Osteogenic efficacy of BMP-2 mixed with hydrogel and bone substitute in peri-implant dehiscence defects in dogs: 16 weeks of healing.

OBJECTIVES: The objective of this study was to determine the effect of bone morphogenetic protein-2 (BMP-2) mixed with either polyethylene glycol hydrogel or synthetic bone substitute (SBS) on new bone formation in peri-implant dehiscence defects after 16 weeks of healing. MATERIALS AND METHODS: A guided bone regeneration procedure was performed in box-type peri-implant defects that were surgically prepared in six beagle dogs. The following four experimental groups were used (i) control (no graft), (ii) SBS+hydrogel, (iii) SBS+BMP-2/hydrogel and (iv) BMP-2/SBS+hydrogel. Volumetric analysis using micro-computed tomography and histomorphometric analysis was performed at 16 weeks post-operatively. RESULTS: The amount of new bone and the total augmented volume did not differ significantly between both BMP-treated groups and the SBS+hydrogel group (p > .05). Likewise, no histometric differences were observed in the values of new bone area and bone-to-implant contact ratio among the three augmentation groups (new bone area: 0.06 ± 0.08, 0.19 ± 0.20, 0.48 ± 0.37 and 0.56 ± 0.60 mm2 [mean ± standard deviation] in groups 1-4, respectively; bone-to-implant contact: 9.44 ± 11.51%, 19.91 ± 15.19%, 46.31 ± 29.82% and 42.58 ± 26.27% in groups 1-4, respectively). CONCLUSION: The osteogenic efficacy of BMP-2 on the regeneration of peri-implant bone defects was not detectable after 16 weeks regardless of the carrier materials.

Bone augmentation at peri-implant dehiscence defects comparing a synthetic polyethylene glycol hydrogel matrix vs. standard guided bone regeneration techniques.

OBJECTIVES: The aim of the study was to test whether or not the use of a polyethylene glycol (PEG) hydrogel with or without the addition of an arginylglycylaspartic acid (RGD) sequence applied as a matrix in combination with hydroxyapatite/tricalciumphosphate (HA/TCP) results in similar peri-implant bone regeneration as traditional guided bone regeneration procedures. MATERIAL AND METHODS: In 12 beagle dogs, implant placement and peri-implant bone regeneration were performed 2 months after tooth extraction in the maxilla. Two standardized box-shaped defects were bilaterally created, and dental implants were placed in the center of the defects with a dehiscence of 4 mm. Four treatment modalities were randomly applied: i)HA/TCP mixed with a synthetic PEG hydrogel, ii)HA/TCP mixed with a synthetic PEG hydrogel supplemented with an RGD sequence, iii)HA/TCP covered with a native collagen membrane (CM), iv)and no bone augmentation (empty). After a healing period of 8 or 16 weeks, micro-CT and histological analyses were performed. RESULTS: Histomorphometric analysis revealed a greater relative augmented area for groups with bone augmentation (43.3%-53.9% at 8 weeks, 31.2%-42.8% at 16 weeks) compared to empty controls (22.9% at 8 weeks, 1.1% at 16 weeks). The median amount of newly formed bone was greatest in group CM at both time-points. Regarding the first bone-to-implant contact, CM was statistically significantly superior to all other groups at 8 weeks. CONCLUSIONS: Bone can partially be regenerated at peri-implant buccal dehiscence defects using traditional guided bone regeneration techniques. The use of a PEG hydrogel applied as a matrix mixed with a synthetic bone substitute material might lack a sufficient stability over time for this kind of defect.

Healing of BoneCeramic™ at buccal dehiscence defects at implants installed immediately into extraction sockets. An experimental study in dogs.

