The Results of Rigid Titanium Plate Reinforcement and Only Conventional Wire Methods in Sternal Fixation in Morbidly Obese Patients.

INTRODUCTION: In this study, it was aimed to compare the clinical results and complications of rigid titanium plate reinforcement and only conventional wire methods for sternum fixation in morbidly obese patients who underwent sternotomy for open-heart surgery. METHODS: The study was planned as a retrospective case-control study. Morbidly obese patients who underwent open-heart surgery with median sternotomy between 2011 and 2021 were analyzed retrospectively. RESULTS: There was no statistically significant difference between the two groups in terms of characteristics of the patients (P≥0.05). Sternal dehiscence, sternum revision, wound drainage, and mediastinitis were significantly less common in the titanium plate group (P≤0.05). There was no statistically significant difference between the groups in terms of 30-day mortality (P≥0.05). CONCLUSION: Rigid titanium plate reinforcement application produced more positive clinical results than only conventional wire application. In addition, it was determined that although the rigid titanium plate application prolonged the operation time, it did not make a significant difference in terms of mortality and morbidity compared to the conventional wire applied group.

Fascial dehiscence: predictable complication? Development and validation of a risk model: a retrospective cohort study.

PURPOSE: Fascial dehiscence is still an important cause of morbidity and mortality in the postoperative period of abdominal surgery. Different authors have sought to identify risk factors for this entity. Two risk scores have been developed, but they include postoperative variables, which hinder preventive decision-making during the early surgical period. Our aim is to identify preoperative and intraoperative risk factors for fascial dehiscence and to develop and validate a risk prediction score that allows taking preventive behaviors. METHODS: All adult patients, with no prior history of abdominal surgery, who underwent midline laparotomy by a general surgery division between January 2009 and December 2019 were included. Recognized preoperative risk factors for fascial dehiscence were evaluated in a univariate analysis and subsequently entered in a multivariate stepwise logistic regression model. A prognostic risk model was developed and posteriorly validated by bootstrapping. This study was conducted following the STROBE statement. RESULTS: A total of 594 patients were included. Fascial dehiscence was detected in 41 patients (6.9%). On multivariate analysis, eight factors were identified: chronic obstructive pulmonary disease (COPD), immunosuppression, smoking, prostatic hyperplasia, anticoagulation use, sepsis, and overweight. The resulting score ranges from 1 to 8. Scores above 3 are predictive of 18% risk of dehiscence with a sensitivity of 70% and specificity of 80% (ROC 0.88). CONCLUSIONS: We present a new preoperative prognostic score to identify patients with a high risk of fascial dehiscence. It can be a guide for decision-making that allows taking intraoperative preventive measures. External validation is still required.

Does Elective Sternal Plating Combined with Steel Wire Reduce Sternal Complication Rates in Patients with Obesity?

INTRODUCTION: In this study, sternal complication rates of sternal closures with steel wire or steel wire combined with titanium plate in patients with obesity that underwent cardiac surgery were investigated. METHODS: The data of 316 patients that underwent cardiac surgery between May 2018 and October 2021 were analyzed retrospectively; 124 patients withbody mass index (BMI) ≥ 30 kg/m2 were divided into group I, patients whose sternotomy was performed with steel wires, and group II, patients whose sternotomy was performed with steel wire combined with titanium plates. RESULTS: A total of 124 patients with BMI ≥ 30 kg/m2 were divided into group I (n=88 [70.9%]) and group II (n=36 [29.1%]). The rate of male patients was found to be significantly higher in group I, whereas the rate of female patients was significantly higher in group II (P<0.001). BMI values were found to be low in group I and high in group II (P<0.001). The distribution of complications was different in the BMI ≥ 35.00-39.99 kg/m2 and ≥ 40 kg/m2 groups (P=0.003). Development of complications was found to be higher in patients with BMI ≥ 40 kg/m2. Sternal dehiscence was observed in two patients in group I, while no dehiscence was observed in group II. CONCLUSION: The lower incidence of complications and the absence of non-infectious sternal complications and sternal dehiscence in patients with BMI ≥ 35 kg/m2 that underwent steel wire combined titanium plate sternal closure strengthened the idea that plate-supported sternal closure can prevent sternal complications in high-risk patients.

The role of the unilateral pectoralis major muscle flap in the treatment of deep sternal wound infection and dehiscence.

