Comparison of silver-embedded occlusive dressings and negative pressure wound therapy following total joint arthroplasty in high BMI patients: a randomized controlled trial.

INTRODUCTION: High body mass index (BMI) and wound drainage following total joint arthroplasty (TJA) can lead to wound healing complications and periprosthetic joint infection. Silver-embedded occlusive dressings and negative pressure wound therapy (NPWT) have been shown to reduce these complications. The purpose of this prospective trial was to compare the effect of silver-embedded dressings and NPWT on wound complications in patients with BMI ≥ 35 m/kg2 undergoing TJA. METHODS: We conducted a randomized control trial of patients who had a BMI > 35 m/kg2 and were undergoing primary TJA between October 2017 and February 2020. Patients who underwent revision surgery, or those with an active infection, previous scar, history of wound healing complications, post-traumatic degenerative joint disease with hardware, or inflammatory arthritis were excluded. Patients were randomized to receive either a silver-embedded occlusive dressing (control) or NPWT. Frequency distributions, means, and standard deviations were used to describe patient demographics, postoperative complications, 90-day readmissions, and reoperations. T-test and chi-squared tests were used to test for significant differences between continuous and categorical variables, respectively. RESULTS: Two hundred-thirty patients with 3-month follow-up were included. One-hundred-fifteen patients received the control and 115 patients received NPWT. There were six patients (5.2%) in the control group with wound complications (drainage: n = 5, non-healing wound: n = 1) and two patients (1.7%) in the NPWT with complications (drainage: n = 2). There were no 90-day readmissions in the control group versus two (1.8%) 90-day readmissions in the NPWT group. Finally, three patients (2.6%) in the control group underwent reoperations (irrigation and debridement [I&D], I&D with modular implant exchange, and implant revision), while none in the NPWT group had undergone reoperation. The two groups showed insignificant differences in wound complications (p = 0.28), 90-day readmissions (p = 0.50), and reoperations (p = 0.25). CONCLUSION: Patients with BMI ≥ 35 m/kg2 undergoing TJA have no statistical difference in early wound complications, readmissions, or reoperations when treated with either silver-embedded dressings or NPWT.

Quality improvement evaluation of postoperative wound dressings in orthopaedic patients.

Dressings play a key role in postoperative wound care, as clinicians aim to optimise the wound healing environment (including optimal exudate management) and prevent complications such as infection and blistering. Excess exudate can lead to wound breakdown, increased bacterial burden and delaying healing, causing an increased risk of wound infection (superficial) and ultimately increasing the risk of surgical site infection (SSI) (deep infection at the site of the prosthesis). This article describes the evaluation of different postoperative dressings in use within the orthopaedic department of a tertiary hospital, as part of a quality improvement program aimed at evaluating the performance of postoperative dressings and ensuring that the most appropriate dressing is used in the management of postoperative wounds in orthopaedic patients. Seven postoperative dressing types were assessed in 307 orthopaedic patients who had undergone surgery. Post-operative dressings were assessed in terms of their ability to handle exudate (in terms of both 'wet' exudate and 'dry' exudate). User satisfaction of the postoperative dressings was also captured. Dressing change frequency was also recorded. Dressing wear was captured in terms of whether the post-operative dressing under evaluation was still in place at the time the patient was discharged (if the primary dressing required changing, it was replaced with Tegderm™ +Pad, as per current hospital practice.) Most healthcare professionals were satisfied, very satisfied or extremely satisfied with the ease of application of the dressings: Mepore® non-occlusive fabric dressing (96%) (current practice), Opsite® Post-Op Visible (95%), Leukomed® Control (94%), Sorbact® (green) surgical dressing (90%), Mepilex® Border Post-Op (87%), Tegaderm®+Pad (76%) and Aquacel® Ag Surgical (73%). The high satisfaction rates for Mepore® may have been influenced by the familiarity with this dressing which, at the time, was the standard current practice dressing. This dressing was ruled out for future use due to it being non-occlusive. Opsite® Post-Op Visible (second highest rating) was associated with three adverse events. Sorbact® surgical dressing was rated fourth in terms of healthcare professional satisfaction with regards to ease of application but was associated with the highest amount (24%) of wet exudate. Mepilex® Border Post-Op (rated fifth for ease of application; 5% wet exudate) was preferred overall because of its flexibility and small amount of wet exudate, ahead of Leukomed® Control (rated third for ease of application; 12% wet exudate), which had more frequent dressing changes than recommended by the manufacturer. A contributory factor to this may have been the dressing's transparency and the ability to observe the small amount of exudate and the nurse feeling the need to change it. In response to the findings of the quality improvement program, a new protocol of care at the major metropolitan teaching hospital has been implemented; for patients undergoing orthopaedic surgery, Mepilex® Border Post-Op (Mölnlycke) is now routinely applied in theatre and is left intact for 7 days as per the manufacturer's recommendations. Since this change in practice and the introduction of Mepilex® Border Post-Op, the incidence of SSIs at this hospital has reduced.

