1
|
Deng Z, Long ZS, Chen G. Mini-Review: Tendon-Exposed Wound Treatments. J INVEST SURG 2023; 36:2266758. [PMID: 37813390 DOI: 10.1080/08941939.2023.2266758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/28/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Tendon-exposed wounds are complex injuries with challenging reconstructions and no unified treatment mode. Furthermore, insufficient tissue volume and blood circulation disorders affect healing, which increases pain for the patient and affects their families and caretakers. REVIEW As modern medicine advances, considerable progress has been made in understanding and treating tendon-exposed wounds, and current research encompasses both macro-and micro-studies. Additionally, new treatment methods have emerged alongside the classic surgical methods, such as new dressing therapies, vacuum sealing drainage combination therapy, platelet-rich plasma therapy, and live-cell bioengineering. CONCLUSIONS This review summarizes the latest treatment methods for tendon-exposed wounds to provide ideas and improve their treatment.
Collapse
Affiliation(s)
- Zhuan Deng
- Department of Orthopedics, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Zhi-Sheng Long
- Department of Orthopedics, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Gang Chen
- Department of Orthopedics, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| |
Collapse
|
2
|
Bishop ME, Comer CD, Kane JM, Maltenfort MG, Raikin SM. Republication of "Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated?". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231188102. [PMID: 37506168 PMCID: PMC10369100 DOI: 10.1177/24730114231188102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
Background Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected (P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified-a significantly lower complication rate than that reported in the literature (P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature (P < .0001; CI 0.067-1.94). Conclusion In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients' overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence Level IV.
Collapse
Affiliation(s)
- Meghan E Bishop
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Carly D Comer
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Justin M Kane
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Baylor University Medical Center, Dallas, TX USA
| | - Mitchell G Maltenfort
- Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA, USA
| | - Steven M Raikin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
3
|
Son TT, Dung PTV, Thuy TTH, Chien VH, Phuc LH, Huy LA. One-stage reconstruction of the massive overlying skin and Achilles tendon defects using a free chimeric anterolateral thigh flap with fascia lata. Microsurgery 2022; 42:659-667. [PMID: 35716021 PMCID: PMC9796470 DOI: 10.1002/micr.30931] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/13/2022] [Accepted: 06/03/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Treatment for large defects in the non-weight-bearing Achilles tendon and soft tissues remains a reconstructive challenge. The free composite anterolateral thigh flap (ALT) with fascia lata (FL) has been indicated in the single-stage reconstruction of the Achilles tendon and soft tissue defect and this technique remain some disadvantages, such as the inability to perform primary flap thinning, requiring secondary flap thinning, and the delayed normalization of the range of motion of the ankle joint. The free chimeric ALT flap with FL was introduced as a novel alternative with many advantages in reconstructing the Achilles tendon and soft tissue defects. This paper reports the reconstruction of the massive Achilles tendon and overlying skin defects using free chimeric ALT flaps with FL. METHODS From June 2017 to October 2020, we performed on a series of 5 patients receiving free chimeric ALT flaps with FL to reconstruct the Achilles tendon and soft tissue defects. The age of patients ranged from 43 to 62 years old. All five patients had full-layer defects of the Achilles tendon with infection. The sizes of the skin defects ranged from 6 × 4 cm to 12 × 10 cm. The perforators from the descending branch of the lateral circumflex femoral arteries are located using a handheld Doppler. The perforators help to design the outline of the ALT flap and fascia flap. The skin flap was thinned under microscopy if the flap was too thick. The anastomosis was accomplished before insetting the flaps into the defect. RESULTS The size of the ALT flap ranged from 10 × 5 cm to 15 × 12 cm, and the size of the FL flap ranged from 7 × 4 cm to 10 × 8 cm. The mean perforator length for the skin flap and fascia lata was 3.3 cm (range, 2.5-5.0 cm) and 5.3 cm (range, 3.5-7.0 cm), respectively. Four patients received skin flap thinning up to 57%-79% of the flap thickness, while one patient did not need to debulk. The thickness of the ALT flap ranged from 6 to 13 mm. All the flaps survived completely and postoperative courses were uneventful without any complications. The follow-up time ranged from 12 to 51 months. All patients were able to stand and ambulate, and they were satisfied with the reconstructive results. CONCLUSIONS The free thin chimeric ALT with FL flap is appeared to be an appropriate treatment for the massive Achilles tendon and overlying skin defects. This may be a practical approach to improve the functional outcomes of patients with infected massive Achilles tendon and overlying skin defects.
