Wounds : a compendium of clinical research and practice最新文献

Background: Exposed cranial bone can present a considerable challenge to the reconstructive surgeon. Removal of the outer cortex of exposed skull bone has proven effective in the management of complex scalp wounds for which traditional reconstruction efforts were limited.

Objective: To demonstrate a simplified approach for management of scalp wounds with exposed skull.

Methods: Chronic wounds with exposed skull bone in elderly patients who were poor candidates for complex reconstructions were treated with removal of the exposed, outer bone cortex. The wounds involved desiccated, exposed bone and sites of superficial osteomyelitis with surrounding thin, atrophic skin that negated local skin flap reconstruction. Conscious sedation and local anesthesia were used during outpatient procedures. A rotating drill with a grinding burr was used to remove the outer cortical bone. The uncovered medullary bone was managed conservatively with moisturizing ointments and light dressings. The patients were followed as outpatients to document progress of wound healing. Skin grafting was not used.

Results: Eight patients with exposed skull after treatment for invasive skin cancers were treated with removal of the outer cortex in the areas of exposure. The patients were elderly (mean age, 83 years), had numerous medical problems, and were poor candidates for complex surgery. Osteomyelitis was present in 3 patients. Seven patients with scalp wounds were successfully treated with cortical craniectomy, including a 92-year-old female with a large defect. A different female patient, with recurrent squamous cell carcinoma of the forehead after radiation, experienced disseminated cancer, and her wounds did not heal.

Conclusion: Exposed skull bone is prone to desiccation and subsequent osteomyelitis if left untreated. Complex reconstructions may not be appropriate in many situations. Atrophic scalp skin, radiation injury, and scarring from previous skin cancer surgery often limit local skin flap options. Cortical craniectomy of the exposed skull bone is a simple, local technique that allows for healthy granulation tissue to develop. Conservative wound therapy ensuring a moist environment allows for secondary wound healing. Skin grafting may be used after a vascular base develops to shorten healing time.

Background: Peristomal pyoderma gangrenosum (PPG) is a critical complication after surgical ileostomy or colostomy placement. While topical treatments are often effective, most of the available vehicles reduce ostomy pouch adhesion. There are no commercially available corticosteroid powders for topical application; however, using powder from crushed corticosteroid tablets or capsules may circumvent this issue.

Objective: To evaluate the safety and efficacy of topical corticosteroid powders to treat PPG.

Methods: This review was registered with the international prospective register of systematic reviews (PROSPERO) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and Embase databases were searched from inception to October 23, 2023, using keywords "crushed", "powdered", "tablets", "capsules", and "pyoderma gangrenosum."

Results: Of 54 results identified, 5 studies comprising 3 case reports and 2 case series met the eligibility criteria. Risk of bias was assessed using Joanna Briggs Institute critical appraisal checklists. The 5 studies included a total of 13 patients. Twelve of 13 patients (92.3%) achieved complete wound healing, a decrease in pain, and improved pouch adherence. No side effects were reported.

Conclusion: Crushed corticosteroid tablets and powder from capsules are potentially useful forms of topical therapy for PPG because of their efficacy and ability to facilitate pouch adhesion. However, there is limited evidence, and future randomized clinical trials are necessary to confirm the findings.

Background: Chronic or hard-to-heal wounds fail to proceed through an orderly and timely healing process, resulting in a lack of anatomic and functional integrity. Infection is a common driver of nonhealing processes; therefore, infection prevention and management are essential components to healing chronic wounds. Inexpensive specialized cleansers, such as pure hypochlorous acid (pHA), can be used to cleanse vulnerable wounds to reduce microbial burden, thereby reducing the risk of infection and significantly decreasing the likelihood of the patient developing a costly wound complication.

Objective: To report the findings of an expert panel composed of 10 health care professionals (HCPs) from diverse medical specialties convened to discuss the use of pHA in various care settings.

Methods: During the panel discussion, experienced HCPs presented specific case examples in which pHA was used, along with associated costs.

Results: A major theme of the panel discussion was the widespread benefit of pHA across various types of wounds and wound care settings. In addition, the patient cases illustrated a negligible economic impact of pHA coupled with positive effects on patient outcomes. This work did not include the development of a consensus statement.

Conclusion: Together, the information presented in the panel discussion supports pHA as a dominant strategy (more effective, less costly) compared with standard wound management practices in many treatment settings.

Background: Calciphylaxis is a rare and life-threatening condition characterized by cutaneous necrosis resulting from vessel calcification and thrombosis. Commonly associated with end-stage renal disease and hyperparathyroidism, calciphylaxis presents as retiform purpura evolving into necrotic eschars.

