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1.
Tissue Eng Part A ; 2020 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-31884890

RESUMO

Painful neuroma formation is a common and debilitating sequela of traumatic or oncologic nerve amputations. Studies suggest that isolating transected nerve stumps within protective caps during amputation surgery or revision procedures may assist in preventing symptomatic nerve-end neuroma formation. This study evaluated the local effects of two porcine small intestine submucosa (pSIS) nerve caps of differing configurations on a terminal nerve end in an animal model. The tibial nerves of 57 Sprague Dawley rats were transected and transposed to the lateral hind leg. The nerves were treated with one of three SIS materials, including (i) a nerve cap with spiraling chambering, termed spiral nerve cap (SNC), (ii) a nerve cap with bifurcated chambers termed chambered nerve cap (CNC), or (iii) an open tube. The surgical control consisted of nerve stumps that were not treated. Overall tissue response, axonal swirling, optical density of axons, and behavioral pain response were quantified at 8 and 12 weeks postoperatively. There were no notable differences between the performance of the SNC and CNC groups. The pSIS nerve caps mitigated aberrant axonal regeneration and decreased neuroma formation and associated pain response. These findings suggest that nerve caps with internal chambers for axonal outgrowth may improve axonal alignment, therefore reducing the likelihood of symptomatic neuroma formation. Impact statement This study provides evidence for using nerve caps with internal structure on nerve stumps after amputation surgeries to reduce or prevent symptomatic neuromas. This study showed that porcine small intestine submucosa had a favorable remodeling profile and tissue response, illustrating that this device can be used to (i) minimize soft tissue attachments around the nerves that are capped, (ii) align axonal outgrowth to guide nerve regeneration away from aberrant neuroma formation, and (iii) act as a barrier between the nerve and external stimuli ultimately remodeling into a new soft tissue layer around the nerve stump thus decreasing symptomatic neuroma formation.

2.
Int Wound J ; 2019 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-31858713

RESUMO

Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty-five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow-up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.

3.
Adv Wound Care (New Rochelle) ; 8(3): 118-124, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31737410

RESUMO

Objective: To determine the utility of instillation negative pressure wound therapy (NPWT) in achieving eradication of infection and definitive wound closure in patients with infected left ventricular assist device (LVAD). Approach: A retrospective review was performed in a series of patients with infected and exposed LVADs who were treated with instillation NPWT in conjunction with surgical debridement. Results: Three consecutive patients were included who developed periprosthetic infection subsequent to LVAD implantation. In all cases, the utilization of a vacuum-assisted closure with instillation (VACi) along with surgical debridement and IV antibiotics eradicated infection resulting in successful retention of hardware. Cases 1 and 2 received definitive wound closure within 3 and 12 days of starting treatment, respectively. Case 3 initially deferred surgery in favor of local wound care. Eventually the patient elected for surgical treatment and underwent closure 164 days after initial presentation. All three patients healed completely without residual evidence of infection. Flap reconstruction with a pedicled rectus flap was used to achieve definitive closure in all patients. One patient subsequently required pump replacement secondary to thrombosis and mechanical pump failure. Innovation: LVAD infections are met with high morbidity and mortality rates, and timely salvage is critical. In this initial series, VACi has proven a viable therapy option to help control and eradicate infection without LVAD removal. Conclusion: This series illustrates the value of newer techniques such as VACi in combination with surgical debridement and antibiotic therapy in effectively salvaging LVADs that were infected.

