Major wound complication risk factors following soft tissue sarcoma resection. Wound-healing complications represent an important source of morbidity in patients treated surgically for soft tissue sarcomas (STS). The purpose of this study was to determine which factors are predictive of major wound complication rates following STS resection, including tumour site, size, grade, and depth, as well as radiotherapy and chemotherapy. We reviewed 256 cases of STS treated surgically between 2000 and 2011. The primary outcome was occurrence of major wound complications post STS resection. Major wound complications were more likely to occur post STS resection with larger tumour diameters (p = 0.001), high grade tumours (p = 0.04), location in the proximal lower extremity (p = 0.01), and use of preoperative radiotherapy (p = 0.01). Tumours located in the adductor compartment were at highest risk of complications. We did not demonstrate a significant difference in complications rates based on method of closure. Diabetes, smoking, obesity, tumour diameter, tumour location in the proximal lower extremity, and preoperative radiotherapy were independent predictors on multivariate analysis. There are multiple predictors for major wound complications post STS resection. A more aggressive resection of irradiated soft tissues, combined with primary reconstruction, should be considered in cases with multiple risk factors

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

Reported wound complication in below knee surgery can be quite high. Recent study demonstrated that increased blood loss and hematoma formation increase wound complications especially in foot and ankle surgeries. Despite the evidence on the benefit of TXA on blood loss in TKA and THA it is not routinely used by surgeon in below knee surgery. To assess the efficacy and safety of this medication in reducing wound complication and blood loss and the risk of thromboembolic complications in patients undergoing below knee surgery. A systematic literature search of PubMed, Embase, Ovid, the Cochrane Library and AAOS and AOFAS conference proceedings was conducted. The primary outcome was the rate of wound complications. Data were analyzed using the Review Manager 5.3 software. Nine studies involving 861 patients met the inclusion criteria. The meta-analysis indicated that TXA, when compared to a control group, reduced wound complications (OR, 0.54; 95% IC, 0.31 to 0.95, p = 0,03), blood loss (MD = −149,4 ml; 95% CI, −205,3ml to −93,6ml), post-operative drainage (MD = −169,8 ml; 95% CI, −176,7 to −162,9 ml) and hemoglobin drop (MD = −8,75 g/dL; 95% IC, −9,6 g/dL to −7,8 g/dL). There was no significant difference in thromboembolic events (RR 0,53; 95% CI, 0,15 - 1,90; p = 0,33). This study demonstrated that TXA could be use in below knee surgery to reduce wound complication and blood loss without increased thromboembolic complications. The small number of studies limit the findings interpretation. Further studies are needed to sustain those resutls

Swelling following an ankle fracture is commonly believed to preclude surgical fixation, delaying operative treatment to allow the swelling to subside. This is in an attempt to achieve better soft tissue outcomes. We aim to identify whether pre-operative ankle swelling influences postoperative wound complications following ankle fracture surgery. This is a prospective cohort study of 80 patients presenting to a tertiary referral centre with operatively managed malleolar ankle fractures. Ankle swelling was measured visually and then quantitatively using the validated ‘Figure-of-eight’ technique. Follow-up was standardised at 2, 6, and 12 weeks post-operatively. Wound complications, patient co-morbidities, operative time, surgeon experience, and hospital stay duration were recorded. The complication rate was 8.75% (n=7), with 1 deep infection requiring operative intervention and all others resolving with oral antibiotics and wound cares. There was no significant difference in wound complication rates associated with quantitative ankle swelling (p=0.755), visual assessment of ankle swelling (p=0.647), or time to operative intervention (p=0.270). Increasing age (p=0.006) and female gender (p=0.049) had a significantly greater probability of wound complications. However, BMI, smoking status, level of the operating surgeon, and tourniquet time were not significantly different. Visual assessment of ankle swelling had a poor to moderate correlation to ‘Figure-of-eight’ ankle swelling measurements ICC=0.507 (0.325- 0.653). Neither ankle swelling nor time to surgery correlates with an increased risk of postoperative wound complication in surgically treated malleolar ankle fractures. Increasing patient age and female gender had a significantly greater probability of wound infection, irrespective of swelling. Visual assessment of ankle swelling is unreliable for quantifying true ankle swelling. Operative intervention at any time after an ankle fracture, irrespective of swelling, is safe and showed no better or worse soft tissue outcomes than those delayed for swelling

