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Sanz Ruiz P, Caeiro Rey JR, Martínez Pastor JC, Martín Alguacil JL, Murcia Asensio A, Moreta Suárez J. Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:97-107. [PMID: 36934806 DOI: 10.1016/j.recot.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/08/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVE In orthopedic surgery, it is clear that an optimal standardized closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyze the clinical practice of surgical wound closure in orthopedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. METHOD an ad hoc group of specialists in orthopedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.
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Affiliation(s)
- P Sanz Ruiz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - J R Caeiro Rey
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - J C Martínez Pastor
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínic de Barcelona, Barcelona, España
| | - J L Martín Alguacil
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vithas de Granada, Granada, España
| | - A Murcia Asensio
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Reina Sofía, Murcia, España
| | - J Moreta Suárez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Galdakao-Usansolo, Bizkaia, España
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Sanz Ruiz P, Caeiro Rey JR, Martínez Pastor JC, Martín Alguacil JL, Murcia Asensio A, Moreta Suárez J. [Translated article] Wound closure after knee and hip replacement (TKA and THA): Survey results on the clinical practice in Spain. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T97-T107. [PMID: 37992859 DOI: 10.1016/j.recot.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/11/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVE In orthopaedic surgery, it is clear that an optimal standardised closure technique has not yet been developed. Locally, there are no objective data describing the standard surgical practice in wound closure. The aim of this study is to analyse the clinical practice of surgical wound closure in orthopaedic surgery by means of a survey of a representative local sample and thus obtain information on the context of closure in Spain. MATERIAL AND METHOD An ad hoc group of specialists in orthopaedic surgery and traumatology was formed. The group of experts, after analyzing the literature, developed a questionnaire of 32 closed multiple-choice questions divided into the following blocks: hemostasis, surgical wound closure (deep, superficial, and cutaneous), and dressings. RESULTS A total of 471 surgeons responded to the survey completely and with sufficient information to perform the descriptive analysis. 79% believe that ATX can influence the decrease in surgical site infection rate. 96% believe that the type of deep closure at the level of the arthrotomy could influence outcomes and complications after hip and/or knee replacements. 85% believe that the type of shallow closure at the subcutaneous level may influence outcomes and complications after hip and/or knee replacement. 64% of surgeons use single-use incisional negative pressure therapy for the treatment of surgical wound complications (seroma, prolonged drainage, dehiscence). CONCLUSIONS There is a high level of variability in wound closure in our setting and a low level of training on the subject. The authors recommend that the different scientific societies invest resources to improve training in this field and reduce the percentage of surgeons who are considered inadequately trained, as well as adapting closure techniques to those considered gold standard according to the evidence.
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Affiliation(s)
- P Sanz Ruiz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - J R Caeiro Rey
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - J C Martínez Pastor
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J L Martín Alguacil
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vithas de Granada, Granada, Spain
| | - A Murcia Asensio
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - J Moreta Suárez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Galdakao-Usansolo, Bizkaia, Spain
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Taday R, Schiffner E, Gehrmann SV, Wilms LM, Kaufmann RA, Windolf J, Latz D. Establishing regions of interest of the lower leg and ankle for perioperative volumetric assessment with a portable 3D scanner in orthopedic and trauma surgery - a pilot study. J Foot Ankle Res 2023; 16:87. [PMID: 38049875 PMCID: PMC10696714 DOI: 10.1186/s13047-023-00684-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Soft tissue swelling assessment benefits from a reproducible and easy to use measurement method. Monitoring of the injured lower extremity is of clinical import during staged soft tissue management. Portable 3D scanners offer a novel and precise option to quantify and contrast the shapes and volumes of the injured and contralateral uninjured limbs. This study determined three regions of interest (ROI) within the lower extremity (lower leg, ankle and foot), that can be used to evaluate 3D volumetric assessment for staged soft tissue management in orthopedic and trauma surgery. METHODS Twelve healthy volunteers (24 legs) were included in this cohort study. Scans of all three ROI were recorded with a portable 3D scanner (Artec, 3D scanner EVA) and compared between the right and left leg using the software Artec Studio (Arctec Group, Luxemburg). RESULTS Mean volume of the right leg was 1926.64 ± 308.84 ml (mean ± SD). ROI: lower leg: 931.86 ± 236.15 ml; ankle: 201.56 ± 27.88 ml; foot: 793.21 ± 112.28 ml. Mean volume of the left leg was 1937.73 ± 329.51 ml. ROI: lower leg: 933.59 ± 251.12 ml; ankle: 201.53 ± 25.54 ml; foot: 802.62 ± 124.83 ml. There was no significant difference of the overall volume between right and left leg (p > 0.05; overall volume: △ difference: 29.5 ± 7.29 ml, p = 0.8; lower leg: △ difference: 21.5 ± 6.39 ml, p = 0.8; ankle: △ difference: 5.3 ± 2.11 ml, p = 0.4; △ difference: 16.33 ± 4.45 ml, p = 0.8. CONCLUSION This pilot study defines three regions of interest of the lower leg and demonstrates no difference between the right and left side. Based on these ROI, further studies are needed to evaluate the clinical applicability of the scanner.