Case report: This report details an atypical case of non-nephrogenic unilateral bullous calciphylaxis in a 71-year-old female, emphasizing the importance of considering calciphylaxis in the differential diagnosis of bullous disorders. The patient's presentation included hemorrhagic bullae on the left leg, prompting a challenging differential diagnosis. Diagnosis was confirmed by skin biopsy, highlighting the role of confirmatory biopsy in atypical cases such as this, with a broad differential diagnosis. Treatment involved intravenous sodium thiosulfate infusions and wound care, resulting in significant improvement after 6 months.

Conclusion: This case underscores the diagnostic complexity of bullous calciphylaxis, and clinicians are urged to consider this condition in patients with painful bullae and retiform purpura. Early recognition is crucial for initiating prompt intervention and improving outcomes in patients with this high-mortality disease.

Background: Negative pressure wound therapy (NPWT) has significantly transformed wound care, particularly the management of complex injuries and unresponsive wounds. Crush injuries from road traffic accidents pose intricate challenges due to their severity, often requiring multimodal interventions. NPWT accelerates healing by stimulating tissue formation and reducing inflammation; however, its use necessitates careful patient selection and wound assessment for potential complications.

Case report: A 16-year-old male sustained catastrophic crush injuries involving extensive soft tissue damage, bone exposure, bowel perforation, and genitourinary trauma in a vehicular accident involving a farm vehicle run-over event. The patient received various interventions, including NPWT combined with tension sutures for wound management. The case highlights the multidisciplinary approach required to manage primary wounds and complications. NPWT facilitated granulation tissue formation, aiding wound closure without necessitating alternative methods such as skin grafting or flap coverage.

Conclusion: This case underscores NPWT's effectiveness in the management of severe crush injuries. While successful wound closure was achieved, as of this writing postoperative-recovery challenges persist, emphasizing the importance of multidisciplinary care in long-term recovery. The case reaffirms NPWT as a valuable option in managing extensive injuries resulting from road traffic accidents.

Background: With the increase in lithium-ion battery-powered technology, clinicians have observed an increase in burn injuries. Typically, these injuries come from malfunctions in e-cigarettes, e-scooters and bikes, and even mobile phones. To the best of the authors' knowledge, this is the first reported case of a patient burned by the lithium-ion battery pack on an electric sock, which is commonly worn by skiers, snowboarders, and winter hikers.

Case report: The patient presented shortly after the initial injury with a full-thickness burn with eschar and surrounding cellulitis. He was treated with oral antibiotics, surgical excision in clinic, and local wound care. The patient was offered surgical wound closure but opted to continue local wound care. Although slow, the patient saw complete wound closure in approximately 3 months with minimal scarring and no further complications.

Conclusion: With lithium-ion technology on the rise, it is important to understand the risks and care necessary to keep these devices safe for everyday use.

Background: Enteroatmospheric fistula (EAF) is an abnormal communication between the gastrointestinal tract and the atmosphere. This phenomenon is still considered one of the most significant challenges faced by general surgeons after abdominal surgery. Primary goals of managing EAF include controlling and diverting intestinal contents outside the abdominal cavity, protecting surrounding tissues from retraction, and promoting wound healing. Achieving these goals is not easy. EAF has a 40% mortality rate. Several techniques have been proposed for managing this problem, including negative pressure wound therapy. The use of bladder catheters, nipples, endoscopic stents, vascular grafts, and fistula funnel, among other options, in the management of EAF has also been described.

Case report: The patient in the current report underwent Hartmann reversal surgery. On postoperative day (POD) 5, he had an anastomotic leak with ischemia of the descending colon and the transverse colon. Resection of the ischemic colon was performed, followed by creation of a terminal ileostomy on the last ileal loop on the right side. The first small orifice of EAF appeared on POD 23, the second on POD 28, and the third on POD 45. On POD 253, the patient underwent resection of the fistulated loop, extensive vitreolysis of the entire small intestine, and mechanical jejunojejunal laterolateral anastomosis to reestablish the canalization toward the previous terminal ileostomy on the right side. Complete closure of the skin was evident on POD 358.

Conclusion: There is no ideal treatment approach that is valid for all cases of EAF. Spontaneous closure of an EAF is unlikely but feasible in the setting of a single, deep lesion with limited output and when intestinal continuity is preserved.

Background: Cadaveric skin grafts were initially used for the management of acute burn wounds. The biological coverage of the wound improves the quality of the wound bed, which prepares it to receive an autologous skin graft. The benefits of cadaveric skin graft in burn wounds have led to its use in the management of acute and chronic wounds of diverse etiologies.

