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1.
Tsuruhito Tanaka Nirmal Panthee Yoshifumi Itoda Naoko Yamauchi Masashi Fukayama Minoru Ono 《European journal of plastic surgery》2016,39(4):247-256
Background
Negative pressure wound therapy (NPWT) is commonly used to accelerate wound healing, especially following thoracic surgery; however, the mechanism remains elusive. Given the important role of vasculogenesis in wound healing, we evaluated whether NPWT might accelerate vasculogenesis in the wound area. Toward this end, we investigated the temporal expression of vascular endothelial growth factor receptors (VEGFRs) in an NPWT-wound healing rabbit model.Methods
Rabbits were divided into an NPWT group and a non-NPWT control group, and tissue samples were collected around wounds made in the skin of each rabbit at five time points: 0, 7, 14, 21, and 28 days after wound creation. Cryopreserved samples were then immunostained and subject to image analysis to evaluate the temporal changes in VEGFR1, VEGFR2, and VEGFR3 expression in the wound-healing process.Results
Results of histological analysis of the temporal changes in VEGFR expression throughout the healing process showed that compared to the control group, VEGFR2 and VEGFR3 were abundantly and rapidly expressed in the NPWT group, and were expressed earlier than VEGFR1.Conclusions
NPWT promotes the expression of VEGFR2 and VEGFR3, which provides insight into the mechanism by which NPWT accelerates wound healing.Level of Evidence: Not ratable.2.
S. Ochman M. J. Raschke C. Stukenborg-Colsman K. Daniilidis 《Operative Orthopadie und Traumatologie》2016,28(5):352-364
Objective
Debridement of infected tissue with the main aim being the re-establishment of mobilization with preservation of standing and walking ability. Prevention of secondary pressure points or amputations due to inadequate resection or deficient soft tissue cover.Indications
In the case of increasing necrosis of the big toe, surgical abrasion and/or amputation is considered unavoidable. Other indications where surgery could be considered include diabetes and its associated angiopathies together with peripheral arterial angiopathy.Contraindications
In the case of insufficient blood supply an expansion of the resection margins should be taken into account. If there are possible alternatives to amputation. Surgery for patients with renal failure requiring dialysis associated with increased complication rate.Surgical technique
A dorsal cuneiform resection is performed to facilitate implantation of a plantar skin transplant and wound healing. Important is the resection of bone in a slide oblique technique. Amputation scars should be outside pressure zones. Partial amputations in the area of the first ray as exarticulation or via the individual amputated segments possible (as opposed to toes 2–5).Postoperative management
Direct postoperative weight-bearing with rigid insole and dispensing aid for 6–8 weeks. Following complete wound healing, foot support with orthopedic arch and transverse strain relief should be advocated, together with a joint roll in ready-made individual shoes.Results
Both trauma and nontrauma cases were included in our present cohort. A total of 7 cases were surgically revised in 2014 due to superficial skin necrosis that was likely the result of skin tension from the wound stitches.3.
4.
Background
When a wound cannot be closed in a linear fashion and either a local flap or skin graft is needed, a purse-string suture can be a useful adjunct to wound closure. Local tissue architecture is maintained in cases where clear surgical margins have not been achieved at the time of extirpative skin cancer surgery. We hypothesized that this technique could be applied to a range of wound sizes and locations to avoid or reduce the need for skin grafting.Methods
We applied a non-absorbable purse-string suture to wounds in 18 patients over a 15-month period and measured the defect size before and after application of the suture intraoperatively. Residual defects were covered with full- or split-thickness skin grafts. Postoperative wound area, scar hypertrophy, partial graft loss and dehiscence following suture removal were additional outcomes.Results
Ten patients achieved primary wound closure with the purse-string suture, while additional skin grafting was required in eight patients. Wounds closed primarily did not re-expand. Skin-grafted subjects had a 53.8% intraoperative wound area reduction but the skin grafts expanded during recovery, and ultimate reduction diminished to 11% on late follow-up. Wounds accounting for this late re-expansion were located on the extremities.Conclusions
Purse-string sutures are helpful for wound closure in wounds that cannot be closed primarily. They can decrease the size of a skin graft if the wound cannot be closed completely. Wound re-expansion, particularly in extremity defects, may occur following early removal of the tension-bearing purse string.5.
