[Conservative treatment options for unguis incarnatus]. / Conservatieve behandelopties bij unguis incarnatus.

Unguis incarnatus (ingrown toenail) is a common problem in daily practice. Persons with unguis incarnatus stage two and three are often referred for surgical partial nail excision, however conservative treatment or minimal-invasive alternatives exist. In the latest Dutch guideline for ingrown toenails, there is minimal attention to these alternatives. A podiatrist can do a spiculectomy and places a bilateral orthonyxia (nail brace) or tamponnade afterwards. This treatment option was studied in a prospective cohort study in 88 persons with high risk for wound healing problems and was found to be a safe and effective treatment option. In this clinical lesson we discuss three casus and their treatment options including minimal-invasive treatments. Guidance of the nail growth needs more attention after procedures just like adequate nail clipping advices to prevent for recurrences. Both are not announced in the latest Dutch guideline.

Lower Extremity Amputation Rates in People With Diabetes Mellitus: A Retrospective Population Based Cohort Study in Zwolle Region, The Netherlands.

OBJECTIVE: Lower extremity amputations are a major complication of diabetes mellitus (DM). In a previous Dutch study, the incident rate of major amputations was 89.2 per 100 000 person years. The primary aim of this study was to describe the lower extremity amputation rates in people with DM in the Zwolle region, where preventive and curative footcare is organised according to the guidelines of the International Working Group of the Diabetic Foot (IWGDF). The secondary aim was to evaluate outcomes and underlying characteristics of these people. METHODS: This was a retrospective regional population based cohort study. Data from all people with DM treated in primary and secondary care, living in the region Zwolle were collected. All amputations in the period 2017 to 2019 were analysed. Comparisons were made between those with and without an amputation. RESULTS: In the analysis 5 915 people with DM were included, with a mean age of 67.8 (IQR 57.9, 75.9) years. Of those people, 47% were women and the median HbA1c was 53 (IQR 47, 62) mmol/mol. Over the three year study period 68 amputations were performed in 59 people: 46 minor, 22 major. This translated into an average annual crude amputation incidence rate of non-traumatic major and minor amputations of 41.5 and 86.9 per 100 000 person years among people with diabetes. Compared with those not undergoing amputations, those who underwent an amputation were more often men, older, mainly had T2DM, were treated in secondary care, had higher diastolic blood pressure, worse diabetic footcare profile, longer DM duration and higher HbA1c. At the end of the follow up, 111 people died: 96 (1.6%) without and 15 (25.4%) with amputations (p < .001). CONCLUSIONS: This retrospective study provides detailed insight into the rate of amputations in Dutch people with diabetes in the region Zwolle. Compared with previous Dutch estimates, these data suggest a considerable decrease in the major amputation incidence rate.

Microbial biofilms and wound healing: an ecological hypothesis.

Man has lived together with microbes for so long that we have become completely dependent on their presence. Most microbes reside in biofilms; structured communities encased in a protective matrix of biopolymers. Under healthy conditions, the microbial biofilm is in balance with itself (endo-balance) and with the host (exo-balance). Integrity of the skin is an important immunological function. Wounds go through a well-orchestrated series of healing steps. However, if for some reason healing times are extended, serious problems related to infection and homeostasis can develop. Based on recent advances in biofilm research and microbiological identification we discuss two hypotheses describing the role of microbial biofilms in chronic wound biology. The first hypothesis describes microbial biofilms as the cause of extended healing times. The second hypothesis is based on the host as cause of extended healing times and basically treats microbial biofilms as a logical consequence of failure to re-build the integrity of the skin.

Cyanoacrylate skin microsealant for preventing surgical site infection after vascular surgery: a discontinued randomized clinical trial.

BACKGROUND: Surgical site infections (SSI) after vascular surgery are related to substantial morbidity. Restriction of bacterial access to the site of surgery with a cyanoacrylate sealant is a new concept. We performed a randomized clinical trial to assess the effect of the sealing of skin with a cyanoacrylate preparation at the site of surgery on the incidence of SSI after arterial reconstruction. METHODS: Patients scheduled for vascular reconstruction in or distal to the groin were randomized into a treatment and a control group. Standard measures for preventing contamination of the surgical field were taken in the control group, whereas cyanoacrylate was used as a skin sealant at the surgical site in the patients in the treatment group. We hypothesized that the incidence of SSI with the use of cyanoacrylate would be two-thirds (67%) lower than that with standard preparation of the surgical site, and performed an interim analysis of 50 patients to assess this. RESULTS: Risk factors among the 50 patients in the study included smoking (28%), hypertension (77%), diabetes mellitus (36%), and hypercholesterolemia (74%). Indications for surgery were invalidating claudication (Fontaine IIb), pain at rest, or tissue necrosis. The overall incidence of SSI was 3/47 (6%), without differences between groups; 9% SSIs in the control group versus 4% SSIs in the intervention group. CONCLUSION: We could not confirm a reduction in the incidence of SSI after inguinal vascular surgery with the use of a cyanoacrylate skin sealant as compared with conventional means for preparing the surgical site.

