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Dilek ÖF, Sevim KZ, Dilek ON. Acellular dermal matrices in reconstructive surgery; history, current implications and future perspectives for surgeons. World J Clin Cases 2024; 12:6791-6807. [PMID: 39687641 PMCID: PMC11525903 DOI: 10.12998/wjcc.v12.i35.6791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 10/03/2024] [Accepted: 10/15/2024] [Indexed: 10/24/2024] Open
Abstract
Large-scale defects of body in the reconstructive surgical practice, and the helplessness of their repair with autologous tissues, have been an important factor in the development of artificial biological products for the temporary, definitive, or staged repair of these defects. A major advance in the field of plastic and other reconstructive surgery in this regard has been the introduction and successful use of acellular dermal matrices (ADMs). In recent years, not only the type of tissue from which ADMs are produced, product range, diversity and areas of use have increased, but their use in reconstructive fields, especially in post oncologic breast surgery, has become highly regarded and this has favored ADMs to be a potential cornerstone in specific and well-defined surgical fields in future. It is essential that reconstructive surgeons become familiar with some of the ADM's as well as the advantages and limitations to their use. This review not only provides basic science and clinical evidence of the current use of ADMs in wide range of surgical fields but also targets to keep them as an important backdrop in the armamentarium of reconstructive surgeons. Brief considerations of possible future directions for ADMs are also conducted in the end.
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Affiliation(s)
- Ömer F Dilek
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul 34396, Türkiye
| | - Kamuran Z Sevim
- Department of Plastic and Reconstructive Surgery, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul 34396, Türkiye
| | - Osman N Dilek
- Department of Surgery, İzmir Katip Celebi University, School of Medicine, İzmir 35150, Türkiye
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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.
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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
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Chintalapudi N, Rice OM, Hsu JR. The use of xenogenic dermal matrices in the context of open extremity wounds: where and when to consider? OTA Int 2023; 6:e237. [PMID: 37448569 PMCID: PMC10337846 DOI: 10.1097/oi9.0000000000000237] [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] [Received: 11/29/2022] [Accepted: 12/14/2022] [Indexed: 07/15/2023]
Abstract
Optimal treatment of orthopaedic extremity trauma includes meticulous care of both bony and soft tissue injuries. Historically, clinical scenarios involving soft tissue defects necessitated the assistance of a plastic surgeon. While their expertise in coverage options and microvascular repair is invaluable, barriers preventing collaboration are common. Acellular dermal matrices represent a promising and versatile tool for orthopaedic trauma surgeons to keep in their toolbox. These biological scaffolds are each unique in how they are used and promote healing. This review explores some commercial products and offers guidance for selection in different clinical scenarios involving traumatic wounds.
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Affiliation(s)
- Nainisha Chintalapudi
- Corresponding author. Address: Nainisha Chintalapudi, MD, Atrium Health Mercy, 2001 Vail Ave, Charlotte, NC 28207. E-mail:
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Taupin P, Gandhi A, Saini S. Integra® Dermal Regeneration Template: From Design to Clinical Use. Cureus 2023; 15:e38608. [PMID: 37284376 PMCID: PMC10239675 DOI: 10.7759/cureus.38608] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 06/08/2023] Open
Abstract
Integra® Dermal Regeneration Template (IDRT, Integra LifeSciences, Princeton, NJ, USA) is a bilayer membrane developed, by Yannas and Burke in the 1980s, to fulfill the unmet need of surgeons having a readily available off-the-shelf dermal regeneration method. IDRT is composed of a sheet of porous cross-linked type I collagen and glycosaminoglycans, with a semi-permeable silicone sheet cover. IDRT is bio-engineered, from adult bovine Achilles tendons and chondroitin-6-sulfate derived from shark cartilage, in a multi-step process involving cross-linking using glutaraldehyde. By design, the composition, porosity, and biodegradation rate of IDRT guides the mechanism of wound repair towards a regenerative pathway. Its mechanism of action involves four distinct phases: imbibition, fibroblast migration, neovascularization, and remodeling/maturation. Originally developed for the post-excisional treatment of deep-partial to full-thickness burns where autograft is limited, over the years its use has expanded to reconstructive surgery.
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Affiliation(s)
| | - Ankur Gandhi
- Research and Development, Integra LifeSciences, Princeton, USA
| | - Sunil Saini
- Research and Development, Integra LifeSciences, Princeton, USA
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Gonzalez GA, Castagno C, Carter J, Chellappan B, Taupin P. Negative pressure wound therapy on complex extremity wounds requiring coverage with a meshed bilayer wound matrix: a retrospective analysis. J Wound Care 2022; 31:S8-S15. [PMID: 36113853 DOI: 10.12968/jowc.2022.31.sup9.s8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The treatment of complex extremity wounds is technically challenging. In this 5-year retrospective review, we compared the use of Integra Meshed Bilayer Wound Matrix (IMBWM; Integra LifeSciences, US) followed by a split-thickness skin graft (STSG) combined with negative pressure wound therapy (NPWT) versus IMBWM followed by STSG alone for the management of these wounds. METHOD Data from patients undergoing management using IMBWM for a complex extremity wound coverage were collected. RESULTS Among the 109 patients studied, the wounds of 62 patients were managed using IMBWM and NPWT, and 47 were managed using IMBWM alone. The most common aetiology of these injuries was trauma. Wound size and location were similar for each group, ranging in size from 2-30cm2 and being primarily on the forearm, followed by the leg and arm. There was a significantly greater take of the IMBWM+STSG with NPWT (96.8%) compared to without NPWT (85.1%, p=0.03). There were significantly fewer reapplications of the dermal matrix required in the NPWT group (3.2%) versus the non-NPWT group (14.9%, p=0.03). There were significantly fewer postoperative complications, prior to STSG, in the NPWT group (3.2%) versus the non-NPWT group (14.9%, p=0.03). CONCLUSION The combination of IMBWM with NPWT leads to a higher success rate, and can reduce the number of dermal matrix reapplications and postoperative complications, in the setting of complex extremity wounds. The use of IMBWM in combination with NPWT has the potential to improve both surgical procedures and patient outcomes in this setting.
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Affiliation(s)
| | | | - Jordan Carter
- Texas Tech University Health Sciences Center, El Paso, TX, US
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Assessment of Two Commonly used Dermal Regeneration Templates in a Swine Model without Skin Grafting. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12063205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the medical care of partial and full-thickness wounds, autologous skin grafting is still the gold standard of dermal replacement. In contrast to spontaneous reepithelializing of superficial wounds, deep dermal wounds often lead to disturbing scarring, with cosmetically or functionally unsatisfactory results. However, modern wound dressings offer promising approaches to surface reconstruction. Against the background of our future aim to develop an innovative skin substitute, we investigated the behavior of two established dermal substitutes, a crosslinked and a non-crosslinked collagen biomatrix. The products were applied topically on a total of 18 full-thickness skin defects paravertebrally on the back of female Göttingen Minipigs—six control wounds remained untreated. The evaluation was carried out planimetrically (wound closure time) and histologically (neoepidermal cell number and epidermis thickness). Both treatment groups demonstrated significantly faster reepithelialization than the controls. The histologic examination verified the highest epidermal thickness in the crosslinked biomatrix-treated wounds, whereas the non-crosslinked biomatrix-treated wounds showed a higher cell density. Our data presented a positive influence on epidermal regeneration with the chosen dermis substitutes even without additional skin transplantation and, thus, without additional donor site morbidity. Therefore, it can be stated that the single biomatrix application might be used in a clinical routine with small wounds, which needs to be investigated further in a clinical setting to determine the size and depths of a suitable wound bed. Nevertheless, currently available products cannot solely achieve wound healing that is equal to or superior to autologous tissue. Thus, the overarching aim still is the development of an innovative skin substitute to manage surface reconstruction without additional skin grafting.
