Return to Play After Surgical Treatment for Acromioclavicular Joint Dislocation: A Systematic Review.

BACKGROUND: Acromioclavicular (AC) joint dislocation is a common clinical problem among young and athletic populations. Surgical management is widely used for high-grade dislocations (Rockwood III-VI) and in high-demand athletes at high risk of recurrence. PURPOSE: To systematically review the evidence in the literature to ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after surgical treatment for AC joint dislocation. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted in the PubMed database. Clinical studies were eligible for inclusion if they reported on RTP after surgical treatment for AC joint dislocation. Statistical analysis was performed with SPSS. RESULTS: We found 120 studies including 4327 cases meeting our inclusion criteria. The majority of patients were male (80.2%), with a mean age of 37.2 years (range, 15-85) and a mean follow-up of 34.5 months. Most were recreational athletes (79%), and the most common sport was cycling. The overall rate of RTP was 91.5%, with 85.6% returning to the same level of play. Among collision athletes, the rate of RTP was 97.3%, with 97.2% returning to the same level of play. In overhead athletes, the rate of RTP was 97.1%, with 79.2% returning to the same level of play. The mean time to RTP was 5.7 months (range, 1.5-15). Specific RTP criteria were reported in the majority of the studies (83.3%); time to return to play was the most commonly reported item (83.3%). Type III Rockwood injuries had the highest RTP rate at 98.7% and the earliest RTP at 4.9 months. Among the different surgical techniques, Kirschner wire fixation had the highest rate of RTP at 98.5%, while isolated graft reconstruction had the earliest RTP at 3.6 months. CONCLUSION: The overall rate of RTP was reportedly high after surgical treatment for AC joint dislocation, with the majority of patients returning to their preinjury levels of sport. There is a lack of consensus in the literature for what constitutes a safe RTP, with further focus on this topic required in future studies.

Posterior Shoulder Instability but Not Anterior Shoulder Instability Is Related to Glenoid Version.

Purpose: To assess and compare glenoid version in patients with anterior shoulder instability (ASI), posterior shoulder instability (PSI), and a control group. Methods: The operative notes of all patients that had undergone arthroscopic shoulder instability repair between January 2017 and May 2022 were retrospectively reviewed. Magnetic resonance imaging scans were then analyzed, and glenoid version was measured by a single blinded observer. A P value <.05 was considered statistically significant. Results: There were 100 patients included in the ASI group, 65 in PSI group, and 100 in the control group. The mean glenoid versions for the ASI group were -16°, -9.1°, and -9.2° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean glenoid versions for the PSI group were -21°, -13.4°, and -16.6° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean versions for the control group were -17.8°, -9.5°, and -9.8° for the vault version, simplified vault version and chondrolabral version, respectively. ANOVA testing and post hoc comparisons revealed the PSI group to be significantly more retroverted than both other groups P < .001. The ASI group's degree of glenoid version was not significantly different to that of the control P = .009. Conclusion: Patients with PSI have a higher degree of retroversion in comparison to those with ASI and control. There is no significant difference in glenoid version among patients with ASI when compared with control. Level of Evidence: Level III, retrospective comparative study.

Autologous Skin Grafts, versus Tissue-engineered Skin Constructs: A Systematic Review and Meta-analysis.