4.
Adv Wound Care (New Rochelle) ; 8(8): 368-373, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31346491

RESUMO

Objective: To evaluate our institutional experience of incisional negative pressure wound therapy (iNPWT) applied immediately after major limb amputation closure or amputation revision closure. Approach: A retrospective review was performed on 25 patients who underwent major limb amputation or amputation revision and had iNPWT placed intraoperatively upon incision closure. Results: Twenty-one patients underwent lower extremity amputation and four underwent upper extremity amputation. Seventeen were primary amputations and eight were amputation revisions. No patients developed dehiscence, seroma, or hematoma. One patient developed a surgical site infection (4%) that was treated with oral antibiotics. The average time to eligibility for prosthetic fitting for lower extremity amputations was 6.3 weeks. Innovation: Amputee patients have increased wound healing demands that can impact prosthetic wear and ambulation status. Stump incisions are located at the distal end of their extremities and often are in areas that have had prior surgical procedures performed. Thus, blood supply to the incision site may not be optimal. iNPWT is an effective incision management technique to promote healing and decrease postoperative complications in this patient population, which can lead to increased mortality. Conclusion: iNPWT is an effective technique of minimizing wound complications in the amputee and should be considered in this high-risk patient population.

5.
J Surg Oncol ; 120(3): 348-358, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31197851

RESUMO

BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.


Assuntos
Cotos de Amputação/inervação , Amputação/métodos , Amputação/reabilitação , Músculo Esquelético/inervação , Neoplasias/cirurgia , Transferência de Nervo/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/reabilitação , Neoplasias Ósseas/cirurgia , Estudos de Coortes , Continuidade da Assistência ao Paciente , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/reabilitação , Osteossarcoma/reabilitação , Osteossarcoma/cirurgia , Equipe de Assistência ao Paciente , Membro Fantasma/prevenção & controle , Sarcoma/reabilitação , Sarcoma/cirurgia , Adulto Jovem
6.
J Am Coll Surg ; 228(3): 217-226, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30634038

RESUMO

BACKGROUND: A majority of the nearly 2 million Americans living with limb loss suffer from chronic pain in the form of neuroma-related residual limb and phantom limb pain (PLP). Targeted muscle reinnervation (TMR) surgically transfers amputated nerves to nearby motor nerves for prevention of neuroma. The objective of this study was to determine whether TMR at the time of major limb amputation decreases the incidence and severity of PLP and residual limb pain. STUDY DESIGN: A multi-institutional cohort study was conducted between 2012 and 2018. Fifty-one patients undergoing major limb amputation with immediate TMR were compared with 438 unselected major limb amputees. Primary outcomes included an 11-point Numerical Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behavior, and interference. RESULTS: Patients who underwent TMR had less PLP and residual limb pain compared with untreated amputee controls, across all subgroups and by all measures. Median "worst pain in the past 24 hours" for the TMR cohort was 1 out of 10 compared to 5 (PLP) and 4 (residual) out of 10 in the control population (p = 0.003 and p < 0.001, respectively). Median PROMIS t-scores were lower in TMR patients for both PLP (pain intensity [36.3 vs 48.3], pain behavior [50.1 vs 56.6], and pain interference [40.7 vs 55.8]) and residual limb pain (pain intensity [30.7 vs 46.8], pain behavior [36.7 vs 57.3], and pain interference [40.7 vs 57.3]). Targeted muscle reinnervation was associated with 3.03 (PLP) and 3.92 (residual) times higher odds of decreasing pain severity compared with general amputee participants. CONCLUSIONS: Preemptive surgical intervention of amputated nerves with TMR at the time of limb loss should be strongly considered to reduce pathologic phantom limb pain and symptomatic neuroma-related residual limb pain.


Assuntos
Amputação/efeitos adversos , Extremidades/inervação , Músculo Esquelético/inervação , Procedimentos Neurocirúrgicos , Membro Fantasma/prevenção & controle , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Medidas de Resultados Relatados pelo Paciente , Membro Fantasma/diagnóstico , Membro Fantasma/etiologia , Adulto Jovem
7.
Ann Surg ; 270(2): 238-246, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30371518

RESUMO

OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.