Wound fluid under occlusive dressings from diabetic patients show an increased angiogenic response and fibroblast migration.

INTRODUCTION: Metabolic diseases like diabetes mellitus often show prolonged healing and chronic wounds. Occlusive wound dressings are known to support wound closure by creating a moist environment which supports collagen synthesis, epithelialization and angiogenesis. We aimed to assess the effect of occlusion on diabetic wound fluid on the cellular level regarding fibroblast activity and angiogenetic response. MATERIAL AND METHODS: 22 split skin donor sites from 22 patients (11 patients with diabetes mellitus) were treated with occlusive dressings intraoperatively. On day 3, fluid and blood serum samples were harvested while changing the dressings. The influence of wound fluid on fibroblasts was assessed by measuring metabolic activity (Alamar Blue assay, Casey Counter), cell stress/death (LDH assay) and migration (in vitro wound healing assay) of fibroblasts. Angiogenesis of endothelial cells (HUVEC) was analyzed with the tube formation assay. Furthermore, a Magnetic Luminex Assay for multi-cytokines detection was performed focusing on inflammatory and pro-angiogenetic cytokines. RESULTS: The influence of wound fluid under occlusive dressings from diabetic patients showed a significantly increased angiogenic response and fibroblast migration compared to the non-diabetic patient group. Additionally, cell stress was increased in the diabetic group. Cytokine analysis showed an increase in VEGF-A in the diabetic group. CONCLUSION: Occlusive dressings may stimulate regenerative effects in diabetic wounds. Our in-vitro study shows the influence of wound fluid under occlusive dressings from diabetic patients on angiogenesis, migration and proliferation of fibroblasts, which are essential modulators of wound healing and scar modulation.

Efficacy of an Innovative Film-Forming Wound Dressing on Open Wounds.

Standards in post-surgery wound care management require a rapid healing process in order to prevent and minimize abnormal scarring. For the healing process to start as early as possible, the ideal dressing should be applied directly on the open wound and perfectly adapt to it. The authors report a case study series regarding the efficacy of a flexible film-forming wound dressing in the form of a gel (Stratamed®, Stratpharma AG, Switzerland) that is approved for the use on open wounds and injured skin. Evidence from the current study shows that, while remaining safe to use, the dressing was efficacious in promoting epithelialization and accelerated wound healing of areas in which skin integrity had been compromised, and at the same time prevented the formation of abnormal scars. Results were observed across a broad range of dermatologic surgical procedures. All treated conditions showed a beneficial outcome, as well as an overall favorable patient treatment perception.

Comparative study of nasal septal retainer and nasal packing in patients undergoing septoplasty.