For over 100 years, autologous skin grafts have remained the gold standard for the reconstruction of wounds but are limited in availability. Acellular tissue-engineered skin constructs (acellular TCs) and cellular tissue-engineered skin constructs (cellular TCs) may address these limitations. This systematic review and meta-analysis compare outcomes between them. Methods: A systematic review was conducted using PRISMA guidelines, querying MEDLINE, Embase, Web of Science, and Cochrane to assess graft incorporation, failure, and wound healing. Case reports/series, reviews, in vitro/in vivo work, non-English articles or articles without full text were excluded. Results: Sixty-six articles encompassing 4076 patients were included. No significant differences were found between graft failure rates (P = 0.07) and mean difference of percent reepithelialization (p = 0.92) when split-thickness skin grafts were applied alone versus co-grafted with acellular TCs. Similar mean Vancouver Scar Scale was found for these two groups (p = 0.09). Twenty-one studies used at least one cellular TC. Weighted averages from pooled results did not reveal statistically significant differences in mean reepithelialization or failure rates for epidermal cellular TCs compared with split-thickness skin grafts (p = 0.55). Conclusions: This systematic review is the first to illustrate comparable functional and wound healing outcomes between split-thickness skin grafts alone and those co-grafted with acellular TCs. The use of cellular TCs seems promising from preliminary findings. However, these results are limited in clinical applicability due to the heterogeneity of study data, and further level 1 evidence is required to determine the safety and efficacy of these constructs.

Has the Increase of Women in Surgical Training Programs Led to a Concomitant Increase in Female Leadership Positions? A 10-Year Analysis.

INTRODUCTION: Women represent greater than 50% of medical students in America and are becoming increasingly well represented in surgical fields. However, parity at the trainee level has yet to be accomplished, and surgical leadership positions have remained disproportionately biased toward men. To date, there have been no comparisons on the progress within plastic surgery and other surgical specialties. This investigates the gender disparity in resident and leadership representation over the past 10 years within surgical specialties and how these disparities compare to plastic surgery. METHODS: Counts of female and male residents and surgical society leaders were collected from 2008 to 2018. Surgical fields included plastic, vascular, urologic, neurologic, orthopedic, cardiothoracic, and general surgery. Leadership positions were defined as board seats on executive committees of major surgical societies or board associations. Data were acquired from publicly available sources or provided directly from the organizations. Resident data were obtained from the Accreditation Council of Graduate Medical Education residents' reports. Individuals holding more than 1 leadership position within a year were counted only once. RESULTS: In our aggregated analysis, the proportion of women in surgical leadership lags behind women in surgical residency training across all specialties (13.2% vs 27.3%, P < 0.01). General surgery had the highest proportion of female residents and leaders (35% and 18.8%, P < 0.01), followed by plastic (32.2% and 17.3%, P < 0.01), vascular (28.2% and 11.3%, P < 0.01), urologic (24.3% and 5.1%), and cardiothoracic surgery (20.5% and 7.8%, P < 0.01). Women in surgical leadership, however, increased at a faster rate than women in surgical training (11% vs 7%, P < 0.05). Plastic surgery showed the greatest rate of increase in both residents and leaders (17% and 19%, P < 0.05) followed by cardiothoracic surgery (16% and 9%, P < 0.05) and general surgery (8% and 14%, P < 0.05). For neurologic and orthopedic surgery, neither the difference in proportions between residents and leaders nor the yearly growth of these groups were significant. CONCLUSIONS: Between 2008 and 2018, women in plastic surgery training and leadership positions have shown the most significant growth compared with other surgical subspecialties, demonstrating a strong concerted effort toward gender equality among surgical professions.

Efficacy of leupeptin in treating ischemia in a rat hind limb model.

Prolonged tourniquet use can lead to tissue ischemia and can cause progressive muscle and nerve injuries. Such injuries are accompanied by calpain activation and subsequent Wallerian-like degeneration. Several known inhibitors, including leupeptin, are known to impede the activity of calpain and associated tissue damage. We hypothesize that employment of leupeptin in a rat model of prolonged hind limb ischemia can mitigate muscle and nerve injuries. Sprague-Dawley rats (n = 10) weighing between 300-400 g were employed in this study. Their left hind limbs were subjected to blood flow occlusion for a period of 2-h using a neonatal blood pressure cuff. Five rats were given twice weekly intramuscular leupeptin injections, while the other five received saline. After 2 weeks, the animals were euthanized, their sciatic nerves and gastrocnemius muscles were harvested, fixed, stained, and analyzed using NIH Image J software. The administration of leupeptin resulted in larger gastrocnemius muscle fiber cross-sectional areas for the right (non-tourniquet applied) hindlimb as compared to that treated with the saline (p = 0.0110). However, no statistically significant differences were found between these two groups for the injured left hindlimb (p = 0.1440). With regards to the sciatic nerve cross-sectional areas and sciatic functional index, no differences were detected between the leupeptin and control treated groups for both the healthy and injured hindlimbs. This research provides new insights on how to employ leupeptin to inhibit the degenerative effects of calpain and preserve tissues following ischemia resulting from orthopedic or plastic surgery procedures.