For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating; they may result in multiple subsequent surgeries and significant patient morbidity. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in resections of irradiated soft tissue sarcoma of the extremities. A consecutive series of patients of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc, Kalamazoo MI) at the time of closure. Three fellowship trained Orthopaedic Oncologic Surgeons were asked to prospectively predict likelihood of wound complications based on fluorescence. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. An a priori power analysis demonstrated that 5 patients were necessary to achieve statistical significance. Univariate and multivariate statistical analyses were performed to identify predictors of wound complications. 14 patients were consecutively imaged. The diagnosis was undifferentiated pleomorphic sarcoma in 9 (64.3%) of patients; 11 (78.6%) tumors were high grade. There were 6 patients with wound complications classified as “aseptic” in 5 cases and secondary to hematoma in 1 case. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. In the area of wound complication, the mean % of maximal signal for wound complications was 49% during the inflow phase and 48% during the peak phase. The mean % maximal signal for peri-incisional tissue without wound complications was 77% during the inflow phase and 83% during the peak phase (p=0.003 and p<0.001). During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC=0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the area under the curve (AUC=0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity 100%. Intraoperative use of indocyanine green fluorescent angiography may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis. Future studies are necessary to validate this technology in a prospective manner and to determine if interventions can be instituted to prevent predicted wound complications

To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery). The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study. Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization. Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications

Abstract. Introduction. FHL transfer for management of chronic Achilles' tendon ruptures is done both open and endoscopically. But there are no published studies comparing open and endoscopic results. Our study aims to compare them and determine the suitability of these methods. Materials and methods. Fourteen patients were treated endoscopically while 26 with an open technique. Of the 26, fourteen had an open Achilles tendon repair and FHL transfer while 12 has only open FHL transfer. All the endoscopic patients had only an FHL transfer. We compared demographics, complications of the procedure, recovery times, return to work and strength after 1 year. We noted ATRS at 6 months and 1 year for all three groups. We also conducted an MRI scan of three patients each of the three groups to determine the state of Achilles tendon and FHL tendon after 1 year of surgery. Results. There were similar complication rates for both the only FHL groups but the open FHL + Achilles' repair had more complications both for wound complications and saphenous neuropraxia. The recovery time, return to work and ATRS at 6 months was better for the endoscopic group as compared to both open groups. The strength and ATRS at 1 year were similar for all three groups. Conclusion. Endoscopic FHL transfer is safe and provides earlier return to work and better 6 months patient satisfaction then the open method. It also has less post op complications than open FHL + Achilles tendon repair, while maintains the same strength after 1 year

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures. This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up. We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up. We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures

Total Joint Arthroplasty (TJA) is a successful orthopaedic procedure allowing dramatic clinical and functional improvements. Globally, there's been an increase in demand and performed cases associated with an increase in complications. Subsequently, focus on the prevention of complications has become important worldwide. The incidence of venous-thrombolic events (VTE) despite great attention has not diminished despite much investigation. A balance between efficacy and safety from the available agents is essential. Low molecular weight heparin (LMWH) has been commonly used, but oral anti-coagulants have become more popular. The aim of this study was to assess the adherence LMWH and the effectiveness and safety of preventing VTE in post-operative arthroplasty patients in a South African setting. We conducted a prospective cohort study that included hip and knee, primary and revision, arthroplasty patients who received thromboprophylaxis with one daily injection of LMWH for 14 days post discharge. Patients who omitted 1 or more doses during the follow up period were classified as “non adherent”. A questionnaire was used at follow up visits at least 6 weeks post-operatively. 100 consecutive patients were followed up. The mean age of patients was 63.45 years. There were 68 % female patients. There was a 92% compliance rate. 60 % of patients had the injection administered by a family member, 38 % administered it themselves and 2 % had the injection administered by health professionals. Venous thromboembolic events were confirmed in 5 % at 7.86 days after surgery. Three patients had persistent wound drainage after surgery, however, none required reoperation or readmission. Compliance with LMWH is high and is comparable with oral agents. It is effective in preventing VTE and safe with regards to bleeding and wound complications in a South African setting. Patient education regarding medications may improve compliance of the medication

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Introduction. The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children. Materials & Methods. A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for. Results. There were 17 cases, in 15 patients, in our case series where calcium sulphate synthetic bone graft was used. The average patient age was 12.0 years (range 5 years – 17 years). Indications for use included likely infection (12), possible infection (3), and 2 elective finger cases (enchondroma and osteotomy). The humerus was the most common target site (5), followed by the femur (4), tibia (3), calcaneum (2), finger (2) and metatarsal (1) also included. There were positive intra-operative microbiology samples for eleven cases (Staphylococcus aureus and Staphylococcus epidermidis). Antibiotics were used in all cases except the elective finger surgery, and choice ranged between vancomycin, gentamicin, or a combination of both. Two patients required return to theatre for management of ongoing deep infection, although one case was later deemed to be non-infective osteomyelitis. Seven patients had undergone debridements prior to the definitive one with calcium sulphate (5 without Calcium Sulphate, 2 with Calcium Sulphate). Three patients experienced wound issues in the form of discharge/leakage, all were managed with dressings and did not require return to theatre. Conclusions. Calcium Sulphate synthetic bone graft, with addition of antibiotics, is an efficacious treatment in the paediatric population and is not associated with any major complications. Wound discharge should be observed for, and patients/parents warned about this, but only as per the adult population