Assuntos
Amputação/reabilitação , Amputados/reabilitação , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Neuroma/cirurgia , Dor Pós-Operatória/cirurgia , Membro Fantasma/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Medição da Dor , Dor Pós-Operatória/diagnóstico , Estudos Prospectivos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Método Simples-Cego
8.
Plast Reconstr Surg ; 143(1): 309-312, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30589808

RESUMO

Approximately 25 percent of major limb amputees will develop chronic localized symptomatic neuromas and phantom limb pain in the residual limb. A method to treat and possibly prevent these pain symptoms is targeted reinnervation. Previous studies prove that targeted reinnervation successfully treats and, in some cases, resolves peripheral neuropathy and phantom limb pain in patients who have undergone previous amputation (i.e., secondary targeted reinnervation). This article seeks to share the authors' clinical indications and surgical technique for targeted muscle reinnervation in below-knee amputation, a surgical description currently absent from our literature. Targeted reinnervation for the below-knee amputee has been performed on 22 patients at the authors' institution. Each patient has been followed on an outpatient basis for 1 year to evaluate symptoms of neuroma or phantom limb pain, patient satisfaction, and functionality. All subjects have denied neuroma pain following amputation. The majority of subjects reported phantom pain at 1 month. However, at 3 months, all patients reported resolution of this pain. Dumanian et al. first noted the improvement of symptomatic neuroma and phantom limb pain in patients undergoing targeted reinnervation to provide intuitive control of upper limb prostheses. These findings have been substantiated by multiple previous studies at various amputation levels. This study extends the success of targeted muscle reinnervation to below-knee amputations and provides a description for this technique.


Assuntos
Cotos de Amputação/inervação , Amputação/métodos , Extremidade Inferior/cirurgia , Transferência de Nervo/métodos , Neuroma/cirurgia , Membro Fantasma/fisiopatologia , Adulto , Amputação/efeitos adversos , Cotos de Amputação/cirurgia , Amputados/reabilitação , Membros Artificiais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/inervação , Músculo Esquelético/cirurgia , Regeneração Nervosa/fisiologia , Neuroma/etiologia , Qualidade de Vida , Estudos Retrospectivos , Tíbia/cirurgia , Resultado do Tratamento
10.
Adv Wound Care (New Rochelle) ; 7(10): 333-338, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30374418

RESUMO

Objective: Infection prevention in spinal surgeries involving implantation of hardware is of utmost priority. Furthermore, successful eradication of infection in hardware salvage is likewise critical in maintaining the long-term retention of the spinal hardware construct. Approach: We report a retrospective case series of three cases where the utilization of a VAC with instillation (VACi) in conjunction with surgical debridement aided in infection control and eradication for both preimplantation and hardware salvage spine patients. Results: Three patients were included. In case 1, VACi was utilized in conjunction with surgical debridement and IV antibiotics in the setting of acute preoperative infection to eradicate infection and enable necessary spinal hardware implementation. Cases 2 and 3 are representative of VACi for salvage of exposed spinal hardware in both the early and delayed infection presentation settings. In both cases, patients developed postoperative infections following spinal instrumentation VACi was utilized in conjunction with surgical debridement and IV antibiotics. Hardware removal was avoided in both cases. All three patients healed completely without residual evidence of infection. Innovation: VACi showed its effectiveness in timely infection eradication before spinal hardware instrumentation and with postoperative spine hardware salvage. Conclusion: This case series demonstrates that VACi can provide infection eradication both preoperatively in high-risk surgical sites, facilitating necessary hardware implementation and postoperatively in situations of hardware salvage.

11.
Regen Med ; 13(4): 443-456, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29985763

RESUMO

full-thickness skin defects remain a reconstructive challenge. Novel regenerative modalities can aid in addressing these defects. A literature review of currently available dermal and epidermal regenerates was performed. The mechanism and application for each skin substitute was analyzed to provide a guide for these modalities. Available epidermal substitutes include autografts and allografts and may be cultured or noncultured. Dermal regenerate templates exist in biologic and synthetic varieties that differ in the source animal and processing. Epidermal and dermal skin substitutes are promising adjunctive tools for addressing certain soft tissue defects and have improved outcomes in reconstructive procedures. The following article provides a comprehensive review of the biologic materials available and the types of complex wounds amenable to their use.