Maggot debridement therapy in the palliative setting.

Success rates of Maggot Debridement Therapy (MDT) differ, but range from 70% to 80%. In this article it is argued that wound closure is not always feasible and is not always the aim of the treatment. A patient is described in whom the intent of MDT was not wound closure, but infection removal, reduction of odor, and eventually prevention of a below knee amputation. This succeeded: the pain was diminished, the odor reduced, and the wound showed signs of healing. Still the patient died. In maggot literature, as with other wound treatments, outcome is recorded as closed or as failed. In our opinion, MDT has other indications besides wound closure.

Maggot debridement therapy of infected ulcers: patient and wound factors influencing outcome - a study on 101 patients with 117 wounds.

INTRODUCTION: It has been known for centuries that maggots are potent debriding agents capable of removing necrotic tissue and slough. In January 2004, the US Food and Drug Administration decided to regulate maggot debridement therapy (MDT). As it is still not clear which wounds are likely or unlikely to benefit from MDT, we performed a prospective study to gain more insight in patient and wound characteristics influencing outcome. PATIENTS AND METHODS: In the period between August 2002 and December 2005, patients with infected wounds with signs of gangrenous or necrotic tissue who seemed suited for MDT were enrolled in the present study. In total, 101 patients with 117 ulcers were treated. Most wounds were worst-case scenarios, in which maggot therapy was a treatment of last resort. RESULTS: In total, 72 patients (71%) were classified as ASA III or IV. In total, 78 of 116 wounds (67%) had a successful outcome. These wounds healed completely (n = 60), healed almost completely (n = 12) or were clean at least (n = 6) at last follow-up. These results seem to be in line with those in the literature. All wounds with a traumatic origin (n = 24) healed completely. All wounds with septic arthritis (n = 13), however, failed to heal and led in half of these cases to a major amputation. According to a multivariate analysis, chronic limb ischaemia (odds ratio [OR], 7.5), the depth of the wound (OR, 14.0), and older age (>or= 60 years; OR, 7.3) negatively influenced outcome. Outcome was not influenced by gender, obesity, diabetes mellitus, smoking, ASA-classification, location of the wound, wound size or wound duration. CONCLUSIONS: Some patient characteristics (i. e. gender, obesity, smoking behaviour, presence of diabetes mellitus and ASA-classification at presentation) and some wound characteristics (i. e. location of the wound, wound duration and size) do not seem to contra-indicate eligibility for MDT. However, older patients and patients with chronic limb ischaemia or deep wounds are less likely to benefit from MDT. Septic arthritis does not seem to be a good indication for MDT.

Extracellular Wound Matrix (OASIS®): Exploring the Contraindications. Results of Its Use in 32 Consecutive Outpatient Clinic Cases.

UNLABELLED: Background. In the authors' experience re-epithelialization after successful debridement and granulation can be the most difficult part of the wound closure process. Extracellular matrix products represent a possible solution. However, in studies discussing the effectiveness of extracellular wound matrix (porcine-derived small intestine submucosa [SIS], [OASIS® Wound Matrix, Healthpoint Ltd, Fort Worth, Tex]), a long list of exclusion criteria has been presented. The present study was designed to explore the contraindications of OASIS Wound Matrix. METHODS: In this study, 32 patients in whom the wounds were fully debrided and granulated were treated with weekly applications of the wound matrix. The exclusion criteria formulated in the reported literature were followed. Seven different outcomes were defined. Various patient and wound characteristics that might influence outcome were recorded. RESULTS: Beneficial outcomes were seen in 80.6 % (n = 25) of the patients. The two main complications seen were infection and hypergranulation tissue. Infection was seen in 7 patients (22.6%). Four patients (57.1%) had an unsuccessful outcome. Hypergranulation tissue occurred in another 7 patients (22.6%) after a couple of applications. They all had a beneficial outcome. CONCLUSION: Much of the exclusion criteria used in previous reports are too strict. Infection should be the only absolute contraindication for starting treatment with OASIS, and it is a good reason to discontinue treatment with an ECM. Hypergranulation tissue (22.6%) is an easily treatable complication that has no negative influence on outcome. Some wounds (77.4%) had no complications, or had easily treatable complications that did not negatively influence the outcome.

Pilot study evaluating a clinical decision tool on suspected scaphoid fractures.

In an earlier study we have proposed a scaphoid decision-protocol in order to improve diagnostic accuracy in case of suspected scaphoid fractures. This pilot study evaluated this protocol. In this pilot study (n = 31) most cases with clinical suspicion of scaphoid fractures reached a positive test result on the combined 7 clinical tests (93.5%). Using this test combination, no scaphoid fractures were missed (no false-negatives; sensitivity 100%), but it also included many patients with no scaphoid fracture. Many of these, however, were found to have another fracture. In total, 48% had a scaphoid fracture, 19% another fracture and 32% no fracture. In the pilot study the proposed protocol seems to be a safe protocol, without missing scaphoid fractures. It leads to a reduction of unnecessary plaster casting of sprained wrists and produces a marked reduction in plain radiographic examinations.