Negative-Pressure Wound Therapy versus Standard Surgical Dressings after Malignant Tumor Resection: A Systematic Review and Meta-Analysis.

BACKGROUND: Negative-pressure wound therapy offers many advantages over standard surgical dressings in the treatment of open wounds, including accelerated wound healing, cost savings, and reduced complication rates. Although contraindicated by device manufacturers in malignancy-resected wounds because of hypothesized risk of tumor recurrence, negative-pressure wound therapy is still applied postoperatively because of limited clinical support. The authors performed a systematic review with meta-analysis to compare negative-pressure wound therapy outcomes with those of standard surgical dressings on open wounds, with their null hypothesis stating there would be no outcome differences. METHODS: A systematic review of the literature on negative-pressure wound therapy and standard surgical dressings on malignancy-resected wounds was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Embase, CINAHL, and Cochrane Central databases. Meta-analysis compared group outcomes, including malignancy recurrence, wound complication, and surgical site infection rates, with a random effects model. RESULTS: A total of 1634 studies were identified and 27 met eligibility criteria, including four randomized controlled trials, four prospective cohort studies, and 19 retrospective reviews. Eighty-one percent of articles ( n = 22) recommended negative-pressure wound therapy in malignancy-resected wounds. Meta-analysis determined that the treatment yielded significantly lower overall surgical site infection ( p = 0.004) and wound complication ( p = 0.01) rates than standard surgical dressings; however, there were no statistically significant differences found for other outcomes between the two groups. CONCLUSIONS: This review demonstrates favorable outcomes of negative-pressure wound therapy over standard surgical dressings for malignancy-resected wounds without an increased risk of malignancy recurrence. However, because limited randomized controlled trials (detailing only incisional wounds for limited malignancies and anatomic regions) are available, additional high-power randomized controlled trials are recommended.

Lung-Derived Selectins Enhance Metastatic Behavior of Triple Negative Breast Cancer Cells.

The lung is one of the deadliest sites of breast cancer metastasis, particularly for triple negative breast cancer (TNBC). We have previously shown that the lung produces several soluble factors that may enhance the metastatic behavior of TNBC, including E-, L-, and P-selectin. In this paper, we hypothesize that lung-derived selectins promote TNBC metastatic behavior and may serve as a potential therapeutic target. Lungs were isolated from mice and used to generate lung-conditioned media (CM). Lung-derived selectins were immunodepleted and TNBC migration and proliferation were assessed in response to native or selectin-depleted lung-CM. A 3D ex vivo pulmonary metastasis assay (PuMA) was used to assess the metastatic progression of TNBC in the lungs of wild-type versus triple-selectin (ELP-/-) knockout mice. We observed that individual lung-derived selectins enhance in vitro migration (p ≤ 0.05), but not the proliferation of TNBC cells, and that ex vivo metastatic progression is reduced in the lungs of ELP-/- mice compared to wild-type mice (p ≤ 0.05). Treatment with the pan-selectin inhibitor bimosiamose reduced in vitro lung-specific TNBC migration and proliferation (p ≤ 0.05). Taken together, these results suggest that lung-derived selectins may present a potential therapeutic target against TNBC metastasis. Future studies are aimed at elucidating the pro-metastatic mechanisms of lung-derived selectins and developing a lung-directed therapeutic approach.

