Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience

Background contextWound dehiscence and surgical site infections (SSIs) can have a profound impact on patients as they often require hospital readmission, additional surgical interventions, lengthy intravenous antibiotic administration, and delayed rehabilitation. Negative pressure wound therapy (NPWT) exposes the wound site to negative pressure, resulting in the improvement of blood supply, removal of excess fluid, and stimulation of cellular proliferation of granulation tissue.PurposeTo assess the incidence of wound infection and dehiscence in patients undergoing long-segment thoracolumbar fusion before and after the routine use of NPWT.Study designRetrospective study.Patient sampleOne hundred sixty patients undergoing long-segment thoracolumbar spine fusions were included in this study.Outcome measuresPostoperative incidence of wound infection and dehiscence.MethodsAll adult patients undergoing thoracolumbar fusion for spinal deformity over a 6-year period at Duke University Medical Center by the senior author (CB) were included in this study. In 2012, a categorical change was made by the senior author (CB) that included the postoperative routine use of incisional NPWT devices after primary wound closure in all long-segment spine fusions. Before 2012, NPWT was not used. After primary wound closure, a negative pressure device is contoured to the size of the incision and placed over the incision site for 3 postoperative days. We retrospectively review the first 46 cases in which NPWT was used and compared them with the immediately preceding 114 cases to assess the incidence of wound infection and dehiscence.ResultsOne hundred sixty (NPWT: 46 cases, non-NPWT: 114 cases) long-segment thoracolumbar spine fusions were performed for deformity correction. Baseline characteristics were similar between both cohorts. Compared with the non-NPWT cohort, a 50% decrease in the incidence of wound dehiscence was observed in the NPWT patient cohort (6.38% vs. 12.28%, p=.02). Similarly, compared with the non-NPWT cohort, the incidence of postoperative SSIs was significantly decreased in the NPWT cohort (10.63% vs. 14.91%, p=.04).ConclusionsRoutine use of incisional NPWT was associated with a significant reduction in the incidence of postoperative wound infection and dehiscence.     

Glycation of extracellular matrix proteins impairs migration of immune cells

The immune response during aging and diabetes is disturbed and may be due to the altered migration of immune cells in an aged tissue. Our study should prove the hypothesis that age and diabetes‐related advanced glycation end products (AGEs) have an impact on the migration and adhesion of human T‐cells. To achieve our purpose, we used in vitro AGE‐modified proteins (soluble albumin and fibronectin [FN]), as well as human collagen obtained from bypass graft. A Boyden chamber was used to study cell migration. Migrated Jurkat T‐cells were analyzed by flow cytometry and cell adhesion by crystal violet staining. Actin polymerization was determined by phalloidin‐Alexa‐fluor 488‐labeled antibody and fluorescence microscopy. We found that significantly fewer cells (50%, p = 0.003) migrated through methylglyoxal modified FN. The attachment to FN in the presence of AGE‐bovine serum albumin (BSA) was also reduced (p < 0.05). In ex vivo experiments, isolated collagen from human vein graft material negatively affected the migration of the cells depending on the grade of AGE modification of the collagen. Collagen with a low AGE level reduced the cell migration by 30%, and collagen with a high AGE level by 60%. Interaction of the cells with an AGE‐modified matrix, but not with soluble AGEs like BSA‐AGE per se, was responsible for a disturbed migration. The reduced migration was accompanied by an impaired actin polymerization. We conclude that AGEs‐modified matrix protein inhibits cell migration and adhesion of Jurkat T‐cells.     

Is there an association between periprosthetic joint infection and low vitamin D levels?

Purpose

Vitamin D is increasingly being recognized as an important mediator of immune function and may have a preventive role in the pathogenesis of periprosthetic joint infection. To the best of our knowledge, no other study has examined possible associations between periprosthetic joint infection and vitamin D deficiency. We investigated the rate of vitamin D deficiency in patients treated for periprosthetic joint infection and whether vitamin D deficiency is independent of other risk factors for vitamin D deficiency in patients with periprosthetic joint infection.

Methods

Serum 25-hydroxyvitamin D (25OHD) levels of every patient scheduled to receive a total prosthesis either of the hip, knee, or shoulder in the orthopaedic department of the Johannes-Guttenberg-University Hospital in Mainz, Germany (109 patients), were measured after admission. Furthermore, serum 25OHD levels were measured for every patient presenting with periprosthetic joint infection (n = 50) or aseptic loosening of the prosthesis (n = 31) scheduled to undergo revision surgery. The prevalence of normal (>30 ng/ml), insufficient (20–30 ng/ml), and deficient (<20 ng/ml) 25OHD levels was determined.

