Instillation negative pressure wound therapy: An effective approach for hardware salvage

Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty‐five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow‐up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.     

Transverse plate fixation of sternum: a new sternal-sparing technique

We report 2 cases of vacuum-assisted closure therapy and thoracic reconstruction using new sternum titatium plates in patients with deep sternal wound infection after median sternotomy. The specific advantage of this new approach is anatomical reduction of the sternum that prevents paradoxical movement and severe anterior chest instability, and improves postoperative outcome.     

Delayed aortic rupture after aortic endograft placement in patient with spinal hardware

Aortic injuries presenting in a delayed fashion after attempted repair of an acute injury are uncommon. We report a case of a patient presenting with an initial aortic injury associated with thoracic spinal hardware placement, which was repaired with an open and endovascular approach, and 5 months later presented with hemoptysis. The cause of hemoptysis was erosion of the descending thoracic aorta between the spinal hardware and the thoracic endograft. The patient underwent descending aorta replacement with a Dacron tube graft, removal of the hardware, and coverage with a pedicled omental flap. This is a unique presentation of erosion of the aorta between the spinal hardware and the earlier placed endovascular stent-graft.     

Successful treatment of infected ascending aortic prosthesis by omental wrapping without graft removal

A deep wound infection after a midline sternotomy is a very serious complication. The severity of it can be increased by the presence of prosthetic material. We present a case of a 76-year-old man who had an infection of an ascending aortic graft develop after a Bentall procedure. Rather than following the "traditional" surgical therapy of graft explantation and debridement, we chose to preserve the graft and protect it by omental translocation. The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged on the postoperative day 6 after an uneventful postoperative course.     

Aortic erosion during negative pressure therapy in a pediatric heart transplant recipient

A happy-ending "series of unfortunate events" is reported of the successful emergency treatment of an erosion of the ascending aorta during negative pressure sternal wound therapy for a relapse of Berlin Heart driveline infection in a pediatric transplant recipient. Several key issues related to assist device-related infections and negative pressure complications are discussed in this peculiar setting.     

Off-pump repair of a giant pseudoaneurysm of a distal saphenous vein bypass graft

Pseudoaneurysm of a saphenous vein bypass graft is a rare occurrence after coronary artery bypass grafting but may have lethal consequences. We treated a giant pseudoaneurysm of a saphenous vein graft to the right coronary artery in an 80-year-old male Jehovah's Witness who had undergone coronary artery bypass grafting 4 and a half years earlier. His history revealed a recurrent sternal wound infection. By using a venous patch to close the damaged graft, we were able to perform a successful surgical repair without the need for extracorporeal circulation.     

Eradication by surfactant irrigation of Staphylococcus aureus from infected complex wounds

Treatment of infected orthopaedic hardware usually requires the removal of the appliance. When the device is removed and immediately replaced, persistent infection frequently complicates this exchange procedure. We modeled the exchange procedure in rats by passing a wire suture through a posterior spinous process and then contaminating the wound with Staphylococcus aureus. We then investigated whether a sequence of surfactant enriched irrigation solutions (Castile soap followed by benzalkonium chloride, sequential surfactant irrigation) had a greater capacity to eradicate Staphylococcus aureus from the experimental wound than did the standard wound irrigant, normal saline. When we left the wire in place through the 2-week course of the study, sequential surfactant irrigation showed only a modest advantage over normal saline (staphylococci recovered from 39% versus 58% of wound cultures respectively). Simple removal of the wire 24 hours after implantation and bacterial contamination prevented wound infection in most animals (with the wire removed, 38% of the animals remained infected versus 85% with the wire left in place), without regard to the irrigation solution. Alternatively, when we removed the wire after 24 hours, irrigated the wound, and then placed a fresh wire back into the wound, sequential surfactant irrigation showed a significant advantage over NS (54% of the animals irrigated with sequential surfactants remained infected versus 100% of the animals irrigated with normal saline). Our findings confirm the importance of a contaminated medical device for promoting foreign body infection; our findings also show that sequential surfactant irrigation has therapeutic value in a rat model of orthopaedic device infection; this irrigation protocol should be studied further as a potential agent for the treatment of infected orthopaedic wounds.     

Repair of right ventricular free wall defect with a de-epithelized pedicled myocutaneous latissimus dorsi muscle flap

Rupture of the right ventricle may occur because of sternal dehiscence or mediastinitis after cardiac surgery. Direct suture, polytetrafluoroethylene patch, fasciae, and muscle flaps have been used to close a right ventricular rupture. A unique occurrence of repair of a full-thickness right ventricle defect with a de-epithelized myocutaneous flap is presented. Our patient experienced a rupture of the right ventricle complicating sternal wound infection. The rupture was reconstructed with a polytetrafluoroethylene patch, but the patch needed to be removed because of infection. The defect was reconstructed with a de-epithelized myocutaneous latissimus dorsi flap. The patient indicated no signs of complication during follow-up.     