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Petrie K, Cox CT, Becker BC, MacKay BJ. Clinical applications of acellular dermal matrices: A review. Scars Burn Heal 2022; 8:20595131211038313. [PMID: 35083065 PMCID: PMC8785275 DOI: 10.1177/20595131211038313] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications. METHODS PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data. RESULTS A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers). CONCLUSION Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario. LAY SUMMARY Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.
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Affiliation(s)
- Kyla Petrie
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Cameron T Cox
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Brendan J MacKay
- Texas Tech University Health Sciences Center, Lubbock, TX, USA.,University Medical Center, Lubbock, TX, USA
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Ibarra G, Gonzalez-Pozega C, Cuervas-Mons M, Rivera A, Fernandez-Ibarburu B, Garcia-Ruano A. Reverse Dermis Flap for Coverage of Distal Leg and Ankle Defects. J Foot Ankle Surg 2021; 60:839-844. [PMID: 33509723 DOI: 10.1053/j.jfas.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/12/2020] [Accepted: 12/14/2020] [Indexed: 02/03/2023]
Abstract
Soft tissue defects of the distal third of the leg and ankle, which frequently expose tendon, bone or osteosynthesis material, are difficult to cover and pose a major challenge to the plastic surgeon. Traditional reconstructive options for this region usually require complex flaps which made them unsuitable for elderly patients or those with multiple comorbidities. We hereby present the reverse dermis flap as an easy and reliable choice to cover this type of wounds and refer our experience in 9 cases in which clinical, operative, and follow-up data were recorded. Of the 9 flaps performed, 8 survived completely and 1 presented a partial flap necrosis, requiring additional surgery. No other operative procedure was required. In conclusion, the reversed dermis flap is a simple, quick, noninvasive, and safe technique for coverage of noble structures such as tendon or bone in the distal third of the leg that every plastic surgeon should incorporate in his surgical armamentary.
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Affiliation(s)
- Gorka Ibarra
- Resident, Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Carlota Gonzalez-Pozega
- Resident, Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Cuervas-Mons
- Surgeon, Traumatology and Orthopaedic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Andres Rivera
- Resident, Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Borja Fernandez-Ibarburu
- Resident, Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Angela Garcia-Ruano
- Surgeon, Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Narayanan AS, Walley KC, Borenstein T, Luther GA, Jackson JB, Gonzalez TA. Surgical Strategies: Necrotizing Fasciitis of the Foot and Ankle Treated With Dermal Regeneration Matrix for Limb Salvage. Foot Ankle Int 2021; 42:107-114. [PMID: 32975443 DOI: 10.1177/1071100720952087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity.Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain.We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option.Level of Evidence: Level V, expert opinion.
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Affiliation(s)
- Arvind S Narayanan
- WakeMed Health and Hospitals, Raleigh, NC, USA.,Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Kempland C Walley
- Department of Orthopaedic Surgery, Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | | | - J Benjamin Jackson
- Department of Orthopaedic Surgery, University of South Carolina, Columbia, SC, USA
| | - Tyler A Gonzalez
- Department of Orthopaedic Surgery, University of South Carolina, Columbia, SC, USA
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Lv Z, Wang Q, Jia R, Ding W, Shen Y. Pelnac® Artificial Dermis Assisted by VSD for Treatment of Complex Wound with Bone/Tendon Exposed at the Foot and Ankle, A Prospective Study. J INVEST SURG 2020; 33:636-641. [PMID: 32643478 DOI: 10.1080/08941939.2018.1536177] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Purpose: This study aims to assess the efficacy and safety of Pelnac dermal regeneration template assisted by vacuum sealing drainage (VSD) and a split-thickness skin graft to cover the large skin and soft-tissue defects at foot and ankle. Methods: This study began from March 2013, up to February 2017. A total of 16 patients met the inclusion and exclusion criteria and were included. For every patient, 2 separate operations were performed, the first being thorough debridement of necrotic tissues immediate coverage of VSD at continuous negative pressure suction, and the second being the autologous split-thickness skin graft. At each follow-up, relevant data were documented. Results: The average follow-up was 16.5 months (range, 12 to 42 months). No infections, hematoma, or seroma were observed. 13 out of 16 patients had a complete skin graft "take" (100%). Patients' satisfaction of esthetic appearance was 76.5 ± 5.2/100. The VSS value was 2.2 ± 2.1, representing a good result. Regarding the sensory recovery, the response "normal or near normal" could be obtained in 14/16 patients. Mean AROM for extension/flexion of the ankle was 48.5 ± 4.8° (range 35-62°), and 93.7% (15/16) of patient could obtain a satisfying functional result. Conclusions: Our report indicated Pelnac provided an effective method for management of complex wounds with underlying bone or tendons exposed.
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Affiliation(s)
- Zhenmu Lv
- Department of Spine Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China.,Department of Hand and Foot Surgery, The No.252 Hospital of People's Liberation Army of China, Baoding, Hebei 071000, P.R. China
| | - Qiusheng Wang
- Department of Hand and Foot Surgery, The No.252 Hospital of People's Liberation Army of China, Baoding, Hebei 071000, P.R. China
| | - Rui Jia
- Department of Hand and Foot Surgery, The No.252 Hospital of People's Liberation Army of China, Baoding, Hebei 071000, P.R. China
| | - Wenyuan Ding
- Department of Spine Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
| | - Yong Shen
- Department of Spine Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, P.R. China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei, 050051, P.R. China
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Haje DDP, Silva CCD. Metatarsal Transfer Associated with Microsurgical Flap in Exposed Foot Fracture: A Case Report and 10-Year Follow-up. JBJS Case Connect 2020; 10:e1900604. [PMID: 32910572 DOI: 10.2106/jbjs.cc.19.00604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 35-year-old female patient presented with an exposed forefoot fracture with bone and dermal loss after a vehicular accident. There was a bone defect at the level of the second toe and the third metatarsal. She was treated by second toe resection and second metatarsal transfer to augment the third metatarsal diaphysis ray (nonvascularized, without any soft-tissue envelope) and a microsurgical forearm flap. CONCLUSION As one option among the reconstruction techniques available for a metatarsal segmental defect, metatarsal transfer associated with a fasciocutaneous radial forearm flap proved to be effective in this patient.
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Affiliation(s)
- Davi de Podestá Haje
- 1Hospital de Base do Distrito Federal and Centro Clinico Orthopectus, Brasília, DF, Brazil 2Centro de Ortopedia e Traumatologia de Brasília, Brasília, DF, Brazil
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McKee D, Osemwengie B, Cox C. Distal Digital Nerve Repair Using Nerve Allograft With a Dermal Substitute: A Case Report. Hand (N Y) 2020; 15:NP47-NP50. [PMID: 31161808 PMCID: PMC7370397 DOI: 10.1177/1558944719854169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Distal digital nerve repairs can present unique challenges for hand surgeons due to their sensitive location and ongoing difficulty obtaining soft tissue coverage in this region. Although autografts and nerve conduits have been shown to be of benefit with nerve gaps, they can have morbidities associated with their use. Nerve allografts have become a viable option over the past decade as their use has increased and data are now showing similar outcomes, particularly in short gap segments. Flaps and skin grafts are traditional coverage options for full thickness wounds but can pose challenges with multiple digit involvement, depth of wound, and critical structures exposed. Methods: We present a case where nerve allograft was used for distal digital nerve repair. Due to the distal nature of the nerve repair in the index digit distal to the trifurcation, the distal end of the nerve graft was connected to multiple small nerve ends. Dermal substitute was placed to achieve distal coverage of the affected digits. Results: At 6-month follow-up, the patient demonstrated improved strength, normal sensation, and full return of digital function. Conclusion: Nerve allograft can be used in combination with dermal skin substitute to achieve normal sensation and return of digital function following distal digital nerve injuries.
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Affiliation(s)
- Desirae McKee
- Texas Tech University Health Sciences Center, Lubbock, USA,Desirae McKee, Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Mail Stop 9436, Lubbock, TX 79430-9436, USA.
| | | | - Cameron Cox
- Texas Tech University Health Sciences Center, Lubbock, USA
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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: 2] [Impact Index Per Article: 0.4] [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.