Results

All tested patient subgroups showed low vitamin D levels. Statistical analysis found no significant difference in vitamin D levels comparing patients with prosthesis and patients with aseptic prosthesis loosening (p = 0.58). Significant differences in 25OHD levels were found comparing patients with periprosthetic joint infection and patients scheduled for primary arthroplasty (p < 0.001). In addition, we found a significant difference (p < 0,001) in 25OHD levels of patients with periprosthetic joint infection compared with patients with aseptic prosthesis loosening.

Conclusion

We found a high frequency of vitamin D deficiency in patients being treated by primary arthroplasty and those with aseptic joint prosthetic loosening and periprosthetic joint infection. Vitamin D deficiency was severe in patients with periprosthetic joint infection.     

Adjacent segment degeneration in the lumbar spine

BACKGROUND: A primary concern after posterior lumbar spine arthrodesis is the potential for adjacent segment degeneration cephalad or caudad to the fusion segment. There is controversy regarding the subsequent degeneration of adjacent segments, and we are aware of no long-term studies that have analyzed both cephalad and caudad degeneration following posterior arthrodesis. A retrospective investigation was performed to determine the rates of degeneration and survival of the motion segments adjacent to the site of a posterior lumbar fusion. METHODS: Two hundred and fifteen patients who had undergone posterior lumbar arthrodesis were included in this study. The study group included 126 female patients and eighty-nine male patients. The average duration of follow-up was 6.7 years. Radiographs were analyzed with regard to arthritic degeneration at the adjacent levels both preoperatively and at the time of the last follow-up visit. Disc spaces were graded on a 4-point arthritic degeneration scale. Correlation analysis was used to determine the contribution of independent variables to the rate of degeneration. Survivorship analysis was performed to describe the degeneration of the adjacent motion segments. RESULTS: Fifty-nine (27.4%) of the 215 patients had evidence of degeneration at the adjacent levels and elected to have an additional decompression (fifteen patients) or arthrodesis (forty-four patients). Kaplan-Meier analysis predicted a disease-free survival rate of 83.5% (95% confidence interval, 77.5% to 89.5%) at five years and of 63.9% (95% confidence interval, 54.0% to 73.8%) at ten years after the index operation. Although there was a trend toward progression of the arthritic grade at the adjacent disc levels, there was no significant correlation, with the numbers available, between the preoperative arthritic grade and the need for additional surgery. CONCLUSIONS: The rate of symptomatic degeneration at an adjacent segment warranting either decompression or arthrodesis was predicted to be 16.5% at five years and 36.1% at ten years. There appeared to be no correlation with the length of fusion or the preoperative arthritic degeneration of the adjacent segment.     

Trochlear nerve palsy after repeated percutaneous balloon compression for recurrent trigeminal neuralgia: case report and pathogenic considerations

OBJECTIVE AND IMPORTANCE: Repeated percutaneous balloon compression for the treatment of idiopathic trigeminal neuralgia is infrequent. When a second procedure is performed, the outcome is unknown. A patient developed an isolated trochlear nerve palsy after undergoing percutaneous trigeminal ganglion balloon compression for a second time. The mechanism of diplopia and the complications associated with this technique were studied. CLINICAL PRESENTATION: The patient was a 67-year-old woman with a history of medically refractory idiopathic trigeminal neuralgia involving all three divisions of the right trigeminal nerve. INTERVENTION: Percutaneous balloon compression was performed. Despite initial total relief from pain without complications, the patient again displayed manifestations of trigeminal neuralgia 3 months after the procedure. The pain disappeared after she underwent a second balloon compression procedure, but she developed an isolated trochlear nerve palsy, which spontaneously resolved in 2 months. CONCLUSION: Isolated trochlear nerve palsy is a rare and reversible complication after percutaneous balloon compression for trigeminal neuralgia. This case illustrates that the mechanism of injury to the fourth nerve is the result of an erroneous technique: excessive penetration of the Fogarty catheter in Meckel's cave beyond the porus trigemini and compression of the cisternal segment of the trochlear nerve when the inflated balloon is pushed against the tentorium.     