Thoracoscopic extrapleural pneumonectomy for mesothelioma

Mesothelioma is the most common primary pleural malignancy. Surgical therapy offers limited cure benefits at the cost of high morbidity. Although technically challenging and performed rarely, a less invasive approach to extrapleural pneumonectomy was developed with the intent to speed convalescence, hasten adjuvant therapies, improve quality of life, and reduce wound surface area for possible tumor contamination.     

Wound healing potential of Cassia fistula on infected albino rat model

BACKGROUND: Infection is the major problem to treat the wound. Antibiotic resistance by the pathogenic microorganism renders drug ineffective and calls for improved designing and development of new drugs. New approach has been developed to isolate active components from botanicals. Our aim was to investigate the potential of Cassia fistula to treat the infected wound on albino rat model. MATERIAL AND METHODS: The alcohol extract of C. fistula leaves was analyzed for antibacterial effect against Staphylococcus aureus ATCC 29213 and Pseudomonas aeruginosa ATCC 27853. Formulated ointment was topically applied on the infected wound. Wound reduction rate, histological analysis, biochemical analysis, and gelatin zymography were obtained to assess the healing pattern. RESULTS: C. fistula treated rats showed, better wound closure, improved tissue regeneration at the wound site, and supporting histopathological parameters pertaining to wound healing. Biochemical analysis and matrix metalloproteinases expression correlated well with the results thus confirming efficacy of C. fistula in the treatment of the infected wound. CONCLUSION: Along with the other activities such as antitumor, antioxidant, hypoglycemic, hepatoprotective, antibacterial, hypocholesterolaemic, and antidiabetic activity, the healing potential of C. fistula provides a scientific rationale for the traditional use of this plant in the management of infected dermal wound and can be further investigated as a substitute to treat infected wounds without using synthetic antibiotics.     

Pulmonary valve replacement for pacing electrodes related bacterial endocarditis

Infective endocarditis of pulmonary valve requiring surgery is rare. We report a case of 80-year-old woman with a permanent pacemaker implanted 14 years ago. She had signs of infection resistant to antibiotic therapy, secondary cachexia, and dyspnea. Echocardiography examination revealed an infectious mass on pacing electrodes in the right atrium, right ventricular dysfunction, and pulmonary hypertension. Removal of the infected pacing system was indicated. During the operation, destruction of the pulmonary valve due to bacterial endocarditis was diagnosed. Replacement with a stented porcine valve was performed. The patient was discharged on postoperative day 20. Seven months after the operation, the patient is in a good condition.     

Infected coronary artery pseudoaneurysm after repeated percutaneous coronary intervention

Coronary stent infection is exceedingly rare, with only 23 reported cases. We present a patient with an everolimus-coated stent infection that led to an infected pseudoaneurysm in the left anterior descending artery. Medical therapy failed and the patient underwent emergent surgical intervention; however, he died of multiorgan failure after the operation.     

Porcine small intestine submucosa matrix (Surgisis) for esophageal perforation

We present a case of traumatic cervical esophageal perforation complicated by delayed diagnosis and foreign body presence successfully repaired with acellular matrix biomaterial made from porcine submucosa (Surgisis mesh [Wilson-Cook, Winston-Salem, NC]). With metal plating eroding into the esophagus from a spinal fixation procedure, the mesh was applied to the defect just under the cricopharyngeus. The patient re-commenced oral intake after 7 days, and an endoscopy at 4 weeks revealed a well-incorporated mesh in an intact esophagus with normal caliber. In this case, Surgisis mesh (Wilson-Cook) proved effective in providing temporary esophageal integrity to allow healing in an infected field where diversion was impossible.     

The lion of the union: the pelvic wound of Joshua Lawrence Chamberlain

PURPOSE: Major General Joshua Lawrence Chamberlain is a true American hero. His medical history and war wounds provide a rare snapshot of Civil War era medicine. In particular the most devastating injury was a rifle shot through the pelvis rupturing the bladder and urethra. We describe this injury and how it affected his life to provide insight into late 19th century urological care. MATERIALS AND METHODS: All available references, including biographies, letters, surgical reports, military documents and prior medical summaries, were reviewed regarding Chamberlain's urological history. RESULTS: While leading the Union charge to Petersburg, Virginia on June 18, 1864, Chamberlain was struck with a minié ball anteriorly below the right greater trochanter. The ball coursed obliquely upward disrupting the bladder and urethra, and embedded behind the left acetabulum. An unprecedented wound exploration in the field hospital was performed to extract the bullet and "reconnect severed urinary organs." Hope for recovery was nonexistent as urine was seen exiting the lower wound postoperatively. This genitourinary injury required 4 subsequent repairs during Chamberlain's lifetime and ultimately left him with a draining urethrocutaneous fistula at the penoscrotal junction. CONCLUSIONS: Survival from catastrophic Civil War wounds was rare, especially from "gut wounds" which had a mortality rate of greater than 90%. Chamberlain not only survived but thrived with his sense of duty carrying him back to the battlefield and beyond. He was plagued during his life with recurrent cystitis and epididymo-orchitis, which in an era without antibiotics was especially miserable. Urosepsis is listed as the cause of death on his death certificate and whether this was true is debatable. However, even if this wound did not cause his death, it surely contributed to it.     