Deep sternal wound infection and dehiscence has been classified as complex wound, and its treatment is a challenge for the surgeon. There are many flap choices for its treatment, each one having advantages and drawbacks. The article by Wang et al. evidenced that the unilateral pectoralis major muscle flap is a simple and effective option for wound closure resulting from sternotomy dehiscence in infants and children. The report discussed herein highlights that the unilateral pectoralis major muscle flap has been a good and feasible option for the reconstruction of the sternal wound in adults, as previously described by our group and other authors. This technique presents low morbidity and acceptable esthetic and functional results, providing stability to the sternal region.

[Surgical wound dehiscence and exposed hardware. Infection foretold?] / Dehiscencia de herida quirúrgica y exposición material de osteosíntesis. ¿Infección segura?

INTRODUCTION: surgical wound dehiscence with exposure of internal fixation material is a serious problem in orthopedic surgery and an important factor for infection. OBJECTIVE: presentation of an unusual case of an adult patient with surgical wound dehiscence and complete exposure of 20 cm of the ulnar plate after six years of surgery, without infection signs, with bone healing and skin behind the plate. CASE PRESENTATION: 39-year-old man with an open Gustilo II Monteggia fracture-dislocation multifracture. The patient had a history of drug dependence. He had an open reduction and internal fixation with an ulnar reconstruction plate. The patient did not have any follow-up. After six years of the surgery, there was a complete exposure of the plate (20 cm) without infection and healing of the fracture with misalignment. After removing the plate, we observed spontaneous epithelialization attached to the bone bed. Skin coverage was complete at two months. CONCLUSION: although unusual, bone consolidation without infection is possible in an open fracture with long-standing exposure to a forearm plate in the adult.

INTRODUCCIÓN: la dehiscencia de herida quirúrgica con exposición de material de fijación interna es un grave problema en cirugía ortopédica y un factor importante de infección. OBJETIVO: descripción del caso inusual de un paciente adulto con dehiscencia de la herida quirúrgica y exposición completa de 20 cm de largo de una placa de cúbito tras seis años de la cirugía, sin signos de infección, consolidación ósea y reepitelización debajo de la placa y adherida al hueso. CASO CLÍNICO: hombre de 39 años que sufrió una fractura-luxación de Monteggia, abierta grado II y multifragmentaria. El paciente tenía historia de drogodependencia en tratamiento con metadona. Fue tratado con fijación interna del cúbito mediante una placa de reconstrucción larga. Postoperatoriamente, el paciente dejó de acudir para evaluación. A los seis años de la cirugía presentaba una completa exposición de la placa (20 cm de longitud), sin signos de infección y consolidación con malalineación de la fractura. Tras el retiro de la placa se observó epitelización espontánea adherida al lecho óseo cubital. La cobertura cutánea fue completa a los dos meses. CONCLUSIÓN: aunque inusual, es posible la consolidación ósea y la ausencia de infección en una fractura abierta con exposición de larga evolución de una placa de antebrazo en el adulto.

Manejo laparoscópico de la dehiscencia anastomótica en cirugía colorrectal / Laparoscopic management of anastomotic dehiscence in colorectal surgery