Background
Coccygodynia is a pain of the coccyx that is typically exaggerated by pressure. Management includes anti-inflammatory medications, physiotherapy, and coccyx manipulation. Coccygectomy is the surgical approach for treating coccygodynia when the conservative management fails. Generally, coccygectomy yields good results. Its most common complication is wound infection.Objective
To determine the effectiveness of coccygectomy in patients with coccygodynia.Methods
A retrospective review of 70 patients (52 females and 18 males) with coccygodynia at King Khalid University Hospital in Riyadh was carried out, and the outcomes were studied. Twenty patients did not respond to conservative management; therefore, bimanual coccyx manipulation was done. Eleven were identified with instability and did not respond to coccygeal manipulation. Coccygectomy was performed on 8 patients while 3 declined.Results
All patients who underwent coccygectomy showed improvement of their symptoms. One case of superficial wound infection and delayed wound healing was encountered.Conclusion
Coccygectomy provides effective pain relief to patients not responding to conservative therapies.6.
Objective
The goal of Pirogoff’s amputation of the hindfoot is a weight-bearing stump with minimal loss of limb length and stable soft tissue coverage with preservation of the sensation of the sole of the heel.Indications
Non-reconstructable forefoot and midfoot after complex trauma, deep bony and soft tissue infection, infected Charcot foot, necrosis or gangrene due to vasculopathy, malignant tumors and deformities.Contraindications
Possibility for reconstruction of the forefoot and midfoot, minor amputation, loss or irreversible destruction of the sole of the heel.Surgical technique
The incision runs from dorsal, 1–2?cm distal of the Chopart joint, to plantar, 5–6?cm distal of the Chopart joint for creation of an adequate plantar skin flap. Exarticulation of the foot from dorsal to plantar through the Chopart joint with preservation of the posteromedial neurovascular bundle. Enucleation of the talus. Minimal resection of the cuboidal and posterior facets of the calcaneus as well as the malleoli inclusive of the distal tibial joint surface. The calcaneus is brought under the tibia and a tibiocalcaneal arthrodesis is performed with two compression screws.Postoperative management
No weight bearing until stable scar formation, early mobilization in a walker. Interim prosthesis after 2–4 weeks and definitive prosthesis after 2–3 months.Results
From January 2010 to December 2014 six patients were treated with a modified Pirogoff’s amputation. Primary wound healing was achieved in four patients and in two patients wound healing was impaired. In one patient the wound was conservatively healed and the other patient needed below knee amputation. Early primary prosthetic treatment was possible in four patients. The tibiocalcaneal arthrodesis healed in all five remaining cases. All patients with a healed Pirogoff stump were able to walk for short distances in bare feet without the prosthesis.7.
Objective
The treatment strategy for diabetic foot syndrome must take into account protective sensibility of the foot, open wounds, infection status, and the rules of septic bone surgery. Interventions are classified as elective, prophylactic, curative, or emergency. Amputations in the forefoot and midfoot region are performed as ray amputations (including metatarsal), which can often be carried out as ”inner“ amputations. Gentle tissue treatment mandatory because of greater risk of revision with re-amputation compared to classical amputation.Indications
Good demarcation of infection, acute osteomyelitis, osteolytic lesions, neurotropic ulcer, arterial and venous blood flow to the other toes, gangrene of other toes with metatarsal affection.Contraindications
Arterial occlusive disease, infection of neighboring areas, avoidable amputations, poorly healing ulcers on the lower leg.Surgical technique
Primary dorsal approach; minimal incisional distance (5 cm) to minimize skin necrosis risk. Atraumatic preparation, minimize hemostasis to not compromise the borderline perfusion situation. In amputations, plantar skin preparation and longer seams placed as dorsal as possible, either disarticulated and maintain cartilage, or round the cortical metatarsal bone after resection.Postoperative treatment
Diabetes control. Braun splint, mobilization in a shoe with forefoot decompression and hindfoot support, physiotherapy. Antibiotics based on resistance testing. If no complications, dressing change on postoperative day 1. Optimal wound drainage by lowering foot several times a day; drainage removal after 12–24 h. Insoles and footwear optimization.Results
Amputations require continued attention and if necessary treatment to avoid sequelae. Insufficient treatment associated with recurrent ulceration and altered anatomy.8.