Collapse
Affiliation(s)
- Tran Thiet Son
- Department of Plastic Reconstructive and Aesthetic SurgeryBach Mai HospitalHanoiVietnam,Department of Plastic SurgerySaint Paul HospitalHanoiVietnam,Department of Plastic and Reconstructive SurgeryHanoi Medical University HospitalHanoiVietnam
| | - Pham Thi Viet Dung
- Department of Plastic Reconstructive and Aesthetic SurgeryBach Mai HospitalHanoiVietnam,Department of Plastic SurgerySaint Paul HospitalHanoiVietnam,Department of Plastic and Reconstructive SurgeryHanoi Medical University HospitalHanoiVietnam
| | - Ta Thi Hong Thuy
- Department of Plastic Reconstructive and Aesthetic SurgeryBach Mai HospitalHanoiVietnam,Department of Plastic SurgerySaint Paul HospitalHanoiVietnam
| | - Vu Hong Chien
- Department of Plastic Reconstructive and Aesthetic SurgeryBach Mai HospitalHanoiVietnam,Department of Plastic SurgerySaint Paul HospitalHanoiVietnam
| | - Le Hong Phuc
- Department of Plastic Aesthetic SurgeryHue University of Medicine and Pharmacy HospitalHueVietnam
| | - Le Anh Huy
- Department of Plastic Reconstructive and Aesthetic SurgeryBach Mai HospitalHanoiVietnam
| |
Collapse
|
4
|
Eser C, Karagoz Ceylan OI, Gencel E, Tabakan I, Kokacya O, Yavuz M. Reconstruction of Achilles region defects: A single-centre experience. Int J Clin Pract 2021; 75:e14908. [PMID: 34547158 DOI: 10.1111/ijcp.14908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reconstruction of Achilles tendon and the overlying tissue defects is a challenging undertaking. The spectrum of available repair methods range from secondary healing to the use of free flaps. The aim of this study was to discuss reconstruction options and to help the surgeon to select reliable approach to achieve favourable outcomes. METHOD In this study, we retrospectively evaluated 14 patients who underwent reconstruction of Achilles region defect between 2016 and 2019 at a single centre. RESULTS Reconstructions were performed with secondary healing (n = 2), negative pressure wound therapy and skin grafting (n = 2), free flaps (n = 6) and local and distant flaps (n = 4). Satisfactory aesthetic and functional outcomes were achieved in all patients. One patient developed partial skin graft loss. Marginal necrosis occurred in one of the local flaps. Wound dehiscence and flap retraction occurred in one of the free (superficial circumflex iliac artery perforator) flaps. One patient undergoing reconstruction with ulnar artery perforator flap developed intraoperative atrial fibrillation; the operation was terminated and reconstruction completed with skin grafting. CONCLUSION Orthoplastic reconstruction should be kept in mind for Achilles tendon defects. The use of special digital imaging techniques facilitates flap surgery and helps minimise the risk of flap complications. Conventional approaches are suitable for shallow small skin lesions. Local flaps are good options for deeper skin defects owing to superior aesthetic outcomes. Super-thin free flaps offer a distinct advantage in skillful hands. The use of multi-content free chimeric flaps for reconstruction of complex defects facilitates better anatomical repair. Cross leg or flow-through flaps may be considered in patients with compromised distal circulation. Selection of the most reliable approach for Achilles reconstruction is a key imperative to achieve favourable outcomes.