Introducción: En los últimos años ha habido una gran difusión de la cirugía laparoscópica para el manejo de la patología colorrectal. La dehiscencia anastomótica es una de las complicaciones más graves, con una elevada morbi-mortalidad. La reoperación por vía laparoscópica podría ser una opción válida para tratar esta complicación, manteniendo ciertos beneficios del abordaje miniinvasivo. Objetivos: Evaluar la factibilidad y seguridad del abordaje laparoscópico en el manejo de la dehiscencia anastomótica en cirugía colorrectal y en forma secundaria comparar los resultados con la reoperación por vía convencional. Materiales y Método: Se analizó una serie retrospectiva, completada en forma prospectiva, se incluyeron 1693 pacientes (junio 2000 - septiembre 2018). Los pacientes que fueron reoperados por dehiscencia anastomótica se dividieron en dos grupos según el abordaje de la reoperación: laparoscópico (Grupo 1, G1) y laparotómico (Grupo 2, G2). Se compararon ambos grupos teniendo en cuenta factores demográficos, estadía hospitalaria, complicaciones, morbilidad y mortalidad. Las complicaciones se estratificaron según la clasificación de Dindo y Clavien, y se tuvieron en cuenta las más graves (categorías 3, 4 y 5). Para el análisis estadístico se utilizó el T student y chi cuadrado. Resultados: Ciento seis (6,26%) pacientes fueron reoperados por dehiscencia anastomótica. Ochenta y cinco (80%) fueron incluidos en el grupo 1 y 21 (20%) en el grupo 2. La única diferencia demográfica entre ambos grupos fue una mayor cantidad de pacientes obesos en el grupo laparoscópico (G1: 17 (20%) vs. G2: 0, p: 0,02). Hubo una tendencia hacia un intervalo menor entre la cirugía inicial y la reexploración, pero sin diferencias estadísticamente significativas (5,18 días vs. 6,23 días, p: 0,22). En 84 (79%) la conducta quirúrgica fue lavado y confección de ostomía proximal de protección (G1: 74 vs. G2: 10, p: 0,001). El desmonte de la anastomosis y la confección de ostomía terminal debió realizarse en 8 pacientes (G1: 4 vs G2: 4, p: 0,02). Nueve pacientes en G1 y 3 pacientes en G2 requirieron más de una cirugía (p: 0,63). Las complicaciones fueron similares entre ambos grupos, sólo se incluyeron los grados 3, 4 y 5 (G1: 21,2% vs G2: 28,6% p: 0,34). El promedio de estadía hospitalaria disminuyó con el abordaje laparoscópico (10,71 días vs. 11,57 días, p: 0,66), a pesar de que no hubo diferencia estadística entre ambos grupos. Conclusiones: La reintervención laparoscópica es un tratamiento válido y seguro para el manejo de la dehiscencia anastomótica en cirugía laparoscópica colorrectal. (AU)

Introduction: In recent years there has been a great diffusion of laparoscopic surgery for the management of colorectal pathology. Anastomotic dehiscence is one of the most serious complications, with high morbidity and mortality. Laparoscopic reoperation could be a valid option to treat this complication, maintaining certain benefits of the minimally invasive approach. Objectives: To evaluate the viability and safety of the laparoscopic approach in the management of anastomotic dehiscence in colorectal surgery and as a secondary end point to compare the results with those of reoperation by conventional approach. Material and Methods: A series of 1693 patients that underwent laparoscopic colorectal surgery was analyzed, from a prospective database (June 2000 - September 2018). Patients were divided into two groups according to the approach performed in the reoperative surgery: laparoscopy (G 1) or laparotomy (G 2). Demographic data, hospital stay, type of complication, morbidity and mortality were analyzed. Dindo-Clavien classification was used to stratify postoperative complications and only categories 3, 4 and 5 were included. Data were statistically analyzed with Student ́s t test and chi-square test.Results: A hundred six patients (6.26%) were reoperated because of AL, 85 (80%) by laparoscopy and 21 (20%) by conventional surgery. The only demographic difference between both groups was that more obese patients were included in G1 (G1: 17, 20% vs. G2: 0, p=0.02). Interval of time between surgeries was lower in G1 without statistical difference (5.18 vs. 6.23 days, p=0.22). In 84 patients (79%) abdominal lavage and loop ostomy was performed (G1: 74 vs. G2: 10, p=0.001). Anastomosis takedown was required in 8 patients (G1: 4 vs. G2: 4, p=0.02). 9 patients in G1 and 3 in G2 needed more than one reexploration (p= 0.63). Postoperative complications were similar in both groups, grades 3, 4 and 5 were included (G1: 21, 2% vs. G2: 28.6%, p= 0.34). In average hospital stay was decreased in G1 (10.7 vs. 11.6 days, p=0.66), without statistical difference. Conclusion: Laparoscopic reintervention can be a safe treatment for anastomotic leakage after laparoscopic colorectal surgery. (AU)

Explantación y reposición de implante con dehiscencia vestibular en la zona estética. Reporte de caso / Explantation and replacement of an implant with a facial dehiscence in the aesthetic region. Case report

RESUMEN: La incidencia de complicaciones en los tejidos periimplantarios, como recesiones y dehiscencias, ha ido en aumento en los últimos años, principalmente asociados a un incorrecto posicionamiento espacial de los implantes. El objetivo de este reporte de caso es presentar el manejo quirúrgico de una complicación estética debida a la mal posición de un implante en la zona anterior. Caso. Paciente se presenta con recesión mucosa y dehiscencia por vestibular del implante 1.2, causados por su mal posicionamiento. Se realiza explantación mediante llave de alto torque e inserción de un nuevo implante en combinación con regeneración ósea (sticky bone) e injerto de tejido conectivo, lo que recupera la armonía gingival. Conclusión. La explantación conservadora acompañada de regeneración tisular ofrecen una interesante alternativa para el tratamiento de defectos estéticos severos asociados a la mal posición de implantes. La sistematización de este tipo de protocolos es fundamental para mejorar su predictibilidad.

