Clinical application of subdermal areolar tissue and superficial fascia graft as a new material for coverage of small exposure of bone cortex or orthopaedic fixation device.

BACKGROUND: The presence of cortical bone, tendon that has been exposed by defects, may result in infection or osteomyelitis. In such cases, perifascial areolar tissue grafting (PATG) may be performed as a minimally invasive surgical procedure. However, perifascial areolar tissue (PAT) is located deep in the subcutaneous layer. It was considered that grafting of the superficial vascular network might enable less invasive surgery. This study reports use of subdermal areolar tissue (SAT) and superficial fascia (SF) to close avascular areas. METHODS: This study treated eight areas of exposed bone, tendon, or orthopaedic fixation device in seven patients treated in the department between 2010-2013. The patients included five men and two women aged 15-80 years. Subdermal areolar tissue grafting (SATG) was performed on four areas, and superficial fascia grafting (SFG) on the remaining four areas. In all cases, split thickness skin graft (STSG) was used to cover the grafted tissue in a single procedure. RESULT: The tissue grafted successfully in seven areas, and primary engraftment of the skin grafts was also achieved in three areas treated with SATG and one area treated with SFG. Additional skin grafting was performed to achieve closure in one site treated with SATG and two sites treated with SFG. The tissue graft became necrotic in one site treated with SFG. There were no problems at any donor sites and no graft site infections or other complications. CONCLUSION: SATG and SFG achieved good clinical results for the closure of exposed avascular tissue or artifacts.

Measurement of vancomycin hydrochloride concentration in the exudate from wounds receiving negative pressure wound therapy: a pilot study.

It has been reported that negative pressure wound therapy (NPWT) is effective in the treatment of contaminated wounds. We hypothesised that systemically administered antibiotics migrate to wound site effectively by NPWT, which provides the antibacterial effect. We measured and compared the concentrations of vancomycin in the exudate and blood serum. Eight patients with skin ulcers or skin defect wounds who were treated with NPWT and were administered an intravenous drip of vancomycin were enrolled in this study. The wound surfaces were muscle, muscle fascia or adipose tissue. We administered vancomycin intravenously to NPWT patients (1-3 g/day). The exudate was obtained using 500 ml V.A.C. ATS canisters without gel. Three days later, the concentrations of vancomycin were measured. The mean concentration of vancomycin in the exudate from NPWT was 67% of the serum vancomycin concentration. We found that concentrations of vancomycin in NPWT exudates are higher than the previously reported concentrations in soft tissue without NPWT. The proactive use of NPWT might be considered in cases of suspected wound contamination when a systemic antibiotic is administered.

Syndactyly correction using a venous flap with the plantar cutaneous venous arch.

A combination of skin grafts and local flaps is widely used in the reconstruction of syndactyly of the toes. Covering the skin defect without skin grafts on the unilateral side of the toe is preferred, and for this purpose, a rotated flap from the plantar area is typically used. However, the flap can become ischemic or congested in some cases. To avoid this, we elevated a plantar flap with the plantar cutaneous venous arch using a triangular venous flap and covered the lateral side of the web in 7 cases of syndactyly. The dorsal flap was used to create the new web, and the opposite lateral side was reconstructed using a skin graft. The flap circulation was stable, the pedicle of the flap was narrow, and the flap relocation was simple. No flap in any patient showed any evidence of congestion or ischemia. Follow-up demonstrated that the new web was patent in all cases, with no evidence of contraction.

Flexor tendon repair with barbed suture: an experimental study.

Various suture materials have been used for tendon repair. Barbed suture in particular has been demonstrated to be effective for both wound closure and tendon repair. Ten fresh-frozen flexor digitorum profundus tendons of pig were transected and repaired using the two-strand modified Kirchmayr-Kessler technique. The samples were divided into two groups: 4-0 barbed absorbable polyglyconate sutures and 4-0 monofilament absorbable polyglyconate sutures. We measured tensile strength and distance that the testing system pulled the tendon using a universal testing machine. Tensile strength at which 1 and 2 mm of gapping occurred was measured visually at the repair site. Tendons repaired by barbed sutures showed greater tensile strength than monofilament sutures forming still 2-mm gap. However, statistical significance was obtained only at 1-mm gap formation. We concluded that for tendon repair, barbed sutures were superior material to monofilament sutures because of their greater tensile strength, reducing both the initial tendon load and the risk of dehiscence.

[Aged burn victims: its special features and treatment].

