phlebitis and thrombophlebitis, postprocedural emphysema, minor surgical site infection, peripheral nerve complication, and intraoperative hemorrhage. Mortality data were extracted from the database using the Uniform Bill patient disposition. Complications were analyzed using univariate and multivariate logistic regression models, whereas mean costs and LOS were compared using the Kruskal-Wallis H-test. Major complications occurred in 3.8% of the patients in the arthroscopy cohort and 5.4% of the patients in the arthrotomy cohort (p = 0.20). Too few patients in our sample died to report based on National (Nationwide) Impatient Sample (NIS) minimum reporting standards. Rates of minor complications were similar for the arthroscopy and arthrotomy cohorts (12.5 vs. 13.9%; p = 0.48). Multivariate analysis did not reveal any greater risk of minor or major complication between the two procedures. Inpatient hospital cost was similar for arthroscopy ( = $15,917; standard deviation [SD] = 14,424) and arthrotomy ( = $16,020; SD = 18,665; p = 0.42). LOS was also similar for both arthrotomy (6.78 days, SD = 6.75) and arthroscopy (6.24 days, SD = 5.95; p = 0.23). Patients undergoing arthroscopic treatment of septic arthritis of the knee showed no difference in relative risk of perioperative complications, LOS, or hospital cost compared with patients who underwent open arthrotomy.

One-stage posterior debridement, bone grafting fusion, and mono-segment vs. short-segment fixation for single-segment lumbar spinal tuberculosis: minimum 5-year follow-up outcomes.

BACKGROUND: To compare the clinical and radiological outcomes between posterior mono-segment and short-segment fixation combined with one-stage posterior debridement and bone grafting fusion in treating single-segment lumbar spinal tuberculosis (LSTB). METHODS: Sixty-two patients with single-segment LSTB treated by a posterior-only approach were divided into two groups: short-segment fixation (Group A, n = 32) and mono-segment fixation (Group B, n = 30). The clinical and radiographic outcomes were analyzed and compared between the two groups. RESULTS: The intraoperative bleeding volume, operation time, and hospitalization duration were lower in Group B than in Group A. All patients achieved the bony fusion criteria. The visual analog scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were substantially improved 3 months postoperatively and at the last visit in both groups, with no significant difference between the two groups (P > 0.05). Kirkaldy-Willis functional evaluation at the final follow-up demonstrated that all patients in both groups achieved excellent or good results. The difference in the angle correction rate and correction loss between Groups A and B was not significant (P > 0.05). CONCLUSIONS: One-stage posterior debridement, bone grafting fusion, and mono-segment or short-segment fixation can provide satisfactory clinical and radiological outcomes. Mono-segment fixation is more suitable for the treatment of single-segment LSTB because the lumbar segments with normal motion can be preserved with less trauma, a shorter operation time, shorter hospitalization, and lower costs.

Changing attitudes toward maggot debridement therapy in wound treatment: a review and discussion.

Maggot debridement therapy is the real-time placement of maggots into a wound by health professionals for the treatment of diabetic ulcers or hard-to-heal wounds infected with antibiotic-resistant bacteria. Maggot debridement therapy shortens healing and disinfects wounds. This paper is a literature review of maggot debridement therapy in the clinical setting today and addresses the costs and benefits of this therapy. It includes recommendations to engage healthcare providers and increase awareness of this therapeutic treatment. A case study is presented on the use of maggot therapy for full debridement of a necrotic wound and clearing of a meticillin-resistant Staphylococcus aureus infection. There is also discussion on how to engage healthcare workers and reduce anxieties about the use of maggots as a treatment for hard-to-heal wounds. Education and awareness are the key factors in changing healthcare workers attitudes to maggot debridement therapy.

Open fractures: epidemiological pattern, initial management and challenges in a sub-urban teaching hospital in Nigeria.