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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
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A Multicentre Study: The Use of Micrografts in the Reconstruction of Full-Thickness Posttraumatic Skin Defects of the Limbs-A Whole Innovative Concept in Regenerative Surgery. Stem Cells Int 2019; 2019:5043518. [PMID: 31885613 PMCID: PMC6915006 DOI: 10.1155/2019/5043518] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/06/2019] [Accepted: 10/03/2019] [Indexed: 12/25/2022] Open
Abstract
The skin graft is a surgical technique commonly used in the reconstructive surgery of the limbs, in order to repair skin loss, as well as to repair the donor area of the flaps and cover the dermal substitutes after engraftment. The unavoidable side effect of this technique consists of unaesthetic scars. In order to achieve the healing of posttraumatic ulcers by means of tissue regeneration and to avoid excessive scarring, a new innovative technology based on the application of autologous micrografts, obtained by Rigenera technology, was reported. This technology was able to induce tissue repair by highly viable skin micrografts of 80 micron size achieved by a mechanical disaggregation method. The specific cell population of these micrografts includes progenitor cells, which in association with the fragment of the Extracellular Matrix (ECM) and growth factors derived by patients' own tissue initiate biological processes of regeneration enhancing the wound healing process. We have used this technique in 70 cases of traumatic wounds of the lower and upper limbs, characterized by extensive loss of skin substance and soft tissue. In all cases, we have applied the Rigenera protocol using skin micrografts, achieving in 69 cases the complete healing of wounds in a period between 35 and 84 days. For each patient, the reconstructive outcome was evaluated weekly to assess the efficacy of this technique and any arising complication. A visual analogue scale (VAS) was administered to assess the amount of pain felt after the micrografts' application, whereas we evaluated the scars according to the Vancouver scale and the wound prognosis according to Wound Bed Score. We have thus been able to demonstrate that Rigenera procedure is very effective in stimulating skin regeneration, while reducing the outcome scar.
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Saldanha V, Tiedeken N, Godfrey B, Ingalls N. Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon. Mil Med 2019; 183:e247-e254. [PMID: 29590411 DOI: 10.1093/milmed/usy022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 01/25/2018] [Accepted: 02/04/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. METHODS A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. FINDINGS Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. DISCUSSION This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.
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Affiliation(s)
- Vilas Saldanha
- Department of Surgery, University of Nevada School of Medicine, 1701 W Charleston Blvd, Suite 490, Las Vegas, NV.,99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
| | - Nathan Tiedeken
- Department of Orthopaedic Surgery, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141
| | - Brandon Godfrey
- 99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
| | - Nichole Ingalls
- Department of Surgery, University of Nevada School of Medicine, 1701 W Charleston Blvd, Suite 490, Las Vegas, NV.,99th Medical Group, Mike O'Callaghan Federal Medical Center, 4700 N, Las Vegas Blvd, Nellis AFB, NV
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LV Z, Yu L, Wang Q, Jia R, Ding W, Shen Y. The use of dermal regeneration template for treatment of complex wound with bone/tendon exposed at the forearm and hand, a prospective cohort study. Medicine (Baltimore) 2019; 98:e17726. [PMID: 31689814 PMCID: PMC6946402 DOI: 10.1097/md.0000000000017726] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this study was to assess the efficacy and safety of Pelnac and split-thickness skin graft for management of complex wound with underlying bone/tendon exposure at forearm and hand.This is a prospective study, beginning from March 2013 up to May 2017. There were 13 patients, with age of 31.2 years. All of them underwent the staged Pelnac and split-thickness skin graft to manage the complex wound with bone/tendon. Postoperatively, scheduled follow-up was conducted.The average follow-up was 15 months. There were no infections, wound necrosis, hematoma, or seroma during the phase when Pelnac was applied. There was 100% "take" of the Pelnac in 12/13 patients. In 11 patients, there was complete skin graft "take". Patients' satisfaction for the esthetic appearance of the grafted area was 75.0 ± 8.5/100. The VSS value was 2.9 ± 2.5. Regarding the sensory recovery, the response of "normal or near normal" could be obtained in 7/13 patients, "slight loss" in 5 patients and "significant loss" in 1 case. The average DASH score was 27.2 ± 18.5, and most patients (12/13) could obtain an acceptable ability to perform the daily activities.Pelnac dermal template is a favorable alternative to flap reconstruction in the treatment of complex wound with underlying tissues exposure.
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Affiliation(s)
- Zhenmu LV
- Department of Spine Surgery, the Third Hospital of Hebei Medical University
- Department of hand and foot surgery, the No.252 hospital of People's Liberation Army of China
| | - Lili Yu
- Department of Neurology, the 2nd Hospital of Hebei Medical University
| | - Qiusheng Wang
- Department of hand and foot surgery, the No.252 hospital of People's Liberation Army of China
| | - Rui Jia
- Department of hand and foot surgery, the No.252 hospital of People's Liberation Army of China
| | - Wenyuan Ding
- Department of Spine Surgery, the Third Hospital of Hebei Medical University
- Key laboratory of biomechanics of Hebei province, Shijiazhuang, Hebei, PR China
| | - Yong Shen
- Department of Spine Surgery, the Third Hospital of Hebei Medical University
- Key laboratory of biomechanics of Hebei province, Shijiazhuang, Hebei, PR China
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17
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Lv Z, Yu L, Wang Q, Jia R, Ding W, Shen Y. Dermal regeneration template and vacuum sealing drainage for treatment of traumatic degloving injuries of upper extremity in a single‐stage procedure. ANZ J Surg 2019; 89:950-954. [PMID: 31230422 DOI: 10.1111/ans.15315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Zhenmu Lv
- Department of Hand and Foot SurgeryThe No. 252 Hospital of People's Liberation Army of China Shijiazhuang China
- Department of Spine SurgeryThe Third Hospital of Hebei Medical University Shijiazhuang China
| | - Lili Yu
- Department of NeurologyThe Second Hospital of Hebei Medical University Shijiazhuang China
| | - Qiusheng Wang
- Department of Hand and Foot SurgeryThe No. 252 Hospital of People's Liberation Army of China Shijiazhuang China
| | - Rui Jia
- Department of Hand and Foot SurgeryThe No. 252 Hospital of People's Liberation Army of China Shijiazhuang China
| | - Wenyuan Ding
- Department of Spine SurgeryThe Third Hospital of Hebei Medical University Shijiazhuang China
- Key Laboratory of Biomechanics of Hebei Province Shijiazhuang China
| | - Yong Shen
- Department of Hand and Foot SurgeryThe No. 252 Hospital of People's Liberation Army of China Shijiazhuang China
- Key Laboratory of Biomechanics of Hebei Province Shijiazhuang China
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18
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McMillan LJ, Parikh HR, Cunningham BP. Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases. JBJS Case Connect 2019; 9:e0148. [PMID: 31140985 DOI: 10.2106/jbjs.cc.18.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication. CONCLUSIONS Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.