Collapse
Affiliation(s)
- Cengiz Eser
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozgun Ilke Karagoz Ceylan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Eyuphan Gencel
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ibrahim Tabakan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Omer Kokacya
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Metin Yavuz
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cukurova University Faculty of Medicine, Adana, Turkey
| |
Collapse
|
5
|
Rasool A, Bashir SA, Ahmad PA, Bijli AH, Baba UF, Yasir M, Wani AH. Management of Wounds with Exposed Bones or Tendons in Children by Vacuum-Assisted Closure Therapy: A Prospective Study. Indian J Plast Surg 2020; 53:97-104. [PMID: 32367923 PMCID: PMC7192708 DOI: 10.1055/s-0039-3400192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background
The management of complex soft tissue defects with exposed bones/tendons is always a challenging task for the surgeon and the problem becomes more pronounced when it comes to the management of these wounds in children. Though flap procedures are considered the standard for managing the complex soft tissue defects with exposed bones/tendons yet small blood vessels for anastomosis, long operative period, increased chances of perioperative thrombosis, and difficult perioperative management in children add to the difficulty in performing flap procedures in children. The vacuum-assisted closure (VAC) therapy has emerged as a novel modality for the management of the difficult wounds with added advantages, especially in children.
Objective
To evaluate the efficacy of VAC in the management of wounds with exposed bones/tendons in children.
Patients and Method
Forty-six children of complex wounds with exposed bones/tendons were included in the study from July 2016 to June 2018.
Results
Out of 46 patients, 31 were male; the patients had a mean age of 8.4 years. Road traffic accident was the most common mode of injury (54%), with most of the wounds located over extremities. The mean duration of VAC therapy was 12 days. More than 90% coverage of the exposed structure was seen in 89% of patients. The wounds were definitively managed by split-thickness skin graft in 89% of patients and flap cover in 6.5% of patients. The mean cost of the VAC therapy at our government run hospital was 187 Indian rupees per day. No significant major complications were seen during the treatment.
Conclusion
VAC therapy is an efficient, safe, and cost-effective modality of treatment for the management of complex wounds in the pediatric population.
Collapse
Affiliation(s)
- Altaf Rasool
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Sheikh Adil Bashir
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Prince Ajaz Ahmad
- Department of Surgery, Sher-i- Kashmir Institute of Medical Sciences Srinagar, Kashmir, India
| | - Akram Hussain Bijli
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Umer Farooq Baba
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mir Yasir
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Adil Hafeez Wani
- Department of Plastic Surgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| |
Collapse
|
6
|
Abstract
There are multiple techniques to treat tendon defects in the event end-to-end repair cannot be achieved after débridement. In general, the choice of treatment technique is based on size of the resultant gap. Although each treatment technique has literature to support its use, there are no data to support the use of one technique over another. Treatment should be based on the experience and discretion of the treating surgeon. This article proposes an algorithm for wound breakdown, infection, and rerupture after Achilles tendon surgery. This algorithm should be used as a guide.
Collapse
Affiliation(s)
- Jordan Liles
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710, USA.
| | - Samuel B Adams
- Duke University Medical Center, 40 Duke Medicine Circle, Room 5309 (Orange), Durham, NC 27710, USA
| |
Collapse
|
7
|
Mohsin M, Zargar HR, Wani AH, Zaroo MI, Baba PUF, Bashir SA, Rasool A, Bijli AH. Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study. Indian J Plast Surg 2019; 50:43-49. [PMID: 28615809 PMCID: PMC5469234 DOI: 10.4103/ijps.ijps_196_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. Materials and Methods: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. Results: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4–9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. Conclusions: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.