OBJECTIVE: To assess the healing outcomes at buccal dehiscence defects after 4 months following implant placement immediately into extraction sockets (IPIES) and filled with a mixture of synthetic hydroxyl apatite (HA) 60% and ß-tri-calcium phosphate (ß-TCP) 40% in comparison with leaving a blood clot. MATERIAL AND METHODS: Eight Labrador dogs were used, and an implant was placed immediately following tooth extraction into the distal alveolus of the third premolars, bilaterally. Standardized buccal defects, 8 mm in depth and 4 mm in width at the coronal and 2 mm in width at the apical outlines were created. A mixture of synthetic HA 60% and ß-TCP 40% was used to fill the defects at the test sites, while the control sites were left unfilled. Collagen membranes were used to cover the defects at both sides, and a non-submerged healing was allowed. After 4 months of healing, biopsies were obtained and processed for morphometric analysis. RESULTS: A vertical gain in the extent of the bony crest and of osseointegration levels of 4.2 ± 2.4 and 3.3 ± 2.1 mm at the test sites and of 5.0 ± 0.8 and 4.6 ± 1.0 mm at the control sites, respectively, were observed. BIC% within the buccal defects reached similar levels (37-42%) both at test and control sites. None of the means of the variables differed significantly between the two groups. New bone formation within the defects was higher, and the percentage of the connective tissue was lower at the control (65.7 ± 11.7% and 2.5 ± 3.3%, respectively) compared to the test sites (16.8 ± 11.3% and 48.9 ± 29.5%, respectively). These differences were statistically significant. CONCLUSIONS: The use of a mixture of synthetic HA 60% and ß-TCP 40% to fill surgically created buccal dehiscence defects at IPIES sites covered with a collagen membrane did not improve osseointegration in the defect area.

Collagen crosslinking in the management of leaking cystic blebs: a prospective study.

PURPOSE: To evaluate the effectiveness and safety of collagen crosslinking for leaking cystic blebs. METHODS: A prospective study was conducted on subjects with cystic bleb leaks without indications for urgent surgical intervention. Collagen crosslinking with riboflavin 0.1 % and ultraviolet A irradiation for 30 min was applied to the cystic bleb surface in five patients. Subjects were followed up for at least 20 weeks (mean: 35.5 ± 11.5 weeks) to monitor the length of time to the cessation of bleb leak, as well as visual acuity, intraocular pressure, and the presence of adverse effects arising from the treatment. RESULTS: Results showed that a single session of collagen crosslinking was effective in stopping cystic bleb leak. In two of the five subjects, the bleb leak subsided 1 week post-treatment, in one patient after 2 weeks, and in the two more complicated cases, after 4 weeks. This effect was maintained for a mean period of 33.5 ± 10.2 weeks after bleb leak cessation. Treatment was effective even in patients with friable conjunctiva following multiple surgical interventions and severe leak, although a longer period was needed for resolution of the bleb leak. The intraocular pressure and visual acuity were largely stable before and after treatment. No side effects or complications arose from this treatment. CONCLUSIONS: We recommend a trial of collagen crosslinking on leaking cystic blebs without indications for immediate surgical interventions. It is a relatively easy, non-invasive, pain-free, and potential repeatable procedure for treating leaking cystic blebs, with the aim of strengthening the underlying pathological conjunctiva.

Effects of chrondro-osseous regenerative compound associated with local treatments in the regeneration of bone defects around implants: an in vivo study.