ABSTRACT: An increase in the incidence of peri-implant soft tissue complications, such as facial recession and dehiscence, has been observed in the last years, mainly associated with an incorrect spatial placement of the implants. This case report focuses on the surgical management of an esthetic complication due to an incorrect implant position in the anterior region. Case report. Patient presented with recession and dehiscence in the facial area of implant 1.2, due to its incorrect placement. Explantation was performed with a high torque wrench, followed by the immediate placement of a new implant in combination with bone regeneration (sticky bone) and soft tissue augmentation. Conclusion. The use of atraumatic explantation techniques followed by guided tissue regeneration offers an interesting alternative for the treatment of severe defects in the esthetic region due to incorrectly placed implants. An adequate systematization of these protocols is key to improve their predictability.

Evaluación de factores de riesgo asociados a dehiscencia anastomótica en cirugía colorrectal: análisis multivariado de 748 pacientes / Evaluation of the risk factors associated with anastomotic dehiscence in colorectal surgery: multivariate analysis of 748 pacients

INTRODUCCIÓN: La dehiscencia anastomótica (DA) es una complicación severa en cirugía colorrectal con una incidencia que oscila entre 2 y 19%. La literatura internacional muestra numerosos estudios sobre la identificación de factores de riesgo (FR), mientras que en la nacional existen solo dos series que analizan esta complicación. OBJETIVO: Realizar una caracterización descriptiva de resultados institucionales y establecer la tasa de DA, sus factores de riesgo asociados y la mortalidad. MATERIALES Y MÉTODO: Serie de casos no concurrente, cuya muestra son pacientes consecutivos intervenidos de patología colorrectal con anastomosis primaria con o sin ostoma derivativo entre los años 2004 y 2016. Se realiza modelo de regresión logística univariable y multivariable. RESULTADOS: Se obtuvieron 748 pacientes, 50,5% mujeres, media de edad fue 56,2. Las indicaciones quirúrgicas más frecuentes fueron cáncer colorrectal en 381 (50,9%) pacientes y enfermedad diverticular en 163 (21,8%). La DA fue de 5,6% (42/748) y la mortalidad fue de 2% (15/748), siendo de 1% para los electivos (7/681). En el análisis univariado encontramos que los FR que tuvieron significancia estadística fueron la albúmina (p < 0,001), altura anastomosis (p < 0,001), transfusión (p < 0,001), localización (colon derecho > izquierdo) (p = 0,011), mientras que en el análisis multivariado fueron la albúmina (p = 0,002) con un OR 3,64 (IC 95% 1,58-8,35) y transfusión (p = 0,015) con un OR 7,15 (IC 95% 1,46-34,91). CONCLUSIÓN: Nuestra serie es la más grande reportada en Chile, con resultados similares a estudios internacionales y nacionales. Establecemos que la hipoalbuminemia y la presencia de transfusiones intraoperatorias se asocian a alta tasa de DA.

INTRODUCTION: Anastomotic leakage (AL) is a severe complication in colorectal surgery, its incidence ranges from 2 to 19%. In international literature, we found numerous studies on the identification of risk factors (RF), while in the national there are only two series that analyze this complication. AIM: Perform a descriptive characterization of institutional results and establish the AL rate, its associated risk factors and mortality. MATERIALS AND METHOD: Non-concurrent series of cases, whose sample is consecutive patients operated for colorectal pathology with primary anastomosis with or without a derivative ostoma between 2004 and 2016. Univariate and multivariable logistic regression model was performed. RESULTS: There were 748 patients, 50.5% women, mean age was 56.2. The most frequent surgical indications were colorectal cancer in 381 (50.9%) patients and diverticular disease in 163 (21.8%). The AL was 5.6% (42/748) and the mortality was 2% (15/748), being 1% for the electives (7/681). In the univariate analysis, we found that the RF that had statistical significance were albumin (p < 0.001), anastomosis height (p < 0.001), transfusion (p < 0.001), location (right colon > left) (p = 0.011), while that in the multivariate analysis were albumin (p = 0.002) with an OR 3.64 (IC 95% 1.58-8.35) and transfusion (p = 0.015) with an OR 7.15 (IC 95% 1.46-34.91). CONLUSION: Our series is the largest reported in Chile, with similar results to international and national studies. We establish that hypoalbuminemia and the presence of intraoperative transfusions are associated with a high rate of AL.