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Affiliation(s)
- Logan J McMillan
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
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19
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Leclère FM, Desnouveaux E, Choughri H, Casoli V. Acellular dermal matrix: New applications for free flap pedicle coverage – A prospective study in 10 patients. J COSMET LASER THER 2018; 20:200-204. [DOI: 10.1080/14764172.2016.1248439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Franck Marie Leclère
- Department of Plastic & Reconstructive Surgery, Burn Surgery, Hand Surgery, Centre of Expertise for Sex Reassignment Surgery, University Hospital Bordeaux (CHU), University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
- Department of Anatomy, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
- INSERM U1189 - ONCO-THAI - Image Assisted Laser Therapy for Oncology, University Hospital Lille, France
| | - Emilie Desnouveaux
- Department of Anatomy, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
| | - H. Choughri
- Department of Plastic & Reconstructive Surgery, Burn Surgery, Hand Surgery, Centre of Expertise for Sex Reassignment Surgery, University Hospital Bordeaux (CHU), University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
| | - Vincent Casoli
- Department of Plastic & Reconstructive Surgery, Burn Surgery, Hand Surgery, Centre of Expertise for Sex Reassignment Surgery, University Hospital Bordeaux (CHU), University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
- Department of Anatomy, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, France
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20
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Chang P, Guo B, Hui Q, Liu X, Tao K. A bioartificial dermal regeneration template promotes skin cell proliferation in vitro and enhances large skin wound healing in vivo. Oncotarget 2018; 8:25226-25241. [PMID: 28423680 PMCID: PMC5421924 DOI: 10.18632/oncotarget.16005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/22/2017] [Indexed: 12/30/2022] Open
Abstract
A novel bioartificial dermal regeneration template has been developed using platelet-rich plasma and acellular animal skin collagen sponge for the treatment of larger area and full thickness skin wounds. This platelet-rich plasma-collagen sponge keeps native skin structure and contains huge amounts of growth factors. The effect of this bioartificial dermal regeneration template was tested in vitro and in vivo via a mimic poor wound healing process by adding collagenase I into cell culture medium or the wound area. The in vitro experimental results indicated that the rat skin cells grew faster and produced more collagen in platelet-rich plasma-collagen sponge with collagenase than those treated either with collagen sponge plus collagenase, or collagenase, or control group without treatment. The in vivo experiments were performed by large rat skin wounds, 1.5 cm diameter, treated either with collagenase, or collagenase plus collagen sponge, or collagenase plus platelet-rich plasma-collagen sponge. The wound without treatment was used as a control. The wounds treated with collagenase-containing platelet-rich plasma-collagen sponge healed 4 times faster than the untreated wounds, 6 times faster than the collagenase treated wounds, 2.4 times faster than collagenase-containing collagen sponge treated wounds. The immunostaining indicated that the healed tissues in the wound areas treated with collagenase-containing platelet-rich plasma-collagen sponge were composed of collagen type I and collagen III with blood vessels and hair follicles. The results demonstrated that this collagenase-containing platelet-rich plasma-collagen sponge works as a bioartificial dermal regeneration template. The application of this collagenase-containing platelet-rich plasma-collagen sponge promotes the traumatic skin wound healing and permits the reconstitution of the inherent barrier functions of the skin.
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Affiliation(s)
- Peng Chang
- Department of Plastic and Reconstructive Surgery, General Hospital of Shenyang Military Area Command, Shenyang, 110840, Liaoning, P.R. China
| | - Bingyu Guo
- Department of Plastic and Reconstructive Surgery, General Hospital of Shenyang Military Area Command, Shenyang, 110840, Liaoning, P.R. China
| | - Qiang Hui
- Department of Plastic and Reconstructive Surgery, General Hospital of Shenyang Military Area Command, Shenyang, 110840, Liaoning, P.R. China
| | - Xiaoyan Liu
- Department of Plastic and Reconstructive Surgery, General Hospital of Shenyang Military Area Command, Shenyang, 110840, Liaoning, P.R. China
| | - Kai Tao
- Department of Plastic and Reconstructive Surgery, General Hospital of Shenyang Military Area Command, Shenyang, 110840, Liaoning, P.R. China
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21
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Abstract
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
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22
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Maurya S, Srinath N, Bhandari PS. Negative pressure wound therapy in the management of mine blast injuries of lower limbs: Lessons learnt at a tertiary care center. Med J Armed Forces India 2018; 73:321-327. [PMID: 29386704 DOI: 10.1016/j.mjafi.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/13/2016] [Indexed: 11/25/2022] Open
Abstract
Background Mine blast injuries of foot are devastating injuries that result in composite tissue loss or amputations. Negative pressure wound therapy has helped in the management of such combat-related wounds. The aim of this study was to report experiences gained in managing such injuries at a tertiary care center. Methods 17 combatants who sustained mine blast injuries were included in this study. Severity of foot injury was assessed as per Foot and Ankle Severity Score. After wound debridement, negative pressure wound therapy was started and foot defect was appropriately reconstructed. Following wound healing, the foot was assessed for Foot and Ankle Severity Score in terms of impairment. The patients were then suitably rehabilitated by shoe modifications, orthosis, or custom-made prosthesis. Results Mean age of soldiers who sustained mine blast injuries was 30.2 years. The mean Foot and Ankle Severity Score was 3.76. Temporary wound closure was achieved using negative pressure wound therapy and it prevented local and systemic infection. The defect could be reconstructed appropriately using split skin graft, regional fasciocutaneous flap, or microvascular free flap. Mean time to definitive reconstructive procedure was 16.5 days. Mean Foot and Ankle Severity Score in terms of impairment was 4.11. All soldiers could be rehabilitated and were returned to their respective units and were able to perform sedentary duties assigned to them. Conclusion The negative pressure wound therapy was helpful in preventing proximal amputations due to mine blast injury and was helpful in satisfactory reconstruction of foot defects.
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Affiliation(s)
- Sanjay Maurya
- Senior Advisor (Surgery) & Reconstructive Surgeon, Command Hospital (Southern Command), Pune 411040, India
| | - N Srinath
- Senior Consultant (Surgery), O/o DGAFMS, New Delhi 11000, India
| | - P S Bhandari
- Consultant (Plastic Surgeon), Brij Lal Hospital, Haldwani, Uttrakhand, India
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23
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Schlanser V, Dennis A, Ivkovic K, Joseph K, Kaminsky M, Messer T, Poulakidas S, Starr F, Bokhari F. Placenta to the Rescue: Limb Salvage Using Dehydrated Human Amnion/Chorion Membrane. J Burn Care Res 2017; 39:1048-1052. [DOI: 10.1093/jbcr/irx031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Victoria Schlanser
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Andrew Dennis
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Katarina Ivkovic
- Institute for Healthcare Innovation at Midwestern University, Downers Grove, Illinois
| | - Kimberly Joseph
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Matthew Kaminsky
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Thomas Messer
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Stathis Poulakidas
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Frederic Starr
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
| | - Faran Bokhari
- Department of Trauma and Burn, Cook County Health and Hospital Systems, Chicago, Illinois
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24
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The Use of Integra® Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis. Aesthetic Plast Surg 2017; 41:472-473. [PMID: 28127661 DOI: 10.1007/s00266-016-0765-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/03/2016] [Indexed: 10/20/2022]
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25
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An Alternative Treatment Strategy for Complicated Chronic Wounds: Negative Pressure Therapy over Mesh Skin Graft. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8395219. [PMID: 28299333 PMCID: PMC5337327 DOI: 10.1155/2017/8395219] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 12/09/2016] [Accepted: 01/30/2017] [Indexed: 11/18/2022]
Abstract
Extensive skin defect represents a real problem and major challenge in plastic and reconstructive surgery. On one hand, skin grafts offer a practical method to deal with skin defects despite their unsuitability for several complicated wounds. On the other hand, negative pressure wound therapy (NPWT), applied before skin grafting, promotes granulation tissue growth. The aim of the study is to evaluate the improvement in wound healing given by the merger of these two different approaches. We treated 23 patients for large wounds of multiple factors. Of these, 15 were treated with the application of V.A.C.® Therapy (KCI Medical S.r.l., Milan, Italy), in combination with skin grafts after a prior unsuccessful treatment of 4 weeks with mesh skin grafts and dressings. Another 8 were treated with only mesh skin graft. Pain reduction and wound area reduction were found statistically significant (p < 0.0009, p < 0.0001). Infection was resolved in almost all patients. According to our study, the use of the negative pressure wound therapy over mesh skin grafts is significantly effective especially in wounds resistant to conventional therapies, thereby improving the rate of skin graft take.
