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The introduction of targeted muscle reinnervation has improved amputation pain outcomes and the control of upper-extremity myoelectric prostheses. However, patients with proximal transhumeral amputation levels and soft tissue deficits present a unique challenge. Existing described targeted muscle reinnervation techniques in transhumeral amputees rely on recipient motor nerves from the biceps and triceps; however, these may be absent in patients with more proximal injuries. Here, we describe the use of the pedicled latissimus dorsi flap for both soft tissue coverage and additional motor targets in patients with high-transhumeral amputation with complex soft tissue deficits.
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OBJECTIVE: This study seeks to assess the status of elective rotations offered in plastic and reconstructive surgery residency programs throughout the country while also qualifying resident and alumni experiences and identifying barriers to offering electives. DESIGN: Two prospective surveys were created for (1) program leadership and (2) residents, fellows, and alumni's who have graduated in the last 5 years. SETTING: This is a multi-institutional survey study. PARTICIPANTS: Of 81 plastic and reconstructive surgery programs, 45 programs, and 102 residents, fellows and/or recent graduates responded to survey 2. RESULTS: Fifty-six percent of respondents stated that their institution offered electives, 62% of which permitted residents to participate in regional, national, and international rotations primarily in the fifth and sixth years of training. Types of elective rotations completed included aesthetic, craniofacial, sex, hand, and microsurgery. Fifty-three percent responding programs denied barriers to offering elective rotations. When programs noted barriers, the most common were cost to resident/department (28%), institutional Graduate Medical Education policy (22%), and lack of service coverage at the home institution (22%). There was no difference between departments versus divisions offering electives (56.3% vs 57.1%, P = 0.95). Programs that did not offer electives spent an average of 14.6 months on general surgery compared with 9.4 months for programs that did offer electives ( P = 0.06). For programs that did not currently offer elective rotations, 71% indicated a desire to do so. CONCLUSION: The primary goal of plastic surgery training programs is to produce plastic surgeons of the highest caliber with regard to safety and competence. Although several regulatory bodies ensure that programs adhere to a similar standard, not all programs have opportunities for residents to experience the breadth of our multifaceted specialty. Elective rotations constitute an excellent supplement to a well-rounded training where gaps may exist.
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Internato e Residência , Cirurgia Plástica , Educação de Pós-Graduação em Medicina , Humanos , Estudos Prospectivos , Inquéritos e Questionários , Estados UnidosRESUMO
Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; pâ¯=â¯.0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; pâ¯=â¯.0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; pâ¯=â¯.0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; pâ¯=â¯.0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; pâ¯=â¯.0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; pâ¯=â¯.0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations.
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Amputação Cirúrgica/métodos , Artropatia Neurogênica/cirurgia , Pé Diabético/cirurgia , Salvamento de Membro/métodos , Centros Médicos Acadêmicos , Idoso , Amputação Cirúrgica/efeitos adversos , Artropatia Neurogênica/diagnóstico , Estudos de Coortes , Terapia Combinada , Desbridamento/métodos , Pé Diabético/diagnóstico , Feminino , Seguimentos , Humanos , Salvamento de Membro/efeitos adversos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Transplante de Pele/métodos , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
BACKGROUND: No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols. METHODS: Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods. RESULTS: Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure. CONCLUSION: Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.
