Efficacy and safety of an anti-infection topical desiccating agent (DEBRICHEM) in hard-to-heal wounds.

A single centre, non-comparative evaluation was undertaken to observe the clinical results achieved when following best practice for the application of Debrichem. The treatment protocol involved use of this debridement product plus standard of care. The sample comprised 21 patients with complex, non-healing wounds of various aetiologies. One patient dropped out of the evaluation for unknown reasons. Wound types were either venous leg ulcers (n=16) or post-traumatic wounds (n=25). The mean wound duration was 22 months (range: 2 weeks-17 years). Over the 4-week follow-up period, there was a decline in the mean percentage of devitalised tissue present on the wounds, reducing from 69% at baseline to 49% at week 4. Most of the devitalised tissue was slough, for which the mean baseline percentage was 63% compared with an endpoint of 49%. Conversely, the mean percentage of granulation tissue increased from 31% at baseline to 51% at week 4. The mean visual analogue pain score reported during application was 4/10, where 0 represents no pain. However, general wound-related pain scores improved during the follow-up period, with no scores above 2 at week 2, compared with five at baseline. The results indicate that Debrichem is a safe and effective method of debridement that requires minimal training and is single use.

Clinical benefits of small intestinal submucosa extracellular matrix and review of the evidence.

There is a clear scientific rationale for using cellular, acellular and matrix-like products (CAMPs), such as small intestinal submucosa extracellular matrix (SIS-ECM), in hard-to-heal wounds, such as diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), pressure ulcers and arterial leg ulcers. The clinical evidence supporting the use of SIS-ECM has grown over the past several decades. This evidence base now encompasses a wide range of hard-to-heal wound indications, including DFUs and VLUs, as well as increasingly complex acute wound indications, such as delayed postoperative wounds, traumatic wounds and burns. The aim of this article is to review the steadily amassed body of evidence that describes the clinical outcomes associated with treatment with SIS-ECM and its potential implications for the overall costs of treatment.

Clinical benefits of small intestinal submucosa extracellular matrix and review of the evidence.

There is a clear scientific rationale for using cellular, acellular and matrix-like products (CAMPs), such as small intestinal submucosa extracellular matrix (SIS-ECM), in hard-to-heal wounds, such as diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), pressure ulcers and arterial leg ulcers. The clinical evidence supporting the use of SIS-ECM has grown over the past several decades. This evidence base now encompasses a wide range of hard-to-heal wound indications, including DFUs and VLUs, as well as increasingly complex acute wound indications, such as delayed postoperative wounds, traumatic wounds and burns. The aim of this article is to review the steadily amassed body of evidence that describes the clinical outcomes associated with treatment with SIS-ECM and its potential implications for the overall costs of treatment.

Wound healing: what is the NICE guidance from the UK?

Alteration of wound healing increases the risk of a patient's morbidity and mortality. This can lead to scarring, infection, malignant transformation and a reduction in quality of life. Management of wounds costs the UK an estimated £5.3 billion annually which is paid for by the state, with further financial burden due to health related productivity loss. Wound care is managed by a broad spectrum of different health professionals leading to different standards of care. For example, only 16% of lower leg wounds have either an ankle-brachial pressure index measurement or Doppler scan. Due to this variation in wound care, we have summarised all available NICE guidelines and guidance up to February 2021 on the topic of wound healing listed in the National Institute for Health and Care Excellence (NICE) archives. The goal is to provide an easy to access summary of wound care interventions. Our search provided us with 18 technology appraisals related to wound healing which have been summarised.

Considering the switch to a latex-free glove policy to safeguard staff and patients.

While it is difficult to imagine that before the late 1800s, surgeons in the theatre environment operated on patients without gloves, gloves are now a clinical necessity. Their use has risen exponentially over the last 30 years, along with concerns over staff and patient allergy and sensitivity to the natural rubber latex proteins used in their manufacture. Having used latex gloves for the better part of 35 years, the author recently evaluated a latex-free alternative. In this article, which presents a rationale for the introduction of a latex-free glove policy across NHS departments and trusts, particularly in theatre settings, the author presents his experience, together with cases from four other surgeons, as well as evidence from the literature regarding potential clinical outcomes, quality of life and cost-effectiveness associated with latex-free gloves.

Properties and use of a honey dressing and gel in wound management.

Wound management is a major clinical challenge and puts a significant financial burden on the NHS. Because of the rise in long-term conditions including diabetes, obesity and an ageing population, practitioners regularly encounter a wide variety of wound types. In recent years, there has been a resurgence of interest in the use of medical-grade honey in the management of wounds. Honey is anti-inflammatory in action and has the capability to treat local infection, promote autolytic debridement, deodorise wounds and promote granulation tissue. Revamil is a recent addition to the range of honey dressings available and is intended to manage the majority of problems that may arise during wound care episodes. The attributes of Revamil will be illustrated through four case studies.