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Vitse J, Bekara F, Bertheuil N, Sinna R, Chaput B, Herlin C. Perforator-based propeller flaps reliability in upper extremity soft tissue reconstruction: a systematic review. J Hand Surg Eur Vol 2017; 42:157-164. [PMID: 27671797 DOI: 10.1177/1753193416669262] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED Current data on upper extremity propeller flaps are poor and do not allow the assessment of the safety of this technique. A systematic literature review was conducted searching PubMed, EMBASE, and the Cochrane Library electronic databases, and the selection process was adapted from the preferred reporting items for systematic reviews and meta-analysis statement. The final analysis included ten relevant articles involving 117 flaps. The majority of flaps were used for the hand, distal wrist, and elbow. The radial artery perforator and ulnar artery perforator were the most frequently used flaps. The were 7% flaps with venous congestion and 3% with complete necrosis. No difference in complications rate was found for different flaps sites. Perforator-based propeller flaps appear to be an interesting procedure for covering soft tissue defects involving the upper extremities, even for large defects, but the procedure requires experience and close monitoring. LEVEL OF EVIDENCE II.
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Affiliation(s)
- J Vitse
- 1 Departments of Plastic and Reconstructive Surgery, Burns and Wound Healing Units, CHRU Lapeyronie, Montpellier, France
| | - F Bekara
- 1 Departments of Plastic and Reconstructive Surgery, Burns and Wound Healing Units, CHRU Lapeyronie, Montpellier, France
| | - N Bertheuil
- 2 Department of Plastic, Reconstructive and Aesthetic Surgery, CHRU Rennes, Rennes, France
| | - R Sinna
- 3 Department of Plastic, Reconstructive and Aesthetic Surgery, CHRU Picardie, Amiens, France
| | - B Chaput
- 4 Department of Plastic, Reconstructive and Aesthetic Surgery, CHRU Rangeuil, Toulouse, France
| | - C Herlin
- 1 Departments of Plastic and Reconstructive Surgery, Burns and Wound Healing Units, CHRU Lapeyronie, Montpellier, France
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27
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Use of a Dermal Regeneration Template Wound Dressing in the Treatment of Combat-Related Upper Extremity Soft Tissue Injuries. J Hand Surg Am 2016; 41:e453-e460. [PMID: 27743751 DOI: 10.1016/j.jhsa.2016.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 08/03/2016] [Accepted: 08/10/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the outcomes of treatment with a dermal regeneration template (DRT) in a cohort of combat casualties with severe upper extremity injuries. METHODS Records of all active duty military patients treated with DRT at our institution between November 2009 and July 2013 were screened. Inclusion criteria were upper extremity open wounds sustained during combat, requiring split-thickness or full-thickness skin grafting for closure. The primary outcome measure was wound healing after the first attempt at definitive treatment (defined as the first application of split-thickness or full-thickness skin graft). Independent variables collected included time from injury to arrival at our facility, mechanism of injury, wound infection, tobacco use, location of wound, number of operative debridements, and patient demographics. RESULTS A total of 60 patients with 69 wounds met the inclusion criteria. Most wounds were to the wrist or forearm (54%) or fingers (19%). All wounds were heavily contaminated, requiring a mean of 2.5 operative debridements before DRT placement. All wounds treated with full-thickness skin grafting after DRT healed completely without further complication. Split-thickness skin grafting was successful in 96% of patients. CONCLUSIONS DRT wound dressings are a helpful adjunct in the treatment of contaminated war wounds to the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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28
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Abstract
Integra dermal regeneration template is commonly used in the developed world.
This case history documents the application of Integra for the first time in
Gaza, Palestine. This single case history illustrates how a tried and tested
technique can be imported to a more challenging environment. The emphasis in
this case history is not to recount a well-known technique of Integra
application but to outline how the environment has to be prepared and the
surgeon adapt to minimise risk and maximise the chances of success. This first
application of Integra in Gaza illustrates the importance of starting with
simple cases when a technique is being piloted in an austere environment.
Patient selection, local theatre set up, staff and surgical technique, as well
as patient follow-up facilities, all need consideration before doing the first
trial of even this most established of products in a new environment. Integra dermal regeneration template is a material that can be applied to
resurface areas of scarring and burns contracture. The template consists of two
layers: the upper layer is a Silone sheet that acts to protect the deeper layer
that consists of a protein matrix. Once an area of troublesome scar has been
surgically removed, it leaves a gap, or defect. The Integra can be applied to
the defect and, providing the areas has a good blood supply, is free of bacteria
and immobilised, a new blood supply enters the protein matrix. This allows the
migration of cells, called fibroblasts, into the matrix. The fibroblasts will
use the matrix as scaffolding to lay down new protein and eventually replace the
matrix. The resultant structure is called a ‘neodermis’. The protective silicone sheet
can then be removed and replaced by a conventional, very thin skin graft. The
advantage to applying this Integra two-stage reconstruction technique to a
scarred area is that the reconstruction will be elastic and expand. In children,
this allows for growth without recurrence of contractures across joints. The application of Integra is a tried and tested technique. This case explains
how, and with due care, it can be used for severe scarred cases in a challenging
environment provided careful technique and follow-up are respected.
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Affiliation(s)
- Fabio Nicoli
- Médecins Sans Frontières, Gaza Clinic, Thaoura Street, Gaza City, Palestine.,Consultant Plastic Reconstructive surgeon, Italy
| | - Ivonne Rampinelli
- Médecins Sans Frontières, Gaza Clinic, Thaoura Street, Gaza City, Palestine.,Consultant Anaesthetist, Chile
| | - Yvette Godwin
- Médecins Sans Frontières, Gaza Clinic, Thaoura Street, Gaza City, Palestine.,Consultant Plastic Reconstructive surgeon, Italy
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29
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Lalezari S, Lee CJ, Borovikova AA, Banyard DA, Paydar KZ, Wirth GA, Widgerow AD. Deconstructing negative pressure wound therapy. Int Wound J 2016; 14:649-657. [PMID: 27681204 DOI: 10.1111/iwj.12658] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 07/06/2016] [Accepted: 07/10/2016] [Indexed: 12/13/2022] Open
Abstract
Since its introduction 20 years ago for the treatment of chronic wounds, negative pressure wound therapy use has expanded to a variety of other wound types. Various mechanisms of action for its efficacy in wound healing have been postulated, but no unifying theory exists. Proposed mechanisms include induction of perfusion changes, microdeformation, macrodeformation, exudate control and decreasing the bacterial load in the wound. We surmise that these different mechanisms have varying levels of dominance in each wound type. Specifically, negative pressure wound therapy is beneficial to acute open wounds because it induces perfusion changes and formation of granulation tissue. Post-surgical incisional wounds are positively affected by perfusion changes and exudate control. In the context of chronic wounds, negative pressure wound therapy removes harmful and corrosive substances within the wounds to affect healing. When skin grafts and dermal substitutes are used to close a wound, negative pressure wound therapy is effective in promoting granulation tissue formation, controlling exudate and decreasing the bacterial load in the wound. In this review, we elucidate some of the mechanisms behind the positive wound healing effects of negative pressure wound therapy, providing possible explanations for these effects in different wound types.
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Affiliation(s)
- Shadi Lalezari
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Christine J Lee
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Anna A Borovikova
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Derek A Banyard
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Keyianoosh Z Paydar
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Garrett A Wirth
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
| | - Alan D Widgerow
- Center for Tissue Engineering, Department of Plastic Surgery, University of California, Irvine, CA, USA
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Maurya S, Bhandari PS. Negative Pressure Wound Therapy in the Management of Combat Wounds: A Critical Review. Adv Wound Care (New Rochelle) 2016; 5:379-389. [PMID: 27679749 DOI: 10.1089/wound.2014.0624] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 03/03/2015] [Indexed: 01/09/2023] Open
Abstract
Significance: Wounds sustained in a combat trauma often result in a composite tissue loss. Combat injuries, due to high energy transfer to tissues, lead to trauma at multiple anatomical sites. An early wound cover is associated with lower rate of infections and a faster wound healing. The concept of negative pressure wound therapy (NPWT) in the management of combat-related wounds has evolved from the civilian trauma and the wounds from nontraumatic etiologies. Recent Advances: Encouraged by the results of NPWT in noncombat-related wounds, the military surgeons during Operation Iraqi Freedom and Operation Enduring Freedom used this novel method in a large percentage of combat wounds, with gratifying results. The mechanism of NPWT in wound healing is multifactorial and often complex reconstructive procedure can be avoided in a combat trauma setting. Critical Issues: Wounds sustained in military trauma are heavily contaminated with dirt, patient clothing, and frequently associated with extensive soft tissue loss and osseous destruction. Delay in evacuation during an ongoing conflict carries the risk of systemic infection. Early debridement is indicated followed by delayed closure of wounds. NPWT helps to provide temporary wound cover during the interim period of debridement and wound closure. Future Directions: Future area of research in combat wounds is related to abdominal trauma with loss of abdominal wall. The concept of negative pressure incisional management system in patients with a high risk of wound breakdown following surgery is under review, and may be of relevance in combat wounds.