OBJECTIVES: The objective of this study was to evaluate the use of a chondroitin sulfate and glycosaminoglycan-based chrondro-osseous regenerative compound (CORC) with different local treatments for bone regeneration in dehiscence defects. The hypothesis is that CORC can enhance bone regeneration with or without local treatment. MATERIALS AND METHODS: Twelve mongrel dogs received four implants each in the right femur. Bony defects (4-mm height × 4-mm width) were created and locally treated as follows: reabsorbable membrane (Mem), hidroxyapatite (HA), hydroxyapatite covered with membrane (HA+Mem), or left untreated (Con). Six dogs received one pill of the CORC daily. After 90 days, the implants were retrieved, and histological sections were obtained. The height of bone formation, new bone area (NBA), and bone to implant contact (BIC) within the threads were evaluated to assess the effects of the use of CORC to promote bone regeneration in the defects. Results were statistically analyzed using ANOVA and Tukey's test with 5% significance level. RESULTS: CORC was not capable to increase the height of bone formation, NBA, and BIC. When the local treatments were analyzed regardless of the use of CORC, HA+Mem and Ha presented higher BIC and height of bone formation. There was no difference for NBA among the local treatments. CONCLUSIONS: The hypothesis was rejected since the use of CORC has not increased any of the parameters evaluated. CLINICAL RELEVANCE: Dehiscence-like defects can compromise soft tissue support and result in loss of periodontal health and implants. Hydroxyapatite can induce bone regeneration in the defects created. CORC in the formulation used in this study did not promote further bone regeneration in dehiscence-like defects.

Efficacy of Dialkylcarbamoylchloride-Coated Dressing in Management of Colonized or Infected Neonatal and Pediatric Wounds.

BACKGROUND: Wound healing is a dynamic process that normally follows a predictable cascade of events. A common cause of delayed wound healing or wound dehiscence is increased colonization with microbes, often leading to infection. Infection may impede the healing process by inducing an undesirable inflammatory response. Systemic antibiotics and topical antiseptics are mainstays of treatment, but their adverse side effects and the potential for emergence of resistant microbial strains have led to a search for alternative approaches for control of bioburden. CASES: We describe two neonates and one 10-year-old girl who experienced delayed wound healing treated with a nonmedicated dressing that exploits bacterial cell-surface hydrophobic interactions via a dressing with a fatty acid (dialkylcarbamoylchloride [DACC]) coating. This dressing was used in a colonized, unstageable occipital pressure injuries, an infected stage 4 pressure injury over a vertebra, and a dehisced surgical sternal wound. Complete closure was achieved in all wounds within 2 to 4 weeks. CONCLUSION: We employed a DACC-coated dressing that provides bacteriostatic activity without creating cytotoxicity or an inflammatory response.

The efficacy of BMP-2 preloaded on bone substitute or hydrogel for bone regeneration at peri-implant defects in dogs.

OBJECTIVES: The objective of this experiment was to test whether or not a synthetic bone substitute (SBS) was more effective than a polyethylene glycol hydrogel as a carrier material for bone morphogenetic protein-2 (BMP-2) when attempting to regenerate bone. MATERIAL AND METHODS: Two identical, box-type dehiscence defects (4 × 4 mm buccolingually and apicocoronally, and 8 mm mesiodistally) were surgically prepared on buccal sides of the left and right edentulous ridge in five beagle dogs. Following implant placement, the defects either received (i) no graft, (ii) SBS+hydrogel, (iii) SBS+BMP-2 loaded hydrogel, and (iv) BMP-2-loaded SBS+hydrogel. The animals were euthanized at 8 weeks postsurgery. Radiographic and histomorphometric analyses were performed. RESULTS: The hydrogel alone was not able to stabilize the grafted bone particles at 8 weeks, and SBS+hydrogel group did not significantly differ from the control group in all volumetric measurements. On the other hand, extensively regenerated new bone was connected with most of the remaining SBS particles in the BMP-2 groups. The BMP-2 groups exhibited significantly greater new bone formation (10.65 mm(3) and 1.47 mm(2) in the SBS+BMP-2-loaded hydrogel group; 14.17 mm(3) and 0.93 mm(2) in the BMP-2-loaded SBS+hydrogel) than non-BMP-2 groups (1.27 mm(3) and 0.00 mm(2) in the control group; 2.01 mm(3) and 0.19 mm(2) in the SBS+hydrogel group) in volumetric and histomorphometric analyses (P < 0.001). However, there were no significant differences between both BMP-2 groups. CONCLUSION: BMP-2 could yield enhanced bone regeneration in the critical-size peri-implant defects regardless of whether SBS or hydrogel is used for preloading, although the outcomes seem to be more reproducible with BMP-2 preloaded on SBS.