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Affiliation(s)
- Roman Taday
- Department of Orthopedic and Trauma Surgery, University Hospital Düsseldorf, Moorenstraße 5, 40255, Düsseldorf, Germany
| | - Erik Schiffner
- Department of Orthopedic and Trauma Surgery, University Hospital Düsseldorf, Moorenstraße 5, 40255, Düsseldorf, Germany.
| | - Sebastian Viktor Gehrmann
- Department of Orthopedic and Trauma Surgery, Katholisches Karl- Leisner Klinikum, Albersallee 5-7, 47533, Kleve, Germany
| | - Lena Marie Wilms
- Department of Radiology, University Hospital Düsseldorf, Moorenstraße 5, 40255, Düsseldorf, Germany
| | - Robert Alexander Kaufmann
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Joachim Windolf
- Department of Orthopedic and Trauma Surgery, University Hospital Düsseldorf, Moorenstraße 5, 40255, Düsseldorf, Germany
| | - David Latz
- Department of Orthopedic and Trauma Surgery, University Hospital Düsseldorf, Moorenstraße 5, 40255, Düsseldorf, Germany
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Lertwongpaisan T, Amornsettachai P, Panyayong W, Suphangul S. Soft tissue dimensional change using customized titanium healing abutment in immediate implant placement in posterior teeth. BMC Oral Health 2023; 23:384. [PMID: 37308877 PMCID: PMC10262413 DOI: 10.1186/s12903-023-03060-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The morphologic and dimensional alveolar bone is significant for resorption in the first 3 months after tooth removal because they restrict treatment outcomes with respect to function and esthetic. Following teeth extraction, the width and height of the alveolar ridge contour are reduced in both the horizontal and vertical dimensions. Following implant placement, the gingival morphology should be changed minimally compared to pre-extraction. Surrounding natural-like tissue is also an ultimate goal of the dental implant treatment, which is correlated with the cervical third contour on the anatomical tooth, for comfortable cleansing, food impaction avoidance, and esthetics. PURPOSE To evaluate the peri-implant soft tissue changes after immediate implant placement (IIP) with the use of a customized titanium healing abutment in the posterior teeth. METHOD Digital impressions using the intraoral scanner (MEDIT i500) were taken from 30 patients. Customized titanium healing abutments were designed and milled before extraction. Flapless extractions were done using surgical guides, 32 immediate implants placement were done in posterior areas, and healing abutments were placed. Soft tissues were scanned during pre-operation, and post-surgery during the 1st, 3rd, and 6th months. A 3D analysis program (Final Surface) evaluated the gingival margin distance, height, contour width, and volume in each period. SPSS was used to analyze the data with a p-value = 0.05. The between-time interval comparisons were done and the analysis was done using a Multivariate test. RESULTS Customized titanium healing abutments used in immediate implantation maintained optimal peri-implant mucosa. In intermittent periods, there was no significant reduction in all aspects of the margin distances and heights. During the entire period, the margin height reduction on the buccal, lingual, mesial, and distal was 0.63 mm, 0.93 mm, 0.08 mm, and 0.24 mm, respectively, and contour width reduction on the buccal, lingual, and buccolingual was 0.59 mm, 0.43 mm, and 1.03 mm, respectively. There was a significant reduction in the total buccolingual contour width in the 1st month and total volume in the 3rd to 6th months. CONCLUSIONS Immediate implant placement with customized titanium healing abutment can achieve the optimal peri-implant mucosa and this protocol is an alternative for soft tissue management.