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Affiliation(s)
- Sanjay Maurya
- Department of Plastic and Reconstructive Surgery, Command Hospital , Udhampur, India
| | - Prem Singh Bhandari
- Department of Plastic and Reconstructive Surgery, Command Hospital , Udhampur, India
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Leclère FM, Casoli V. Use of bioartificial dermal regeneration template for skin restoration in combat casualty injuries. Regen Med 2016; 11:359-60. [PMID: 27250674 DOI: 10.2217/rme-2016-0044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A letter in response to: Seavey JG, Masters ZA, Balazs GC, Tintle SM, Sabino J, Fleming ME & Valerio IL. Use of bioartificial dermal regeneration template for skin restoration in combat casualty injuries. Regen. Med. 11(1), 81-90 (2016).
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Affiliation(s)
- Franck Marie Leclère
- Department of Anatomy, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, 33076 Bordeaux, France.,Department of Plastic & Reconstructive Surgery, Burn Surgery, University Hospital Bordeaux, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - Vincent Casoli
- Department of Anatomy, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, 33076 Bordeaux, France.,Department of Plastic & Reconstructive Surgery, Burn Surgery, University Hospital Bordeaux, University of Bordeaux, Centre François-Xavier-Michelet, Groupe hospitalier Pellegrin, Place Amélie-Raba-Léon, 33076 Bordeaux, France
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Yuan XG, Zhang X, Fu YX, Tian XF, Liu Y, Xiao J, Li TW, Qiu L. Sequential therapy with "vacuum sealing drainage-artificial dermis implantation-thin partial thickness skin grafting" for deep and infected wound surfaces in children. Orthop Traumatol Surg Res 2016; 102:369-73. [PMID: 27038673 DOI: 10.1016/j.otsr.2016.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 12/29/2015] [Accepted: 01/06/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a "vacuum sealing drainage (VSD) - artificial dermis implantation (ADI) - thin partial thickness skin grafting (TSG)" sequential therapy for deep and infected wounds in children. MATERIALS AND METHODS Fifty-three pediatric patients with deep and infected wounds were treated with sequential VSD-ADI-TSG therapy. The efficacy of this treatment was compared with that of the surgical debridement-change dressings-thin partial thickness skin grafting previously performed on 20 patients. Survival of tissue grafts, color and flexibility, subcutaneous fullness and scar formation of the graft site were examined and compared. RESULTS The sequential therapy combined the advantages of the VSD treatment, in reducing tissue necrosis and infection on the wound surfaces and promoting the growth of granulation tissue, with the enhancement of grafting by artificial dermis. Compared with the 20 controls, skin grafted on the artificial dermis was more smooth and glossy, while the textures of the region were more elastic, and the scars were significantly lighter in Vancouver scale. CONCLUSION The sequential VSD-ADI-TSG therapy is a simple and effective treatment for children with deep and infected wounds. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- X-G Yuan
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - X Zhang
- Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Y-X Fu
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - X-F Tian
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Y Liu
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - J Xiao
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - T-W Li
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - L Qiu
- Children's Hospital of Chongqing Medical University, Department of Burns and Plastic Surgery, No. 136, Zhongshan 2nd Road, 400014 Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics in Chongqing (CSTC2009CA5002), Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China.
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Connolly M, Ibrahim ZR, Johnson ON. Changing paradigms in lower extremity reconstruction in war-related injuries. Mil Med Res 2016; 3:9. [PMID: 27042328 PMCID: PMC4818384 DOI: 10.1186/s40779-016-0080-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 03/21/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage. METHODS A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications. RESULTS Extremity injuries account for over 60 % of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage. CONCLUSION Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.
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Affiliation(s)
- Margaret Connolly
- Department of Surgery, University of Maryland Medical Center, 22 S Greene St., Baltimore, MD 21201 USA
| | - Zuhaib R Ibrahim
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, 601 N Caroline St., Baltimore, MD 21287 USA
| | - Owen N Johnson
- Johns Hopkins University School of Medicine, 601 N Caroline St., Baltimore, MD 21287 USA
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Distally based sural flap for ankle and foot coverage in children. Orthop Traumatol Surg Res 2016; 102:111-6. [PMID: 26726097 DOI: 10.1016/j.otsr.2015.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 10/01/2015] [Accepted: 10/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot. HYPOTHESIS We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients. MATERIAL AND METHODS A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1). RESULTS Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients. DISCUSSION The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site. LEVEL OF EVIDENCE IV, retrospective case-series study.
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Seavey JG, Masters ZA, Balazs GC, Tintle SM, Sabino J, Fleming ME, Valerio IL. Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries. Regen Med 2016; 11:81-90. [DOI: 10.2217/rme.15.83] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.
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Affiliation(s)
- Jonathan G Seavey
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 USA
| | - Zachary A Masters
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - George C Balazs
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 USA
| | - Scott M Tintle
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 USA
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Jennifer Sabino
- Department of General Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
| | - Mark E Fleming
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889 USA
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Ian L Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Ste 2100, Columbus, OH 43212, USA
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Abstract
OBJECTIVES Trauma-related hemipelvectomy is a rare and often fatal injury that poses a number of challenges to the treating surgeon. Our objective was to identify patient and injury characteristics that have proven difficult to treat, and to describe management techniques. DESIGN Retrospective review. SETTING Level II trauma center. PATIENTS Thirteen consecutive patients who underwent 14 combat-related hemipelvectomies between 2001 and 2013. INTERVENTION We reviewed our prospective trauma registry, along with the patients' medical records, radiographs, and clinical photographs. MAIN OUTCOME MEASUREMENTS Injury severity scores, required surgical procedures, ambulatory status, and bowel and bladder function. RESULTS Hemipelvectomy was indicated for insufficient soft tissue coverage, complicated by life-threatening local infection and/or a dysvascular hemipelvis. Five patients underwent resection for angioinvasive fungal infections. All patients sustained a genitourinary injury, with 7 requiring suprapubic catheters and all undergoing diverting colostomy. After a median of 2 years of follow-up, 2 patients had normal urinary continence and 3 regained fecal continence. The surviving patients required a mean of 44 operations. One patient returned to community ambulation. CONCLUSIONS This is the largest published series of trauma-related hemipelvectomies. Our lessons learned may benefit civilian surgeons who are confronted with high-energy open injuries to the pelvic girdle. Although the decision to perform hemipelvectomy should not be taken lightly, this procedure can be lifesaving and should be performed in a timely fashion when indicated. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Hayashi A, Komoto M, Tanaka R, Natori Y, Matsumura T, Horiguchi M, Matsuda N, Yoshizawa H, Mizuno H. The availability of perifascial areolar tissue graft for deep cutaneous ulcer coverage. J Plast Reconstr Aesthet Surg 2015; 68:1743-9. [PMID: 26354999 DOI: 10.1016/j.bjps.2015.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/01/2015] [Accepted: 08/07/2015] [Indexed: 11/18/2022]
Abstract
Soft tissue defects or skin ulcers associated with tendon or bone exposure located distally on the extremities are always difficult to treat. The introduction of the vacuum-assisted closure (VAC) and dermal templates has led to major changes in ulcer treatment strategies. However, it is necessary to find an alternative method to treat these defects when VAC is not available. Perifascial areolar tissue (PAT) is the loose connective tissue on the deep fascia that could be a candidate for repairing soft tissue defects or skin ulcers. Grafting PAT on the exposed bone or tendon, including a wide coverage of well-vascularized tissue surrounding the granulation tissue, can prepare the wound to be subsequently closed by a skin graft. In this study, the PAT was used in various situations and its optimal usage and outcomes were evaluated. A total of 13 PAT grafts were performed and were especially useful for covering narrow ulcers with narrow tendon exposure and filling fistula areas. In comparison to other cases, covering the exposed cortical bone ulcers seemed to be more difficult to perform. However, an option for these ulcers could be the exposure of bone marrow and usage of intraosseous blood flow. It was also possible for the simultaneous engraftment of PAT and skin in narrow areas and could be an alternative in cases of small concave ulcers or fistulae. The PAT graft is a simple and minimally invasive procedure that can be a good alternative when VAC is not available.