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Aim. The most frequent mechanical failure in the osteosynthesis of intertrochanteric fractures is the cut-out. Fracture pattern, reduction quality, tip-apex distance or the position of the cervico-cephalic screw are some of the factors that have been associated with higher cut-out rates. To date, it has not been established whether underlying bacterial colonization or concomitant infection may be the cause of osteosynthesis failure in proximal femur fractures (PFF). The primary objective of this study is to assess the incidence of infection in patients with cut-out after PFF osteosynthesis. Method. Retrospective cohort study on patients with cut-out after PFF osteosynthesis with endomedullary nail, from January 2007 to December 2020. Demographic data of patients (such as sex, age, ASA), fracture characteristics (pattern, laterality, causal mechanism) and initial surgery parameters were collected (time from fall to intervention, duration of surgery, intraoperative complications). Radiographic parameters were also analyzed (tip-apex distance and Chang criteria). In all cut-out cases, 5 microbiological cultures and 1 anatomopathological sample were taken and the osteosynthesis material was sent for sonication. Fracture-related infection (FRI) was diagnosed based on Metsemakers et al (2018) and McNally et al (2020) diagnostic criteria. Results. Of the 67 cut-out cases, 16 (23.9%) presented clinical, analytical or microbiological criteria of infection. Of these sixteen patients, only in 3 of them the presence of an underlying infection was suspected preoperatively. A new osteosynthesis was performed in 24 cases (35.8%) and a conversion to arthroplasty in the remaining 43 (64.2%). A comparative analysis was performed between cases with and without infection. The groups were comparable in terms of demographic data and postoperative radiological data (using Chang criteria and tip-apex distance). Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs 22%, p = 0.014), higher rates of leukocytes counts (11.560 vs 7.890, p = 0.023) and time to surgery (5.88 vs 3.88 days, p = 0.072). Conclusions. One out of four osteosynthesis failure in PFF is due to underlying FRI and in almost 20% were not unsuspected before surgery. In PFF osteosynthesis failures, underlying infection should be taken into account as a possible etiological factor and thus a preoperative and intraoperative infection study should be always performed

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the health care system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with a 2-year cumulative risk of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown post-operatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastics surgery is associated with increased rates of prosthesis retention and limb salvage

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

Introduction. The incidence of periprosthetic fractures is increasing as the population ages. Wound complications and surgical site infections following surgery to treat periprosthetic fractures are a major source of patient morbidity and health care burden. This study evaluates the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing wound complications and surgical site infections (SSIs) after periprosthetic fracture surgery about the hip and knee. Methods. An IRB-approved retrospective quality improvement analysis of sixty-five consecutive periprosthetic fracture surgeries performed by four surgeons at a single institution in a fifteen-year period was performed. ciNPT was selectively used on patients in the last 20 months of the study period. Rates of wound complications, surgical site infections, and reoperation were compared with those of a sterile antimicrobial dressing (AMD). Results. AMD was used on 44 patients, while ciNPT was used in 21 patients. Compared with those treated with AMD, patients treated with ciPNT developed fewer wound complications 5% (1/21) vs 25% (11/44) (p = 0.045), deep infections 0% (0/21) vs 20% (9/44) (p = 0.014), and underwent fewer reoperations 5% (1/21) vs 20% (9/44) (p = 0.045). All patients had at least thirty days of follow up. Conclusion. Our findings suggest that ciNPT decreases the incidence of wound complications, deep infections, and reoperations in patients requiring surgical management of periprosthetic fractures about the hip and knee