PURPOSE: Nasal packing is frequently used after septoplasty and some complications caused by nasal packing are unavoidable. A nasal septal retainer has recently been developed. We evaluated the safety and clinical efficacy of the retainer in septoplasty, and the subjective symptoms of patients with the retainer were compared with Merocel nasal packing. METHODS: A prospective, randomized, controlled study was performed in patients who had undergone septoplasty. In total, 39 patients were randomized to receive Merocel (n = 17) or the retainer (n = 22) after septoplasty. The deviation of nasal septum and nasal mucosa was evaluated by endoscopy. The clinical efficacy and subjective symptoms were compared using the visual analog scale. RESULTS: During the packing/retaining period, the mean scores of headache, nasal obstruction, epiphora, and facial pressure in the retainer group were significantly lower than in the Merocel group (P < 0.05); the mean scores of nasal pain, nasal itching, rhinorrhea, dysphagia, and sleep disturbance in the retainer group were lower than in the Merocel group, but the difference did not reach statistical significance. On the removal of Merocel/retainer, nasal pain was significantly lower in patients with the retainer (P < 0.05). In the retainer group, the incidence of grade 1 bleeding was 45.5%, and grade 0 bleeding was 54.5%. In the Merocel group, the incidence of grade 2 bleeding was 23.5%, grade 1 was 47.1%, and grade 0 was 29.4%. CONCLUSIONS: The nasal septal retainer is suitable for use after septoplasty with more beneficial effects than nasal packing.

Xenoenxerto (pele da Tilápia-do-Nilo) e hidrofibra com prata no tratamento das queimaduras de II grau em adultos / Nile tilapia skin xenograft versus silver-based hydrofiber dressing in the treatment of second-degree burns in adults

Introdução: Estudos recentes apontam a utilização do curativo biológico com base em animais aquáticos como biomaterial na medicina regenerativa, apresentando boa aderência ao leito das feridas. O objetivo foi avaliar a eficácia da utilização da pele da Tilápia-do-Nilo (Oreochromis niloticus) como curativo biológico oclusivo, no manejo/tratamento de queimaduras de 2º grau em adultos. Métodos: Estudo clínico com 30 pacientes aleatoriamente tratados com pele da Tilápia-do-Nilo (n = 15) e hidrofibra com prata Aquacel Ag® (n =1 5). Resultados: Em relação à duração, o tratamento com a pele da Tilápiado-Nilo obteve uma média de dias de tratamento (9,6 ± 2,4) similar ao material comparativo (10,7 ± 4,5). Quanto ao relato de dor durante a troca de curativos, não houve diferença estatisticamente significante (p > 0,68) entre os grupos. Após a troca do curativo, não houve inferioridade no registro do valor na escala analógica de dor, em que 66,7% dos tratados com pele da Tilápia-do-Nilo relataram diminuição dos eventos álgicos. Constatou-se ainda que 60% dos pacientes tratados com a pele da Tilápia-do-Nilo não tiveram seus curativos substituídos em qualquer momento do tratamento. Para o curativo Aquacel AG®, 53,3% dos pacientes tiveram mais de uma substituição de curativos. Conclusões: Com base na pesquisa, pode-se concluir que a pele da Tilápia-do-Nilo é eficaz como curativo biológico oclusivo. Houve similaridade entre os grupos para a média de dias de tratamento (completa cicatrização da ferida) e para o relato de dor durante a realização do curativo. Também, a não inferioridade relacionada a dor após os curativos e suas trocas (quando existentes) e na quantidade de substituições destes.

Introduction: Recent studies have suggested the use of biological dressings made of aquatic animals as biomaterials in regenerative medicine since they demonstrate good adherence to the wound bed. The objective of this study was to evaluate the efficacy of Nile tilapia skin (Oreochromis niloticus) as an occlusive biological dressing in the management and treatment of second-degree burns in adults. Methods: This clinical study included 30 patients randomly treated with Nile tilapia skin (n = 15) or Aquacel Ag® silver-based hydrofiber dressing (n = 15). Results: The Nile tilapia skin yielded a similar mean treatment time (9.6 ± 2.4 days) to that of the comparative material (10.7 ± 4.5 days). There was no statistically significant intergroup difference (p > 0.68) in pain during dressing changes. No disadvantage in pain was noted, as 66.7% of patients treated with Nile Tilapia skin reported a decrease in pain events. Moreover, 60% of the patients treated with the Nile Tilapia skin did not require dressing replacement at any time during treatment. For the Aquacel AG® dressing, 53.3% of the patients required more than one dressing replacement. Conclusions: Our findings suggest that the Nile tilapia skin is as effective as an occlusive biological dressing. The average treatment time (complete wound healing) and pain reports during dressing changes were similar between groups. Furthermore, pain after and number of dressing exchanges (when performed) were not worse.