Body Contouring in Massive Weight Loss Patients Receiving Venous Thromboembolism Chemoprophylaxis: A Systematic Review.

Venous thromboembolism (VTE) events are the leading cause of morbidity and mortality in plastic surgery. Currently, there is no consensus regarding the use of VTE chemoprophylaxis in the context of the risk for bleeding following specific body contouring procedures. Furthermore, there is increasing popularity of these procedures in the massive weight loss (MWL) patient population, who may be at higher risk due to multiple risk factors. The purpose of this study was to stratify the incidence of VTE and bleeding events among individual, specific body contouring procedures in MWL patients receiving chemoprophylaxis. METHODS: A systematic review was designed according to PRISMA guidelines. We screened all articles published between 1988 and 2018 reporting chemoprophylaxis status, VTE, and bleeding events in MWL patients undergoing body contouring procedures. RESULTS: Thirty-one publications were reviewed. The VTE incidence for any procedure was too low to reach significance. Overall, hematoma incidence in single-procedure patients (8.7%) was significantly higher than concomitant-procedure patients (4.2%, P < 0.01). However, when stratified into operative and nonoperative hematomas, no significant difference between single- and concomitant-procedure groups overall was demonstrated for either category. Individually, only thighplasty patients had a higher rate of operative hematomas when undergoing thighplasty alone (5.3%) compared with thighplasty with concomitant procedures (0.6%, P < 0.05). CONCLUSIONS: Overall, MWL patients undergoing single body contouring procedures (among abdominoplasty, belt lipectomy, thighplasty) were found to have a higher risk of hematoma compared with those undergoing combined contouring procedures. However, stratified hematoma data revealed no differences in overall risk between single- and multiple-procedure operations.

Postoperative Venous Thromboembolism Prophylaxis Utilizing Enoxaparin Does Not Increase Bleeding Complications After Abdominal Body Contouring Surgery.

BACKGROUND: Venous thromboembolism (VTE) chemoprophylaxis warrants an individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery. OBJECTIVES: The aim of this study was to determine the safety of a 7-day postoperative enoxaparin regimen for VTE prophylaxis compared with a single preoperative dose of heparin in abdominal body contouring surgery. METHODS: This single-institution pre-post study investigated the safety of a 7-day enoxaparin postoperative regimen in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 U subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once daily for 7 days postoperatively. RESULTS: A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk-assessment model. There were no statistically significant differences in the 2 primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7% vs 10.1%, P = 0.029), which was secondary to higher rates of revision procedures. CONCLUSIONS: A 7-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for postdischarge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate.

Acellular Dermal Matrix Sterility: Does It Affect Microbial and Clinical Outcomes Following Implantation?

The use of acellular dermal matrices (ADMs) in breast reconstruction is a controversial topic. Recent literature has investigated the effects of ADM sterilization on infectious complications, although with varying conclusions. Previous work by our group showed no difference between aseptic and sterilized products immediately out of the package. In this study, we investigate the microbiologic profiles of these agents after implantation. METHODS: In this prospective study, we cultured samples of ADM previously implanted during the first stage of tissue expander-based immediate breast reconstruction. A 1 cm2 sample was excised during the stage II expander-implant exchange procedure, and samples were incubated for 48 hours in tryptic soy broth. Samples with growth were further cultured on tryptic soy broth and blood agar plates. Patient records were also analyzed, to determine if ADM sterilization and microbial growth were correlated with infectious complications. RESULTS: In total, 51 samples of ADM were collected from 32 patients. Six samples were from aseptic ADM (AlloDerm), 27 samples were from ADM sterilized to 10-3 (AlloDerm Ready-to-Use), and 18 samples were from products sterilized to 10-6 (AlloMax). No samples demonstrated bacterial growth. Only 5 patients experienced postoperative complications, of whom only 1 patient was infectious in nature. We failed to demonstrate a statistically significant correlation between sterility and postoperative complications. CONCLUSIONS: Our findings showed no difference in microbial presence and clinical outcomes when comparing ADM sterility. Furthermore, no samples demonstrated growth in culture. Our study brings into question the necessity for terminal sterilization in these products.