Treating a chronic wound in a nonadherent patient: a case study.

BACKGROUND: Limited evidence suggests that various formulations containing Balsam of Peru, castor oil, and trypsin (BCT) exert multiple actions that may promote wound healing such as shedding damaged skin cells, stimulation of localized blood flow, antimicrobial actions, and local analgesic actions. CASE: An 81-year-old man was referred to our home-based wound care center for treatment of an excoriation-induced chronic dehiscence of an abdominal surgical wound. He had failed multiple topical therapies, primarily owing to persistent pruritus of the wound and periwound skin, resulting in removal of his dressing to scratch the wound and periwound skin. We used a spray containing BCT to promote wound healing and relieve pruritus; this addition resulted in wound closure within 38 days of treatment. CONCLUSIONS: We recommend considering BCT spray when maintenance of dressing is impaired and wound healing delayed owing to pruritus. We found the BCT spray easy to use and well-accepted by our patient who was unable to tolerate other forms of topical therapy over a period of 6 months.

Surveillance of late-onset bleb leak, blebitis and bleb-related endophthalmitis--a UK incidence study.

AIMS: To determine the incidence of late-onset bleb leak (BL), blebitis (B) and bleb-related endophthalmitis (BRE) after trabeculectomy surgery, and report the management approaches employed by UK ophthalmologists. METHODS: Prospective case ascertainment study reporting of incident cases fulfilling the study definitions of BL, B and BRE through the reporting mechanism provided by the British Ophthalmic Surveillance Unit (BOSU; United Kingdom) for the period July 2007 to August 2008 (13 months). Two questionnaires completed at initial reporting and 6 months later were used to collect clinical details related to presentation, early and late management and outcome. RESULTS: Ninety-eight cases were reported to the British Ophthalmic Surveillance Unit during the study period. Seventy-one first questionnaires were returned (response rate 72.4%). Of these, 11 were erroneous/duplicated. Sixty second questionnaires were sent out, and of these 37 fully completed questionnaires were returned. Analysis was, therefore, based upon 60 initial and 37 follow-up questionnaires. Overall incidences were estimated for isolated bleb leak (0.22%), blebitis without bleb leak (0.1%), blebitis with bleb leak (0.11%), and BRE with or without bleb leak (0.17%). Visual outcome in the BL group was good; however, in the BRE group half the patients ended with visions of perception of light or worse. There was a great variance in the initial and late management of these conditions. Surgical intervention for bleb leak seemed to result in the best chance of leak closure. CONCLUSIONS: These complications of trabeculectomy surgery are relatively low but potentially visually devastating. This study updates the knowledge of the incidence of these complications, and suggests that no consistent management approach to any of the reported conditions was practised. In view of the potentially catastrophic consequences of these complications, formal guidance as to best practice would be beneficial, and further research to establish this is required.

The effect of autologous serum eye drops on the conjunctivalization over exposed porous polyethylene orbital implant (Medpor(®)) in the rabbit model.

PURPOSE: To assess the efficacy of autologous serum eye drops (AS) in enhancing conjunctivalization over a scleral patch graft on exposed porous polyethylene orbital implant (Medpor(®)). METHODS: Eighteen rabbits were underwent evisceration, implantation of Medpor(®) and homologous scleral patch graft. The conjunctival edge was sutured leaving 5 mm-diameter circular defect. In group A, 20% AS were applied 8 times a day and only balanced salt solution was applied in group B. Digital anterior segment photography was obtained 1, 3, 7, 10, 14, and 21 days after surgery and analyzed with Image Pro Plus(®) software. RESULTS: In the early postoperative period, the average conjunctival growth rate (mm(2)/day) was faster in group A, but failed to show statistical significance (3.79 vs. 3.03, p = 0.26 in 1~3days, 2.39 vs. 1.80, p = 0.59 in 4- days, 0.03 vs. -0.02, p = 0.94 in 7-10 days, Mann-Whitney test). The complete healing rate was higher (67% vs. 56%, p = 0.5, Fisher's exact test) and the mean elapsed time for complete healing (days) was shorter in group A (17.3 vs. 18.2, p = 0.83, Mann-Whitney test), but did not show a statistically significant difference. CONCLUSION: In a rabbit model, 20% AS did not appear to facilitate the healing of small conjunctival defects of exposed porous orbital implant.