Collapse
Affiliation(s)
- Mir Mohsin
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Haroon Rashid Zargar
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Adil Hafeez Wani
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Mohammad Inam Zaroo
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | | | - Sheikh Adil Bashir
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Altaf Rasool
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Akram Hussain Bijli
- Department of Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
8
|
Bishop ME, Comer CD, Kane JM, Maltenfort MG, Raikin SM. Open Repair of Acute Achilles Tendon Ruptures: Is the Incidence of Clinically Significant Wound Complications Overestimated? FOOT & ANKLE ORTHOPAEDICS 2017. [DOI: 10.1177/2473011417699834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Conflicting evidence exists regarding the optimal management of acute Achilles tendon ruptures. Operative repair is thought to afford patients a lower risk of rerupture, albeit at a higher overall risk of wound complications. Methods: A retrospective chart review of 369 consecutive patients undergoing open repair of acute Achilles tendon ruptures performed by a single foot and ankle fellowship-trained orthopedic surgeon was undertaken. Healing was classified as no complications, complications without prolonging treatment, complications requiring prolonged local treatment, and complications requiring operative intervention. A statistical analysis comparing the rates of complications in this cohort to that reported in the literature was conducted. Results: There were a total of 33 (8.94%) wound complications. Compared to the rates reported in the literature, no significant difference was detected ( P = .3943; CI 6.24-12.33). However, when the complications not requiring additional treatment or prolonged care were excluded, only 9 wound complications (2.44%) were identified—a significantly lower complication rate than that reported in the literature ( P < .0001; CI 1.12-4.58). There were only 2 (0.54%) major complications requiring operative intervention, also a significantly lower rate than in the literature ( P < .0001; CI 0.067-1.94). Conclusion: In the past, wound-healing complications have been cited as a concern when treating patients operatively. We found that when solely looking at healing complications prolonging the patients’ overall recovery, a significantly lower rate of complications existed compared to that reported in the literature. Level of Evidence: Level IV.
Collapse
Affiliation(s)
- Meghan E. Bishop
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Carly D. Comer
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Justin M. Kane
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Baylor University Medical Center, Dallas, TX USA
| | | | - Steven M. Raikin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
9
|
Marchesi A, Parodi PC, Brioschi M, Riccio M, Perrotta RE, Colombo M, Calori GM, Vaienti L. Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature. Injury 2016; 47 Suppl 4:S147-S153. [PMID: 27492062 DOI: 10.1016/j.injury.2016.07.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.
Collapse
Affiliation(s)
- A Marchesi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Via Morandi, 30 - 20097, Milan, Italy.
| | - P C Parodi
- Department of Plastic and Reconstructive Surgery, University of Udine, Udine, Italy
| | - M Brioschi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato. Università degli Studi di Milano, San Donato Milanese, Milan, Italy
| | - M Riccio
- Department of Reconstructive Plastic Surgery-Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
| | - R E Perrotta
- Department of Medical and Surgery Specialties, Section of Plastic Surgery, University of Catania, Catania, Italy
| | - M Colombo
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - G M Calori
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - L Vaienti
- Department of Plastic and Reconstructive Surgery. I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Milan, Italy
| |
Collapse
|
10
|
Increased Cost of Negative Pressure Dressings Is Not Justified for Split-Thickness Skin Grafting of Low-Risk Wounds. J Orthop Trauma 2015; 29:301-6. [PMID: 25463425 DOI: 10.1097/bot.0000000000000259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To determine whether negative pressure dressings (NPDs) are superior to conventional compressive dressings (CDs) for split-thickness skin grafts (STSGs) placed on healthy, low-risk wounds, (2) To determine the cost difference of NPDs versus that of CDs. DESIGN Retrospective. SETTING Level I Trauma Center. PATIENTS/PARTICIPANTS One hundred ninety-five traumatic wounds treated with STSG. MAIN OUTCOME MEASUREMENTS Patients were assigned outcomes based on postoperative documentation: completely healed, incompletely healed (small areas of graft necrosis), failed, or lost to follow-up. The costs associated with each dressing type were documented. RESULTS Thirty five of 195 STSGs were lost to follow-up, leaving n = 120 