Assuntos
Derme , Regeneração , Pele Artificial , Animais , Derme/lesões , Derme/fisiologia , Epiderme/lesões , Epiderme/fisiologia , Humanos
12.
Adv Wound Care (New Rochelle) ; 6(8): 261-267, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28831329

RESUMO

Scope and Significance: There are ∼185,000 amputations each year and nearly 2 million amputees currently living in the United States. Approximately 25% of these amputees will experience chronic pain issues secondary to localized neuroma pain and/or phantom limb pain. Problem: The significant discomfort caused by neuroma and phantom limb pain interferes with prosthesis wear, subjecting amputees to the additional physical and psychological morbidity associated with chronic immobility. Although numerous neuroma treatments are described, none of these methods are consistently effective in eliminating symptoms. Translational Relevance: Targeted muscle reinnervation (TMR) is a surgical technique involving the transfer of residual peripheral nerves to redundant target muscle motor nerves, restoring physiological continuity and encouraging organized nerve regeneration to decrease and potentially prevent the chaotic and misdirected nerve growth, which can contribute to pain experienced within the residual limb. Clinical Relevance: TMR represents one of the more promising treatments for neuroma pain. Prior research into "secondary" TMR performed in a delayed manner after amputation has shown great improvement in treating amputee pain issues because of peripheral nerve dysfunction. "Primary" TMR performed at the time of amputation suggests that it may prevent neuroma formation while avoiding the risks associated with a delayed procedure. In addition, TMR permits the target muscles to act as bioamplifiers to direct bioprosthetic control and function. Summary: TMR has the potential to treat pain from neuromas while enabling amputee patients to return to their activities of daily living and improve prosthetic use and tolerance. Recent research in the areas of secondary (i.e., delayed) and primary TMR aims to optimize efficacy and efficiency and demonstrates great potential for establishing a new standard of care for amputees.

13.
J Tissue Eng Regen Med ; 11(12): 3523-3529, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28326683

RESUMO

Complex, full-thickness soft tissue defects secondary to large burns, trauma and war-related injuries continue to challenge reconstructive surgeons. To achieve positive surgical outcomes in these patient populations, novel approaches are needed to restore the functional, protective and aesthetic properties of skin. Herein, we provide the first report describing the staged use of a dermal regenerate template (DRT) with a spray-on epidermal regenerative modality (spray skin) in addition to autologous split-thickness skin grafting (STSG) in non-burn trauma and compare these results with those of patients treated with DRT and STSG alone. A pilot study was performed to evaluate whether the use of spray skin technology (ReCell, Avita Medical) as an adjunct to DRT (Integra, Integra Lifesciences) and autologous skin grafting in the treatment of patients with large full-thickness soft tissue losses impacts donor site burden as well as recipient and donor site re-epithelialization. In this retrospective study, two patients who were treated with DRT and STSG alone (control group) were compared with two patients who were treated with DRT and spray skin/STSG in combination (experimental group). The mechanisms of injury, total defect and treatment sizes, time to complete re-epithelialization, lengths of follow-up, outcomes and complications were reviewed. Our group observed that using a DRT in conjunction with spray skin/STSG can reduce donor site burden and decrease time to complete healing. It can also permit greater or larger meshing ratios, while aiding in improved re-pigmentation when compared with similar wounds treated with a DRT and autologous skin grafting alone. Copyright © 2017 John Wiley & Sons, Ltd.


Assuntos
Derme/patologia , Transplante de Pele , Adulto , Humanos , Perna (Membro)/patologia , Projetos Piloto , Regeneração , Adulto Jovem
14.
J Hand Surg Am ; 41(12): e453-e460, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27743751