Meta-analysis of organ damage after conversion from off-pump coronary artery bypass procedures

The relative efficacy of off-pump and on-pump coronary revascularization is uncertain. A complication of off-pump surgery which is rarely considered is intraoperative conversion to cardiopulmonary bypass. Consequently, meta-analysis was performed of studies comparing morbidity after converted and nonconverted off-pump coronary revascularization. There were significant increases in the likelihood of stroke, myocardial injury, bleeding, renal failure, wound infection, intraaortic balloon pump requirement, transfusion, and respiratory and gastrointestinal complications after conversion. The underlying mechanisms need to be urgently elucidated. Prevention and treatment protocols for conversion warrant serious consideration and the risk of conversion may need to be discussed when obtaining informed patient consent.     

Wound Complications and Treatment of the Infected Implantable Cardioverter Defibrillator Generator

A bstract Since 1980, the automatic implantable cardioverter defibrillator (ICD) has evolved as effective therapy for prevention of sudden cardiac death following documented sustained ventricular tachycardia or fibrillation. During a 5-year period, 412 ICD devices were implanted at the University of Michigan Hospitals with a wound complication rate of 4.1%. In this group, there were 13 infections, 3 erosions of the generator pocket, and 1 wound hematoma. Of the 16 patients with infection or erosion, 12 patients were treated with a rectus abdominis muscle flap closure and 4 with ICD generator removal. In 83% (n = 12) of the muscle flap patients, the wound healed uneventfully. Preoperative chest CT scanning was found to be helpful in identifying probable infection of the epicardial leads. In these cases, all hardware had to be removed to achieve resolution of the infection. We concluded that rectus abdominis muscle flaps were helpful in salvaging infected or exposed ICD generators in the absence of infected epicardial leads.     

Suturing of penetrating wounds to the heart in the nineteenth century: the beginnings of heart surgery

The beginnings of cardiac surgery go back to the 19th century. This article describes the history of the first attempts to operate on the heart. In 1882, Dr Block from Danzig, and in 1895, Simplicio Del Vecchio, published reports of animal experiments showing that the suturing of heart wounds is possible. After unsuccessful attempts by Axel Cappelen in Norway and Guido Farina in Italy, it was Ludwig Rehn of Germany who first sutured a laceration of the right ventricle of a human heart. Shortly afterward, Antonio Parrozzani successfully sutured a stab wound of the left ventricle. Following cardiac surgery back to its very beginnings, it is striking that the first attempts in the 19th century to repair the injured heart were regarded with great skepticism, and that heart suturing only slowly became an established method of treatment. Once the concept of cardiac surgery had become accepted, however, many kinds of operations were developed, paving the way for an explosion in the number of cardiac operations, as we well know, in the century that followed.     

Massive acute aortic regurgitation after infected pacemaker lead removal: a word of caution

We report a case of massive acute aortic valve regurgitation in a 54-year-old man secondary to a percutaneous extraction of infected permanent pacemaker leads. This case emphasizes how carefully patients should be monitored during and after the procedure, regardless of their hemodynamic status. The patient successfully underwent urgent surgical intervention.     

Management of radiated reoperative wounds of the cervicothoracic spine: the role of the trapezius turnover flap

Reoperation for malignant disease of the cervicothoracic spine can lead to compromised wound healing secondary to poor tissue quality from previous operations, heavily irradiated beds, and concomitant steroid therapy. Other complicating factors include exposed dura and spinal implants. Introducing well-vascularized soft tissue to obliterate dead space is critical to reliable wound healing. The purpose of this study was to determine the efficacy of the trapezius turnover flap in the management of these complex wounds. This study is a retrospective review of all patients undergoing trapezius muscle turnover flaps for closure of complex cervicothoracic wounds after spinal operations for metastatic or primary tumors. Six patients (3 male/3 female) were operated over an 18-month period (mean patient age, 43 years). Primary pathologies included radiation-induced peripheral nerve sheath tumor (N = 2), chondrosarcoma (N = 1), nonsmall-cell lung cancer (N = 1), paraganglioma (N = 1), and spindle cell sarcoma (N = 1). Trapezius muscle turnover flaps were unilateral and based on the transverse cervical artery in every patient. Indication for flap closure included inability to perform primary layered closure (N = 3), open wound with infection (N = 2), and exposed hardware (N = 1). All patients had previous operations of the cervicothoracic spine (mean, 5.8 months; range 2-9 months) for malignant disease and prior radiation therapy. Exposed dura was present in all patients, and 2 patients had dural repairs with bovine pericardial patches. Spinal stabilization hardware was present in 4 patients. All patients underwent perioperative treatment with systemic corticosteroids. All flaps survived, and primary wound healing was achieved in each patient. The only wound complication was a malignant pleural effusion communicating with the back wound, which was controlled with a closed suction drain. All wounds remained healed during the follow-up period. Four patients died from progression of disease within 10 months of surgery. The trapezius turnover flap has been used successfully when local tissue conditions prevent primary closure, or in the setting of open, infected wounds with exposed dura and hardware. The ease of flap elevation and minimal donor site morbidity make it a useful, single-stage reconstructive option in these difficult wounds.