INTRODUCTION: Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our centre and share our experiences on the initial management and problems encountered. METHODS: This was an 18 month prospective study of patients that presented with open fractures at our emergency room. Already prepared data collection sheets were used to collect relevant data directly from patients and patients' files. RESULTS: There were 58 open fractures in 52 patients (31 males and 21 females). Mean age of patients was 36.4 ± 12.2 years. Most patients (82.7%) fell within the age group of 20-49 years. Traders (28.9%) and students (19.6%) were mostly affected. Most open fractures (88.5%) were due to road traffic accidents. The tibia and fibula were the most frequently affected (44.4%). Most injuries were Gustilo et al. types IIIA & IIIB (79.3%) open fractures. Patients had initial resuscitation followed by debridement in 42 cases (72%). Fractures were initially stabilized with external fixators in 23 cases (39.7%) and cast slabs in 19 cases (32.8%). The average time between presentation and debridement was 30 hours and average hospital stay was 36 days. Forty two point five per cent of wounds were infected. CONCLUSION: Open fractures were mostly due to road traffic accidents and affected the tibia and fibula most frequently with Gustilo et al. types IIIA and IIIB forming the bulk of the injuries. Management was challenging with late presentations, scarcity of resources and consequent high rate of infections, prolonged morbidity and hospital stay. These problems were worsened by delay in antibiotic commencement and initial debridement, sub-optimal treatment at peripherial hospitals and mis-management by traditional bone setters.

Surgical Diabetic Foot Debridement: Improving Training and Practice Utilizing the Traffic Light Principle.

Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episodes, higher hospital morbidity, and hospital length of stay (LOS). This study aims to assess protocolized diabetic-foot-debridement: Red-Amber-Green (RAG) model as part of a value-based driven intervention. The model highlights necrotic/infected tissue (red-zone, nonviable), followed by areas of moderate damage (amber-zone), healthy tissue (green-zone, viable). Sequential training of orthopedic surgeons supporting our emergency service was undertaken prior to introduction. We compared outcomes before/after RAG introduction (pre-RAG, n = 48; post- RAG, n = 35). Outcomes measured included: impact on number of debridement/individual admission, percentage of individuals requiring multiple debridement, and length-of-hospital-stay as a function-of-cost. All-patients fulfilled grade 2/3, stage-B, of the Texas-Wound-Classification. Those with evidence of ischemia were excluded. The pre-RAG-group were younger (53.8 ± 11.0 years vs 60.3 ± 9.2 years, P = .01); otherwise the 2-groups were matched: HbA1c, white blood cell count, and C-reactive protein. The post-RAG-group underwent significantly lower numbers of debridement's (1.1 ± 0.3 vs 1.5 ± 0.6/individual admission, P = .003); equired fewer visits to theatre (8.6% vs 38%, P = .003), their LOS was reduced (median LOS pre-RAG 36.0 vs post-RAG 21.5 days, P = .02). RAG facilitates infection clearance, fewer theatre-episodes, and shorter LOS. This protocolized-management-tools in acute severely infected diabetic foot infection offers benefits to patients and health-care-gain.

Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States.

INTRODUCTION: When introducing a new intervention into burn care, it is important to consider both clinical and economic impacts, as the financial burden of burns in the USA is significant. This study utilizes a health economic modeling approach to estimate cost-effectiveness and burn center budget-impact for the use of the RECELL® Autologous Cell Harvesting Device to prepare autologous skin cell suspension (ASCS) compared to standard of care (SOC) split-thickness skin graft (STSG) for the treatment of severe burn injuries requiring surgical intervention for definitive closure. METHODS: A hospital-perspective model using sequential decision trees depicts the acute burn care pathway (wound assessment, debridement/excision, temporary coverage, definitive closure) and predicts the relative differences between use of ASCS compared to SOC. Clinical inputs and ASCS impact on length of stay (LOS) were derived from clinical trials and real-world use data, American Burn Association National Burn Repository database analyses, and burn surgeon interviews. Hospital resource use and unit costs were derived from three US burn centers. A budget impact calculation leverages Monte Carlo simulation to estimate the overall impact to a burn center. RESULTS: ASCS treatment is cost-saving or cost-neutral (< 2% difference) and results in lower LOS compared to SOC across expected patient profiles and scenarios. In aggregate, ASCS treatment saves a burn center 14-17.3% annually. Results are sensitive to, but remain robust across, changing assumptions for relative impact of ASCS use on LOS, procedure time, and number of procedures. CONCLUSIONS: Use of ASCS compared to SOC reduces hospital costs and LOS of severe burns in the USA. FUNDING: AVITA Medical.

Single- versus 2-stage reconstruction for chronic post-radiation chest wall ulcer: A 10-year retrospective study of chronic radiation-induced ulcers.