STSG-NPD, n = 40 STSG-CD. Of the remaining 120 STSGs treated with NPD, 91 completely healed, 23 incompletely healed, and 6 failed. Of the 40 STSGs treated with a CD, 37 completely healed, 1 incompletely healed, and 2 failed. Patients treated with CDs had a higher likelihood of healing relative to those treated with the NPD (P = 0.018). Analyzing the outcomes as failed versus "not failed" revealed no significant difference between the groups (P = 1.00). There were more smokers in the CD group (P = 0.022). In this series, the mean cost associated with NPD compared with that of CD was $2370 more per patient. CONCLUSIONS There is a high rate of successful healing of STSGs for traumatic extremity wounds regardless of the dressing used. The increased cost of NPDs is not justified in wounds that are at a low risk of developing STSG failure. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
11
|
Hulsen J, Diederich R, Neumeister MW, Bueno RA. Integra® dermal regenerative template application on exposed tendon. Hand (N Y) 2014; 9:539-42. [PMID: 25414619 PMCID: PMC4235916 DOI: 10.1007/s11552-014-9630-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tendon without paratenon presents the reconstructive surgeon with a tissue coverage challenge. Integra® dermal regenerative template has been shown to initiate a stable, vascularized bed for skin grafting over tendon. However, histological processes that occur during incorporation have not been described. The purpose of this study is to characterize the pattern of changes that occur when Integra® is applied to an avascular tendon. We hypothesize that vascular incorporation will originate from the wound periphery and proceed toward the tendon center. METHODS A full-thickness defect was created over a denuded Achilles tendon in a single hind limb in eight New Zealand white rabbits. Integra was placed over the avascular tendon, and the limb was dressed and splinted. Two animals were euthanized at each timepoint (weeks 1, 2, 3, and 4), and hematoxylin and eosin (H&E)-stained tissue specimens were microscopically evaluated. RESULTS Week 1 specimens demonstrated limited adherence between Integra and the tendon, while myofibroblasts were found encircling the tendon. No cellularity was noted centrally. At week 2, the dermis-Integra junction had increasing vascularity and the central portion developed increasing cellularity. By week 3, Integra was completely revascularized. At week 4, Integra had the histological appearance of normal dermis. CONCLUSION Neovascularization of Integra® over exposed tendon occurs from the peripheral tissue. Ingrowth proceeds from the dermis-Integra interface toward the center of the graft. Four weeks after application to the denuded tendon, Integra has the histological appearance of native dermis.
Collapse
Affiliation(s)
- John Hulsen
- />Department of Plastic Surgery, The Ohio State University, 915 Olentagy River Road, Suite 2100, Columbus, OH 43212-3153 USA
| | - Ryan Diederich
- />Division of Plastic Surgery, Southern Illinois University School of Medicine, PO Box 19653, Springfield, IL 62794-9653 USA
| | - Michael W. Neumeister
- />Division of Plastic Surgery, Southern Illinois University School of Medicine, PO Box 19653, Springfield, IL 62794-9653 USA
| | - Reuben A. Bueno
- />Division of Plastic Surgery, Southern Illinois University School of Medicine, PO Box 19653, Springfield, IL 62794-9653 USA
| |
Collapse
|
12
|
Malahias M, Jordan DJ, Hindocha S, Khan W, Juma A. The development and future of reconstructive and microvascular surgery of the hand. Open Orthop J 2014; 8:415-22. [PMID: 25408783 PMCID: PMC4235081 DOI: 10.2174/1874325001408010415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/03/2014] [Accepted: 05/27/2014] [Indexed: 11/22/2022] Open
Abstract
The hand is often thought of as a key discriminator in what makes humans human. The hand is both intricate and fascinating in its design and function, allowing humans to interact with their surroundings, and each other. Due to its use in manipulation of the person’s environment, injury to the hand is common. Devastating hand injuries have a profound, physical, psychological, financial and socially crippling effect on patients. Advances in operative techniques and improvements in microscopes and instruments allowed Malt &McKhann to perform the first successful arm replantation in 1962 [1]. This was followed by a myriad of autologous free flaps of varying composition, that were discovered after the mapping of the cutaneous blood circulation by Taylor and Palmer [2] and Mathes & Nahai’s classification of muscle flaps [3] providing us with countless options to harvest and transfer healthy, well vascularised tissues into areas of injury. Since the late sixties, with the emerging subspecialty of microvascular reconstruction, surgeons have had the technical ability to salvage many amputated parts, even entire limbs. The measure of functional outcomemust incorporate the evaluation and severity ofthe initial injury and the subsequent reconstructive surgeries [4].
