Transcutaneous Oximetry Does Not Reliably Predict Wound-healing Complications in Preoperatively Radiated Soft Tissue Sarcoma

Abstract

Background Surgical wound-healing complications after tumor resections in tissue that has been preoperatively radiated are a major clinical problem. Most studies have reported that complications occur in more than 30% of patients undergoing such resections in the lower extremity. There is currently no available method to predict which patients are likely to have a complication. Transcutaneous oximetry has been identified in preliminary studies as potentially useful, but the available evidence on its efficacy for this application thus far is inconclusive. Questions/purposes (1) Does transcutaneous oximetry measurement below 25 mmHg at any location in the surgical wound bed predict a wound-healing complication?(2) Does recovery (increase) in transcutaneous oxygen measurement during the rest period between the end of radiation and the time of surgery protect against woundhealing complications? Methods A prospective, multi-institution study was coordinated to measure skin oxygenation at three timepoints in patients undergoing surgery for a lower extremity soft tissue sarcoma after preoperative radiation. Between 2016 and 2020, the five participating centers treated 476 patients for lower extremity soft tissue sarcoma. Of those, we considered those with a first-time sarcoma treated with radiation before limb salvage surgery as potentially eligible. Based on that, 21% (98 of 476) were eligible; a further 12% (56 of 476) were excluded because they refused to participate or ultimately, they were treated with a flap, amputation, or skin graft. Another 1% (3 of 476) of patients were lost because of incomplete datasets or follow-up less than 6 months, leaving 8% (39 of 476) for analysis here. The mean patient age was 62 6 14 years, 62% (24 of 39) of the group were men, and 18% (7 of 39) of patients smoked cigarettes; 87% (34 of 39) of tumors were intermediate/high grade, and the most common histologic subtype was undifferentiated pleomorphicThe institution of one or more of the authors (LMN, BJM) has received, during the study period, funding from the Orthopaedic Research and Education Foundation (award number 16-054) and funding provided by the Musculoskeletal Tumor Society. Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Research

“…A prospective, multi-institution study from Cleveland (Ohio, USA) measured skin oxygenation at three timepoints in 39 patients undergoing surgery for a lower extremity soft-tissue sarcoma after preoperative radiation. 3 The authors identified no difference in the odds of a wound-healing complication between patients whose transcutaneous oxygen measurements were ≥ 25 mmHg at all timepoints compared with those who had one or more readings below that threshold. Furthermore, there was no difference in the odds of a wound-healing complication between patients who had recovery of skin oxygenation between radiation and surgery and those who did not.…”

CORR Insights®: Transcutaneous Oximetry Does Not Reliably Predict Wound-healing Complications in Preoperatively Radiated Soft Tissue Sarcoma

“…In the current study, Nystrom et al [9] prospectively assessed skin oxygenation in patients undergoing surgery for lower extremity soft tissue sarcoma after preoperative radiation at three timepoints (before radiation, right after radiation, and within 24 hours before the surgery), which were selected based on the rationale that radiotherapy would predictably interfere in a time-dependent fashion with skin oxygenation. They found no benefit from measurement of transcutaneous oxygen tension (TcO 2 ) in anticipating wound complications, using a TcO 2 reading with a cutoff of 25 mmHg and as a continuous variable.…”

“…Despite the obvious relationship between hypoxia and wound breakdown, numerous variables may have contributed to this null result. As pointed out by the authors [9], transcutaneous oximetry provides limited focal sampling and, despite the use of multiple leads, only a small portion of the wound surface is assessed. In addition, even with the standardized radiation regimen of 50 Gy in 25 fractions they used for all patients, variability in tumor volume and anatomic compartment may cause differences in the volumetric conformity during the radiation treatment plan (radiation conformity index), extent of radiated skin, and relationship with the incision site and length.…”

“…However, endothelial degeneration, capillary occlusion, and ischemia are key pathologic and clinical features of postradiation sequelae [8]. Therefore, the natural question is why oximetry didn't make a difference, despite the promise seen in the authors' published pilot study [10] that "proposed using preoperative measurement of TcO 2 at the proposed incision site to classify patients into high-risk and low-risk categories for the development of wound complications after resection" [9].…”

Hyaluronic Acid-Modified ZIF-8 Nano-Vehicle for Self-Adaption Release of Curcumin for the Treatment of Burns

“…2 The destruction of the skin's barrier function causes bacterial infection, leading to wound ulceration and delayed recovery, 3 even fatal complications such as sepsis, necrotizing pneumonia, endocarditis, and other infection-related diseases. 4 For third-degree burns, the most common and most serious kind of burns, 5 the central issue of treatment is promoting wound healing and reducing the incidence of burn infection. 6,7 Curcumin is a natural source drug and has a good wound healing effect.…”