RESUMO

PURPOSE: To assess the outcomes of treatment with a dermal regeneration template (DRT) in a cohort of combat casualties with severe upper extremity injuries. METHODS: Records of all active duty military patients treated with DRT at our institution between November 2009 and July 2013 were screened. Inclusion criteria were upper extremity open wounds sustained during combat, requiring split-thickness or full-thickness skin grafting for closure. The primary outcome measure was wound healing after the first attempt at definitive treatment (defined as the first application of split-thickness or full-thickness skin graft). Independent variables collected included time from injury to arrival at our facility, mechanism of injury, wound infection, tobacco use, location of wound, number of operative debridements, and patient demographics. RESULTS: A total of 60 patients with 69 wounds met the inclusion criteria. Most wounds were to the wrist or forearm (54%) or fingers (19%). All wounds were heavily contaminated, requiring a mean of 2.5 operative debridements before DRT placement. All wounds treated with full-thickness skin grafting after DRT healed completely without further complication. Split-thickness skin grafting was successful in 96% of patients. CONCLUSIONS: DRT wound dressings are a helpful adjunct in the treatment of contaminated war wounds to the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Traumatismos do Braço/cirurgia , Transplante de Pele/métodos , Pele Artificial , Lesões dos Tecidos Moles/cirurgia , Guerra , Cicatrização/fisiologia , Adulto , Traumatismos do Braço/diagnóstico , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Medição da Dor , Cuidados Pós-Operatórios/métodos , Estudos Retrospectivos , Medição de Risco , Lesões dos Tecidos Moles/diagnóstico , Resultado do Tratamento , Adulto Jovem
15.
Adv Wound Care (New Rochelle) ; 5(9): 403-411, 2016 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-27679751

RESUMO

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.

16.
Adv Wound Care (New Rochelle) ; 5(9): 412-419, 2016 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-27679752

RESUMO

Background: A large volume of service members have sustained complex injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF). These injuries are complicated by contamination with particulate and foreign materials, have high rates of bacterial and/or fungal infections, are often composite-type defects with massive soft tissue wounds, and usually have multisystem involvement. While traditional treatment modalities remain a mainstay for optimal wound care, traditional reconstruction approaches alone may be inadequate to fully address the scope and magnitude of such massive complex wounds. As a result of these difficult clinical problems, the use of regenerative medicine therapies, such as autologous adipose tissue grafting, stem cell therapies, nerve allografts, and dermal regenerate templates/extracellular matrix scaffolds, is increased as adjuncts to traditional reconstructive measures. Basic and Clinical Science Advances: The beneficial applications of regenerative medicine therapies have been well characterized in both in vitro studies and in vivo animal studies. The use of these regenerative medicine techniques in the treatment of combat casualty injuries has been increasing throughout the recent war conflicts. Clinical Care Relevance: Military medicine has shown positive results when utilizing certain regenerative medicine modalities in treating complex war wounds. As a result, multi-institution clinical trials are underway to further evaluate these observations and reconstruction measures. Conclusion: Successful combat casualty wound care often requires a combination of traditional aspects of the reconstructive ladder/elevator with adoption of various regenerative medicine therapies. Due to the recent OIF/OEF conflicts, a high volume of combat casualties have benefited from adoption of regenerative medicine therapies and increased access to innovative clinical trials. Furthermore, many of these patients have had long-term follow-up to report on clinical outcomes that substantiate current treatment paradigms and concepts within regenerative medicine, reconstructive, and rehabilitation care. These results are applicable to not only combat casualty care but also to nonmilitary patients.

17.
Regen Med ; 11(6): 571-87, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27549369

RESUMO

Bone tissue engineering (BTE) intends to restore structural support for movement and mineral homeostasis, and assist in hematopoiesis and the protective functions of bone in traumatic, degenerative, cancer, or congenital malformation. While much effort has been put into BTE, very little of this research has been translated to the clinic. In this review, we discuss current regenerative medicine and restorative strategies that utilize tissue engineering approaches to address bone defects within a clinical setting. These approaches involve the primary components of tissue engineering: cells, growth factors and biomaterials discussed briefly in light of their clinical relevance. This review also presents upcoming advanced approaches for BTE applications and suggests a probable workpath for translation from the laboratory to the clinic.