Occlusive dressing-induced secretomes influence the migration and proliferation of mesenchymal stem cells and fibroblasts differently.

BACKGROUND: Fingertip injuries treated with occlusive dressings (ODs) lead to nearly scar-free, functionally, and aesthetically pleasing results. We hypothesized that paracrine factors in the wound fluid (secretome) may influence migration and proliferation of mesenchymal stem cells (MSCs) and fibroblasts and modulate the wound-healing process. METHODS: We could collect wound fluid samples from 4 fingertip injuries and 7 split skin donor sites at the 5th day during dressing change. Blood serum samples served as controls. The proliferation rate of MSCs and fibroblasts (HS27) was continuously measured through impedance analysis for 60 h and by Alamarblue analysis after 72 h. Cell migration was evaluated continuously for 15 h and confirmed by the in vitro wound-healing assay. RESULTS: Migration of MSCs under the influence of both wound fluids was significantly faster than controls from 4 to 6 h after incubation and reversed after 9 h. MSC proliferation in wound fluid groups showed a significant increase at 5 and 10 h and was significantly decreased after 45 h. Fibroblasts in wound fluid groups showed overall a significant increase in migration and a significant decrease in proliferation compared to controls. CONCLUSION: OD-induced secretomes influence MSCs and fibroblasts and thereby possibly modulate wound healing and scar tissue formation.

Topical 1% propranolol ointment with occlusion in treatment of pyogenic granulomas: An open-label study in 22 children.

BACKGROUND: Pyogenic granuloma (PG) is a common, acquired, benign vascular neoplasm of the skin and mucous membranes. It occurs most often in children and adolescents. First-line treatment options for PG are based on destructive approaches. Pain, permanent scarring, and pigmentation are potential complications of these therapies. METHODS: This single-arm, open-label, prospective study evaluated the efficacy of topical propranolol for treatment of PGs in children. All patients clinically diagnosed with cutaneous PG consecutively at the Dermatology Pediatric Outpatient Service of the University of Bologna from January 2010 to December 2010 received a compounded formulation of propranolol ointment 1%. RESULTS: We found propranolol ointment to be effective in consecutive patients; 59.0% completely regressed in a mean of 66 days, 18.2% remained stable, and 22.7% did not respond. No side effects (eg, skin irritation, allergy, bleeding) were observed. CONCLUSION: Topical propranolol ointment 1% with occlusion appears to be an effective treatment for PGs in children. Early treatment was associated with a more favorable outcome.

Digital Ischemia After Application of Self-Adherent Elastic Wrap Dressing: A Case Series.

Self-adherent elastic wrap dressings are a convenient option to manage pediatric hand and finger injuries. However, when improperly applied, they have the potential to cause devastating complications. We detail in this report 5 cases of dressing-induced ischemic injury to the hand in pediatric patients with a review of the literature. All patients were treated by the senior author between 2007 and 2015 and were retrospectively reviewed for initial injury, frequency of dressing changes, presence of pain, time to evaluation by the orthopedic hand team, treatment, and outcome. Patients' families were contacted for clinical updates and to obtain current photographs. Age at injury ranged from 11 months to 3 years with 2 girls and 3 boys. Only 1 of 5 patients complained of pain or discomfort during the onset of their ischemic injury. Treatment of the ischemic injury included local wound care without surgery in 3 cases (including sympathetic block in 1) and surgical intervention with partial or complete digital amputation in 2 cases. At final follow-up, 2 of the 5 patients reported currently being bothered by the appearance of the injured hand; however, none had persistent pain or difficulty using the hand. Through these examples, health care professionals can be educated on the potentially disastrous complications of improper dressing application in the pediatric population and can be encouraged to share this information with patients' families.