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Affiliation(s)
- Tanporn Lertwongpaisan
- Residency Training Program, Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Parinya Amornsettachai
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Woraphong Panyayong
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Suphachai Suphangul
- Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
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Kotsailidi EA, Michelogiannakis D, Barmak AB, Madianos P, Caton JG, Tsigarida A. Root coverage surgery for dentin hypersensitivity reduction: a systematic review and meta-analysis of randomized controlled trials. Quintessence Int 2023; 0:0. [PMID: 36853626 DOI: 10.3290/j.qi.b3931397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of root coverage surgery in reducing dentin hypersensitivity (DH) through a systematic review and meta-analysis. DATA SOURCES Unrestricted search of four indexed databases up to September 2022 was performed to identify randomized controlled trials (RCTs) evaluating the effect of root coverage surgery on DH frequency and/or intensity pre-surgically (baseline) and at least 3 months post-surgically. Two authors independently conducted study screening and data extraction. Subgroup meta-analyses were performed separately for stimulated and unstimulated DH frequency and intensity at different timepoints. The risk of bias and quality of the available evidence were assessed. RESULTS Nineteen RCTs presenting data from 7 days to 30 months after root coverage surgery with various treatment modalities were included from the 662 identified studies. A total of 486 patients contributed 784 recession defects. Results from the subgroup meta-analyses showed that, overall, root coverage surgery reduced the risk for DH by 67% (RR 0.33, CI: [0.21-0.53]) and 53% (RR 0.47, CI: [0.38-0.58] upon unstimulated and stimulated DH assessment, respectively. The DH intensity was also significantly reduced (mean VAS score difference: 2.37, CI: [2.02-2.71]) upon stimulated DH assessment. No significant changes in DH intensity were observed upon unstimulated DH assessment. The included studies did not have high risk of bias and the quality of evidence was low to high. CONCLUSION Existing evidence suggests that root coverage surgery may effectively reduce the DH frequency and intensity.
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Serratelli D, Jacobs T, Ziccardi V. A combination of hyaluronic acid filler and subnasal lip lift superiorly reestablishes lip esthetics: a case report. Quintessence Int 2023; 0:0. [PMID: 36757309 DOI: 10.3290/j.qi.b3877547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
With increasing age and edentulism, numerous aesthetic changes occur to the perioral region. The upper lips lose definition, flatten and lengthen, the cupid's bow is lost, and the oral commissures descend. The nasolabial folds deepen, marionette lines become prominent, vertical rhytids around the lips form, and chin rhytids form. Chronic exposure to UVA radiation from the sun can lead to photodamage, characterized by wrinkles, lentigines, actinic keratoses, and other pigment changes. In addition, edentulism leads to jaw atrophy, which often compromises soft tissue support. Removable dentures, the conventional treatment to restore missing teeth, not only replaces teeth, but also provides support to the lips via the labial flange. Implant supported fixed prostheses are a very popular option to restore completely edentulous arches; these prostheses are flangeless, providing no bulk to the lips. Addressing changes in the perioral region due to aging and edentulism requires a combination of treatments, with each addressing different issues. Onabotulinum toxin A can be used to treat dynamic perioral and chin rhytids, and upturn the corners of the mouth. Hyaluronic acid filler can be used to treat deep nasolabial folds, marionette lines, and re-volumize the lips. Chemical peels can treat photodamaged skin, static rhytids, and other dermatological pathologies. The subnasal lip lift, developed by Cardoso and Sperli in 1971, has become an increasingly common technique used to rejuvenate the upper lip in elderly and edentulous patients. This case report describes an elderly patient who was treated with a combination of subnasal lip lift, hyaluronic acid filler, Onabotulinum toxin A, and chemical peel to achieve superior perioral esthetics. This case will highlight the synergy of each procedure when done in combination to achieve highly effective results.