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Affiliation(s)
- Ayato Hayashi
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Masakazu Komoto
- Department of Plastic and Reconstructive Surgery, Juntendo University Sizuoka Hospital, Sizuoka, Japan
| | - Rica Tanaka
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuhei Natori
- Department of Plastic and Reconstructive Surgery, Kawasakinanbu Hospital, Kanagawa, Japan
| | - Takashi Matsumura
- Department of Plastic and Reconstructive Surgery, Juntendo University Sizuoka Hospital, Sizuoka, Japan
| | - Masatoshi Horiguchi
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Norifumi Matsuda
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hidekazu Yoshizawa
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroshi Mizuno
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Verbelen J, Hoeksema H, Pirayesh A, Van Landuyt K, Monstrey S. Exposed tibial bone after burns: Flap reconstruction versus dermal substitute. Burns 2015; 42:e31-7. [PMID: 26376411 DOI: 10.1016/j.burns.2015.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/03/2015] [Indexed: 11/26/2022]
Abstract
A 44 years old male patient had suffered extensive 3rd degree burns on both legs, undergoing thorough surgical debridement, resulting in both tibias being exposed. Approximately 5 months after the incident he was referred to the Department of Plastic and Reconstructive Surgery of the University Hospital Gent, Belgium, to undergo flap reconstruction. Free flap surgery was performed twice on both lower legs but failed on all four occasions. In between flap surgery, a dermal substitute (Integra(®)) was applied, attempting to cover the exposed tibias with a layer of soft tissue, but also without success. In order to promote the development of granulation tissue over the exposed bone, small holes were drilled in both tibias with removal of the outer layer of the anterior cortex causing the bone to bleed and subsequently negative pressure wound therapy (NPWT) was applied. The limited granulation tissue resulting from this procedure was then covered with a dermal substitute (Glyaderm(®)), consisting of acellular human dermis with an average thickness of 0.25mm. This dermal substitute was combined with a NPWT-dressing, and then served as an extracellular matrix (ECM), guiding the distribution of granulation tissue over the remaining areas of exposed tibial bone. Four days after initial application of Glyaderm(®) combined with NPWT both tibias were almost completely covered with a thin coating of soft tissue. In order to increase the thickness of this soft tissue cover two additional layers of Glyaderm(®) were applied at intervals of approximately 1 week. One week after the last Glyaderm(®) application both wounds were autografted. The combination of an acellular dermal substitute (Glyaderm(®)) with negative pressure wound therapy and skin grafting proved to be an efficient technique to cover a wider area of exposed tibial bone in a patient who was not a candidate for free flap surgery. An overview is also provided of newer and simpler techniques for coverage of exposed bone that could question the universal plastic surgery paradigm that flap surgery is the only way to cover these defects.
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Affiliation(s)
- Jozef Verbelen
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | - Henk Hoeksema
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | | | - Koenraad Van Landuyt
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium
| | - Stan Monstrey
- Department of Plastic and Reconstructive Surgery - Burn Center Gent University Hospital, Gent, Belgium.
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Balazs GC, Dickens JF, Brelin AM, Wolfe JA, Rue JPH, Potter BK. Analysis of Orthopaedic Research Produced During the Wars in Iraq and Afghanistan. Clin Orthop Relat Res 2015; 473:2777-84. [PMID: 25758377 PMCID: PMC4523534 DOI: 10.1007/s11999-015-4244-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Military orthopaedic surgeons have published a substantial amount of original research based on our care of combat-wounded service members and related studies during the wars in Iraq and Afghanistan. However, to our knowledge, the influence of this body of work has not been evaluated bibliometrically, and doing so is important to determine the modern impact of combat casualty research in the wider medical community. QUESTIONS/PURPOSES We sought to identify the 20 most commonly cited works from military surgeons published during the Iraq and Afghanistan conflicts and analyze them to answer the following questions: (1) What were the subject areas of these 20 articles and what was the 2013 Impact Factor of each journal that published them? (2) How many citations did they receive and what were the characteristics of the journals that cited them? (3) Do the citation analysis results obtained from Google Scholar mirror the results obtained from Thompson-Reuters' Web of Science? METHODS We searched the Web of Science Citation Index Expanded for relevant original research performed by US military orthopaedic surgeons related to Operation Iraqi Freedom and Operation Enduring Freedom between 2001 and 2014. Articles citing these studies were reviewed using both Web of Science and Google Scholar data. The 20 most cited articles meeting inclusion criteria were identified and analyzed by content domain, frequency of citation, and sources in which they were cited. RESULTS Nine of these studies examined the epidemiology and outcome of combat injury. Six studies dealt with wound management, wound dehiscence, and formation of heterotopic ossification. Five studies examined infectious complications of combat trauma. The median number of citations garnered by these 20 articles was 41 (range, 28-264) in Web of Science. Other research citing these studies has appeared in 279 different journals, covering 26 different medical and surgical subspecialties, from authors in 31 different countries. Google Scholar contained 97% of the Web of Science citations, but also had 31 duplicate entries and 29 citations with defective links. CONCLUSIONS Modern combat casualty research by military orthopaedic surgeons is widely cited by researchers in a diverse range of subspecialties and geographic locales. This suggests that the military continues to be a source of innovation that is broadly applicable to civilian medical and surgical practice and should encourage expansion of military-civilian collaboration to maximize the utility of the knowledge gained in the treatment of war trauma. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- George C. Balazs
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Building 19, Floor 2, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Jonathan F. Dickens
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Building 19, Floor 2, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Alaina M. Brelin
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Building 19, Floor 2, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | - Jared A. Wolfe
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Building 19, Floor 2, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
| | | | - Benjamin K. Potter
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Building 19, Floor 2, 8901 Wisconsin Avenue, Bethesda, MD 20889 USA
- />Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD USA
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Abstract
The management of blast-related soft tissue wounds requires a comprehensive surgical approach that acknowledges extensive zones of injury and the likelihood of massive contamination. The experiences of military surgeons during the last decade of war have significantly enhanced current understandings of the optimal means of mitigating infectious complications, the timing of soft tissue coverage attempts, and the reconstructive options available for definitive wound management. Early administration of antibiotics in the setting of soft tissue wounds and associated open fractures is the single most important aspect of open fracture care. Both civilian and military reports have elucidated the incidence of invasive fungal infection in the setting of high-energy injuries with significant wound burdens, and novel treatment protocols have emerged. The type of reconstruction is predicated upon the zone of injury and location of the soft tissue defect. Multiple reports of military cohorts have suggested the equivalency of various techniques and types of soft tissue coverage. Longer-term follow-up will inform future perspectives on the durability of these surgical approaches.
