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

Background: Skin and soft tissue infections are commonly encountered in clinical practice, and they are typically responsive to antibiotics and drainage. In most cases, cellulitis can be diagnosed via physical examination by a health care professional, based on the typical appearance of the skin and on symptoms such as redness, swelling, warmth, and pain. However, persistent cellulitis or nonresolving abscesses may require in-depth evaluation. When encountering refractory skin and soft tissue infections, clinicians should consider factors such as nontuberculous mycobacterial infection, underlying osteomyelitis, foreign bodies, and malignancy, among other factors.

Case report: A 65-year-old male underwent 5 incision and drainage procedures at 2 different hospitals over 8 months without resolution of cellulitis. At the patient's presentation to the hospital of the authors of the current report, the authors successfully identified and removed a hidden abscess pocket, resulting in healing.

Conclusion: In cases of recurrent skin and soft tissue infections that are unresponsive to standard treatments, preoperative imaging and hematologic studies are crucial to exclude underlying causes such as malignancy, atypical infections, foreign bodies, osteomyelitis, and hidden abscesses outside the initial surgical field. The current case highlights the importance of a comprehensive intraoperative examination to identify and remove any hidden abscesses to aid in the successful resolution of chronic infection. This report highlights the importance of a thorough approach in managing intricate cases of skin and soft tissue infections when standard interventions are not successful.

Background: Surgical site infection (SSI) is a potential complication of spine surgery and a significant cause of readmission and surgical revision. Furthermore, the presence of comorbidities, along with the rising frequency of spinal surgeries, may result in secondary infections, thereby elevating the risk of these infections and affecting overall health.

Objective: To assess the study authors' approach for preventing and managing postoperative infections in their center and identify the spine surgeries most susceptible to infection.

Materials and methods: The authors conducted a retrospective study of 2559 patients at a single clinical center who underwent various lumbar spine surgeries, including interlaminar device plus diskectomy, diskectomy, interlaminar device plus recalibration, unilateral recalibration, and bilateral recalibration, among others, between March 1, 2015, and March 31, 2023.

Results: Of these 2559 patients, 54 (2.11%) were readmitted due to infection and underwent reoperation. The most common isolated microorganism was Staphylococcus aureus. Infection occurred in 1.9% of instrumentation surgeries and 2.3% of non-instrumentation surgeries; this difference was not statistically significant. Infected patients received empiric dual antibiotic therapy after sampling of the surgical site and before identification of the causative organisms.

Conclusion: The results of this study indicate that comorbidities increase the risk of infection. However, the authors did not find that instrumentation in spinal surgery escalates this risk. Empiric dual antibiotic therapy was effective in managing SSI prior to identification of the microorganisms via culture.

Background: Nontuberculous mycobacteria (NTM) periprosthetic infections after breast augmentation procedures are increasingly common worldwide and should raise suspicion after empirical antimicrobial therapy fails but clinical signs of infection persist. In this case experience, the authors suggest the use of negative pressure wound therapy (NPWT) for NTM-infected wounds to obtain a faster periprosthetic space closure, shorten healing time, and anticipate breast reimplantation.

Case report: This case report describes the successful application of NPWT to manage wound healing after breast removal in a 60-year-old female who underwent secondary breast augmentation 7 years before. The patient presented with an M. abscessus infection of the left breast after lung segmentectomy that persisted post-implant removal and targeted antibiotic therapy. Based on clinical and laboratory findings, the authors opted for a debridement of the periprosthetic space associated to a radical capsulectomy. Application of NPWT for wound drainage and closure allowed a faster recovery, reduced interval from implant removal to reimplantation, and led to a pleasant cosmetic result.

Conclusion: The use of NPWT for wound management after NTM peri-implant infection may help to encourage faster periprosthetic space drainage and closure, thus expediting the timing of a negative culture and breast reimplantation.

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.