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Abstract
Gingival recession is a common finding in daily clinical practice. Several issues may be associated with the apical shift of the gingival margin such as dentine hypersensitivity, root caries, non-carious cervical lesions (NCCLs), and compromised aesthetics. The first step in an effective management and prevention program is to identify susceptibility factors and modifiable conditions associated with gingival recession. Non-surgical treatment options for gingival recession defects include establishment of optimal plaque control, removal of overhanging subgingival restorations, behaviour change interventions, and use of desensitising agents. In cases where a surgical approach is indicated, coronally advanced flap and tunnelling procedures combined with a connective tissue graft are considered the most predictable treatment options for single and multiple recession defects. If there is a contraindication for harvesting a connective tissue graft from the palate or the patient wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be a valuable treatment alternative. For gingival recession defects associated with NCCLs a combined restorative-surgical approach can provide favourable clinical outcomes. If a patient refuses a surgical intervention or there are other contraindications for an invasive approach, gingival conditions should be maintained with preventive measures. This paper gives a concise review on when and how to treat gingival recession defects.
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Affiliation(s)
- Jean-Claude Imber
- Department of Periodontology and Operative Dentistry, University of Mainz, Mainz, Germany; Department of Periodontology, University of Bern, Bern, Switzerland
| | - Adrian Kasaj
- Department of Periodontology and Operative Dentistry, University of Mainz, Mainz, Germany.
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Garner MR, Warner SJ, Heiner JA, Kim YT, Agel J. Soft tissue management in open tibial shaft fractures: A comparison of institutional preferences and resultant early clinical outcomes. Bone Jt Open 2020; 1:481-487. [PMID: 33215142 PMCID: PMC7659664 DOI: 10.1302/2633-1462.18.bjo-2020-0122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487.
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Affiliation(s)
- Matthew R Garner
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Stephen J Warner
- Memorial Hermann Hospital - Texas Medical Center, MGovern Medical School at UTHealth, UT Physicians Orthopedics Trauma, Houston, Texas, USA
| | | | - Yesul T Kim
- MGovern Medical School at UTHealth, Houston, Texas, USA
| | - Julie Agel
- Department of Orthopaedics, Harborview Medical Center, Seattle, Washington, USA
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Debel M, Toma S, Vandenberghe B, Brecx MC, Lasserre JF. Alveolar ridge dimensional changes after two socket sealing techniques. A pilot randomized clinical trial. Clin Oral Investig 2020; 25:1235-1243. [PMID: 32591869 DOI: 10.1007/s00784-020-03428-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 06/22/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This pilot study aimed to assess dimensional changes following two different alveolar socket sealing techniques. MATERIAL AND METHODS Twenty-one patients requiring tooth extraction and implant placement were randomly allocated to two different alveolar ridge preservation techniques. In the control group, demineralized bovine bone mineral (DBBM) and a gingival soft tissue punch were used to fill and seal the socket, whereas in the test group, the extraction socket was filled with DBBM and sealed with a hemostatic gelatin sponge. Digitalized impressions were taken before and 6 months after tooth extraction. The comparison was made on horizontal and vertical dimensional changes. RESULTS The mean vertical loss was 0.8 ± 0.6 mm for the control group and 0.7 ± 0.5 mm for the test one. No statistical difference was found between groups for the vertical shrinkage. The horizontal dimensional narrowing of the alveolar socket was respectively 7.1/4.0/2.5 mm at levels 1, 3, and 5 mm from a coronal reference level for the control group. The test group showed dimensional changes of 4.8/2.3/1.3 mm at the three different levels, respectively. A significant difference was found at levels 3 and 5 mm. Referring to a visual analog pain scale, patients reported more severe pain in the control group (5.7/10) when compared with the test group (2.8/10). The difference was statistically highly significant (P ≤ 0.001). CONCLUSIONS A significant difference was found between control and test groups regarding the horizontal dimensional changes and the post-operative pain. CLINICAL RELEVANCE Regarding this primary result, the socket sealing technique with a hemostatic sponge provides an effective and inexpensive protocol with less post-operative pain.