The use of an antimicrobial primary wound contact layer as liner and filler with NPWT.

In negative pressure wound therapy (NPWT), wound fillers are used to ensure that the negative pressure is applied across the entire wound surface. At present, foam and gauze are the most commonly used fillers. Both ensure equal distribution of negative pressure, but foam is more absorbent, while gauze is more malleable and conformable. There is no strong clinical research evidence demonstrating the superiority of one type of wound filler over another. However, there are reports that foam can cause pain and trauma at dressing change as a result of ingrowth of tissue into its open pore structure. For this reason, when foam is used as a filler, a liner may also be applied as a wound contact layer. This supplement describes preliminary clinical evidence on the use of Cutimed Sorbact as an alternative to foam and gauze during NPWT. Seven cases in which it was successfully used on complex pre- and postoperative wounds are described.

Efficacy of an imaging device at identifying the presence of bacteria in wounds at a plastic surgery outpatients clinic.

OBJECTIVE: Current standard diagnostic practice of bacterial infections by visual inspection under white light is subjective, and microbiological sampling is suboptimal due to high false negative rates and the lengthy time needed for culture results to arrive. The MolecuLight i:X Imaging Device attempts to combat the issues faced in standard practice by providing a non-contact, real-time method of visualising bacteria within wounds. Our aim was to test this imaging device in a series of patients. METHOD: A single-centre prospective observational study was conducted in the Queen Elizabeth Hospital, Birmingham. During Plastic Surgery Outpatient dressings clinics, patients had their wounds photographed with the imaging device under white light and violet light illumination. Microbiological swabs were obtained of all the wounds. Any clinical signs and symptoms of infection were noted. White light and violet light photographs were compared with correlate visible clinical signs and symptoms with auto-fluorescence images. Auto-fluorescence images were then compared with the microbiological swab results to discern any differences. RESULTS: There were 14 patients with seventeen separate wounds imaged. Of the 17, eight wounds were positive for bacterial growth on microbiological culture. All eight of these were detected positive for bacteria according to auto-fluorescence imaging. There was one wound was detected positive for bacteria by auto-fluorescence imaging with negative microbiological results. CONCLUSION: This study demonstrated the potential benefit of the imaging device due to the correlation between microbiological test results and auto-fluorescence imaging. The device greatly reduces the time taken waiting for results and it is simple, quick to use and non-contact. There is potential for the imaging device to guide swab sampling and aid health professionals in the diagnosis and management of wound infections.

Using negative pressure wound therapy to prevent surgical site infection.

It is estimated that, at the very least, 5% of patients who undergo surgery develop a surgical site infection (SSI). There has been much interest in the use of negative pressure wound therapy (NPWT) as a prophylactic treatment to reduce the risk of SSI. Evidence suggests it can accelerate healing times, reduce both the length of hospital stay and the frequency of dressing changes, and improve patients' quality of life. The efficacy of traditional and portable NPWT systems is similar. However, the latter has an advantage in that it increases patient mobility and does not hinder individuals from carrying out activities of daily living. There are also economic data suggesting that portable NPWT devices are associated with long-term cost savings.

Cell salvage in acute and chronic wounds: a potential treatment strategy. Experimental data and early clinical results.

On 9 May 2018, the authors took part in a closed panel discussion on the impact of cell salvage in acute and chronic wounds. The goal was to deliberate the possible use of plurogel micelle matrix (PMM) as a new treatment strategy for wound healing and the authors openly shared their experiences, thoughts, experimental data and early clinical results. The outcome of the panel discussion has been abridged in this paper. The cell membrane consists of a lipid bilayer, which provides a diffusion barrier separating the inside of a cell from its environment. Cell membrane injury can result in acute cellular necrosis when defects are too large and cannot be resealed. There is a potential hazard to the body when these dying cells release endogenous alarm signals referred to as 'damage (or danger) associated molecular patterns' (DAMPs), which trigger the innate immune system and modulate inflammation. Cell salvage by membrane resealing is a promising target to ensure the survival of the individual cell and prevention of further tissue degeneration by inflammatory processes. Non-ionic surfactants such as poloxamers, poloxamines and PMM have the potential to resuscitate cells by inserting themselves into damaged membranes and stabilising the unstable portions of the lipid bilayers. The amphiphilic properties of these molecules are amenable to insertion into cell wall defects and so can play a crucial, reparative role. This new approach to cell rescue or salvage has gained increasing interest as several clinical conditions have been linked to cell membrane injury via oxidative stress-mediated lipid peroxidation or thermal disruption. The repair of the cell membrane is an important step in salvaging cells from necrosis to prevent further tissue degeneration by inflammatory processes. This is applicable to acute burns and chronic wounds such as diabetic foot ulcers (DFUs), chronic venous leg ulcers (VLUs), and pressure ulcers (PUs). Experimental data shows that PMM is biocompatible and able to insert itself into damaged membranes, salvaging their barrier function and aiding cell survival. Moreover, the six case studies presented in this paper reveal the potential of this treatment strategy.

