Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
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Management of complex surgical wounds of the back: identifying an evidence-based approach

  • Zolper, Elizabeth G. (Georgetown University School of Medicine) ;
  • Saleem, Meher A. (Georgetown University School of Medicine) ;
  • Kim, Kevin G. (Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital) ;
  • Mishu, Mark D. (Georgetown University School of Medicine) ;
  • Sher, Sarah R. (Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital) ;
  • Attinger, Christopher E. (Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital) ;
  • Fan, Kenneth L. (Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital) ;
  • Evans, Karen K. (Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital)
  • Received : 2020.10.21
  • Accepted : 2021.07.29
  • Published : 2021.11.15
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Abstract

Background Postoperative dehiscence and surgical site infection after spinal surgery can carry serious morbidity. Multidisciplinary involvement of plastic surgery is essential to minimizing morbidity and achieving definitive closure. However, a standardized approach is lacking. The aim of this study was to identify effective reconstructive interventions for the basis of an evidence-based management protocol. Methods A retrospective review was performed at a single tertiary institution for 45 patients who required 53 reconstruction procedures with plastic surgery for wounds secondary to spinal surgery from 2010 to 2019. Statistical analysis was performed for demographics, comorbidities, and treatment methods. Primary outcomes were postoperative complications, including dehiscence, seroma, and infection. The secondary outcome was time to healing. Results The overall complication rate was 32%, with dehiscence occurring in 17%, seroma in 15% and infection in 11% of cases. Median follow-up was 10 months (interquartile range, 4-23). Use of antibiotic beads did not affect rate of infection occurrence after wound closure (P=0.146). Use of incisional negative pressure wound therapy (iNPWT) was significant for reduced time to healing (P=0.001). Patients treated without iNPWT healed at median of 67.5 days while the patients who received iNPWT healed in 33 days. Demographics and comorbidities between these two groups were similar. Conclusions This data provides groundwork for an evidence-based approach to soft tissue reconstruction and management of dehiscence after spinal surgery. Timely involvement of plastic surgery in high-risk patients and utilization of evidence-based interventions such as iNPWT are essential for improving outcomes in this population.

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References

  1. Casper DS, Zmistowski B, Hollern DA, et al. The effect of postoperative spinal infections on patient mortality. Spine (Phila Pa 1976) 2018;43:223-7. https://doi.org/10.1097/BRS.0000000000002277
  2. Xu H, Rozanski C, Taub PJ. The value of plastic surgery spinal closures: a review of 782 spine cases. Ann Plast Surg 2019;83:201-5. https://doi.org/10.1097/SAP.0000000000001831
  3. Fei Q, Li J, Lin J, et al. Risk factors for surgical site infection after spinal surgery: a meta-analysis. World Neurosurg 2016;95:507-15. https://doi.org/10.1016/j.wneu.2015.05.059
  4. Blumberg TJ, Woelber E, Bellabarba C, et al. Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection. Spine J 2018;18:300-6. https://doi.org/10.1016/j.spinee.2017.07.173
  5. Atkinson RA, Jones A, Ousey K, et al. Management and cost of surgical site infection in patients undergoing surgery for spinal metastasis. J Hosp Infect 2017;95:148-53. https://doi.org/10.1016/j.jhin.2016.11.016
  6. Shepard J, Ward W, Milstone A, et al. Financial impact of surgical site infections on hospitals: the hospital management perspective. JAMA Surg 2013;148:907-14. https://doi.org/10.1001/jamasurg.2013.2246
  7. Piper K, DeAndrea-Lazarus I, Algattas H, et al. Risk factors associated with readmission and reoperation in patients undergoing spine surgery. World Neurosurg 2018;110:e627-35. https://doi.org/10.1016/j.wneu.2017.11.057
  8. Peng XQ, Sun CG, Fei ZG, et al. Risk factors for surgical site infection after spinal surgery: a systematic review and meta-analysis based on twenty-seven studies. World Neurosurg 2019;123:e318-29. https://doi.org/10.1016/j.wneu.2018.11.158
  9. Chieng LO, Hubbard Z, Salgado CJ, et al. Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review. Neurosurg Focus 2015;39:E17.
  10. Gu W, Tu L, Liang Z, et al. Incidence and risk factors for infection in spine surgery: a prospective multicenter study of 1764 instrumented spinal procedures. Am J Infect Control 2018;46:8-13. https://doi.org/10.1016/j.ajic.2017.09.025
  11. Ogihara S, Yamazaki T, Inanami H, et al. Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: a prospective multicenter surveillance study with registry of 4027 cases. PLoS One 2018;13:e0205539. https://doi.org/10.1371/journal.pone.0205539
  12. Weinstein MA, McCabe JP, Cammisa FP Jr. Postoperative spinal wound infection: a review of 2,391 consecutive index procedures. J Spinal Disord 2000;13:422-6. https://doi.org/10.1097/00002517-200010000-00009
  13. Singh K, Samartzis D, Heller JG, et al. The management of complex soft-tissue defects after spinal instrumentation. J Bone Joint Surg Br 2006;88:8-15.
  14. Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373-9. https://doi.org/10.1016/S0895-4356(96)00236-3
  15. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. https://doi.org/10.1016/0021-9681(87)90171-8
  16. Horii C, Yamazaki T, Oka H, et al. Does intrawound vancomycin powder reduce surgical site infection after posterior instrumented spinal surgery? A propensity score-matched analysis. Spine J 2018;18:2205-12. https://doi.org/10.1016/j.spinee.2018.04.015
  17. Howlin RP, Brayford MJ, Webb JS, et al. Antibiotic-loaded synthetic calcium sulfate beads for prevention of bacterial colonization and biofilm formation in periprosthetic infections. Antimicrob Agents Chemother 2015;59:111-20. https://doi.org/10.1128/AAC.03676-14
  18. Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg 2008;122:280-8. https://doi.org/10.1097/PRS.0b013e31817742a9
  19. Barton A, Blitz M, Callahan D, et al. Early removal of post-mastectomy drains is not beneficial: results from a halted randomized controlled trial. Am J Surg 2006;191:652-6. https://doi.org/10.1016/j.amjsurg.2006.01.037
  20. Sood A, Kotamarti VS, Therattil PJ, et al. Sclerotherapy for the management of seromas: a systematic review. Eplasty 2017;17:e25.
  21. Garvey PB, Rhines LD, Dong W, et al. Immediate soft-tissue reconstruction for complex defects of the spine following surgery for spinal neoplasms. Plast Reconstr Surg 2010;125:1460-6. https://doi.org/10.1097/PRS.0b013e3181d5125e
  22. Spruance SL, Reid JE, Grace M, et al. Hazard ratio in clinical trials. Antimicrob Agents Chemother 2004;48:2787-92. https://doi.org/10.1128/AAC.48.8.2787-2792.2004
  23. Nordmeyer M, Pauser J, Biber R, et al. Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care. Int Wound J 2016;13:1176-9. https://doi.org/10.1111/iwj.12436
  24. Adogwa O, Fatemi P, Perez E, et al. Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience. Spine J 2014;14:2911-7. https://doi.org/10.1016/j.spinee.2014.04.011
  25. Hallock GG. Reconstruction of posterior trunk defects. Semin Plast Surg 2011;25:78-85. https://doi.org/10.1055/s-0031-1275174
  26. Mathes DW, Thornton JF, Rohrich RJ. Management of posterior trunk defects. Plast Reconstr Surg 2006;118:73e-83e. https://doi.org/10.1097/00006534-200609151-00091