Development of In Vitro Bioengineered Vascular Grafts for Microsurgery and Vascular Surgery Applications.

INTRODUCTION: The use of vascular grafts is continuing to rise due to the increasing prevalence of coronary artery bypass grafting and microvascular flap-based tissue reconstructions. The current options of using native vessels (saphenous vein) or the synthetic grafts (Dacron) have been unable to manage current needs. In this study, we employed an original tissue engineering approach to develop a multi-layered vascular graft that has the potential to address some of the limitations of the existing grafts. MATERIALS AND METHODS: Biomaterials, gelatin and fibrin, were used to develop a two-layered vascular graft. The graft was seeded with endothelial cells and imaged using confocal microscopy. The graft's architecture and its mechanical properties were also characterized using histology, Scanning Electron Microscopy and rheological studies. RESULTS: Our methodology resulted in the development of a vascular graft with precise spatial localization of the two layers. The endothelial cells fully covered the lumen of the developed vascular graft, thus providing a non-thrombogenic surface. The elastic modulus of the biomaterials employed in this graft was found to be 5.186 KPa, paralleling that of internal mammary artery. The burst pressure of this graft was also measured and was found close to that of the saphenous vein (~2000 mm Hg). CONCLUSIONS: We were successfully able to employ a unique method to synthesize a multi-layered vascularized graft having adequate biological and mechanical properties. Studies are ongoing involving implantation of this developed vascular graft in the rat femoral artery and characterization of parameters such as vascular remodeling and patency.

Digital Image Speckle Correlation to Optimize Botulinum Toxin Type A Injection: A Prospective, Randomized, Crossover Trial.

BACKGROUND: Historically, physicians have relied on their subjective measures when determining the site and dosages for botulinum toxin type A injections. Digital image speckle correlation is a technology that tracks pore movement from rest to maximal exertion, allowing for the determination of the optimal sites of injection. In this prospective, randomized, crossover trial, the efficacy of using digital image speckle correlation was compared to physician assessment in choosing botulinum toxin type A injection sites. METHODS: Ten female patients were analyzed in this blinded crossover study. Subjects were randomized to either injections based on digital image speckle correlation analysis or injections based on the 2004 facial aesthetics consensus recommendations. All patients received 20 U of botulinum toxin type A in the glabellar region and were crossed over and reinjected after 6 months. Follow-up was completed with the Facial Line Outcomes 11-item survey and repeated imaging with digital image speckle correlation, to measure patient satisfaction and degree of paralysis, respectively. Statistical comparison was completed by means of matched sample t test. RESULTS: On average, the digital image speckle correlation analysis provided 4.8 injection sites, whereas the practitioner chose five injections sites. Patients receiving digital image-directed injections had higher rates of satisfaction on the Facial Line Outcomes instrument (p = 0.0003) and a larger degree of paralysis (p = 0.003). Furthermore, muscle function returned to normal later in patients injected with digital image speckle correlation (17.9 weeks versus 20 weeks; p = 0.03). CONCLUSIONS: This study demonstrates the benefits of using digital image speckle correlation in determining optimal botulinum toxin type A injection location. Digital analysis allows practitioners to better treat facial rhytides by eliminating subjective decisions regarding dose and site of injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Comparison of the Basal View and a Previously Standardized Cleft Lip Rating Scale.

OBJECTIVES: Numerous scales assessing the aesthetics of cleft lip repair exist. Most, including the Asher-McDade scale, use frontal and lateral views, while neglecting a basal view. We believe this view is important for properly assessing the aesthetics of repair. In this study, we evaluate the basal view in comparison to the Asher-McDade scale. METHODS: This scale was based on progressive columellar shortening and alar flaring/slumping. A panel of 4 plastic surgeons applied the basal and Asher-McDade scales to pictures of patients with repaired unilateral cleft lip in 56 multiethnic participants aged 5 years to 18 years; images were scored from 1 to 5 (best). Statistical analysis was done via Spearman correlation. RESULTS: Scores from plastic surgeons correlated strongly for each view. There was moderate correlation for the basal view with both nasal form and deviation scores ( P < .05). As expected, there were no strong correlations between the basal view and vermillion border or profile. DISCUSSION: The Asher-McDade scale has been used to evaluate cleft lift repairs but is limited due to its subjective nature. The basal view scale grades these repairs by using a scale of progressive columellar shortening and alar flaring/slumping, which provides an opportunity for quantification and standardization. Our results show that the basal view correlates with the Asher-McDade scale among raters, thus providing an objective and validated measure of cleft lip repair.

Infectious Loss of Tissue Expanders in Breast Reconstruction: Are We Treating the Right Organisms?

BACKGROUND: Postoperative infections following tissue expander-based breast reconstruction represent a significant threat to the reconstructive process. Studies have found the incidence to be as high as 29%. There has been abundant research into the risk factors associated with these infections, although very few studies have focused on the causative organisms. The purpose of this study was to investigate the bacterial flora associated with tissue expander infections after breast reconstruction. METHODS: A retrospective analysis of all patients who underwent tissue expander-based breast reconstruction at our institution between February 2010 and April 2013 was conducted. The medical records were reviewed for demographic information, medical history, operative technique, postoperative course, and culture results. Descriptive data analysis was then performed. RESULTS: A total of 56 tissue expander infections were identified in 49 patients during the study period. 41.1% of the cultures grew gram-positive organisms, whereas 28.6% grew gram-negative species. The 2 most common organisms were Staphylococcus aureus (17.9%) and Staphylococcus epidermidis (14.3%). Pseudomonas aeruginosa was the most frequent gram-negative species and was also the third most frequent organism cultured (10.9%). DISCUSSION: Due to the high rate of infection in breast reconstruction patients, adequate perioperative prophylaxis is necessary. The surgeon must also be prepared to treat patients who may return with infection postoperatively. Although the majority of our infections were secondary to normal skin flora, a significant proportion were caused by gram-negative species. Given these results, the empiric antibiotic of choice for postoperative infections should be reconsidered to cover for these various organisms.

Is Sterile Better Than Aseptic? Comparing the Microbiology of Acellular Dermal Matrices.

INTRODUCTION: Postoperative infections are a major complication associated with tissue-expander-based breast reconstruction. The use of acellular dermal matrix (ADM) in this surgery has been identified as a potential reservoir of infection, prompting the development of sterile ADM. Although aseptic and sterile ADMs have been investigated, no study has focused on the occurrence and clinical outcome of bacterial colonization before implantation. METHODS: Samples of aseptic AlloDerm, sterile Ready-To-Use AlloDerm, and AlloMax were taken before implantation. These samples were incubated in Tryptic soy broth overnight before being streaked on Trypticase soy agar, MacConkey agar, and 5% blood agar plates for culture and incubated for 48 hours. Culture results were cross-referenced with patient outcomes for 1 year postoperatively. RESULTS: A total of 92 samples of ADM were collected from 63 patients. There were 15 cases of postoperative surgical site infection (16.3%). Only 1 sample of ADM (AlloMax) showed growth of Escherichia coli, which was likely a result of contamination. That patient did not develop any infectious sequelae. Patient outcomes showed no difference in the incidence of seroma or infection between sterile and aseptic ADMs. CONCLUSIONS: This study evaluates the microbiology of acellular dermal matrices before use in breast reconstruction. No difference was found in the preoperative bacterial load of either aseptic or sterile ADM. No significant difference was noted in infection or seroma formation. Given these results, we believe aseptic processing used on ADMs is equivalent to sterile processing in our patient cohort in terms of clinical infection and seroma occurrence postoperatively.