Case 15: use as an instillation solution with NPWT.

A patient with purpura fulminans, which resulted in amputation of three limbs, developed a Pseudomonas infection on the buttocks. Treatment comprised negative pressure wound therapy, with octenilin as the irrigation fluid. This eradicated the infection, resulting in granulation tissue formation.

Case 16: further success as an instillation solution with NPWT.

An amputation stump developed a particularly painful abscess, which required incision and drainage. Combined use of NPWT and octenilin Wound Irrigation Solution as the instillation fluid proved successful, with a reduction in pain and sufficient healing for the wound to be closed in theatre.

The use of an antimicrobial primary wound contact layer as liner and filler with NPWT.

In negative pressure wound therapy (NPWT), wound fillers are used to ensure that the negative pressure is applied across the entire wound surface. At present, foam and gauze are the most commonly used fillers. Both ensure equal distribution of negative pressure, but foam is more absorbent, while gauze is more malleable and conformable. There is no strong clinical research evidence demonstrating the superiority of one type of wound filler over another. However, there are reports that foam can cause pain and trauma at dressing change as a result of ingrowth of tissue into its open pore structure. For this reason, when foam is used as a filler, a liner may also be applied as a wound contact layer. This supplement describes preliminary clinical evidence on the use of Cutimed Sorbact as an alternative to foam and gauze during NPWT. Seven cases in which it was successfully used on complex pre- and postoperative wounds are described

Use of Fish Skin Graft in Management of Combat Injuries Following Military Drone Assaults in Field-Like Hospital Conditions.

INTRODUCTION: The 2020 Nagorno-Karabakh war was an armed conflict between Azerbaijan and Armenia over an ethnically and historically significant region. This manuscript is a report on the forward deployment of acellular fish skin graft (FSG) from Kerecis™, a biologic, acellular matrix derived from the skin of wild-caught Atlantic cod that contains intact epidermis and dermis layers. The usual intention of treatment under adverse circumstances is to temporize wounds until better treatment can be attained, although ideally, rapid coverage and treatment are necessary to prevent long-term complications and loss of life and limb. An austere environment, such as the one experienced during the conflict described here, presents considerable logistical barriers for the treatment of wounded soldiers. MATERIALS AND METHODS: Dr H. Kjartansson from Iceland and Dr S. Jeffery from the United Kingdom traveled to Yerevan, near the heart of the conflict, to deliver and train on using FSG in wound management. The primary goal was to use FSG in patients where stabilization and improvement in the wound bed were needed before skin grafting. Other goals were to improve healing time, achieve earlier skin grafting, and have better cosmetic outcomes upon healing. RESULTS: Over the course of two trips, several patients were managed with fish skin. Injuries included large-area full-thickness burn and blast injuries. Management with FSG induced wound granulation several days sooner in all cases, and even weeks in some instances, allowing a stepdown in the reconstruction ladder with earlier skin grafting procedures and a reduction in requirement of flap surgery. CONCLUSIONS: This manuscript describes a successful first instance of forward deployment of FSGs to an austere environment. FSG, in this military context, has shown great portability, with easy transfer of knowledge. More importantly, management with fish skin has shown faster granulation rates in burn wounds for skin grafting, resulting in improved patient outcomes with no documented infections.

Functional splinting of upper limb injuries with gauze-based topical negative pressure wound therapy.

Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negative-pressure dressing system.

Fasciotomy: a call for proper placement.

INTRODUCTION: It is important that acute compartment syndrome is recognised and treated early. Treatment involves surgical decompression and it is imperative that this is performed in a timely and appropriate manner. The knowledge of plastic and orthopaedic surgery trainees of the safe technique for performing lower leg fasciotomy was examined. METHODS: Survey of knowledge of fasciotomy was performed amongst plastic and orthopaedic surgery trainees. They were asked to fill in a questionnaire during a regional teaching session. RESULTS: There were 29 respondents; 19 plastic surgery trainees and 10 from orthopaedic surgery. Most trainees had little experience of watching, assisting or performing fasciotomies. When asked to mark the placement of fasciotomy incisions and plane of dissection, only 47% of plastic and 10% of orthopaedic surgery trainees were correct. DISCUSSION: Clinical experience and knowledge of lower leg fasciotomy is poor amongst trainees surveyed. In this paper, the pathophysiology, diagnosis and treatment of compartment syndrome are described. Examples of poorly placed fasciotomy incisions, as well as the consequences of these, are also presented.