Pedro Henrique Alves de Morais Vinícius Lacerda Ribeiro Igor Eduardo Caetano de Farias Luiz Eduardo Almeida Silva Fabiana Pirani Carneiro Joel Paulo Russomano Veiga João Batista de Sousa 《World journal of emergency surgery : WJES》2012,7(Z1):S10
Introduction
Most trauma patients are drunk at the time of injury. Up to 2% of traumatized patients develop sepsis, which considerably increases their mortality. Inadequate wound healing of the colonic repair can lead to postoperative complications such as leakage and sepsis.Objective
To assess the effects of acute alcohol intoxication on colonic anastomosis wound healing in septic rats.Methods
Thirty six Wistar rats were allocated into two groups: S (induction of sepsis) and AS (alcohol intake before sepsis induction). A colonic anastomosis was performed in all groups. After 1, 3 or 7 days the animals were killed. Weight variations, mortality rate, histopathology and tensile breaking strength of the colonic anastomosis were evaluated.Results
There was an overall mortality of 4 animals (11.1%), three in the group AS (16.6%) and one in the S group (5.5%). Weight loss occurred in all groups. The colon anastomosis of the AS group didn’t gain strength from the first to the seventh postoperative day. On the histopathological analysis there were no differences in the deposition of collagen or fibroblasts between the groups AS and S.Conclusion
Alcohol intake increased the mortality rate three times in septic animals. Acute alcohol intoxication delays the acquisition of tensile strength of colonic anastomosis in septic rats. Therefore, acute alcohol intoxication before sepsis leads to worse prognosis in animal models of the abdominal trauma patients.9.
Background
Immune-compromised patients incur a high risk of surgical wound dehiscence and colonization by multidrug resistant organisms. Common treatment has been debridement and spontaneous secondary healing.We report on the results obtained in nine such patients whose wounds were treated by debridement, negative pressure dressing and direct closure.Methods
All immune-compromised patients referred to our Institution between March 1, 2010 and November 30, 2011 for dehiscent abdominal wounds growing multidrug resistant organisms were treated by serial wound debridements and negative pressure dressing. They were primarily closed, despite positive microbiological cultures, when clinical appearance was satisfactory.As a comparison, records from patients treated between March 1, 2008 and February 28, 2010 who, according to our Institution’s policy at that time, had been left to heal by secondary intention, were retrieved and examined.Results
Nine patients were treated by direct wound closure, five had been treated previously by secondary intention healing.Overall, ten patients had received liver transplant, 1 kidney transplant, 1 was HIV infected, 1 suffered from multi-organ failure, 1 was undergoing hemodialysis.Wound dehiscence involved skin and subcutaneous layers in all patients, in two the muscular layer was also involved.Mean healing time was significantly shorter in patients treated more recently by primary intention in comparison with historical patients (28 vs 81 days). The only complication observed was a small superficial abscess that developed around a non-absorbable stitch 10 months after closure in a patient treated by primary closure.Conclusions
According to our results, fast healing can be safely obtained by closure of a clinically healthy wound, despite growth of multidrug resistant organisms, even in immune-compromised patients.10.
Purpose of review
Bone fracture healing is a complex physiological process relying on numerous cell types and signals. Inflammatory factors secreted by immune cells help to control recruitment, proliferation, differentiation, and activation of hematopoietic and mesenchymal cells. Within this review we will discuss the functional role of immune cells as it pertains to bone fracture healing. In doing so, we will outline the cytokines secreted and their effects within the healing fracture callus.Recent findings
Macrophages have been found to play an important role in fracture healing. These immune cells signal to other cells of the fracture callus, modulating bone healing.Summary
Cytokines and cellular signals within fracture healing continue to be studied. The findings from this work have helped to reinforce the importance of osteoimmunity in bone fracture healing. Owing to these efforts, immunomodulation is emerging as a potential therapeutic target to improve bone fracture healing.11.
Background
Endoscopic management of leakages and perforations of the upper gastrointestinal tract is gaining in importance as it can significantly reduce the morbidity and mortality of surgical interventions.Objective
A summary of the current literature with the focus on success rates for endoscopic vacuum therapy (EVT) in the upper gastrointestinal tract is presented. Technical aspects are demonstrated and the role of EVT as a new therapeutic option for esophageal defects of different etiologies is discussed.Material and methods
After endoscopic assessment of the geometry of the leakage defect a polyurethane foam sponge is cut into the corresponding shape, connected to a nasal gastric tube and endoscopically placed into the defect. Continuous negative pressure of 100–125 mmHg generated by a vacuum pump is applied via the drainage tube resulting in effective drainage of the cavity and the induction of wound healing by formation of granulation tissue. The foam sponge is replaced in the same way every 3–5 days. Technical aspects are demonstrated and the background literature is discussed.Results
The first series of cases demonstrate excellent healing rates with a very low procedure-related morbidity.Conclusion
It appears likely that this technique will become the new therapeutic standard for leakages in the upper gastrointestinal tract.12.