Assuntos
Doenças Ósseas/terapia , Regeneração Óssea/fisiologia , Osso e Ossos/citologia , Engenharia Tecidual/métodos , Animais , Humanos
19.
Am Surg ; 82(6): 540-5, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27305887

RESUMO

Immediate reconstruction after the surgical treatment of breast cancer has increased in the last decade. The purpose of this study is to use the National Surgical Quality Improvement Program database to analyze long-term trends in breast reconstruction. Women who underwent mastectomy for invasive or in situ breast cancer or prophylaxis between 2005 and 2011 were selected from the National Surgical Quality Improvement Program database. Trends and predictors for reconstruction were explored. In 44,410 women identified, immediate reconstruction increased from 30.0 to 39.6 per cent from 2005 to 2011 (P < 0.001). This trend persisted after adjustment for patient characteristics using multivariate logistic regression [odds ratio (OR) 1.09/year, 95% confidence interval (CI) 1.07-1.10]. Reconstruction type was 77.9 per cent implant, 13.3 per cent pedicle flap, 5.5 per cent free flap, and 3.3 per cent other. Pedicle flaps decreased from 27.1 to 9.2 per cent (P < 0.001), implant-based reconstruction increased from 66.3 to 81.3 per cent (P < 0.001), and free flaps remained stable between 4 and 7 per cent. Independent predictors for reconstruction were young age (stepwise decrease in OR from 1 to 0.02 by decade as age increased from 40 to 80, all P < 0.001), carcinoma in situ (OR 1.51, 95% CI 1.42-1.61), prophylaxis (OR 1.89, 95% CI 1.63-2.19), bilateral resection (OR 2.55, 95% CI 2.42-2.69), and non-Hispanic white race (OR 0.67 for other races, 95% CI 0.64-0.70). Immediate breast reconstruction has steadily increased since 2005 with an associated rise in implant-based reconstruction. Based on these trends, discussion with a reconstructive surgeon should be an early part of the newly diagnosed breast cancer patient's treatment algorithm.


Assuntos
Carcinoma de Mama in situ/cirurgia , Neoplasias da Mama/cirurgia , Mamoplastia/estatística & dados numéricos , Mastectomia/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Implantes de Mama/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Melhoria de Qualidade , Retalhos Cirúrgicos/estatística & dados numéricos , Estados Unidos
20.
J Reconstr Microsurg ; 32(6): 421-30, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26878685

RESUMO

Introduction Photochemical tissue bonding (PTB) uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. In phase 1 of this two-phase study, nerve gaps repaired with bonded isografts were superior to sutured isografts. When autograft demand exceeds supply, acellular nerve allograft (ANA) is an alternative although outcomes are typically inferior. This study assesses the efficacy of PTB when used with ANA. Methods Overall 20 male Lewis rats had 15-mm left sciatic nerve gaps repaired using ANA. ANAs were secured using epineurial suture (group 1) or PTB (group 2). Outcomes were assessed using sciatic function index (SFI), gastrocnemius muscle mass retention, and nerve histomorphometry. Historical controls from phase 1 were used to compare the performance of ANA with isograft. Statistical analysis was performed using analysis of variance and Bonferroni all-pairs comparison. Results All ANAs had signs of successful regeneration. Mean values for SFI, muscle mass retention, nerve fiber diameter, axon diameter, and myelin thickness were not significantly different between ANA + suture and ANA + PTB. On comparative analysis, ANA + suture performed significantly worse than isograft + suture from phase 1. However, ANA + PTB was statistically comparable to isograft + suture, the current standard of care. Conclusion Previously reported advantages of PTB versus suture appear to be reduced when applied to ANA. The lack of Schwann cells and neurotrophic factors may be responsible. PTB may improve ANA performance to an extent, where they are equivalent to autograft. This may have important clinical implications when injuries preclude the use of autograft.


Assuntos
Regeneração Nervosa/fisiologia , Regeneração Nervosa/efeitos da radiação , Processos Fotoquímicos , Nervo Isquiático/lesões , Nervo Isquiático/transplante , Técnicas de Fechamento de Ferimentos , Animais , Modelos Animais de Doenças , Corantes Fluorescentes , Masculino , Músculo Esquelético/inervação , Ratos , Ratos Endogâmicos Lew , Recuperação de Função Fisiológica , Nervo Isquiático/patologia , Nervo Isquiático/efeitos da radiação , Cicatrização/fisiologia , Cicatrização/efeitos da radiação
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