Citric acid treatment of postoperative wound in an operated case of synovial sarcoma of the knee.

A 40-year-old female presented with history of swelling at the upper and middle of the left leg since 6 months was confirmed as post cancer surgery non healing wound not responding to conventional antibiotic therapy and local wound care in an operated case of synovial sarcoma of the knee, monophasic fibrous type with no lung metastasis. Post surgical non healing wound not responding to conventional therapy was treated successfully with local application of 3% citric acid ointment for 25 days.

Surgical wound dehiscence complicated by methicillin-resistant Staphylococcus aureus infection in a diabetic patient with femorotibial vascular bypass occlusion.

Diabetic patients with critical limb ischaemia may be affected by severe wound and skin ulcer infections. We report a case of a patient with bilateral femorotibial occlusion and methicillin-resistant Staphylococcus aureus infection. The patient was treated with femoroperoneal vascular bypass, debridement of wound dehiscence and targeted antimicrobial therapy for symptom resolution and healing of the wound.

Incision separation after eye rubbing on a postradial keratotomy cornea: a case report.

OBJECTIVE: The purpose of this case report is to explore the diagnosis and the treatment of a complication secondary to a radial keratotomy (RK) surgery. It illustrates the fact that, even more than 20 years after the procedure, corneas that underwent RK procedures may still be at risk for complications. METHODS: The patient was seen in emergency department in September 2008 for a red and painful eye. Examination revealed a separation of one RK incision consequent to heavy eye rubbing. Treatment initiated for this condition is similar to treatment of minor corneal erosion and is explained. RESULTS: After intensive lubrication, the condition healed in 2 weeks, without further complications. CONCLUSION: It is shown that patients after RK remain at risk for corneal complications over the years after their initial surgical procedures. Patients should be educated about the fragility of their cornea and globe and to do not rub their eyes. Eye care practitioners should reinforce these messages periodically. A close follow-up of post-RK patients is needed to keep these patients in optimal ocular health.

Novel synthesized zinc oxide nanoparticles loaded alginate-chitosan biofilm to enhanced wound site activity and anti-septic abilities for the management of complicated abdominal wound dehiscence.

Wound dehiscence is a surgical complication and its management is inevitable because 25% to 35% of patients suffered from post laparotomy wound dehiscence. The excellent biodegradability and biocompatibility of chitosan and alginate have provided ample space for future developments in biomedical applications. Hence, the present work is directed towards the synthesis of robust biofilm made up of chitosan (CS), zinc oxide (ZnO) nanoparticles and Alginate (Alg). Chitosan and alginate were used for their pore forming ability, and ZnO is for its antibacterial action. The proposed biofilm was characterized with different characterization techniques such as Fourier Transform Infrared (FTIR) spectroscopy, UV-vis spectroscopy, X-ray Diffraction (XRD), Scanning Electron Microscopy (SEM) and Transmission Electron microscopy (TEM) analyses. FTIR results inferred the strong interaction between the three components. The surface morphology of ZnO-CS/Alg. biofilm was exhibited as the spherical shaped nanoparticles which are firmly anchored on the polymer matrix. TEM analysis also confirmed the formation of biofilm. The XRD analysis confirmed the presence of ZnO in the biopolymer. The line broadening suggests that the crystallize size is in few nanometers. The average crystallite size was estimated as 50 nm using Scherrer formula. The antibacterial activity of the biofilm was successfully established against bacterial pathogens. Therefore, the developed materials have a potential play as antimicrobial role for the abdominal wound healing and biomedical fields.