Purpose
The purpose of this study is to evaluate the surgical technique and review the therapeutic effect of vacuum sealing drainage combined with ileostomy treating patients of traumatically buttock skin necrosis.Methods
26 patients with buttock wounds were dressed and 6–12 days later, buttock skin necrosis boundaries were clear and debridement was performed. General surgeons were invited to perform the ileostomy. Thorough debridement was conducted and vacuum sealing drainage (VSD) devices were used to cover buttock wounds. Debridement and VSD were operated every 5–7 days until the granulation tissue of buttock wound was fresh. Then epidermal skin graft from thigh was performed to cover the granulation wound. About 3 months later after skin graft survival completely, the ileum was reversed by general surgeons and the patients recovered defecation using anus.Results
The granulation tissues of all patients were fresh after debridement and VSD 2–3 times. In 20 cases, transplanted epidermal skin grew well. In six cases, necrosis was observed at the margins of the flap and further debridement and skin graft were conducted. During the follow-up period of approximate 6 months, the flaps grew well and the patients defecated normally from anus.Conclusions
Treating traumatically cutaneous necrosis of buttocks with vacuum sealing drainage and ileostomy can gain good therapeutic effect.13.
14.
Objective
Tension-free skin closure after partial aponeurectomy of fingers in Dupuytren’s disease with flexion contracture.Indications
Contractures of the proximal interphalangeal (PIP) joint >30° in Dupuytren’s disease cannot sufficiently treated by Z-plasty due to the contracted skin conditions.Contraindications
Preoperative scar tissue or impaired circulation in the operation region and infections.Surgical technique
The primary plan is to place a sliding flap into the incision line with the PIP joint in a flexed position, under regional anesthesia and temporary arrest of the blood supply of the upper arm by cuffing. Definitive incising round the sliding flap after achieving a PIP extension position and covering of the sliding flap either by another dorsal side flap or by full thickness skin graft.Postoperative management
Immobilization in a palmar splint, hand physiotherapy and massaging of the scar.Results
In the time period June 2008 to December 2010 a total of 40 patients were surgically treated. The preoperative angle of contracture in the PIP joint was 30–60° in 25 patients (group 1), 60–90° in 10 patients (group 2) and > 90° in 5 patients (group 3). The angle of contracture 12 months postoperatively was 10–15° in group 1, 20–30° in group 2 and 30–40° in group 3 and after 24 months 15–20° in group 1, 30–45° in group 2 and 40–60° in group 3 . The angle of contracture of the PIP joint was greatest for digit 5. Revision surgery resulted in a poorer outcome. Recovery of sensation lasted up to 2 years after surgery. Complications which occurred were problems in wound healing (4), loss of a flap (1), partial loss of the skin transplant without revision (3), arthrodesis (1) and amputation of digit 5 (1).15.
Valerio Cozza Gilda Pepe Marco Cintoni Flavio De Maio Giuseppe Tropeano Sabina Magalini Gabriele Sganga Giovanni Delogu Daniele Gui 《World journal of emergency surgery : WJES》2018,13(1):53
Background
Negative pressure wound therapy is now largely used to treat infected wounds. The prevention and reduction of healthcare-associated infections is a high priority for any Department of Health and great efforts are spent to improve infection control systems. It is assumed that vacuum-assisted closure (VAC®) dressings should be watertight and that all the secretions are gathered in a single container but there is no consistent data on air leakage and possible dispersion of bacteria from the machine.Methods
We have conducted a prospective experimental study on 10 patients with diagnosis of wound infection to verify whether the filtration process is microbiologically efficient. We compared the bacteria population present in the wound to the one present in the air discharged by the VAC® machine.Results
This study shows that the contamination of the VAC® machine is considerably lower than the environment or wound contamination.Conclusions
Negative pressure wound therapy system does not represent a risk factor for healthcare-associated infections.16.
Kai Chen Jin-ti Lin Shuai-bo Sun Jian Lin Jian-zhong Kong Nai-feng Tian 《Journal of orthopaedic surgery and research》2018,13(1):321
Background
Wound infections after posterior spinal surgery are a troublesome complication; patients are occasionally forced to remove the internal fixation device, which can lead to instability of the spine and injury to the spinal cord. The purpose of this study was to evaluate the efficacy of modified vacuum-assisted closure (VAC) for treating an early postoperative spinal wound infection.Methods
We conducted a retrospective study of 18 patients with wound infections after posterior spinal surgery from 2014 to 2017 at a single tertiary center. All patients included in the study received modified VAC treatment (VAC combined with a closed suction irrigation system, CSIS) until the wound satisfied the secondary closure conditions. Detailed information was obtained from the medical records.Results
Wound size decreased significantly after 1?week of the modified VAC treatment. Three patients were treated with VAC three times and one patient received the VAC treatment four times; the remaining patients received the VAC treatment twice. The patients had excellent wound beds after an average of 8?days. The wound healed completely after an average of 17?days, and the average hospital stay was 33?days. There was no recurrence of infection at the 1-year follow-up.Conclusions
This study demonstrates that VAC combined with a CSIS is a safe, reliable, and effective method to treat a wound infection after spinal surgery. This improved VAC procedure provides an excellent wound bed to facilitate wound healing and shorten the hospital stay.17.