Objective: To evaluate the use of cadaveric skin graft and subsequent autologous split-thickness skin graft (STSG) in the management of wounds of diverse etiologies at a single institution.

Materials and methods: A retrospective analysis was performed of patients with wounds of different etiologies managed with cadaveric skin grafts followed by a second procedure in which autologous STSG was performed from May 2017 through May 2022 in the Plastic and Reconstructive Surgery Department of German Hospital, Buenos Aires, Argentina.

Results: A total of 25 patients with wounds of different etiologies were included. The mean affected body surface area (BSA) was 1.87%. The mean engraftment percentage of the cadaveric skin graft was 96.6%. The mean engraftment percentage of the STSG was 90.6%. All patients demonstrated improvement in local edema and inflammation, reduced secretions, and reduced pain after treatment. Two patients (8%) had complications, with 1 case of delayed healing of the donor site and 1 case of hypertrophic scarring.

Conclusions: Cadaveric skin graft with subsequent STSG is a simple, safe, and effective alternative for the management of complex wounds of diverse etiologies. This technique is particularly useful in patients with multiple comorbidities who are at risk of recurrence and of developing multiple wounds during their lifetime.

Background: Acute and chronic wounds in the acute hospital setting are commonly managed with soft silicone multilayer foam dressings (SSMFDs). While many SSMFDs are indicated for wear time of up to 7 days, they are often changed more frequently.

Objective: To use real-world data on dressing change practices and clinical outcomes to examine whether a built-in indicator on a proprietary SSMFD could reduce unnecessary dressing changes.

Materials and methods: Health care professionals (HCPs) were screened and recruited from a health care research panel to complete per wound data capture forms. Outcomes reported included dressing wear time, healing rates, dressing change frequency, user satisfaction, and adverse events. Outcomes were reported as an aggregated data set.

Results: A total of 53 wounds were analyzed. The mean treatment period was 23.83 days, which included dressing changes every 2 to 3 days on average. Of the 53 cases analyzed, the unique change indicator on the SSMFD was used to guide dressing change frequency 98% of the time. Overall, 21% of wounds completely healed (n = 11), 70% (n = 37) showed improvement, 9% (n = 5) were static, and 0% deteriorated.

Conclusion: Real-world data on use of the proprietary SSMFD in an acute setting indicates that the SSMFD can allow for the optimization of dressing change protocols to enable appropriate dressing change frequency, allowing for undisturbed healing and maximizing HCP and dressing resources.

Background: Venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs) are examples of chronic wounds that pose an ongoing health care challenge. Despite significant progress in managing such wounds, challenges persist that require innovative solutions. Cellular, acellular, and matrix-like products (CAMPs) are advanced therapies designed to facilitate chronic wound healing. Polylactic acid (PLA) is a synthetic material used in alloplastic CAMPs that has shown promise in the management of burns and traumatic injuries.

Objective: To retrospectively assess the effect of PLA in promoting chronic wound healing compared with 2 other well-established CAMPs.

Materials and methods: This retrospective chart review, which was conducted in 3 high-volume wound care clinics, aimed to compare the efficacy of 2 advanced wound care products vs a PLA alloplastic CAMP in promoting DFU and VLU closure. The study included 131 wounds treated with a non-CAMP collagen dressing, fish skin grafts (FSGs), or PLA matrices. Inclusion criteria included single Wagner grade 1 or 2 DFUs or Clinical-Etiology-Anatomy-Pathophysiology classification score C6 VLUs, present for at least 12 to 52 weeks, and measuring between 1 cm² and 20 cm². Patients received weekly treatments with 1 of 3 CAMPs, along with standard care. The primary outcome was time to achieve full healing, and the secondary outcome was the proportion of ulcers healed at 12 weeks.

Results: The PLA alloplastic CAMP demonstrated superior outcomes, with a 50% and 20% reduction in time to heal DFUs compared with collagen dressings and FSG, respectively (P < .001). For VLUs, PLA exhibited even more impressive results, achieving 95% and 40% reduction compared with collagen and FSG, respectively (P < .001). PLA allografts displayed a 55% higher rate of full healing by 12 weeks compared with collagen dressings, and a 26% higher rate compared with FSG (P < .001).

Conclusion: This study highlights the unique attributes of PLA for achieving wound closure. PLA-based alloplastic CAMPs are promising treatments, offering rapid healing, increased closure rates, and multifaceted benefits for wound healing.