Myth-busting the zone of injury concept: a prospective study on the vascular response to high-energy lower extremity trauma.

BACKGROUND: Although the zone of injury concept is widely accepted, no histologic studies of vessel wall changes causing the phenomena are reported. This prospective study investigated the vascular response to high-energy lower extremity trauma to evaluate the validity of the zone of injury concept. METHODS: The histologic appearance of arterial and venous walls in the zone of injury was studied in 19 patients (median age 46 [interquartile range 29.5-62.5] years) who underwent osteosynthesis and free-flap reconstruction due to high-energy lower extremity open fracture. Vascular samples were harvested from the injured extremity and control samples were harvested from the free-flap donor site. Histologic and morphometric characteristics of the vessels were analyzed microscopically and using digital pathology QuPath software. RESULTS: Vascular samples were harvested on post-injury days 1-11. Intimal thickness was >3 times greater in arteries harvested from the zone of injury than in control samples (P<0.01) and the intima/media ratio was 2-fold that in control samples (P=0.01). Arterial intimal fibrosis was more evident in vessels harvested from the zone of injury (P<0.01), but medial fibrosis and medial thickness did not differ significantly between groups. Venous intimal thickening (P<0.01) and the intima/media ratio (P=0.02) were superior in samples from the zone of injury. Fibrosis-related changes did not differ between groups (P=0.45). CONCLUSIONS: These findings support the validity of the zone of injury concept by providing a novel histologic basis for this phenomenon. Intimal thickening and arterial intimal fibrosis are prominent histologic features of vessels affected by major lower extremity trauma.

Surgical and patient-reported outcomes after total knee arthroplasty requiring soft tissue flap reconstruction - A 12-year experience from high-volume arthroplasty hospital.

BACKGROUND: This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital. METHODS: Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups. RESULTS: Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n = 27; EC group n = 31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p = 0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p = 0.36). Oxford Knee Score was 34.5 vs. 25.5 (p = 0.21), and range of motion was 100° vs. 93° (p = 0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p = 0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p = 0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p = 0.03). CONCLUSIONS: Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Effectiveness of autologous platelet-rich plasma gel in the treatment of hard-to-heal leg ulcers: a randomised control trial.

OBJECTIVE: Regenerative medicine products such as autologous platelet-rich plasma (autologous PRP) gel may speed up the process of healing. Clinical studies show promising results in the treatment of diabetic foot ulcers (DFUs), however there is lack of scientific evidence of autologous PRP effectiveness in treating leg ulcers of other aetiology. This study evaluates the effectiveness of autologous PRP gel in the treatment of hard-to-heal leg ulcers compared with existing conventional treatment. METHOD: A prospective, randomised controlled, open-labelled clinical trial was carried out between 2014 and 2018. An eight-week study protocol was chosen or until 100% wound re-epithelialisation was observed. Wound size reduction, granulation tissue formation, microbiological wound bed changes and safety were evaluated. RESULTS: A total of 69 patients (35 in the autologous PRP group and 34 in the control group) were included in the study; 25.71% of the autologous PRP group and 17.64% of control group had ulcers completely re-epithelialised (p>0.05). Wound size reduction in the autologous PRP group was 52.35% and 33.36% in the control group (p=0.003). The autologous PRP group showed superiority over conventional treatment in wound bed coverage with granulation (p=0.001). However, more frequent wound contamination was observed at the end of treatment in the autologous PRP group (p=0.024). No severe adverse events were noted during the study. Both treatment methods were considered equally safe. CONCLUSION: Topical application of autologous PRP gel in leg ulcers of various aetiology show beneficial results in wound size reduction and induces the granulation tissue formation. However, it is associated with more frequent microbiological wound contamination.

Importance of sentinel lymphatic node biopsy in detection of early micrometastases in patients with cutaneous squamous cell carcinoma.

BACKGROUND: Cutaneous squamous cell carcinoma (CSCC) is the second most common malignant skin cancer with a tendency to spread through the lymphogenic pathway. Metastases are found in 2-6% of cases. The aim of this study was to determine CSCC micrometastases when non-invasive examination methods do not detect them. METHOD: A total of 88 patients were included in the study with clinically diagnosed, histologically confirmed CSCC and no distant or regional lymph node metastases detected during instrumental tests. The patients were grouped into low- and high-risk CSCC groups. They underwent one-stage surgery - radical tumour excision and sentinel lymph node/nodes biopsy (SLNB). Significance level of 0.05 was chosen for testing statistical hypotheses. RESULTS: One hundred and fifty-three sentinel lymph nodes (SLNs) were detected and excised in 88 patients. Micrometastases were found in five SLNs of three patients with high-risk CSCC. The rate of micrometastases was 3.4%; however, in the high-risk group it was 6.5%. The mean diameter of CSCC with micrometastases in SLN was 5.6 ± 3.5 cm, and that without micrometastases was 1.5 ± 1.1 cm (p = 0.003). The depth of CSCC according to Breslow in the patients with detected micrometastases in SLN was 3.5 ± 1.2 mm, and that without detected micrometastases was 2.2 ± 1.4 mm (p = 0.047). Patients with micrometastases in sentinel lymphatic nodes underwent radical lymphadenectomy. There was neither recurrence of CSCC metastases in regional lymph nodes nor distant metastases during the research period detected. CONCLUSIONS: In patients with CSCC the rate of micrometastases directly correlates with the depth and diameter of the tumour. In patients with high-risk CSCC the rate of micrometastases is 6.5%.