Gait analysis in patients with idiopathic scoliosis

Introduction The goal of this study was to observe scoliotic subjects during level walking to identify asymmetries—which may be related to a neurological dysfunction or the spinal deformity itself—and to correlate these to the severity of the scoliotic curve.Methods We assessed the gait pattern of ten females (median age 14.4) with idiopathic scoliosis characterised by a left-lumbar and a right-thoracic curve component. Gait analysis consisted of 3D kinematic (VICON) and kinetic (Kistler force plates) measurements. The 3D-segment positions of the head, trunk and pelvis, as well as the individual joint angles of the upper and lower extremities, were computed during walking and static standing. Calculation of pertinent kinetic and kinematic parameters allowed statistical comparison.Results All subjects walked at a normal velocity (median: 1.22 m/s; range:1.08–1.30 m/s; height-adjusted velocity: 0.75 m/s; range: 0.62–0.88 m/s). The timing of the individual gait phases was normal and symmetrical for the whole group. Sagittal plane hip, knee and ankle motion followed a physiological pattern. Significant asymmetry was observed in the trunks rotational behaviour in the transverse plane. During gait, the pelvis and the head rotated symmetrically to the line of progression, whereas trunk rotation was asymmetric, with increased relative forward rotation of the right upper body in relation to the pelvis. This produced a torsional offset to the line of progression. Minimal torsion (at right heel strike) measured: median 1.0° (range: 5.1°–8.3°), and maximal torsion (at left heel strike) measured 11.4° (range 6.9°–17.9°). The magnitude of the torsional offset during gait correlated to the severity of the thoracic deformity and to the standing posture, whereas the range of the rotational movement was not affected by the severity of the deformity. The ground reaction forces revealed a significant asymmetry of [Msz], the free rotational moment around the vertical axis going through the point of equivalent force application. On the right side, the initial endo-rotational moment was lower, followed by a higher exo-rotational moment than on the left. All the other force parameters (vertical, medio–lateral, anterior–posterior), did not show a significant side difference for the whole group. The use of a brace stiffened torsional motion. However the torsional offset and the asymmetry of the free rotational moment remained unchanged.Conclusion The most significant and marked asymmetry was seen in the transverse plane, denoted as a torsional offset of the upper trunk in relation to the symmetrically rotating pelvis. This motion pattern was reflected by a ground-reaction-force asymmetry of the free rotational moment. Further studies are needed to investigate whether this behaviour is solely an expression of the structural deformity or whether it could enhance the progression of the torsional deformity.No financial assistance was provided for this work     

Donor Kidney Exchanges

Kidney transplantation from live donors achieves an excellent outcome regardless of human leukocyte antigen (HLA) mismatch. This development has expanded the opportunity of kidney transplantation from unrelated live donors. Nevertheless, the hazard of hyperacute rejection has usually precluded the transplantation of a kidney from a live donor to a potential recipient who is incompatible by ABO blood type or HLA antibody crossmatch reactivity. Region 1 of the United Network for Organ Sharing (UNOS) has devised an alternative system of kidney transplantation that would enable either a simultaneous exchange between live donors (a paired exchange), or a live donor/deceased donor exchange to incompatible recipients who are waiting on the list (a live donor/list exchange). This Regional system of exchange has derived the benefit of live donation, avoided the risk of ABO or crossmatch incompatibility, and yielded an additional donor source for patients awaiting a deceased donor kidney. Despite the initial disadvantage to the list of patients awaiting an O blood type kidney, as every paired exchange transplant removes a patient from the waiting list, it also avoids the incompatible recipient from eventually having to go on the list. Thus, this approach also increases access to deceased donor kidneys for the remaining candidates on the list.     

Amylase Isoenzymes in the Acute Abdomen: An Adjunct in those Patients with Elevated Total Amylase

The role of routine isoamylase determinations in differentiating acute pancreatitis from other causes of an acute abdomen with hyperamylasemia and/or hyperamylasuria was evaluated. Values were analyzed from a control group of 21 patients with acute pancreatitis (group I) and from 100 consecutive patients diagnosed in our emergency department as having an acute abdomen (group II). In group I, 100% of patients had hyperamylasemia, hyperamylasuria, and a P isoamylase fraction greater than 0.75 of the total amylase value. In group II, 50% of patients had hyperamylasemia and/or hyperamylasuria. Of these patients, 44% had a P isoamylase fraction less than 0.75 of the total amylase value, a finding apparently incompatible with a diagnosis of acute pancreatitis as identified by our control group. We conclude that routine isoamylase determinations in patients with an acute abdomen and hyperamylasemia and/or hyperamylasuria allows the differentiation from acute pancreatitis in 44% of cases.     

Clinical presentation of wandering spleen

Background: Wandering spleen (WS) is an uncommon condition with a variety of clinical presentations. Methods: The medical files of 5 children who underwent operation for WS in the authors' department during the period 1996 through 2000 were retrospectively reviewed. Results: Splenic salvage procedures (retroperitoneal splenopexy) were performed in 4 patients. One patient underwent splenectomy because of splenic necrosis. Conclusions: Early diagnosis and surgical treatment is mandatory to prevent complications. Every effort should be made to preserve the spleen, especially among the pediatric population, and splenopexy is the procedure of choice even in the asymptomatic patient. J Pediatr Surg 37:E30.