Uso de curativo a vácuo como terapia adjuvante na cicatrização de sítio cirúrgico infectado / Using vacuum therapy as an adjunctive treatment for healing of infected surgical sites

Resumo Infecções de sítios cirúrgicos com envolvimento de próteses sintéticas constituem grande desafio para tratamento. Apresentamos o caso de uma paciente com múltiplas comorbidades, histórico de enxerto aortobifemoral há 6 anos e reabordagem das anastomoses femorais por reestenoses há 5 anos. Apresentou dor inguinal esquerda e abaulamento súbitos com diagnóstico de pseudoaneurisma femoral roto e instabilidade hemodinâmica. Foi submetida a correção emergencial com interposição de prótese de dácron recoberta por prata e correção de grande hérnia incisional abdominal com tela sintética ao mesmo tempo. No pós-operatório, manteve-se por longo período sob terapia intensiva com dificuldade de extubação. Nesse ínterim, apresentou deiscência das suturas e fístula purulenta inguinal esquerda em contato com a prótese vascular. Optou-se pelo tratamento conservador, com desbridamento das feridas e aplicação de curativo a vácuo. A paciente evoluiu com melhora e cicatrização das feridas. Essa pode se constituir em ferramenta importante em casos similares.

Abstract Infections at the sites of surgery involving synthetic prostheses are challenging to treat. We present a case of a patient with multiple comorbidities who had undergone an aortobifemoral bypass 6 years previously and then re-intervention at the femoral anastomoses for restenosis 5 years previously. The patient presented with acute left inguinal pain and swelling and was diagnosed with a ruptured femoral pseudoaneurysm and hemodynamic instability. A repair was conducted by interposition of a silver-coated Dacron graft in the emergency room, and a large abdominal incisional hernia was repaired with synthetic mesh during the same intervention. After surgery, the patient remained intubated in intensive care for a long period. Meanwhile, she presented dehiscence of sutures and a left inguinal purulent fistula that was in contact with the vascular prosthesis. Conservative treatment was chosen, with debridement of wounds and vacuum therapy. The patient improved and the wounds healed. This could be an important tool in similar cases.

The effect of 2 adhesive products on skin integrity used for fixation of hip and knee surgical dressings: a randomized controlled trial.

PURPOSE: The aim of this study was to compare effects of 2 adhesive products, a nonwoven porous adhesive bandage (NPAB) and transparent film adhesive bandage (TFAB), on skin integrity for fixation of hip and knee surgical dressings. MATERIALS AND METHODS: A prospective, randomized study was conducted on 300 patients who underwent hip and knee surgery (arthroplasty, fixation of fractures, tumor operations, etc). Participants were randomized into 2 equal groups according to the applied surgical dressing fixation product (NPAB or TFAB). Skin changes (edema, erythema, blister, peeling of blister, mechanical peeling, and maceration), drying of incision, serous discharge, and early infection symptoms were evaluated. RESULTS: The skin integrity was found to be impaired in 4.0% (n = 6) of the 150 NPAB patients and in 10.7% (n = 16) of the 150 TFAB patients (P = .02). Logistic regression analysis showed that the risk of impaired skin integrity increased 2.5-fold when TFAB was applied (P = .03). CONCLUSION: The NPAB was associated with a reduced likelihood of impaired skin integrity following hip and knee surgery.

Study of Microorganism Growth Pattern in Nasal Pack of Patients Visiting the Department of ENT, Head and Neck Surgery.

Background Nasal packs are utilized nearly by otorhinolaryngologists for controlling epistaxis and post nasal procedures. Complications have been reported due to them; therefore the use of antibiotics is a common practice among otorhinolaryngologists. Objective To detect microbiological flora associated with nasal packing and find evidence to support the benefit of systemic antibiotics with it. Method A prospective, analytical study was conducted on 51 patients presenting to the Department of ENT, KUSMS from June to September 2015 who required nasal packing. Approval of the local Institutional review committee (IRC) was taken. The mid part of the pack was collected in a sterile bottle under aseptic technique and sent to microbiology department. Specimen collection, culture, identification tests were done according to the guidelines by American Society for Microbiology. Data were collected using the individual patient records and Microsoft Office Excel 2007. Statistical analysis was performed with SPSS 16.0. Result Among the 51 cultures; 33 (64.7%) were positive. In 18 (35.3%) cultures no organism was grown. Statistical analysis did not show significance between duration of pack kept with microbial growth (p=0.051) or the type of pack kept (p=0.212) .It showed significance with foul smell of the pack to the growth (p <0.001). Conclusion Microbiological flora was associated with nasal pack. Antibiotic soaked nasal packs have lesser incidence of positive bacterial growth when compared with plain nasal packs. Nasal packs kept for less than 48 hours have lesser incidence of positive bacterial growth when compared with nasal packs kept for more than 48 hours. Therefore, administering systemic antibiotics in cases when we plan to keep the pack for longer duration is recommended.