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Affiliation(s)
- M Debel
- Department of Periodontology, Université Catholique de Louvain (UCL)-Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - S Toma
- Department of Periodontology, Université Catholique de Louvain (UCL)-Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - B Vandenberghe
- Advimago, Center for Advanced Oral Imaging, Rue Emile Claus 42, 1050, Brussels, Belgium
| | - M C Brecx
- Department of Periodontology, Université Catholique de Louvain (UCL)-Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - J F Lasserre
- Department of Periodontology, Université Catholique de Louvain (UCL)-Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Reiter G, Weil F, Thomas B, Kühner C, Wittenberg G, Schäfer A, Grützner PA, Kneser U. [Reconstruction of lower limbs in old age-an interdisciplinary approach : Geriatric assessment, perioperative management, diagnostics and treatment targets]. Chirurg 2019; 90:795-805. [PMID: 31463658 DOI: 10.1007/s00104-019-01022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Complex injuries of the lower extremities in geriatric patients with multiple pre-existing comorbidities represent an increasing challenge to an interdisciplinary team of surgeons. Functional reconstruction of the extremity through osteosynthesis, revascularization and defect coverage aims to preserve mobility and achieve an early return to activities of daily life at home, while avoiding major amputation and the associated risks regarding morbidity and mortality. An interdisciplinary assessment of geriatric patients regarding dystrophy of soft tissue and skín, cardiovascular and metabolic comorbidities as well as specific geriatric diagnostics are crucial steps in ensuring favorable outcomes. Perioperatively, all improvable risk factors should be actively optimized and a specialized interdisciplinary approach to treatment planning (extremity board) is absolutely necessary for success of treatment. It outlines the special features of the geriatric assessment, diagnostics, perioperative management and treatment targets.
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Garg S, Khanna V, Goyal M, Joshi N. Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures. J Clin Orthop Trauma 2019; 10:941-948. [PMID: 31528072 PMCID: PMC6739465 DOI: 10.1016/j.jcot.2018.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 06/03/2018] [Accepted: 10/24/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tibia fracture is the most common long bone fracture. The fractures of tibia are commonly open fractures due to subcutaneous position of the tibia. The choice of technique for stabilization of open tibia fractures includes - External fixation, unreamed intra-medullary nails [URTN], Reamed intra-medullary nails, ORIF with Plating. OBJECTIVES To evaluate & compare the results of Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures. METHODS This prospective clinical study [Randomized chit box] was done on 50 patients presenting to our institute within 24 h of injury. Only those who were skeletally mature with open tibia fracture Grade IIIA & IIIB [Gustilo-Anderson] were included in this study. After initial management, radiological assessment was done. Following this adequate wound debridement, skeletal stabilization with either primary URTN or external fixator was done. Inspection and debridement were repeated at 48-h intervals until the wound was considered clean. RESULTS 50 cases [25 each group] were compared in terms of - Final Alignment of the Fracture, Presence of Infection/Non-union/Mal-union, Hardware failure, Time to Bone Union, Number of Operative Procedures after index admission. Mean time to full weight bearing was 20.96 weeks in URTN group versus 24.8 weeks in Ex-fix group. 5 in URTN group required further surgery for non-union versus 11 patients in Ex-fix group. There were 6 significant pin track infection. Removal of nail was required in 1 case of deep infection. CONCLUSION This study supports the use of the URTN over External fixator in the treatment of severe open tibia fractures.