New sternal closure methods versus the standard closure method: systematic review and meta-analysis.

OBJECTIVES: This study aimed to evaluate, by means of a systematic review, the efficiency of new methods for sternal closure in order to prevent sternal wound complications after sternotomy. METHODS: The method of study was a systematic review of randomized clinical trials. We included studies that used rigid plates, thermoreactive clips, cables and flat wires, in comparison with the standard closure method. Patients included adults, regardless of gender and race. RESULTS: Seven clinical trials were included involving 1810 patients. Five trials were carried out in the USA, 1 in Australia and 1 in Italy, and the trials include both male and female patients. The included studies compared conventional sternal closure with new closure methods (rigid plate, thermoreactive clips, cables and flat wires). The new sternal closure methods make little or no difference compared to the standard closure when we analyse deep sternal wound infection [risk ratio 0.38, 95% confidence interval (CI) 0.02-7.63; I2 = 74%; 5 studies], superficial wound infection (risk ratio 1.34, 95% CI 0.46-3.92; I2 = 11%, 3 studies) and death (risk ratio 1.16, 95% CI 0.42-3.21; I2 = 0%, 3 studies), but pain score was lower in new sternal closure methods (mean difference -0.57, 95% CI -0.98 to -0.16, I2 = 0%, 3 studies). There were no meta-analyses of sternal union, hospital stay, reoperation or mechanic ventilation time because of the high heterogeneity between the studies in terms of these outcomes. CONCLUSIONS: New sternal closure methods probably make little or no difference regarding the prevention of sternal complications in the postoperative period when compared to the standard closure method.

Severe Dehiscence of Gastrojejunal Anastomosis after Gastric Bypass: Its Cure by Using Partially Covered Stent and Avoiding Migration.

BACKGROUND: Gastric leak is a severe complication of gastric bypass that is associated with significant morbidity and mortality. Anastomosis dehiscence usually occurs at gastrojejunal anastomosis and can appear simultaneously with gastric leak, for which treatment can be a challenge. Fistula may have several clinical impacts, depending on patient-related factors, fistula characteristics, onset time, and therapy proposal. Abdominal toilet, drainage, gastrostomy, and revisional surgery constitute the traditional approaches to dehiscence and fistula closure, with variable results. Currently, endoscopic stents are gaining space, promoting fistula sealing, secretion deviation, treating gastric stricture, and allowing early oral diet. Herein, we present a case of severe gastrojejunal anastomosis dehiscence treated with partially covered stent. MATERIALS AND METHODS: We present a video of a 39-year-old man with a body mass index of 40 Kg/m2 who underwent a Roux-en-Y gastric bypass and presented fever and leukocytosis. Gastric leak was diagnosed 7 days after the bariatric surgery. At first, he was submitted to three reoperations: laparotomy with abdominal toilet, abdominal drain, and gastrostomy. Sepsis was controlled, but drain output maintained the same debit. On the 22nd POD, it was decided to place a metallic stent. As the first step, an endoscopist looked at the lesser curvature. There was no continuity to the alimentary limb, and the anastomosis was disrupted. Careful inflation and washing was done, allowing identification of the alimentary limb, followed by guidewire passage, with radioscopic control. Once the guidewire was positioned, stent placement was possible and safe. Upper edge of stent was placed in the lower third of the esophagus. RESULTS: Patient progressed uneventfully. After 4 weeks, stent removal was attempted. However, it was not possible due to endoluminal tissue hyperplasia. Argon plasma was used three times to promote proliferative mucosa ablation. Stent was removed after 53 days, with no migration. The abdominal drain was removed 1 week later. After 6-months follow-up, the patient remains asymptomatic. CONCLUSION: Early dehiscence closure was observed, without recurrence. The use of partially covered self-expandable metallic stent is associated with lower migration rates; however, removal can be technically difficult due to tissue hyperplasia.