Are Prophylactic Postoperative Antibiotics Necessary for Immediate Breast Reconstruction? Results of a Prospective Randomized Clinical Trial.

BACKGROUND: Closed-suction drains, implants, and acellular dermal matrix (ADM) are routinely used in tissue expander-based immediate breast reconstruction (TE-IBR). Each of these factors is thought to increase the potential for surgical site infection (SSI). Although CDC guidelines recommend only 24 hours of antibiotic prophylaxis after TE-IBR, current clinical practices vary significantly. This study evaluated the difference in SSI between 2 different prophylactic antibiotic durations. STUDY DESIGN: A noninferiority randomized controlled trial was designed in which TE-IBR patients received antibiotics either 24 hours postoperatively or until drain removal. The primary outcome was SSI, as defined by CDC criteria. Operative and postoperative protocols were standardized. Secondary endpoints included clinical outcomes up to 1 year and all implant loss, or reoperation. RESULTS: There were 112 TE-IBR patients (180 breasts) using ADM who were randomized into 2 study arms, with 62 patients in the 24-hour group and 50 in the extended group. Surgical site infection was diagnosed in 12 patients in the 24-hour group and 11 in the extended group (19.4% vs 22.0%, p = 0.82). The extended group had 7 patients who required IV antibiotics and an overall implant loss in 7 patients (14.0%). The 24-hour group had 4 patients who required IV antibiotics, with 3 requiring removal (4.8%). Patients with diabetes, postoperative seroma, or wound dehiscence were all more likely to develop SSI (p < 0.02). CONCLUSIONS: In a randomized controlled noninferiority trial, 24 hours of antibiotics is equivalent to extended oral antibiotics for SSI in TE-IBR patients. Additional multicenter trials will further assess this important aspect of TE-IBR postoperative care.

AdVEGF-All6A+ Preconditioning of Murine Ischemic Skin Flaps Is Comparable to Surgical Delay.

BACKGROUND: Surgical flap delay is commonly used in preconditioning reconstructive flaps to prevent necrosis. However, staged procedures are not ideal. Pharmacologic up-regulation of angiogenic and arteriogenic factors before flap elevation poses a nonsurgical approach to improve flap survival. METHODS: Male Sprague Dawley rats were divided into control (n = 16), surgical delay (Delay), AdNull, AdEgr-1, and AdVEGF (n ≥ 9/group) groups. Delay rats had a 9 cm × 3 cm cranial based pedicle skin flap incised 10 days prior to elevation. Adenoviral groups received 28 intradermal injections (10(9) pu/animal total) throughout the distal two thirds of the flap 1 week prior to elevation. At postoperative day (POD) 0 flaps were elevated and silicone sheeting was placed between flap and wound bed. Perfusion analysis in arbitrary perfusion units of the ischemic middle third of the flap using laser Doppler imaging was conducted preoperatively and on POD 0, 3, and 7. Clinical and histopathologic assessments of the skin flaps were performed on POD 7. RESULTS: AdVEGF (50.8 ± 10.9 APU) and AdEgr-1 (39.3 ± 10.6 APU) perfusion levels were significantly higher than controls (16.5 ± 4.2 APU) on POD 7. Delay models were equivalent to controls (25.9 ± 6.8 APU). AdVEGF and Delay animals showed significantly more viable surface area on POD 7 (14.4 ± 1.3 cm(2), P < 0.01 and 12.4 ± 1.2 cm(2), P < 0.05, respectively) compared with Controls (8.7 ± 0.7 cm(2)). CONCLUSIONS: AdVEGF preconditioning resulted in flap survival comparable to surgical delay. Adenoviral preconditioning maintained perfusion levels postoperatively while surgical delay did not.

Utilizing Indocyanine Green Dye Angiography to Detect Simulated Flap Venous Congestion in a Novel Experimental Rat Model.

