Wound Complications in Pediatric Extremity Bone Sarcoma Patients Following Extirpative Surgery

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Transcript

Hello, my name is Ayesha Qureshi. I hold a medical degree from the University of Manchester School of Medicine, and I'm currently a postdoctoral research fellow in the Centre for Regenerative Medicine at Nationwide Children's Hospital in Columbus, Ohio. I am a part of the Plastic and Reconstructive Surgical Department where my work kind of focuses on improving clinical outcomes and conducting research in pediatric bone care.

Why are wound complications so important to investigate in this patient population?

So specifically looking at what inspired my current line of work in bone complications while extirpative surgery in pediatric bone extremity sarcoma patients, I think this research was prompted by several key observations. At our institution, we noticed a rising frequency of wound complications in pediatric extremity bone sarcoma patients falling, extirpative, and reconstructive surgeries. Upon reviewing the literature after, it became clear that there was a limited understanding of wound complications within the specific patient group, despite really the complexity of the procedures that they undergo. And the challenge with these complications is that if severe, they can delay chemotherapy or even disrupt treatment entirely, ultimately affecting survival outcomes. This to us highlighted the need for a more systematic investigation into the incidents and contributing factors of wound complications in osteosarcoma and Ewing sarcoma patients.
 
We also observed that existing wound classification systems, while effective in grading surgical complications, often fail to capture the critical impact of delays in chemotherapy timelines. And in response, we aimed to develop a novel classification system specifically designed to account for these treatment delays, offering potentially a more relevant framework for managing care in this context.

What are the details of the cases you analyzed?

Delving into a few of the details about the cases that we analyzed, we conducted a comprehensive analysis of 88 pediatric patients with bone sarcomas at our tertiary center over a span of 16 years. Our cohort was predominantly osteosarcoma, with the remainder being Ewing sarcoma, and we had a median age of around 12 and a half years. We also utilized the Child Opportunity Index, which is actually a national metric that measures neighborhood resources and conditions influencing children's development. And notably, we found that around 43% of our patients came from areas with low or very low opportunity scores, adding a crucial socioeconomic dimension to our analysis. Then, regarding our surgical approach, around 88% of our patients underwent limb salvage procedures rather than amputations. As well, 93% of the patients required reconstructive surgery, they're on 54% having orthopedic reconstruction alone, 22% having plastic and reconstructive surgery alone, and around 24% requiring both specialties’ involvement.
 
What were our primary findings? So we observed that a significant portion of our cohort, specifically around 43%, experienced wound complications, unfortunately. And these complications were categorized using our novel classification system, ranging from grades 1, which indicated a minor wound dehiscence or infection that could be managed with oral antibiotics or local wound care to all the way to grade 4, where the wound complication necessitated removal from the planned protocol entirely. And notably, over half of these patients presented with grade three wounds, meaning they experienced delays in their systemic treatment protocols. Then in examining the timeline of wound development post-surgery, we found that the most critical period for wound complications occurred within the first 3 months, So this highlighted to us the importance of intensified monitoring during this time.
 
We then identified a couple of factors that influence the development of wound complications. First the location of the malignancy varied significantly between groups. The majority of patients who developed wound complications had tumors in the tibia or fibula, while those with femoral malignancies were associated with kind of a lower risk of complications. And then additionally, both plastic surgery and orthopedic teams were more frequently involved in the care of patients who developed wound complications compared to those without wound complications.

What should lower extremity surgeons take away from your research?

I think one of the main takeaways is the importance of a standardized classification system for post-extirpative surgical wounds. This system should especially consider the impact on treatment delays. I think another key point is the value of using larger datasets to better identify risk factors and refine management strategies. This can ultimately improve clinical practice and help tailor interventions more effectively. From our data, for example, we also noticed that earlier involvement from plastic surgery will likely be beneficial. In some cases, delays in reconstructive procedures due to perhaps late referrals after the initial surgery likely worsened mood outcomes. And this highlights to us the need for more proactive interdisciplinary collaboration.
 
But ultimately, the goal is to improve how we classify wound complications and also to optimize care for pediatric bone coma patients. By addressing delays in chemotherapy protocol we can enhance survival rates and really advanced wound planning would be essential to minimize complications in this vulnerable group.