Development of a clinical decision tool for suspected scaphoid fractures.

Scaphoid fractures are the most common carpal fractures; their overall incidence is however low. Missing a scaphoid fracture may lead to a non-union with a possible disastrous outcome for the patient; for this reason, treatment of a suspected scaphoid fracture, even without a proven fracture on the first radiograph, has been conservative with plaster treatment. There are many clinical tests developed to diagnose a scaphoid fracture. However not all tests are equally practical, and their sensitivity and specificity are not always known, or are very low. In this study 18 clinical tests were evaluated and a subset of 7 tests remained, which were found to be practical and/or had a high enough sensitivity. A clinical decision protocol was developed using a combination of these seven tests, in order to improve diagnostic accuracy and at the same time reduce unnecessary plaster cast treatment of patients with a suspected scaphoid, who turn out to only have a sprained wrist.

Maggot debridement therapy: free-range or contained? An in-vivo study.

OBJECTIVE: To determine which method of maggot debridement therapy--free-range or contained--is more effective for wound healing. METHODS: In vivo study of 64 patients with 69 chronic wounds that showed signs of gangrenous or necrotic tissue. Patients were treated with either free-range or contained maggot debridement therapy according to maggot availability, dressing difficulty, and physician preference. RESULTS: Significantly better outcomes were achieved with the free-range technique versus the contained technique (P = .028). With the free-range technique, the mean number of maggot applications and the total number of maggots per treatment were significantly lower than with the contained application technique (P = .028 and P < .001, respectively). CONCLUSION: This clinical in vivo study supports in vitro studies in which containment of maggots was found to reduce the effectiveness of maggot debridement therapy.

Conservative treatment of a closed fracture of the clavicle complicated by pneumothorax: a case report.

Isolated clavicle fractures are frequently encountered in the accident and emergency department. Complications of isolated clavicle fractures are rare. Pneumothorax as a complication of a clavicle fracture has only been reported five times in English literature. In all five cases the pneumothorax was treated by a thoracostomy and the clavicle fracture was treated conservatively. In our case, both pneumothorax and clavicle fracture were treated conservatively with good result. Although isolated clavicle fractures rarely present with complications and normally heal with routine immobilisation, we must be aware of the serious complications that may occur, which require urgent treatment. Thorough history, physical examination, with particular attention to the neurovascular and chest examinations and radiographs of the clavicle are necessary to prevent overlooking these potentially serious complications.

START Trial: a pilot study on STimulation of ARTeriogenesis using subcutaneous application of granulocyte-macrophage colony-stimulating factor as a new treatment for peripheral vascular disease.

BACKGROUND: Granulocyte-macrophage colony-stimulating factor (GM-CSF) was recently shown to increase collateral flow index in patients with coronary artery disease. Experimental models showed beneficial effects of GM-CSF on collateral artery growth in the peripheral circulation. Thus, in the present study, we evaluated the effects of GM-CSF in patients with peripheral artery disease. METHODS AND RESULTS: A double-blinded, randomized, placebo-controlled study was performed in 40 patients with moderate or severe intermittent claudication. Patients were treated with placebo or subcutaneously applied GM-CSF (10 microg/kg) for a period of 14 days (total of 7 injections). GM-CSF treatment led to a strong increase in total white blood cell count and C-reactive protein. Monocyte fraction initially increased but thereafter decreased significantly as compared with baseline. Both the placebo group and the treatment group showed a significant increase in walking distance at day 14 (placebo: 127+/-67 versus 184+/-87 meters, P=0.03, GM-CSF: 126+/-66 versus 189+/-141 meters, P=0.04) and at day 90. Change in walking time, the primary end point of the study, was not different between groups. No change in ankle-brachial index was found on GM-CSF treatment at day 14 or at day 90. Laser Doppler flowmetry measurements showed a significant decrease in microcirculatory flow reserve in the control group (P=0.03) and no change in the GM-CSF group. CONCLUSIONS: The present study does not support the use of GM-CSF for treatment of patients with moderate or severe intermittent claudication. Issues that need to be addressed are dosing, the selection of patients, and potential differences between GM-CSF effects in the coronary and the peripheral circulation.

Exclusion of a crural pseudoaneurysm with a PTFE-covered stent-graft.

PURPOSE: To describe the successful endovascular treatment of an iatrogenic anterior tibial artery pseudoaneurysm with a polytetrafluoroethylene-covered stent-graft. CASE REPORT: A 58-year-old man was admitted to our hospital with pseudoarthrosis and malunion of the right distal tibia. Fibulotomy and intramedullary fixation were performed, which was complicated by a pseudoaneurysm of the anterior tibial artery. Under local anesthesia, a 4x31-mm Symbiot covered stent was successfully placed over the origin of the pseudoaneurysm. At 12 months, the pseudoaneurysm remained excluded, and the anterior tibial artery was patent. CONCLUSIONS: Endovascular treatment of a crural artery pseudoaneurysm seems to be a feasible treatment option. Further experience with this technique is needed to validate its safety and long-term patency.