Collapse
Affiliation(s)
- Marco Malahias
- Plastic Surgery Department, Good Hope Hospital, West Midlands, UK
| | | | | | - Wasim Khan
- Royal National Orthopaedic Hospital, London, UK
| | - Ali Juma
- Plastic Surgery Unit, Countess of Chester Hospital, Chester, UK
| |
Collapse
|
13
|
Malahias M, Hindocha S, Saedi F, McArthur P. Topical negative pressure therapy: current concepts and practice. J Perioper Pract 2012; 22:328-32. [PMID: 23162996 DOI: 10.1177/175045891602201004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Research into topical negative pressure therapy (TNPT) started in 1989 with Dr Louis Argenta and Prof Michael Morykwas of Wake Forest University School of Medicine in North Carolina, USA. In 1997, Morykwas and Argenta concluded that TNPT both enhanced granulation tissue formation and helped bacterial clearance, through the actions of negative pressure Armstrong and Lavery confirmed this in 2005, concluding that TNPT therapy was promoting the development of granulation tissue. Numerous other studies have proved that TNPT is beneficial for a myriad of other wounds including: sternotomy wounds, extensive de-gloving injuries, various soft tissue injuries prior to surgical closure, skin grafting, pressure sores, leg ulcers, sacral pressure ulcers, acute traumatic soft tissue defects, and soft tissue defects following rigid stabilisation of lower extremity fractures. This review aims to summarise the clinical and scientific concepts of TNPT and its future applications.
Collapse
|
14
|
Abstract
BACKGROUND Over the last 15 years, negative-pressure wound therapy has become commonly used for treatment of a wide variety of complex wounds. There are now several systems marketed, and additional products will be available in the near future. Many clinicians have noted a dramatic response when negative-pressure wound therapy technology has been used, prompting a number of scientific investigations related to its mechanism of action and clinical trials determining its efficacy. METHODS The peer-reviewed literature within the past 5 years was reviewed, using an evidence-based approach. RESULTS Negative-pressure wound therapy works through mechanisms that include fluid removal, drawing the wound together, microdeformation, and moist wound healing. Several randomized clinical trials support the use of negative-pressure wound therapy in certain wound types. Serious complications, including bleeding and infection, have recently been reported by the U.S. Food and Drug Administration in a small number of patients. CONCLUSIONS Negative-pressure wound therapy has dramatically changed the way complex wounds are treated. The rapid introduction of this technology has occurred faster than large-scale randomized controlled studies or registry studies have been conducted. Further clinical studies and basic science studies will help surgeons to better understand the evidence and use this technology in the future.
Collapse
|
15
|
Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus. Injury 2011; 42 Suppl 1:S1-12. [PMID: 21316515 DOI: 10.1016/s0020-1383(11)00041-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.
Collapse
|
16
|
Trephination and Subatmospheric Pressure Therapy in the Management of Extremity Exposed Bone. ACTA ACUST UNITED AC 2010; 69:1591-6. [DOI: 10.1097/ta.0b013e3181edba5e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Knobloch K, Vogt P. The importance of sufficient debridement prior to Achilles tendon coverage. J Plast Reconstr Aesthet Surg 2010; 63:e329-30. [DOI: 10.1016/j.bjps.2009.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 06/27/2009] [Accepted: 06/30/2009] [Indexed: 11/25/2022]
|
18
|
Boyce A, Atherton DD, Tang R, Jawad M. The use of Matriderm® in the management of an exposed Achilles tendon secondary to a burns injury. J Plast Reconstr Aesthet Surg 2010; 63:e206-7. [DOI: 10.1016/j.bjps.2009.02.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 02/04/2009] [Accepted: 02/07/2009] [Indexed: 10/21/2022]
|