Krischak GD Augat P Blakytny R Claes L Kinzl L Beck A 《Archives of orthopaedic and trauma surgery》2007,127(6):453-458
Introduction
Non-steroidal anti-inflammatory drug (NSAID) is well known to significantly delay fracture healing. Results from in vitro studies implicate an impairment of osteoblast proliferation due to NSAIDs during the initial stages of healing. We studied whether diclofenac, a non-selective NSAID, also impairs appearance of osteoblasts in vivo during the early phase of healing (at 10 days).Materials and methods
Two defects (Ø 1.1 mm) were drilled within distal femurs of 20 male Wistar rats. Ten rats received diclofenac continuously; the other obtained a placebo until sacrificing at 10 days. Osteoblast proliferation was assessed by cell counting using light microscopy, and bone mineral density (BMD) was measured using pQCT.Results
Osteoblast counts from the centre of bone defect were significantly reduced in the diclofenac group (median 73.5 ± 8.4 cells/grid) compared to animals fed with placebo (median 171.5 ± 13.9 cells/grid). BMD within the defect showed a significant reduction after diclofenac administration (median 111.5 ± 9.3 mg/cm³) compared to the placebo group (median 177 ± 45.4 mg/cm³).Conclusion
The reduced appearance of osteoblasts in vivo implicates an inhibiting effect of diclofenac on osteoblasts at a very early level of bone healing. The inhibition of proliferation and migration of osteoblasts, or differentiation from progenitor cells, is implicated in the delay of fracture healing after NSAID application.18.
Sanjay Kalra Palash Aiyer Minakshi Bhardwaj Vijay Grover Vijay Kumar Gupta 《Indian Journal of Thoracic and Cardiovascular Surgery》2016,32(2):113-119
Purpose
The great saphenous vein harvested with a traditional open technique often results in leg wound complications. An endoscopic harvesting technique may decrease incidence of these complications.Methods and material
Fifty consecutive patients having elective primary coronary artery bypass surgery were prospectively and randomly assigned to either endoscopic great saphenous vein harvesting (EVH—group A) or open great saphenous vein harvesting (OVH—group B). Both groups were demographically similar and received identical management. Leg wound healing was evaluated at discharge, 1 week, 1 month and 6 months for evidence of complications.Result
The patient in endoscopic vein harvesting group had increased harvest time and an insignificant increase in vein injuries at the time of harvesting but decreased incision closure times when compared with traditional longitudinal open vein harvesting. Conversion from endoscopy to a traditional longitudinal open vein harvest occurred in 5 % of patients. Leg wound complications were significantly reduced postoperatively in the endoscopic vein harvesting group in comparison with the open vein harvesting group. Histological evaluation of structural integrity of vein samples shows that there is no significant difference between both the groups. No patient was readmitted to the hospital for leg wound complications in either group.Conclusion
EVH is a safe, reliable method for saphenous vein harvesting. The best indication for EVH may be in patients who are in increased risk for wound infection and in whom cosmetics is a major concern.19.
Background
Dermal regeneration template (DRT) has been well implicated in the reconstruction of full-thickness burn injury. This case series specifically presents our experience and our clinical application of Pelnac® to achieve wound closure with complex acute full-thickness defect.Methods
A retrospective review of patients treated with Pelnac for complex wound defects from 2008 to 2014 at Concord Burns Unit was carried out. Variables such as wound aetiology, wound size and complications were considered.Results
Five patients (four females and one male with a mean age 54?±?20) all had full-thickness defects (mean defect size 4.3?±?2.0 % TBSA), some with exposed tendon and bone. The wounds were treated with Pelnac®; the silicone layer was removed at postoperative day 14 and a split-thickness skin graft (0.2 to 0.3 mm) was applied. Clinically, the reconstructed areas demonstrated good granulation tissue at 14 days with good take of the skin graft. There were no major acute graft loss, rejection or associated infection. However, there were small areas of graft loss which did not require re-grafting.Conclusions
DRT provides a safe and efficacious alternative when dealing with acute contaminated full-thickness wounds. Pelnac® seems versatile in obtaining wound coverage in difficult complex wounds, especially in critically ill patients where free or pedicle flap reconstruction would be problematic.Level of Evidence: Level V, therapeutic study.20.