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Anticoagulantes/uso terapêutico , Retalhos de Tecido Biológico/irrigação sanguínea , Extremidade Inferior/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Trombofilia/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Adulto , Idoso , Protocolos Clínicos , Feminino , Sobrevivência de Enxerto , Humanos , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Trombofilia/complicações , Trombofilia/fisiopatologia , Resultado do Tratamento , Tromboembolia Venosa/fisiopatologia , Adulto JovemRESUMO
INTRODUCTION: Wound breakdown following total knee arthroplasty (TKA) increases the risk of device exposure, infection, and major amputation. Although a variety of options to facilitate coverage of compromised knee joint prostheses exist, the relative safety, efficacy, and functional impact of each has not been determined. OBJECTIVE: This study aims to identify those perioperative factors that influence reconstructive and functional outcomes in patients with periprosthetic TKA defects. MATERIALS AND METHODS: A 5-year retrospective review of outcomes following surgical management of TKA wounds was undertaken. Data pertaining to the timing of presentation, type and frequency of operative interventions, rates of implant/limb salvage, ambulatory status, visual analogue scores (VAS) for pain, and complications were collected. RESULTS: Thirty patients were identified during the study period with a mean follow-up of 20 months. Rates of limb salvage (66.7% vs. 91.7% vs. 75% vs. 0%, P < .001) and postoperative ambulation (100% vs. 83.3% vs. 75% vs. 54.5%, P = .036) were significantly different between patients who underwent primary closure, local muscle flap coverage, free tissue transfer coverage, and above-the-knee amputation, respectively. The number of debridements prior to definitive closure did not significantly influence rates of limb salvage (P = .21). Active tobacco use (odds ratio [OR], 4; 95% confidence interval [CI], 1.13-14.2; P = .03) and time to initial presentation from the index joint replacement (OR, 0.99; 95% CI, 0.9-1.0; P = .04) adversely impacted device salvage. Both of these factors similarly influenced the overall likelihood of limb salvage (OR, 6.5; 95% CI, 1.5-28.8; P = .01; OR, 0.99; 95% CI, 0.99-1.0; P = .04). The VAS scores were not significantly different between index closure types (P = .77) but were significantly lower for patients who required < 10 debridements prior to definitive closure (P = .02). CONCLUSIONS: Early intervention with limited-frequency, and thorough debridement and prompt soft tissue coverage optimizes the chances of functional limb salvage in patients with complex periprosthetic TKA wounds. These findings may inform practice patterns and surgical treatment of patients presenting with compromised TKA and suggest that early involvement by reconstructive surgeons should be advocated to optimize reconstructive and functional outcomes in this difficult patient population.
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Outpatient-based sharp debridement is considered an important element for the care of a chronic ulcer. OBJECTIVE: The aim of this study is to evaluate the change in bacterial amounts with sharp debridement in a clinical setting. MATERIALS AND METHODS: Bacterial autofluorescence, quantitative cultures, semiquantitative cultures, and qualitative speciation were performed predebridement and postdebridement during a single clinic visit. RESULTS: Thirty-six wounds were included in the analysis. The mean patient age was 62 years (range, 27-83 years), and there were 13 (36.11%) women and 23 (63.89%) men with an average body mass index of 33.8 kg/m² (range, 16.7-55.9 kg/m²). Of the 36 patients, 24 (66.67%) had type 2 diabetes and 19 (52.78%) had a prior history of lower extremity amputation. Majority of the ulcers were diabetic neuropathic (27, 75%); the most common location was on the plantar aspect of the foot (14, 41.67%) with a mean ulcer duration of 10 months (range, 1-36), mean ulcer area of 6.3 ± 12.8 cm² (range, 0.18-62.06 cm²), and mean volume of 2.2 ± 4.4 cm³ (range, 0.05-9.66 cm³). There was no statistically significant difference in bacterial autofluorescence between the predebridement (4.15 ± 8.82) and the postdebridement (4.65 ± 9.48) images (P = .32). There was a statistically significant difference in quantitative culture results between the predebridement (6.7 x 104 ± 1.4 x 106 CFU/cm²) and the postdebridement (1.7 x 104 ± 3.1 x 106 CFU/cm²) cultures (P = .04), although this is not a log reduction. CONCLUSIONS: There is no statistically significant difference between the predebridement versus postdebridement semiquantitative culture results or a detectable pattern of change for the most common bacterial species encountered. These results suggest little impact of clinic-based sharp debridement on bacteria.