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Affiliation(s)
- Andrew J. Sheean
- />Department of Orthopedic Surgery and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX USA
| | - Scott M. Tintle
- />Department of Orthopedic Surgery, National Naval Medical Center, Bethesda, MD USA
| | - Peter C. Rhee
- />Department of Orthopedic Surgery and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX USA
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Gordon W, Kuhn K, Staeheli G, Dromsky D. Challenges in definitive fracture management of blast injuries. Curr Rev Musculoskelet Med 2015; 8:290-7. [PMID: 26104316 PMCID: PMC4596208 DOI: 10.1007/s12178-015-9286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The United States military remains engaged in the longest armed conflict in this nation's history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.
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Affiliation(s)
- Wade Gordon
- />Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Kevin Kuhn
- />Naval Medical Center San Diego, San Diego, CA USA
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Weigert R, Leclere FM, Delia G, De Luca L, Al Mutairi K, Casoli V. Long-term patient-reported functional and cosmetic outcomes following severe traumatic foot and ankle wound reconstruction with acellular dermal matrix. J COSMET LASER THER 2015; 17:321-9. [DOI: 10.3109/14764172.2015.1027231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length. Ann Plast Surg 2015; 73:183-9. [PMID: 24691339 DOI: 10.1097/sap.0b013e3182a638d8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. METHODS A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. RESULTS Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. CONCLUSIONS The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.
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Fleming ME, Bharmal H, Valerio I. Regenerative medicine applications in combat casualty care. Regen Med 2015; 9:179-90. [PMID: 24750059 DOI: 10.2217/rme.13.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.
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Affiliation(s)
- Mark E Fleming
- Department of Orthopaedics, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
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Michot A, Chaput B, Gobel F, Menez T, de Bonnecaze G, Pelissier P. Chronic ischaemia does not appear to hinder healing with Integra(®) : implementation at a tibial artery bypass site. Int Wound J 2015; 13:1003-5. [PMID: 25586165 DOI: 10.1111/iwj.12408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/10/2014] [Indexed: 12/01/2022] Open
Abstract
Wounds with exposed vessels, especially in artery bypass procedures, can pose a barrier to adequate skin healing. Skin grafts or flaps are sometimes difficult to perform in the face of the ischaemia that is often present in such cases. We report a case of a 73-year-old man who presented with grade IV peripheral arterial disease necessitating salvage of the lower limb using artery bypass surgery. Immediate exposure of femorotibial artery secondary to skin necrosis following the bypass led us to propose an innovative means of wound coverage using Integra(®) , a well-known dermal regeneration template. The wound healed uneventfully with an appearance similar to that of the adjacent skin. Integra(®) seems to be less demanding in terms of the vascular wound bed and the degree of oxygenation than a conventional skin graft. This finding could support further indications for this dermal regeneration template.
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Affiliation(s)
- Audrey Michot
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Bordeaux Segalen, Bordeaux, France.
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Toulouse Rangueil, Toulouse, France
| | - Fabienne Gobel
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Bordeaux Segalen, Bordeaux, France
| | - Tiphaine Menez
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Bordeaux Segalen, Bordeaux, France
| | - Guillaume de Bonnecaze
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Toulouse Rangueil, Toulouse, France
| | - Philippe Pelissier
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Bordeaux Segalen, Bordeaux, France
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Acellular dermal matrix-based gene therapy augments graft incorporation. J Surg Res 2015; 195:360-7. [PMID: 25676463 DOI: 10.1016/j.jss.2015.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 10/30/2014] [Accepted: 01/07/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acellular dermal matrix (ADM) is widely used for structural or dermal replacement purposes. Given its innate biocompatibility and its potential to vascularize, we explored the possibility of ADM to function as a small interfering RNA (siRNA) delivery system. Specifically, we sought to improve ADM vascularization by siRNA-mediated inhibition of prolyl hydroxylase domain-2 (PHD2), a cytoplasmic protein that regulates hypoxia inducible factor-1α, and improve neovascularization. MATERIALS AND METHODS Fluorescently labeled siRNA was used to rehydrate thin implantable ADM. Pharmacokinetic release of siRNA was determined. Twelve millimeter sections of ADM reconstituted with PHD2 siRNA (nonsense siRNA as control) and applied to dorsal wounds of 40 FVB mice. Grafts were sewn in, bolstered, and covered with occlusive dressings. Photographs were taken at 0, 7, and 14 d. Wounds were harvested at 7 and 14 d and analyzed (messenger RNA, protein, histology, and immunohistochemistry). RESULTS Release kinetics was first-order with 80% release by 12 h. By day 14, PHD2-containing ADM appeared viable and adherent, whereas controls appeared nonviable and nonadherent. Real-time reverse transcription-polymerase chain reaction demonstrated near-complete knockdown of PHD2, whereas vascular endothelial growth factor and FGF-2 were increased 2.3- and 4.7-fold. On enzyme-linked immunosorbent assay, vascular endothelial growth factor was increased more than fourfold and stromal cell-derived factor doubled. Histology demonstrated improved graft incorporation in treated groups. Immunohistochemical demonstrated increased vascularity measured by CD31 staining and increased new cell proliferation by denser proliferating cell nuclear antigen staining in treated versus controls. CONCLUSIONS We concluded that ADM is an effective matrix for local delivery of siRNA. Strategies to improve the matrix and/or genetically alter the local tissue environment can be envisioned.
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Saab IR, Sarhane KA, Ezzeddine HM, Abu-Sittah GS, Ibrahim AE. Treatment of a paediatric patient with a distal lower extremity traumatic wound using a dermal regeneration template and NPWT. J Wound Care 2014; 23:S5-8. [PMID: 25289652 DOI: 10.12968/jowc.2014.23.sup10.s5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Degloving injuries are common in trauma and represent a spectrum of complex wounds, the management of which may be highly challenging especially in the paediatric population. In severe injuries leading to wounds reaching tendon and bone, vascularity is compromised precluding traditional wound management, and sometimes necessitating amputation. This report highlights the use of a dermal regeneration template combined with vacuum-assisted closure (VAC) in the treatment of complex traumatic degloving wounds. Here, we present a case of a five-year-old boy who sustained a high-energy shear injury to his lower extremity that resulted in an extensive degloving wound involving the distal third of his leg and the dorsum of his foot. After debridement, the patient underwent VAC combined with a dermal skin substitute placement, followed by split-thickness skin grafting. The extremity healed with no complications and without the need for amputation or flap reconstruction, achieving satisfactory recovery of range of motion and favourable cosmetic results.
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Affiliation(s)
- I R Saab
- General Surgery Resident, Department of Surgery, Division of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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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: 0.6] [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.
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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
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Jordan DJ, Malahias M, Hindocha S, Juma A. Flap decisions and options in soft tissue coverage of the lower limb. Open Orthop J 2014; 8:423-32. [PMID: 25408784 PMCID: PMC4235066 DOI: 10.2174/1874325001408010423] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [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: 12/18/2022] Open
Abstract
THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.
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Affiliation(s)
- Daniel J Jordan
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Marco Malahias
- Department of Plastic Surgery, Heart of England NHS Foundation Trust, UK
| | - Sandip Hindocha
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Ali Juma
- Department of Plastic Surgery, Countess of Chester Hospital, Chester, UK
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Reconstruction of traumatic defect of the lower third of the leg using a combined therapy: negative pressure wound therapy, acellular dermal matrix, and skin graft. Case Rep Surg 2014; 2014:783812. [PMID: 25177509 PMCID: PMC4142539 DOI: 10.1155/2014/783812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 07/07/2014] [Accepted: 07/17/2014] [Indexed: 11/25/2022] Open
Abstract
The reconstruction of lower third of the leg is one of the most challenging problems for plastic and reconstructive surgeons and current approaches are still disappointing. We show an easy option to obtain a coverage of traumatic pretibial defects with good aesthetic and functional results: the association of negative pressure wound therapy, acellular dermal matrix, and skin graft. The choice of this combined therapy avoids other surgical procedures such as local perforator flaps and free flaps that require more operating time, special equipment, and adequate training.
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