Radiation therapy can have adverse effects on normal tissue and cause chronic ulcers. The purpose of this study was to compare breast cancer patients who underwent single-stage reconstruction with patients who underwent 2-stage reconstruction for chronic radiation-induced necrotic ulcers of the chest wall.This retrospective study comprised of 50 patients with chronic radiation-induced chest wall ulcers who underwent chest wall reconstruction in our hospital between January 2002 and January 2016. All patients developed ulcers after undergoing breast cancer surgery, followed by radiation therapy. These patients were divided into 2 groups: group A, patients who underwent debridement and reconstruction with tissue flaps simultaneously in a single-stage procedure; group B, patients who underwent debridement and omentum majus tamping in the 1st stage, followed by surgical reconstruction with skin grafting or flap transfer 2 weeks later. The postoperative complications and outcomes were evaluated and compared.These patients were followed up for 48 to 55 months (mean: 50 months), and overall survival was 98%. One patient in group A died of septicemia 5 days after the operation. Six patients in group A developed flap infection, among which 4 patients progressed to flap necrosis (group A: 6/25 vs group B: 0/25; P = .000).Compared to single-stage reconstruction, surgical reconstruction in 2 stages was safer and more effective in treating chronic radiation-induced ulcers of the chest wall, and is associated with fewer postoperative complications. The omentum majus flap was the most ideal tissue for the repair of these defects.

An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis.

BACKGROUND & AIMS: Infected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. METHODS: We performed a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017. Patients were randomly assigned to groups that received minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection, n = 32) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy, n = 34). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. RESULTS: The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11-0.80; P = .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P = .999), none of the patients assigned to the endoscopic approach developed enteral or pancreatic-cutaneous fistulae compared with 28.1% of the patients who underwent surgery (P = .001). The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P = .007). The physical health scores for quality of life at 3 months was better with the endoscopic approach (P = .039) and mean total cost was lower ($75,830) compared with $117,492 for surgery (P = .039). CONCLUSIONS: In a randomized trial of 66 patients, an endoscopic transluminal approach for infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life. Clinicaltrials.gov no: NCT02084537.

Operative Management of Abdominal Wound Dehiscence: Outcomes and Factors Influencing Time to Healing in Patients Undergoing Surgical Debridement With Primary Closure.

INTRODUCTION: Plastic surgeons are often consulted by other surgical teams for management of wound dehiscence following abdominopelvic surgery. OBJECTIVE: The purpose of this study is to determine whether operative debridement and primary closure of abdominopelvic wounds are safe and expeditious for patients. MATERIALS AND METHODS: A retrospective analysis was conducted on a database of patients who underwent operative debridement and closure at a single institution between January 2011 and December 2015 for dehisced abdominal or pelvic wounds acquired from prior obstetric, gynecologic, transplant, plastic, or general surgery procedures. RESULTS: Of the 163 patient records identified, 43 patients met inclusion criteria. The median time from final debridement and primary surgical closure to complete wound healing was 27 days. Time to healing differed significantly by index procedure type (P = .004), with obstetric procedures requiring the shortest median time (12.0 days) and general surgery procedures requiring the longest (39.5 days). Wound healing took 3.6 times longer for patients with diabetes (P = .046) and 11.4 times longer for patients who experienced delayed superficial wound healing or redehiscence (P = .003). Nevertheless, with the exception of 4 patients who died of other causes, all wounds (39/39; 100%) achieved complete wound closure. CONCLUSIONS: Operative debridement and closure of abdominopelvic wound dehiscence through a multidisciplinary team approach with plastic surgery results in expeditious wound healing with minimal complications, and it may be safer and more cost effective than healing by secondary intention.

Comparative cost and clinical effectiveness of clostridial collagenase ointment for chronic dermal ulcers.

Chronic dermal ulcers affect approximately 2.4-4.5 million people in the USA and are associated with loss of function, decreased quality of life and significant economic burden. Debridement is a critical component of wound care involving removal of nonviable tissue from chronic wounds to stimulate the granulation and epithelialization process. Clostridial collagenase ointment has been used as a method of wound debridement for more than 50 years and is currently the only enzymatic debriding ointment with US FDA approval. This review discusses the results of recent real-world studies that build upon the evidence demonstrating the clinical effectiveness, cost-effectiveness and safety of clostridial collagenase ointment across wound types and care settings.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.