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina.

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.

Application of Unilateral Pectoralis Major Muscle Flap in the Treatment of Sternal Wound Dehiscence.

OBJECTIVE: This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence. METHODS: A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained. RESULTS: During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision. CONCLUSION: The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

Application of unilateral pectoralis major muscle flap in the treatment of sternal wound dehiscence

Abstract Objective: This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of the sternal wound dehiscence. Methods: A retrospective study including patients who underwent unilateral pectoralis major muscle flap was performed for the treatment of sternotomy dehiscence due to coronary artery bypass, valve replacement, congenital heart disease correction and mediastinitis, between 1997 and 2016. Data from the epidemiological profile of patients, length of hospital stay, postoperative complications and mortality rate were obtained. Results: During this period, 11 patients had their dehiscence of sternotomy treated by unilateral pectoralis major muscle flap. The patients had a mean age of 54.7 years, the mean hospital stay after flap reconstruction was 17.9 days (from 7 to 52 days). In two patients, it was necessary to harvest a flap from the rectus abdominis fascia, in association with the pectoralis major muscle flap, to facilitate the closure of the distal wound. In the postoperative period, seroma discharge from the surgical wound was observed in six patients, five reported intense pain (temporary), three had partial cutaneous dehiscence, and two presented granuloma of the incision. Conclusion: The complex wound from sternotomy dehiscences presents itself as a challenge to surgical teams. Treatment should include debridement of necrotic tissue and preferably coverage with well-vascularized tissue. We propose that the unilateral pectoralis major muscle flap is an interesting and low morbidity option for the reconstruction of sternal wound dehiscences, with proper sternum stability and satisfactory functional and aesthetic outcomes.

The role of free flaps for salvage of the exposed total ankle arthroplasty.

Total ankle arthroplasty in the right circumstances cannot only relieve discomfort; but, unlike an ankle arthrodesis, can restore enhanced ambulatory capabilities. Subsequent wound healing issues have the potential to ultimately lead to implant removal, a disaster that can be avoided by as early intervention as possible that will provide sustainable wound closure. Over the past 5 years, 5 patients have presented in a delayed fashion with wound breakdown following total ankle arthroplasty that required a free flap for successful prosthesis salvage. The mean wound size was 78.0 cm2 (range 14-200 cm2 ). Two gracilis and 2 latissimus dorsi muscle free flaps were chosen as a malleable means not just to cover but to fill these usually large 3-dimensional wounds. A single radial forearm perforator free flap was selected in one case for a superficial wound that required a long vascular pedicle to reach outside the zone of injury. The postoperative course for all was uneventful, with a minimum follow-up of 4 months. Function preservation following total ankle arthroplasty wound breakdown even after an untimely delay in referral can still be maintained using microsurgical tissue transfers. © 2014 Wiley Periodicals, Inc. Microsurgery 37:34-37, 2017.

Outcomes of Wound Dehiscence Post-Penetrating Keratoplasty.

PURPOSE: Penetrating keratoplasties (PKs) carry a lifetime risk of developing wound dehiscence, which can lead to severe consequences to vision. To better understand the risk, we analyzed the characteristics and outcomes of a series of patients with wound dehiscence post-PK. METHODS: Data were collected retrospectively on 31 eyes from 30 patients with a history of wound dehiscence repair post-PK between January 1, 2009, and April 30, 2014, and followed up at the Cornea Service at Wills Eye Hospital. Only patients who had surgical repair of an open wound dehiscence were included, excluding those with wound slippage but no aqueous leak. RESULTS: The mean age at wound dehiscence was 56 years with a mean time from PK to dehiscence of 9.8 years. Among the 31 eyes, 26 (26/31, 84%) had trauma-induced dehiscence, while 5 had unknown causations or no reported trauma. The mean size of dehiscence was 153 ± 66 degrees. Visual outcomes ranged from 20/50 to no light perception, with a majority between 20/100 and hand motion (18/30, 60%). Twenty eyes (20/26, 76%) lost their lens at dehiscence. All 10 phakic eyes lost their lenses. Five patients retained their lens implants and had a better mean visual outcome (average = 20/400) than the 10 patients who lost their implants (average = 20/800) (1 lens status was unknown postdehiscence). CONCLUSIONS: Wound dehiscence is a lifelong risk after PK regardless of the age, indication for corneal transplant, and time since transplant. A better visual outcome was associated with retained pseudophakia and clear corneas.