The percentage of aged patients in burns are enlarged today. Usually they have some physiological disorders and less reserve organic functions. In treatment for aged burn victims, special care should be taken to keep their general conditions. And to keep their original ADLs, super early surgical treatment is very effective. In post surgical period, patients need to manage both different conditions one is to keep rest at the operated area and the other to exercise active general rehabilitation. In these purpose, we use negative pressure dressings for skin graft instead of tie-over dressings.

Chronological histological findings of cultured epidermal autograft over bilayer artificial dermis.

The application of cultured epidermal autograft (CEA) over bilayer artificial dermis theoretically should minimize surgical stress and donor site morbidity in severe burn patients. However, CEA over regenerated dermis is very fragile and easily detaches soon after application, because the very weak attachment. We performed chronological histological studies of the wounds of a 29 year-old patient, which was reconstructed using CEA (JACE(®)) and bilayer artificial dermis (Integra™). These studies included immunohistochemistry of anti-collagen (types III, IV, and VII) and anti-laminin, in addition to H&E and EVG staining. Reconstructed epidermis and dermis showed almost normal histological appearance with time, but formation of basement membrane proteins was delayed. Absent or immature basement membrane protein in the early phase after the CEA application was considered to be an important problem. In the late phase after the CEA application over the bilayer artificial dermis, the reconstructed skin was very durable and demonstrated no sign of skin stripping (although there was still a lack of basement membrane proteins).

The estimation of tissue loss during tangential hydrosurgical debridement.

The preservation of healthy tissue during surgical debridement is desirable as this may improve clinical outcomes. This study has estimated for the first time the amount of tissue lost during debridement using the VERSAJET system of tangential hydrosurgery. A multicenter, prospective case series was carried out on 47 patients with mixed wound types: 21 (45%) burns, 13 (28%) chronic wounds, and 13 (28%) acute wounds. Overall, 44 (94%) of 47 patients achieved appropriate debridement after a single debridement procedure as verified by an independent photographic assessment. The percentage of necrotic tissue reduced from a median of 50% to 0% (P < 0.001). Median wound area and depth increased by only 0.3 cm (6.8%) and 0.5 mm (25%), respectively. Notably, 43 (91%) of 47 wounds did not progress into a deeper compartment, indicating a high degree of tissue preservation.

Evaluation of pain intensity measurement during the removal of wound dressing material using 'the PainVision™ system' for quantitative analysis of perception and pain sensation in healthy subjects.

Reducing pain caused by the removal of adhesive wound dressing materials is very important in clinical practice and is also one of the factors to consider when choosing dressing materials. A visual analogue scale is the most popular method for assessing pain, but it is subjective and is difficult to evaluate quantitatively or statistically. Recently, a new method for the quantitative measurement of pain intensity using a painless electrical stimulation system, PainVision™, has been developed. In this study, we evaluated pain intensity during the removal of wound dressing materials in healthy volunteers by comparing pain during the removal of wound dressing materials, which use acrylic pressure-sensitive adhesive and pain during the removal of materials, which use soft silicone adhesive, as evaluated using the PainVision™ system. Pain intensity was significantly lower with the dressing materials, which use soft silicone adhesive when measured with the PainVision™ system. The PainVision™ system promises to be useful for the quantitative assessment of pain caused by the removal of adhesive wound dressing materials. Further studies are needed to determine whether the PainVision™ system is also effective in measuring pain caused by the removal of wound dressing materials in actual wounds.

Quantification of the physical properties of keloid and hypertrophic scars using the Vesmeter novel sensing device.

There is still no objective method or reliable device to measure and assess the physical properties of keloid and hypertrophic scars. Using the Vesmeter, we measured the physical properties of keloid and hypertrophic scars, and investigated how their physical properties changed during the process of clinical follow-up. We followed up 11 patients with keloid (n = 6) and hypertrophic (n = 5) scars for 4 months, and measured their physical properties three times over a 2-month period using the Vesmeter. Measurements included hardness, elasticity, penetration depth, relaxation time, viscosity and viscoelastic ratio. All physical properties were measured simultaneously while an indenter was pressed onto the lesion and digitalise the measured data by analysing the wave forms of the lesion's surface behaviour. Data collection was repeated three times for each measurement point, and the average of these three values was used. Overall hardness and viscosity decreased in nine patients, whereas penetration depth increased in nine. Relaxation time decreased in nine patients and elasticity increased in six. Vesmeter was considered to be an objective, convenient and comparatively reliable measuring device for the quantification of the physical properties of keloid and hypertrophic scars.