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Affiliation(s)
- Sandeep Garg
- S. M. S. Hospital, Jaipur, India
- Corresponding author. E 56, Bajaj Nagar Appartments, Near Gandhinagar Railway Station, Jaipur, India.
| | - Vikram Khanna
- National Institute of Medical Sciences, Jaipur, India
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Abstract
BACKGROUND Pilon fractures are mainly severe and prognostically serious injuries with a high rate of relevant soft tissue involvement. The adequate decision making and choice of treatment in the early phase of trauma are of paramount importance for the final outcome. This essentially encompasses the management of the soft tissue damage, the surgical planning and the differentiated selection of procedures. GOALS/MATERIAL AND METHODS Most concepts of staged treatment nowadays offer a wide range of options which are integrated into expert-based algorithms. The aim of the present analysis was to display the strategy variations for the treatment of pilon fractures taking into account the advantages and disadvantages of the corresponding treatment concepts. RESULTS A staged procedure including primary closed reduction employing ligamentotaxis and fixation of the joints of the hindfoot via tibiocalcaneal metatarsal fixation offers a safe basis for consecutive imaging and the selection of specific approaches for definitive reconstruction. A simultaneous reconstruction and fixation of the fibula during the primary intervention are generally not recommended in order to avoid any limitations for subsequent reconstructive procedures. A time frame for definitive reconstruction covers a period of up to 3 weeks after trauma and allows a detailed planning considering the individual dynamics of the soft tissue situation and any logistic requirements. For the choice of the definitive treatment concept a wide range of procedures and implants are available. There are also valid concepts for primary treatment of defined fracture constellations while primary arthrodesis represents a solution in cases of major destruction of the joint surface. DISCUSSION AND CONCLUSION Knowledge of the multiple procedural variations for pilon fracture treatment creates the basis to optimize the treatment modalities and to take into account individual parameters of the fracture.
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Affiliation(s)
- Thomas Mittlmeier
- Abt. für Unfall‑, Hand- und Wiederherstellungschirurgie, Chirurgische Klinik und Poliklinik, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
| | - Alice Wichelhaus
- Abt. für Unfall‑, Hand- und Wiederherstellungschirurgie, Chirurgische Klinik und Poliklinik, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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Kumar VV, Jacob PC, Kuriakose MA. Sub-Periosteal Dissection with Denture-Guided Epithelial Regeneration: A Novel Method for Peri-Implant Soft Tissue Management in Reconstructed Mandibles. J Maxillofac Oral Surg 2015; 15:449-455. [PMID: 27833336 DOI: 10.1007/s12663-015-0854-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND In patients with reconstructed mandibles using free fibula flaps, management of soft tissues around implants supporting dental rehabilitation, is often a clinical problem. AIM The aim of this paper is to describe a new technique, namely "Sub-periosteal dissection and denture-guided epithelial regeneration (SD-DGER)", as a method of peri-implant soft tissue management in these patients. MATERIALS AND METHODS The technique consists of performing a subperiosteal dissection with creation of buccal and lingual flaps. These flaps form the buccal and lingual vestibule. Implants are placed and an interim denture is immediately loaded onto the implants to guide the regenerated epithelium. A keratinized mucosal layer is formed on the bare fibula bone in six months time. RESULTS This technique was successful in producing fixed keratinized epithelial tissue around implants in patients with mandibles reconstructed using the free fibula flap in patients who did not undergo radiotherapy. CONCLUSION The sub-periosteal dissection with denture guided epithelial regeneration is a predictable form of peri-implant soft tissue management in selected patients with reconstructed jaws.