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Desbridamento , Úlcera/microbiologia , Úlcera/terapia , Cicatrização/fisiologia , Infecção dos Ferimentos/microbiologia , Infecção dos Ferimentos/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Desbridamento/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Free tissue transfer is one option for preservation of form and function in the native limb, in the setting of soft tissue paucity. However, the data on patient functionality after microvascular intervention is inconsistently reported. The Lower Extremity Function Scale (LEFS) measures patient-reported difficulty in carrying out 20 physical activities, on a Likert scale, the sum of which correlates with descriptive functional stages of 1-5. We assess limb functionality in this cohort of microvascular patients using the LEFS survey. METHODS: A retrospective chart review was conducted at a single academic medical center of 101 consecutive free flaps, from 2011 to 2016. Of the flaps that met inclusion criteria, 39 had completed LEFS surveys. Mean LEFS scores were calculated, and the effects of risk factors such as diabetes, age, and smoking status were analyzed. RESULTS: The mean LEFS score after free tissue transfer was 50.3 (SD ± 21.1), with a mean follow up survey time of 3.0 years (SD ± 1.3). The score correlated with Stage 4 function, or "independent community ambulation," and age was the only demographic factor associated with decreased functionality in this group. This is compared with mean LEFS score of 43.1 (SD ± 18.4) in cohort of 55 below knee amputations (BKAs), and 38.3 (SD ± 14.9) in 28 above knee amputations (AKAs), both correlating with Stage 3 function: "limited community ambulation." CONCLUSIONS: Functional outcomes scores such as the LEFS demonstrate that patients can obtain an adequate level of functionality for independent community activity after free tissue transfer, although functional improvement diminishes with age.
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Atividades Cotidianas , Cotos de Amputação/cirurgia , Avaliação da Deficiência , Retalhos de Tecido Biológico/transplante , Procedimentos de Cirurgia Plástica/métodos , Centros Médicos Acadêmicos , Adulto , Idoso , Amputados/reabilitação , Estudos de Coortes , Feminino , Fêmur/cirurgia , Seguimentos , Humanos , Modelos Lineares , Extremidade Inferior/cirurgia , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Medição de Risco , Tíbia/cirurgia , Resultado do Tratamento , Cicatrização/fisiologia , Ferimentos e Lesões/cirurgiaRESUMO
BACKGROUND/OBJECTIVE: Loss of domain often complicates attempts at delayed wound closure in regions of high tension. Wound temporization with traction-assisted internal negative pressure wound therapy (NPWT), using bridging retention sutures, can minimize the effects of edema and elastic recoil that contribute to progressive tissue retraction over time. The investigators evaluated the safety and efficacy of this technique for complex wound closure. MATERIALS AND METHODS: Between May 2015 and November 2015, 18 consecutive patients underwent staged reconstruction of complex and/or contaminated soft tissue defects utilizing either conventional NPWT or modified NPWT with instillation and continuous dermatotraction via bridging retention sutures. Instillation of antimicrobial solution was reserved for wounds containing infected/exposed hardware or prosthetic devices. Demographic data, wound characteristics, reconstructive outcomes, and complications were reviewed retrospectively. RESULTS: Eighteen wounds were treated with traction-assisted internal NPWT using the conventional (n = 11) or modified instillation (n = 7) technique. Defects involved the lower extremity (n = 14), trunk (n = 3), and proximal upper extremity (n = 1), with positive cultures identified in 12 wounds (67%). Therapy continued for 3 to 8 days (mean, 4.3 days), resulting in an average wound surface area reduction of 78% (149 cm² vs. 33 cm²) at definitive closure. Seventeen wounds (94%) were closed directly, whereas the remaining defect required coverage with a local muscle flap and skin graft. At final follow-up (mean, 12 months), 89% of wounds remained closed. In 2 patients with delayed, recurrent periprosthetic infection (mean, 7.5 weeks), serial debridement/hardware removal mandated free tissue transfer for composite defect reconstruction. CONCLUSION: Traction-assisted internal NPWT provides a safe and effective alternative to reduce wound burden and facilitate definitive closure in cases where delayed reconstruction of high-tension wounds is planned.