Wound complications are common in patients with soft tissue sarcomas (STS) treated with surgical excision. Limited data is available on predictive factors for wound complications beyond the relationship to neo-adjuvant or adjuvant radiotherapy. Likewise, the association between blood transfusion, patient comorbidities and post-operative outcomes is not well described. In the present study we identified the predictive factors for blood transfusion and wound complications in patients undergoing surgical resection of soft tissue sarcoma from a national cohort. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent surgical resection of a STS from 2005 to 2013. Primary malignant soft tissue neoplasms were identified using the following ICD-9 codes: 171.2, 171.3 and 171.6. Patients treated with both wide excision and amputation were identified using the current procedural terminology (CPT) codes. Prolonged operative time was defined as greater than 90th percentile of time required per procedure. A multivariable logistic regression model was used to identify associations between patient factors and post-operative wound complications (superficial and deep surgical site infections (SSI), and wound dehiscence). A similar regression model sought to identify prognostic factors for blood transfusion and associations with post-operative outcomes. A total of 788 patients met our inclusion criteria. Of theses, 64.2% had tumours in the lower limb, 23.1% patients had tumours in the upper limb, and 12.7% patients had pelvic tumours. Six hundred and forty patients (81.2%) underwent surgical excision; 148 (18.8%) patients had an amputation. Multivariable logistic regression modeling identified American Society of Anaesthesiologist (ASA) class 3 and 4 (OR=2.3, P=0.03; OR=8.3, P=0.001, respectively), amputation (OR=14.0, P<0.001) and prolonged operative time (OR=4.6, P<0.001) as significant predictors of blood transfusion. Radiotherapy (OR=2.6, P=0.01) and amputation (OR=2.6, P=0.01) were identified as predictors of superficial SSI, whereas ASA class 4 (OR=6.2, P=0.03), prolonged operative time (OR=3.9, P=0.012) and return to the operating room (OR=10.5, P<0.001) were associated with deep SSI. Male gender (OR=1.8, P=0.03), diabetes (OR=2.3, P=0.03), ASA class 3 (OR=2.4, P=0.003), amputation (OR=3.8, P<0.001) and steroids (OR=4.5, P=0.03) were identified as predictors for wound dehiscence and open SSI. A national cohort demonstrates that male gender, diabetes, chronic steroid use, higher ASA score and radiotherapy are associated with an increased incidence of wound complications. One in twenty-three patients undergoing resection of an STS will require a blood transfusion, and this risk is correlated with amputation, prolonged operative time and increased ASA score. Strategies to decrease the risk of blood transfusion and wound complication should be considered for these patient groups

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Introduction. Joint reconstruction remains a successful and popular surgery with advances in approaches, implants and techniques continually forthcoming. Various methods of skin closure exist to address issues in efficiency, aesthetics, and barrier to infection. While subcuticular skin closure techniques offer an aesthetic advantage to conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-loc absorbable suture, theoretically distribute tension evenly through the wound and help decrease knot-related complications. To our knowledge, no literature exists on the rate of wound complications in joint arthroplasty with the use of V-loc suture for skin closure. We hypothesize that despite theoretical gains, skin closure with a V-loc (Covidien, Mansfield, MA) absorbable suture should be performed with caution. Methods & Materials. A retrospective chart review was conducted of 278 consecutive primary joint reconstruction cases performed by a single surgeon in 12 months from July 2009 through June 2010. Pre-operative history & physical reports were evaluated for co-morbidities (i.e diabetes mellitus), smoking status and body mass index (BMI). Operative dictations by the attending surgeon provided information on the surgical procedure, use of drain, wound closure technique and type of suture/staple used for skin closure. Skin was closed by the primary surgeon and his chief resident. Wounds were closed via staple gun or subcuticular stitch (3-0 Biosyn vs V-Loc) in a consecutive manner, depending on the surgeon's preference in that period. Post-operative clinic notes were reviewed to determine the occurrence of wound complications, issuance of antibiotic prescriptions, or return to the operating room. The cohort consisted of 106 males and 161 females at an average age of 63 years (range: 18–92). Overall, there were 153 procedures at the knee (including TKA, uni-compartmental arthroplasty, patello-femoral arthroplasty) and 125 procedures at the hip (including THA and hemi-arthroplasty). Results. In review of 278 consecutive primary joint reconstruction cases, there were 17 (6.1%) post-operative wound complications noted, including cellulitis, stitch abscesses, wound dehiscence, and deeper infections requiring OR irrigation and debridement. In 181 cases, staples were used for skin closure; in these cases, seven wound complications were noted (7/181, 3.9%). In 49 cases closed via a subcuticular Biosyn suture there were 4 wound complications noted (4/49, 8.1%). Six wound complications occurred in cases closed with a V-loc suture (6/45, 13.3%). Discussion. Aesthetics and efficiency often are the driving forces of innovation. We present the rate of wound complications in various superficial wound closure methods, including the V-loc, an innovative absorbable barbed suture. Based on our clinical experience, we promote consideration of wound and infectious complications when choosing a method of skin closure in joint reconstruction procedures

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor