One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

PURPOSE: Periprosthetic infection represents a major complication in breast reconstruction, frequently leading to expander-implant loss. Recent studies report variable success in the salvage of infected breast prostheses through systemic antibiotic therapy and surgical intervention. There is currently no consensus regarding a management algorithm for attempted salvage. The purpose of this pilot study was to evaluate the early outcomes of a protocol using antibiotic-impregnated polymethylmethacrylate (PMMA) implant placement with expander device exchange. METHODS: A retrospective database was queried to identify all patients with infected implant-based breast reconstruction who were treated by the study authors and who underwent attempted salvage under the study protocol. All patients received intravenous antibiotics followed by surgical debridement of the infected pocket, insertion of antibiotic-impregnated PMMA plates and/or beads, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed with the PMMA implants remaining in situ until exchanged to permanent implants. RESULTS: All patients with infected prosthetic breast reconstructions achieved implant pocket sterilization using this method. At a mean follow-up of 8.2 months (range, 1-19 months), none of these patients have required reoperation for capsular contracture. One patient, while under treatment with prednisone for a rash, developed recurrent infection, which led to explantation of her implant. Two patients underwent radiation therapy while an antibiotic plate and tissue expander were in place, with no observed exposure or infection recurrence. CONCLUSIONS: Sustained local antibiotic delivery using PMMA implants and expander device exchange can successfully salvage an infected breast implant. Perceived benefits include shorter time to completed reconstruction, preserved skin envelope integrity, and possibly improved long-term aesthetic outcomes.

Application of a hydrogel spacer for postoperative salvage radiotherapy of prostate cancer.

BACKGROUND: In contrast to primary radiotherapy, no reports are available for a hydrogel spacer application in postoperative salvage radiotherapy for prostate cancer. CASE REPORT: A 77-year-old patient presented 20 years after radical prostatectomy with a digitally palpable local recurrence at the urethrovesical anastomosis (PSA 5.5 ng/ml). The hydrogel spacer (10 ml, SpaceOAR™) was injected between the local recurrence and rectal wall under transrectal ultrasound guidance. Treatment planning was performed with an intensity-modulated technique up to a total dose of 76 Gy in 2-Gy fractions. The same planning was performed based on computed tomography before spacer injection for comparison. RESULTS: The local recurrence, initially directly on the rectal wall, could be displaced more than 1 cm from the rectal wall after hydrogel injection. With a mean total dose of 76 Gy to the planning target volume, rectal wall volumes included in the 70 Gy, 60 Gy, 50 Gy isodoses were 0 cm(3), 0 cm(3), and 0.4 cm(3) with a spacer and 2.9 cm(3), 4.5 cm(3), and 6.2 cm(3) without a spacer, respectively. The patient reported rectal urgency during radiotherapy, completely resolving after the end of treatment. The PSA level was 5.4 ng/ml a week before the end of radiotherapy and dropped to 0.9 ng/ml 5 months after radiotherapy. CONCLUSION: A hydrogel spacer was successfully applied for dose-escalated radiotherapy in a patient with macroscopic local prostate cancer recurrence at the urethrovesical anastomosis to decrease the dose at the rectal wall. This option can be considered in specifically selected patients.

Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

BACKGROUND: Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. METHODS: A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. RESULTS: The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. CONCLUSIONS: Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place.

BACKGROUND: This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant. METHODS: Records of women treated at a single institution between June of 1997 and December of 2011 were reviewed. Two patient groups were identified based on type of immediate breast reconstruction: tissue expander followed by exchange with a permanent implant and permanent implant. The study endpoint was rate of reconstruction failure, defined as a replacement, loss of the implant, or conversion to flap. RESULTS: The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09). CONCLUSIONS: Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Secondary Salvage of the Unsatisfactory Microtia Reconstruction.

BACKGROUND: Because auricular reconstruction is a complex and relatively uncommon procedure, there are many patients that have had disappointing reconstructions. This study describes the authors' large experience with secondary procedures in patients with unsatisfactory or failed initial ear reconstruction. METHODS: A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from March of 1991 to December of 2017 was reviewed. Demographic data and outcomes were assessed. Patients with acquired absence of the ear were not included. RESULTS: There were 144 microtia patients that met the inclusion criteria. Patient age at the time of the secondary reconstruction ranged from 3 to 59 years. Follow-up duration ranged from 1 to 21 years. Primary reconstruction was performed with rib cartilage in 91 patients, porous polyethylene implant in 47 patients, prosthesis in four patients, and irradiated cadaver rib cartilage in two patients. All secondary reconstructions were performed with porous polyethylene implants. The alloplastic framework was covered with a temporoparietal fascia flap in 76 patients, an occipital fascia flap in 64 patients, and a free fascia flap in four patients (two radial forearm flaps in the same patient, one contralateral temporoparietal fascia flap, and one lateral arm flap). Fourteen patients (10 percent) had complications requiring revision surgery. Secondary surgery was successful in all but one patient. CONCLUSIONS: These data represent the largest series of secondary total ear reconstructions. The use of a porous polyethylene implant is an ideal method for these patients because of its minimal morbidity and relatively low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A novel use of cement as a salvage procedure in patients with complex spinal injuries with proximal junctional failure.

Long-construct fixations can be complicated by proximal junctional kyphosis. In elderly, high-risk patients with numerous comorbidities, lengthy surgical times and increased blood loss associated with revision osteotomies and extension of fusions are not often tolerated and pose serious life-threatening risks. We present a salvage technique used in a patient with proximal junctional failure and demonstrate its role in improving symptoms and functionality in those not deemed fit for major surgery. Pre- and postoperative pain scores in accordance with the visual analogue scale, walking distances and radiographs were reviewed in a patient who underwent the salvage technique to ascertain the subjective and objective difference in pain and functionality. The patient showed marked improvement in pain scores and walking distances postoperatively. Additionally, the degree of proximal junctional kyphosis was lower on postoperative radiographs. While holding risks of its own, our described technique can be performed in select cases and is a good salvage procedure in high-risk patients. It prevents their exposure to the risks that accompany large revision operations and fusion models with further potential to fail. We recommend that our technique is performed only at specialist centres.

Tibiotalocalcaneal fusion with a cemented coated retrograde nail as a salvage procedure for infected ORIF of the ankle. / Artrodesis tibiotalocalcánea con clavo retrógrado cementado con antibiótico en rescate de osteosíntesis infectada de tobillo.

Tibiotalocalcaneal arthrodesis is an effective salvage procedure in cases of combined ankle and subtalar osteoarthritis as well as severe multiplanar deformities and severe joint destruction of the hindfoot. Special mention should be made of this procedure in cases of bone loss, especially from the talus, secondary to failed previous surgeries or bone infection, often being the only way to achieve a stable and painless foot and ankle. We present a case of ankle fracture in a patient with associated morbidity and multiple complications following osteosynthesis, in which tibiotalocalcaneal arthrodesis with cemented with antibiotic coated retrograde nail has achieved a satisfactory final result.

Treatment of type II odontoid fracture with a novel technique: Titanium cable-dragged reduction and cantilever-beam internal fixation.

Surgical methods for type II odontoid fracture can be classified into 2 main groups: anterior or posterior approach. A more effective way to achieve bone fusion with the lowest possible surgical risk is needed. Therefore, the aim of our study was to describe and evaluate a novel technique, cable-dragged reduction/cantilever beam internal fixation for the treatment of type II odontoid fracture.This was a retrospective study enrolled 34 patients underwent posterior cable-dragged reduction/cantilever-beam internal fixation surgery. Medical records, rates of reduction, the location of the instrumentation and fracture healing during follow-up were analyzed. Once fracture healing was obtained, instrumentation was removed. Neck pain (scored using a visual analog scale [VAS]), neck stiffness, patient satisfaction, and neck disability index (NDI) were recorded before and after removing the instrumentation during follow-up.The mean duration of follow up was 22.8 ±â€Š5.3 months. There was no iatrogenic damage to nerves or blood vessels. Radiographic evaluation showed complete reduction in the 20 patients with fracture displacement and satisfactory fracture healing in all 34 cases. Titanium cable breakage was observed in 4 patients after fracture healing. After removal of instrumentation, significant improvements were seen in neck-pain VAS score, neck stiffness, patient satisfaction, and NDI (all P < .01).Posterior cable-dragged reduction/cantilever-beam internal fixation was an optimal salvage maneuver to conventional surgical methods such as anterior screw fixation and C1-C2 screw-rod system. The operative difficulty and incidence of nerve and vascular injury were reduced. Its major disadvantage is the exposure and screw-setting at C3, which is left intact in traditional surgery, and it is suitable only for patients with intact C1 posterior arches.

Agility to INBONE: anterior and posterior approaches to the difficult revision total ankle replacement.

Total ankle replacement is now acknowledged as a viable alternative to ankle arthrodesis for end-stage ankle arthritis. The authors present a series of 14 patients who were converted from the Agility total ankle replacement to an INBONE total ankle replacement. This report is unique in that anterior and posterior approaches are discussed and detailed. Although the authors present successful conversion of the Agility total ankle replacement to an INBONE total ankle replacement, the difficulty of this procedure is demonstrated by the high complication rate and 2 early failures.

High-dose-rate brachytherapy for patients with maxillary gingival carcinoma using a novel customized intraoral mold technique.

OBJECTIVE: The purpose of this study was to introduce a novel customized intraoral mold treatment for maxillary gingival carcinoma (UGC). STUDY DESIGN: Two patients with UGC were treated as salvage therapy using this technique. The mold was designed to keep normal soft tissues adjacent to the tumor away from the radioactive source as much as possible, and it was shielded by lead. The radiation dose on the buccal mucosa and tongue was measured at the inner and outer surfaces of the intraoral mold before starting high-dose-rate brachytherapy by the remote afterloading system, and was reduced to almost one tenth. RESULTS: The patient had no recurrence and no severe adverse effects on the normal soft tissue adjacent to the tumor until the end of the follow-up period. CONCLUSION: High-dose-rate brachytherapy using the novel customized intraoral mold might be a treatment option of not only salvage therapy, but definitive therapy of UGC.

Biomechanical comparison of anatomic trajectory pedicle screw versus injectable calcium sulfate graft-augmented pedicle screw for salvage in cadaveric thoracic bone.

Many salvage options for failed thoracic pedicle screws exist including the use of a different trajectory or the augmentation of the screw with polymethylmethacrylate cement. Although polymethylmethacrylate immediately increases the construct stiffness and the pull-out strength, it may cause bone necrosis, toxin relaxation, and/or neural injury. On the other hand, calcium sulfate bone grafts have a high potential for biologic incorporation and no thermal damage effect. In the current study, polyaxial pedicle screws were first inserted with a straightforward approach on both sides in 17 fresh human cadaveric thoracic vertebrae. The maximal insertion torque for each screw was measured and then the pull-out strengths were recorded. Afterward, these pedicle screws were randomly assigned to be replaced either by graft augmentation or by anatomic trajectory technique for salvage. The graft-augmented screws were placed using the previous holes. The maximum insertional torque for each anatomic trajectory screw was measured. Finally, the pull-out strengths of the revision screws were recorded. The mean maximum insertional torque decreased with the anatomic trajectory salvage technique when compared with the straightforward approach, 0.23 versus 0.38 Nm, respectively (P=0.003). The anatomic trajectory revision resulted in decreased pull-out strength when compared with the pull-out strength of the straightforward technique, 297 versus 469 N, respectively (P=0.003). The calcium sulfate graft augmentation increased the pull-out strength when compared with the pull-out strength of the straightforward technique, 680 versus 477 N, respectively (P=0.017). The mean pull-out strength ratio of revised screw to original was 0.71 for anatomic trajectory and 1.8 for graft-augmented screws, a statistically significant difference (P=0.002).