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Affiliation(s)
- Vinay V Kumar
- Department of Surgical Oncology- Head and Neck Surgery, Majumdar Shaw Cancer Center, Narayana Health, Bommasandra, Bengaluru, India ; Department of Oral and Maxillofacial Surgery, M.R. Ambedkar Dental College & Hospital, 37, Lazar Layout, Frazer Town, Bengaluru, 560005 India ; Department of Oral Maxillofacial and Plastic Surgery, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - P C Jacob
- Department of Prosthodontics, Krishnadevaraya College of Dental Sciences, Bengaluru, India ; Ora-Care Dental Clinic, 81-Coles Road, Frazer Town, Bengaluru, India
| | - Moni A Kuriakose
- Department of Surgical Oncology- Head and Neck Surgery, Majumdar Shaw Cancer Center, Narayana Health, Bommasandra, Bengaluru, India
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Dugan TR, Hubert MG, Siska PA, Pape HC, Tarkin IS. Open supracondylar femur fractures with bone loss in the polytraumatized patient - Timing is everything! Injury 2013; 44:1826-31. [PMID: 23601115 DOI: 10.1016/j.injury.2013.03.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/07/2013] [Accepted: 03/18/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open supracondylar femur fractures are rare, complex injuries which occur in polytrauma patients and are complicated by bone loss, contamination, compromised soft tissues, and poor host condition. The purpose of this study is to demonstrate a successful treatment protocol for these challenging injuries. METHODS A consecutive series of 15 open supracondylar femur fractures in 14 polytrauma patients (ages 16-75, mean 41) were treated at one Level I trauma centre by a single surgeon. Fracture patterns included seven AO/OTA Type C2 and eight Type C3 fractures. All fractures were open and classified by Gustillo/Anderson as type IIIA (10 fractures) and type IIIB (five fractures). Stage I was performed within 24h and included thorough open fracture care and early definitive fixation with a laterally based locking device and antibiotic bead placement. Stage II was performed several months later (average 3.6 months) when the soft tissue envelope had revascularized and the polytrauma patient had recovered from their other injuries. Stage II consisted of either an anterior incision or subvastus approach to the distal femur, bone grafting, BMP application, and addition of medial column support to create rigid fixation. RESULTS All fractures (15/15) healed uneventfully. Union was determined by absence of pain and radiographic union in 3/4 cortices. Mean time to union was 4 months. There were no deep infections and alignment was maintained (average tibiofemoral angel of 5° of valgus) although several limbs were complicated by knee stiffness. CONCLUSIONS Healing of open supracondylar femur fractures with critical sized bone defects requires diligent surgical timing in order to optimise the host and wound bed. Thorough initial debridement and early definitive fixation halt ongoing soft tissue injury, restores length and alignment, and allow for sterilisation of the wound. After patients have recovered from their other injuries and the soft tissue sleeve has revascularized, bone grafting with BMP supplementation and medial column plating allows for rigid fixation of the femur and offers the biology these fracture patterns require for successful union without infection.
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Faschingbauer M, Meiners J, Schulz AP, Rudolf KD, Kienast B. Operative Treatment and Soft Tissue Management of Open Distal Tibial Fractures - Pitfalls and Results. Eur J Trauma Emerg Surg 2009; 35:527-31. [PMID: 26815375 DOI: 10.1007/s00068-009-9170-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 09/03/2009] [Indexed: 10/20/2022]
Abstract
Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I-IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3-5 days. Gustilo II patients needed an average of 1.1 (0-3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0-16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3-28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up.
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Affiliation(s)
- Maximilian Faschingbauer
- Department of Traumatology, Orthopedics and Sports Medicine, BG Trauma Centre, Hamburg, Germany. .,Department of Traumatology, Orthopedics and Sports Medicine, BG Trauma Centre, Bergedorfer Straße 10, 21033, Hamburg, Germany.
| | - Jan Meiners
- Department of Traumatology, Orthopedics and Sports Medicine, BG Trauma Centre, Hamburg, Germany
| | - Arndt Peter Schulz
- Department of Trauma and Orthopedics, University of Lübeck, Lübeck, Germany
| | - Klaus-Dieter Rudolf
- Department of Hand, Plastic and Microsurgery, BG Trauma Centre, Hamburg, Germany
| | - Benjamin Kienast
- Department of Traumatology, Orthopedics and Sports Medicine, BG Trauma Centre, Hamburg, Germany
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