Oral doxycycline and azithromycin in the management of recurrent conjunctival dehiscence following glaucoma drainage implantation in a child.

Aqueous drainage devices play an important role in the treatment of refractory glaucomas; however, they can be associated with early and late postoperative complications, including conjunctival dehiscence, which must be repaired surgically. Recurrent dehiscence despite surgical repair is uncommon and can be sight threatening. We discuss possible causes and management options of recurrent conjunctival dehiscence in a 2-year-old and the role of oral doxycycline and azithromycin in its management.

Tissue glue in sutureless vitreoretinal surgery for the treatment of wound leakage.

BACKGROUND AND OBJECTIVE: To assess the surgical outcomes of the use of tissue glue to close sclerotomy sites when required and the views of ultrasound biomicroscopy of the sclerotomy sites in 23- and 25-gauge vitrectomy systems. PATIENTS AND METHODS: A 25-gauge transconjunctival sutureless vitrectomy was performed in 38 eyes and a 23-gauge transconjunctival sutureless vitrectomy was performed in 46 eyes for various vitreoretinal diseases. Wound leakage occurred at the sclerotomy sites at the end of the surgery in 6 eyes with 23-gauge transconjunctival sutureless vitrectomy and 7 eyes with 25-gauge transconjunctival sutureless vitrectomy. The sclerotomy sites were closed by using tissue glue to prevent wound leakage and evaluated with ultrasound biomicroscopy postoperatively. RESULTS: No wound leakage was observed at the end of the surgical procedure or during the follow-up period. Abnormal fibrous ingrowth was not detected at the sclerotomy sites by means of ultrasound biomicroscopy. CONCLUSION: The results demonstrated the efficacy of tissue glue for closing site ports when wound leakage is observed in transconjunctival sutureless vitreoretinal surgery.

Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial.

To evaluate the effect of postoperative irrigation with chlorhexidine on inflammatory complications after the extraction of lower third molars under local anaesthesia, we recruited 100 patients to participate in a controlled, single-blind, randomised clinical trial. They were assigned to one of two groups: the intervention group (postoperative irrigation of the surgical site with chlorhexidine for seven days) or the control group (postoperative chlorhexidine mouth rinse for seven days). The primary outcome variables were pain, swelling, trismus, infection, and alveolar osteitis. The secondary outcome variables were wound dehiscence and food impaction. A total of 95 participants completed the study (47 in the irrigation group and 48 in the rinse group). In the irrigation group, alveolar osteitis and facial swelling had reduced significantly at seven days postoperatively (both p<0.01). Pain scores had also reduced significantly at seven days (p<0.01), but not at 48hours, and patients had lower levels of food impaction (p<0.01) and less severe symptoms (p=0.02). Routine irrigation with chlorhexidine after the extraction of third molars helps to reduce pain and lowers the incidence of alveolar osteitis.

Repositioning of free cap four days after LASIK.

PURPOSE: To report management and outcome of late repositioning of flap dislodgement after LASIK. METHODS: A 27-year-old man underwent LASIK in the right eye for correction of myopia, which was complicated by free cap. The flap was repositioned, but dislodged 2 days later. The dislodged flap was stored in balanced salt solution for 48 hours and repositioned 4 days after initial surgery. RESULTS: Postoperatively, the flap remained apposed, but diffuse lamellar keratitis and epithelial ingrowth developed, which was managed with topical steroids and topical mitomycin C. Stromal haze gradually decreased by 16 months postoperatively, resulting in best spectacle-corrected visual acuity of 20/20. CONCLUSIONS: Flap dislodgement > 48 hours postoperatively can be repositioned with good visual outcome. The flap should be preserved in the event of such complication.