A case of eyelid paraffinoma that developed after endoscopic sinus surgery.

Paraffin has been used as a liquid prosthesis for medical purposes, and is still the base material in some ointments. However, it sometimes causes foreign-body reaction resulting in paraffinoma. We present a case of paraffinoma in a 64-year-old woman, which occurred in the eyelid after endoscopic sinus surgery for chronic sinusitis. During surgery, a small perforation developed in the left lamina papyracea, and therefore tetracycline ointment gauze was inserted. Two days after discharge, her left eyelid became swollen. The result of an open biopsy was paraffinoma. Total resection of the tumor was performed, and at the time of writing there has been no recurrence for 1 year after surgery.

Anatomical study of the perforators from the ulnar palmar digital artery of the little finger and clinical uses of digital artery perforator flaps.

Our aim was to explore the anatomical features of the cutaneous perforators from the ulnar palmar digital artery of the little finger and to establish the anatomical basis of the ulnar palmar digital artery perforator flap for reconstruction of the ulnar aspect of the palm and fingers. We found that at least one perforator is present between the metacarpophalangeal (MCP) joint and 9 mm proximal to the MCP joint. This finding establishes the anatomical basis of the distal base ulnar palmar digital artery perforator flap for reconstruction of the ulnar aspect of the palm and fingers.

Comparison of Doppler sonography and multidetector-row computed tomography in the imaging findings of the deep inferior epigastric perforator artery.

BACKGROUND: Multidetector-row computed tomography (MDCT) has been recently introduced to detect the perforator vessels. The aim of this study is to compare the MDCT with Doppler ultrasound and assess the usefulness of the MDCT for the preoperative planning. METHODS: Five healthy adult men were first assessed for the perforators and marked with rubber using the Doppler ultrasound before MDCT was performed. Using these images, the number and the location of the perforator were evaluated. RESULTS: We could detect 83 perforators on five cases, while could detect 35 perforators by the Doppler ultrasound. We measured the distance from the fascia perforating points to rubber markings points. It ranged from 0 to 22.47 mm (7.62 mm on average). CONCLUSION: MDCT angiography is useful for preoperative planning of deep inferior epigastric artery perforator flap at the point of more accurate anatomical findings and clear images of perforator vessels compared to the findings using Doppler ultrasound.

Perioperative hemodilutional autologous blood transfusion in burn surgery.

It is important to avoid or minimise allogeneic blood transfusion, because of possible alloimmunisation or disease transmission. In burn cases these risks are high, and predonated autologous transfusion is not practical. Perioperative haemodilutional autologous blood transfusion is considered applicable in burn surgery. This study evaluates the effectiveness of the technique in the treatment of burns.

An anatomic study of the intermuscular septum of the lower leg; branches from the posterior tibial artery and potential for reconstruction of the lower leg and the heel.

The anatomy of the intermuscular septum (IMS) of the lower leg has been studied in 10 legs of 10 cadavers. The IMS was well developed in the distal half of the lower leg and its vascular supply from the posterior tibial artery was frequently seen at 60mm proximal from the tip of the medial malleolus. We advocate that these anatomical features contribute to clinical applications of the IMS flap. It may be useful for reconstruction of the lower leg and heel as safer options with less morbidity.

High-tension electrical injury to the heart as assessed by radionuclide imaging.

To evaluate cardiac complications associated with electrical injury, 7 patients with high-tension electrical injury (6,600 V alternating current) underwent 201Tl and 123I-metaiodobenzylguanidine (MIBG) imaging in addition to conventional electrocardiographic and echocardiographic assessments. Electrocardiography showed transient atrial fibrillation, second degree atrioventricular block, ST-segment depression, and sinus bradycardia in each patient. Echocardiography showed mild hypokinesis of the anterior wall in only 2 patients, but 201Tl and 123I-MIBG myocardial scintigraphy showed an abnormal scan image in 6/7 and 5/6 patients, respectively. Decreased radionuclide accumulation was seen primarily in areas extending from the anterior wall to the septum. Decreased radionuclide accumulation was smaller in extent and milder in degree in 123I. MIBG than in 201Tl imaging. These results suggest that even in patients without definite evidence of severe cardiac complications in conventional examinations, radionuclide imaging detects significant damage due to high-tension electrical injury, in which sympathetic nerve dysfunction might be milder than myocardial cell damage.