Uso exclusivo de fios absorvíveis em fendas labiopalatais / Exclusive use of absorbable suture threads in cleft lip and palate

INTRODUÇÃO: O tratamento de fendas labiopalatais tem etapas que podem trazer traumas psicológicos consideráveis aos pacientes e familiares. O uso de fios absorvíveis pode eliminar um destes momentos desconfortáveis. Contudo, a utilização exclusiva deste tipo de material de síntese ainda não é a preferência de todos os cirurgiões, principalmente em planos musculares. MÉTODOS: Levantados os dados dos pacientes operados no Hospital Universitário da Universidade Federal do Rio de Janeiro, submetidos à correção de fendas labiais ou palatais, nas quais foram utilizados somente fios absorvíveis (poliglecaprona 25 - Monocryl® ou poliglactina 910 - Vicryl Rapide®) em todos os panos de sutura (mucosa, músculo, pele). O período avaliado foi de 2007 a 2014. RESULTADOS: Encontramos 360 pacientes que se enquadraram no estudo. Não observamos diferenças quanto ao aspecto local das feridas durante o processo de absorção dos fios. A incidência de deiscências ou fístulas se manteve abaixo de 1% e não houve complicações relacionadas ao objetivo do estudo. As cicatrizes não se mostraram, a longo prazo, diferentes das obtidas com o uso de fios inabsorvíveis, utilizados em outros tipos de cirurgias. CONCLUSÕES: O uso exclusivo destes fios absorvíveis se mostrou uma opção eficaz e segura. Proporcionou cicatrizes de boa qualidade, força tênsil adequada (mesmo em planos musculares) e não observamos complicações relacionadas ao processo de absorção dos materiais empregados.

INTRODUCTION: The treatment of orofacial clefts comprises steps that may result in considerable psychological trauma for patients and their caregivers. The use of absorbable sutures may help to eliminate these uncomfortable situations. However, the exclusive use of this synthetic material is still not preferred by surgeons, particularly in the muscle planes. METHODS: Data from patients who underwent surgery at the University Hospital of the Federal University of Rio de Janeiro from 2007 to 2014 were used. The patients underwent correction of cleft lip or palate, using only absorbable sutures (poliglecaprone 25 - Monocryl® or polyglactin 910 - Vicryl Rapide®) in all suture planes (mucosa, muscle, skin). RESULTS: We found 360 patients who met the inclusion criteria for this study. We did not observe differences in terms of the local appearance of the wounds during the suture absorption process. The incidence of dehiscence or fistula cases was below 1%, and there were no complications regarding the objectives of the study. In the long term, the scars did not differ from those obtained with non-absorbable sutures used in other types of surgeries. CONCLUSIONS: The exclusive use of absorbable sutures was shown to be an efficient and safe option. These resulted in good quality scars and adequate tensile strength (even in muscle planes), and we did not observe complications related to the absorption process of the material used.

Prolapso transvaginal de omento como signo de rotura uterina / Omentum Transvaginal Prolapse as a Sign of Uterine Rupture

La rotura uterina es un evento obstétrico adverso poco común, causante de elevada morbilidad y mortalidad materno-fetal, cuya principal etiología es la dehiscencia de la cicatriz uterina previa. Excepcionalmente la rotura uterina pasa inadvertida y su diagnóstico se realiza tiempo después de sucedida, como es el caso que se presenta; de una mujer, en la cual se diagnosticó el prolapso transvaginal de omento meses después de un parto vaginal sin complicaciones. En la revisión de la literatura no se encontró el reporte de casos similares, de ahí el interés científico de su presentación(AU)

Uterine rupture is a rare adverse obstetric event, causing high morbidity and maternal and fetal mortality. Its main etiology is dehiscence of the previous uterine scar. Exceptionally uterine rupture goes unnoticed and its diagnosis is performed long after it occurs, as is the case presented here, a woman, in which the omentum transvaginal prolapse was diagnosed months after an uncomplicated vaginal delivery. In reviewing the literature, no similar cases reporting was found, hence the scientific interest in the presentation(AU)

A new classification of post-sternotomy dehiscence.

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.