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Edema/prevenção & controle , Tratamento de Ferimentos com Pressão Negativa , Lesões dos Tecidos Moles/terapia , Infecção da Ferida Cirúrgica/prevenção & controle , Técnicas de Sutura , Cicatrização/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Desbridamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Lesões dos Tecidos Moles/patologia , Suturas , Tração , Resultado do TratamentoRESUMO
Patient-reported outcome measures derived from quality of life instruments are an important tool in monitoring disease progression and treatment response. Although a number of validated instruments are available, the Short Form-36 (SF-36) quality of life survey is the most widely used. It is imperative that the patients answer all the questions in this instrument for appropriate analysis and interpretation. It has been hypothesized that fewer questions (i.e., the Short Form-12 [SF-12]), will result in greater survey completion rates. The present study was a randomized prospective study comparing the completion rates for the SF-36 and SF-12 quality of life surveys. Patients presenting with a chronic wound were asked to complete the SF-36 or SF-12 survey. After an a priori power analysis was performed, the completion rates, patterns of skipped questions, and demographic information were analyzed using t tests for continuous variables or Fisher's exact test for categorical variables and both multivariate linear regression and logistic regression. A total of 59 subjects (30 completed the SF-12 and 29 completed the SF-36) participated in the present study. The SF-12 group had an 80% (24 of 30) completion rate compared with a 55% (16 of 29) completion rate for the SF-36 group (p < .05). However, the length of the survey did not affect the completion rate nor was a statistically detectable pattern of skipped questions found. College graduates were more likely to complete both surveys compared with high school graduates (p < .07). Although it is unclear why, our study results indicate that the SF-12 yields a higher total survey completion rate. However, completion appears independent of the shorter survey length.
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Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida/psicologia , Ferimentos e Lesões/terapia , Adulto , Idoso , Doença Crônica , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Centros de Atenção Terciária , Centros de Traumatologia , Estados Unidos , População Urbana , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/psicologiaRESUMO
BACKGROUND: In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. METHODS: A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. RESULTS: A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. CONCLUSIONS: Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.
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BACKGROUND: Objective assessment of wound dimensions is essential for tracking progression and determining treatment effectiveness. A reliability study was designed to establish intrarater and interrater reliability of a novel mobile 3-dimensional wound measurement (3DWM) device. METHODS: Forty-five wounds were assessed by 2 raters using a 3DWM device to obtain length, width, area, depth, and volume measurements. Wounds were also measured manually, using a disposable ruler and digital planimetry. The intraclass correlation coefficient (ICC) was used to establish intrarater and interrater reliability. RESULTS: High levels of intrarater and interrater agreement were observed for area, length, and width; ICC = 0.998, 0.977, 0.955 and 0.999, 0.997, 0.995, respectively. Moderate levels of intrarater (ICC = 0.888) and interrater (ICC = 0.696) agreement were observed for volume. Lastly, depth yielded an intrarater ICC of 0.360 and an interrater ICC of 0.649. Measures from the 3DWM device were highly correlated with those obtained from scaled photography for length, width, and area (ρ = 0.997, 0.988, 0.997, P < 0.001). The 3DWM device yielded correlations of ρ = 0.990, 0.987, 0.996 with P < 0.001 for length, width, and area when compared to manual measurements. CONCLUSION: The 3DWM device was found to be highly reliable for measuring wound areas for a range of wound sizes and types as compared to manual measurement and digital planimetry. The depth and therefore volume measurement using the 3DWM device was found to have a lower ICC, but volume ICC alone was moderate. Overall, this device offers a mobile option for objective wound measurement in the clinical setting.
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Processamento de Imagem Assistida por Computador , Fotogrametria , Ferimentos e Lesões/diagnóstico por imagem , Ferimentos e Lesões/patologia , Progressão da Doença , Humanos , Reprodutibilidade dos Testes , Fenômenos Fisiológicos da PeleRESUMO
Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is an adjunctive therapy that can be used in the management of complex wounds with infection. NPWTi-d incorporates the intermittent instillation of a topical solution to the wound in a programmed manner. Unlike standard negative pressure wound therapy, NPWTi-d delivers topical wound solutions directly to the wound, allows the solution to dwell over the wound bed, and removes the solution during the negative pressure phase. The authors review the evidence for using NPWTi-d and the role it may potentially play in helping to reduce hospital stay, number of debridement operations and cost.