The management of wound-related procedural pain (volitional incident pain) in advanced illness.

PURPOSE OF REVIEW: The prevention and treatment of wound-related procedural pain is one of the greatest areas of unmet need within wound management. Also referred to as 'Volitional Incident Pain', it is the most prevalent subtype of breakthrough pain experienced by patients afflicted with wounds. Novel formulations of existing analgesics are now available to address this challenge. RECENT FINDINGS: This review focuses on the principles of breakthrough pain assessment including those patients with cognitive impairment. Current management principles are discussed with an emphasis on the novel formulations of fentanyl citrate that may be delivered through the sublingual, buccal, and nasal mucosal routes. SUMMARY: Novel formulations of fentanyl citrate, delivered through an array of noninvasive routes, allow for rapid-onset and short-acting effects that better match the onset and duration of wound-related procedural pain.

A multicenter, randomized, vehicle-controlled phase 2 study of blue light photodynamic therapy with aminolevulinic acid HCl 20% topical solution for the treatment of actinic keratoses on the upper extremities: the effect of occlusion during the drug incubation period.

BACKGROUND: Photodynamic therapy (PDT) with aminolevulinic acid (ALA) has been shown to be safe and effective in the treatment of actinic keratoses (AKs) of the face and scalp. A recent small study has suggested that ALA-PDT can be effective for AKs of the dorsal hands/forearms. However, studies designed to provide sufficient statistical power to test this hypothesis are lacking in the literature. OBJECTIVES: To determine and compare the safety and efficacy of blue light ALA-PDT vs blue light placebo vehicle (VEH) in the treatment of AKs of the upper extremities and to evaluate the effect of occlusion after application of ALA vs VEH. METHODS: ALA or VEH was applied to both dorsal hands/forearms for the 3-hour incubation period before blue light treatment (10 J/ cm2). One extremity of each subject was covered with occlusive dressing during the incubation period. Treatment was repeated at week 8 if any AK lesions remained. RESULTS: The median AK lesion clearance rate at week 12 was 88.7% for extremities treated with occluded ALA (ALA+OCC), 70.0% for extremities treated with nonoccluded ALA, 16.7% for extremities treated with occluded VEH (VEH+OCC), and 5.6% for extremities treated with nonoccluded VEH (P<.0001). ALA+OCC resulted in a significantly higher clearance rate compared with the nonoccluded extremity at weeks 8 (P=.0006) and 12 (P=.0029). Thirty-four percent (12/35) of extremities treated with ALA+OCC had complete clearance of lesions at week 12 compared with 0% (0/35) of extremities treated with VEH+OCC (P=.0002). The safety pro!le in this study is consistent with previously reported side effects of the therapy. CONCLUSION: Blue light ALA-PDT following a 3-hour incubation appears efficacious for AK clearance of the upper extremities. Incubation using an occlusive dressing significantly increases the efficacy of the procedure and also increases the incidence and severity of some acute inflammatory side effects of PDT.

Anterior cranial base reconstruction following a complicated nasal septoplasty.

We present a 29 year old man who had unilateral visual loss and 3rd cranial nerve palsy after a nasal septoplasty. Nasal packing was extending from the right nasal cavity into the right frontal lobe passing through the right orbit. A combined trans-cranial and endoscopic endonasal approach was performed to safely remove the nasal packing and to achieve a leak-proof sealing of the anterior cranial base. This surgical technique proved successful in the management of this unique complication and should be considered in the surgical management of foreign body removal from the anterior cranial base.