BACKGROUND: Venous congestion is a leading cause for free flap failure and still relies on clinical observation as the diagnostic gold standard. We sought to characterize blood flow in a variable venous congestion murine hind limb model using indocyanine green (ICG, SPY Pack, LifeCell, Branchburg, NJ) angiography. METHODS: Male Sprague-Dawley rats (Charles River, Hudson, NY) underwent bilateral partial amputation at the inguinal ligament, leaving only the femoral vessels and femur intact. Complete unilateral venous occlusion was achieved via suture ligation, while partial occlusion was achieved by surrounding the femoral vein with a synthetic microtube to achieve 25, 75, 85, or 92% occlusion. Relative blood flow of occluded and control limbs was tracked with ICG angiography throughout a 90-minute time course. RESULTS: ICG angiography detected statistically significant (p < 0.05) reductions in limb blood flow 1 and 2 minutes following ICG injection in the 100, 92, and 85% occluded limbs when compared with contralateral control limbs. Dynamic tracking using the slope of ICG inflow for 45 seconds postinjection reflected this same significant difference. No statistically significant change in limb blood flow or dye influx rate was observed in the 25 and 75% occlusion groups. CONCLUSIONS: ICG angiography can detect venous congestion in a rat lower extremity model reliably at occlusion rates ≥ 85%. This method may offer surgeons an intraoperative diagnostic tool to identify venous congestion at extremely early time points, allowing for immediate intervention. Further investigation and characterization is warranted in a larger animal model before clinical adaptation.

Biochemical characterization of a factor X activator protein purified from Walterinnesia aegyptia venom.

Factor X of blood coagulation cascade can be activated by both intrinsic and extrinsic activating complex, trypsin and some kind of snake venom. A factor X activator protein is reported in Elapidae snake venom. The aim of this study was to evaluate biochemical properties of factor X activator protein because of its prospective application in biochemical research and therapeutics. Crude venom was fractionated on a HPLC system Gold 126/1667 using a combination of Protein PAK 125 and Protein PAK 60 Columns. Molecular weight was determined using SDS-PAGE. Walterinnesia aegyptia venom was fractionated into several protein peaks, but procoagulant and factor X activation activity coexisted into peak no.6. It appeared as single band on native PAGE and molecular weight was 60,000 ± 3. Purified up to 37-fold over crude venom. It shortened recalcification time, effect was dose-dependent and strictly Ca(2++)-dependent. Factor X activator seems to be able to activate factor X specifically because it showed no activation activity on human prothrombin, plasminogen, or protein C. It did not hydrolyze factor Xa substrate S-2222, thrombin substrate S-2238, plasmin substrate S-2251 or S-2302 and kalikrein substrate S-2266. It did not hydrolyze synthetic ester benzoyl arginine ethyl ester. Procoagulant activity was completely inhibited by irreversible serine protease inhibitors phenylmethylsulphonyl fluoride and N-p-tosylphenylalanine chloromethyl ketone. This study illustrates that factor X activator from W. aegyptia is though different in many aspects from factor X activators of Viperidae and Crotalidae venoms, but shows several properties identical to factor X activators from Elapidae venoms.

Creation of gastric conduit free-graft with intraoperative perfusion imaging during pancreaticoduodenectomy in a patient post esophagectomy.

As surgery becomes more successful for complicated malignancies, patients survive longer and can unfortunately develop subsequent malignancies. Surgical resection in these settings can be treacherous and manipulations of the patient's anatomy need to be closely considered before embarking on major operations. We report a case of a patient who survived esophageal resection for locally advanced esophageal cancer only to develop a new pancreatic head malignancy. Careful upfront planning allowed for a successful resection with an uncomplicated recovery. She underwent open pancreaticoduodenectomy, and to maintain perfusion to the gastric conduit a microvascular anastomosis of the gastroepiploic pedicle was performed to the middle colic vessels. Intraoperative fluorescent imaging was used to evaluate the anastomosis as well as gastric and duodenal perfusion during the case.