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Antibacterianos/uso terapêutico , Tratamento de Ferimentos com Pressão Negativa/métodos , Irrigação Terapêutica/métodos , Cicatrização/fisiologia , Infecção dos Ferimentos/terapia , Ferimentos e Lesões/terapia , Terapia Combinada , Humanos , Instilação de MedicamentosRESUMO
BACKGROUND: Negative-pressure wound therapy (NPWT) and its variations are an established adjunctive modality for the treatment of wounds. Since its introduction, there have been an increasing number of publications with periods of rapid increases in the number of publications after innovations to the technology. Its application in different wound types and varying clinical scenarios has also contributed to the growing number of publications. METHODS: A comprehensive literature review (1998-2016) was performed using key words most relevant to NPWT using PubMed/Medline and OVID. Eligibility criteria included higher level evidence studies. RESULTS: One thousand three hundred and forty-seven publications were identified. A total of 26 publications are included in this review: 16 comparing NPWT with standard wound dressing, 6 comparing variations of NPWT, and 4 for NPWT with instillation. The level of evidence, wound type studied, reported outcomes and impact, and key findings are tabulated and discussed. CONCLUSIONS: The number of publications has grown significantly since the inception of NPWT. In part, this reflects the variations of NPWT that have developed. However, a greater number of robust, randomized, prospective studies are needed to support its wide spread use.
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Tratamento de Ferimentos com Pressão Negativa , Ferimentos e Lesões/terapia , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin that is a significant source of impaired quality-of-life for affected individuals. For patients with refractory disease, radical resection of all involved tissue may offer the only potential option for a cure. However, high rates of recurrence after wide local excision have led investigators to seek alternative therapeutic combinations. We present our experience and a literature review. METHODS: A comprehensive literature review (1982-2016) was performed on PubMed and Ovid MEDLINE, using key words relevant to HS. RESULTS: A total of 1842 publications were identified, and 15 publications were included in this review on: surgical intervention (n = 10), biologic therapy (n = 4), and joint surgical and biologic treatment (n = 1) of HS. The treatment type, level of evidence, and key findings are assessed and discussed. CONCLUSIONS: Recent trials demonstrating the safety and efficacy of biologic therapy alone in patients with moderate-to-severe HS have spurred questions regarding the potential utility of these agents as adjuncts to more traditional surgical interventions. The results of the literature search advocate a role for radical resection and biologic therapy in the setting of moderate-to-severe disease. Preliminary results from limited case series suggest a potential role for combined management in the setting of advanced, recalcitrant disease.
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Procedimentos Cirúrgicos Dermatológicos , Hidradenite Supurativa/terapia , Imunossupressores/uso terapêutico , Terapia Combinada , Hidradenite Supurativa/diagnóstico , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: The establishment of a healthy wound bed through adequate debridement of infected, senescent, and/or devitalized tissue is central to the progression of normal wound healing. Although a variety of surgical and nonsurgical strategies have been proposed, none have proven completely effective in all settings. This review focuses on the principles and techniques of modern debridement practices employed in the management of complex wounds. METHODS: A comprehensive review of the PubMed/Medline and Ovid databases was performed to identify basic science and clinical studies using key words most relevant to biofilm, debridement, and wound healing. English language articles that were peer reviewed and that met the standard of evidence-based medicine were included. Level of evidence for various debridement approaches was rated utilizing the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations. RESULTS: The value of both operative and nonoperative debridement techniques, their indications, and limitations are described. With an emphasis placed on surgical debridement, this review highlights technical adjuncts that can be used to optimize wound bed preparation, including preoperative topical staining of the wound, as well as the use of color-guided endpoints to prevent removal of excess healthy tissue. The indications for using temporizing measures for wound control such as negative pressure wound therapy with and without installation are also discussed. CONCLUSION: Optimal management requires a multimodal approach that centers around operative debridement and incorporates the use of adjunctive measures to facilitate the removal of infected tissue, biofilm, and/or senescent cells that impede the progression of normal wound healing.
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Desbridamento/métodos , Cicatrização , Infecção dos Ferimentos/prevenção & controle , Humanos , Ferida Cirúrgica/terapiaRESUMO
As the prevalence of chronic wounds continues to rise, the need for point of care wound assessment has also increased. While a variety of technologies have been developed to improve diagnostic abilities and monitoring of wounds, none have proven completely effective in all settings. Further, many of the stalwart wound management techniques remain costly, time consuming, and technically challenging. The two key pivotal events of ischemia and infection can lead to limb loss. A relatively new crop of fluorescence-based technologies, including devices that measure pathogenic auto-fluorescence, fluorescence angiography, or map cutaneous oxygenation, are increasingly being utilized for adjunct wound assessment-both clinical and operative settings can address these events. These technologies offer rapid, efficient, visual, and quantitative data that can aid the wound provider in evaluating the viability of tissues, ensuring adequate perfusion, and optimizing wound bed preparation. In the following review, pathogenic auto-fluorescence is compared to gross evaluation of wound infection and culture based diagnostics, indocyanine green fluorescence angiography is compared to various methods of visual and physical assessments of tissue perfusion by the practitioner, and cutaneous oxygenation is compared to clinical signs of ischemia. We focus on the current applications of fluorescence technologies in wound management, with emphasis placed on the evidence for clinical and operative implementation, a safety analyses, procedural limitations, and the future direction of this growing field of wound assessment.
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Angiografia/métodos , Oximetria/métodos , Testes Imediatos , Espectrometria de Fluorescência/métodos , Infecção da Ferida Cirúrgica/diagnóstico , Ferimentos e Lesões/diagnóstico , Carga Bacteriana/métodos , Humanos , Infecção da Ferida Cirúrgica/microbiologia , Avaliação da Tecnologia Biomédica , Cicatrização , Ferimentos e Lesões/microbiologiaRESUMO
Advanced age is associated with an increased risk of vascular morbidity, attributable in part to impairments in new blood vessel formation. Mesenchymal stem cells (MSCs) have previously been shown to play an important role in neovascularization and deficiencies in these cells have been described in aged patients. Here we utilize single cell transcriptional analysis to determine the effect of aging on MSC population dynamics. We identify an age-related depletion of a subpopulation of MSCs characterized by a pro-vascular transcriptional profile. Supporting this finding, we demonstrate that aged MSCs are also significantly compromised in their ability to support vascular network formation in vitro and in vivo. Finally, aged MSCs are unable to rescue age-associated impairments in cutaneous wound healing. Taken together, these data suggest that age-related changes in MSC population dynamics result in impaired therapeutic potential of aged progenitor cells. These findings have critical implications for therapeutic cell source decisions (autologous versus allogeneic) and indicate the necessity of strategies to improve functionality of aged MSCs.
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Envelhecimento , Células-Tronco Mesenquimais/metabolismo , Tecido Adiposo/citologia , Animais , Células Cultivadas , Análise por Conglomerados , Técnicas de Cocultura , Citocinas/metabolismo , Redes Reguladoras de Genes , Células Endoteliais da Veia Umbilical Humana , Humanos , Masculino , Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais/citologia , Camundongos , Camundongos Endogâmicos C57BL , Transdução de Sinais , Transcriptoma , Tubulina (Proteína)/metabolismo , CicatrizaçãoRESUMO
One of the major intracellular barriers to nonviral gene delivery is efficient endosomal escape. The incorporation of histidine residues into polymeric constructs has been found to increase endosomal escape via the proton sponge effect. Statistical and diblock copolymers of N-(2-hydroxypropyl)methacrylamide (HPMA), oligolysine, and oligohistidine were synthesized via reversible-addition fragmentation chain transfer (RAFT) polymerization and tested for in vitro transfection efficiency, buffering ability, and polyplex uptake mechanism via the use of chemical endocytic inhibitors. Interestingly, histidine-containing statistical and diblock polymers exhibited increased buffer capacity in different endosomal pH ranges. Statistical copolymers transfected better than block copolymers that contained similar amounts of histidine. In addition, only the polymer containing the highest incorporation of oligohistidine residues led to increases in transfection efficiency over the HPMA-oligolysine base polymer. Thus, for these polymer architectures, high histidine incorporation may be required for efficient endosomal escape. Furthermore, inhibitor studies indicate that nonacidified caveolae-mediated endocytosis may be the primary route of transfection for these copolymers, suggesting that alternative approaches for increasing endosomal escape may be beneficial for enhancing transfection efficiency with these HPMA-oligolysine copolymers.