Effectiveness of different means of surgically treating cranio-cerebral wounds following whole body x-irradiation of animals

In 184 rabbits experiments it was demonstrated that debridement with suction of the damaged portion of the brain within the macroscopically intact brain tissue and a leak-proof suture undertaken on the 1st and 3rd day following a penetrating skull-brain trauma in irradiated with 400 r and non-irradiated animals prevents heamorrhagic and purulent complications, permits primary healing of the wound, and a nearly 100% survival of the animals. The irradiated animals without debridement died in 67% of cases, non-irradiated--in 43%. Debridement limited to wound debris washing-out failed to free the irradiated animals from purulent complications, but prevented the development of cerebral haematomas, the mortality being reduced to 40%. In the non-irradiated animals such debridement did not alter the mortality figures.     

Normoxic wound fluid contains high levels of vascular endothelial growth factor

OBJECTIVE: To examine the temporal integration of vascular endothelial growth factor (VEGF), which has been shown to be present in wound fluid, with the putatively related processes of wound fluid oxygen content, wound angiogenesis, and granulation tissue formation. SUMMARY BACKGROUND DATA: During cutaneous wound repair, new tissue formation starts with reepithelialization and is followed by granulation tissue formation, including neutrophil and macrophage accumulation, fibroblast ingrowth, matrix deposition, and angiogenesis. Because angiogenesis and increased vascular permeability are characteristic features of wound healing, VEGF may play an important role in tissue repair. METHODS: A ventral hernia, surgically created in the abdominal wall of female swine, was repaired using silicone sheeting and skin closure. Over time, a fluid-filled wound compartment formed, bounded by subcutaneous tissue and omentum. Ultrasonography was performed serially to examine the anatomy and dimensions of the subcutaneous tissue and wound compartment. Serial wound fluid samples, obtained by percutaneous aspiration, were analyzed for PO2, PCO2, pH, and growth factor concentrations. RESULTS: Three independent assays demonstrate that VEGF protein is present at substantially elevated levels in a wound fluid associated with the formation of abdominal granulation tissue. However, the wound fluid is not hypoxic at any time. Serial sampling reveals that transforming growth factor beta-1 protein appears in the wound fluid before VEGF. CONCLUSIONS: The results suggest that VEGF is a prominent regulator of wound angiogenesis and vessel permeability. A factor other than hypoxia, perhaps the earlier appearance of another growth factor, transforming growth factor beta-1, may positively regulate VEGF appearance in the wound fluid.     

Leptospirosis: its diagnostic and treatment characteristics

To close extensive infected wounds and to replace long bone defects, along with other methods a method of graded tissue strain (GTS) has been developed and introduced into practice (246 patients). The method differs from all others in that it requires no transfer of elaborate flaps while replacing soft tissue defects; and no graft or foreign body is introduced externally into the wound in replacing long bone defect. Soft tissue defect is gradually replaced by wound-adjacent intrinsic tissues, the wound is closed by related skin and bone defect is filled by an osseous regenerate which is formed during graded transposition of the osteotomized fragment. At the same time good blood supply and tissue innervation retain, which contributes to their resistance to purulent infection. The analysis of the findings has led to the conclusion that GTS is an indispensible contribution to the development of plastic purulent surgery allowing the anatomic and functional integrity of the diseased segment to be restored.     

Extra- and intrafocal trans-tissue vulnus synthesis and adaptation-reposition units of the device for treatment of wounds

Based on the data available in the literature and their own findings, The authors present a working classification of units for intra- and extrafocal transtissue vulnus synthesis, the so-called wound adapters. The design characteristics make it possible to bring close together and to fix the edges of a wound. Each model is critically evaluated by taking into account the revealed disadvantages and the ways of removing them in further more up-to-date models are considered. Comparative assessment of the closure of various wounds with a wound adapters and via routine suturing showed the benefits of the methods by using the proposed units: they speed up and facilitate technique of suture application, increase atraumacity and asepsis, create conditions for making a precision suture. The positive results of experimental studies and clinical observations suggest that wound adapters are promising in their practical application and that transtissue apparatus vulnus synthesis has considerable opportunity in soft tissue lesions.     

Wound healing and repair: a review of the art and science

This chronological review of the major biological events that occur secondary to injury of mucoperiosteal tissue from either simple surgical wounding or trauma discusses the materials used to repair the compromised tissue surgically. Suturing techniques and post-surgical wound maintenance also are reviewed. The physiological stages of wound healing, factors affecting wound healing, and wound repair techniques are discussed.     

Development of new wound dressing composed of spongy collagen sheet containing dibutyryl cyclic AMP

Although cyclic AMP has been considered to regulate cell proliferation, the mechanism of this function is largely unknown. Recent studies suggest that cyclic AMP promotes the proliferation of skin cells in a dose-dependent manner. An ointment containing dibutyryl cyclic AMP has been used in the treatment of skin ulcers and found to be effective in promoting tissue repair. To search more efficacious wound management, the authors developed a new wound dressing composed of a spongy atelo-collagen sheet containing dibutyryl cyclic AMP. This wound dressing was evaluated in two types of animal tests. One is the application of the wound dressing to a full-thickness skin defect in order to evaluate the granulation tissue formation and the wound size reduction. The wound dressing was found to promote the granulation tissue formation and naturally reduce the wound size. The other test was the application of the wound dressing to the full-thickness skin defect, leaving behind a skin island in a central portion, in order to evaluate the epithelialization. This skin island left in a full-thickness skin defect was extremely enlarged. The enlargement of the skin island seems to be related to the epithelialization from the margin of the skin island as well as by the expansion of a skin island induced by contraction of the developed granulation tissue in the surrounding wound area. These results suggest that an atelo-collagen spongy sheet containing dibutyryl cyclic AMP is effective in promoting the granulation tissue formation and epithelialization.     

A prospective randomized study of wound approximation with tissue glue in circumcision in children

OBJECTIVE: Bleeding and wound infection are the most common complications of circumcision. Cyanoacrylate tissue glue has been claimed to have the advantage of being haemostatic, bacteriostatic and easy to use. The purpose of this study is to assess the feasibility of using the tissue glue in approximation of circumcision wound in children. METHODOLOGY: A prospective randomized trial was carried out on 86 boys consecutively admitted into the Duchess of Kent Children's Hospital, Hong Kong. The results of wound approximation with cyanoacrylate tissue glue and suturing with interrupted 4/0 plain catgut were compared. The operations were carried out by the same surgeon using identical technique except for the wound approximation. The wound was assessed 1 day, 2 days, 3 days, 1 week and 1 month postoperatively. RESULTS: There was no statistically significant difference between the two groups in the rates of wound inflammation, infection, bleeding, dehiscence and cosmetic appearance, but the duration of operation was longer using tissue glue (19.8 min vs 16.5 min, P = 0.002). CONCLUSIONS: We conclude that tissue glue approximation of circumcision wounds in children is a feasible alternative, but it offers no extra advantage when compared to suturing.     

Wound healing of scleral self-sealing incision: a comparison of ultrasound biomicroscopy and histology findings

PURPOSE: The goal of this study was to compare the morphologic findings of wound healing in scleral self-sealing incisions using ultrasound biomicroscopy and histology. METHODS: Using a slit-knife, we made a scleral self-sealing incision in the rabbit eye. At various time points postoperatively, ultrasound biomicroscopy was performed to evaluate wound healing; the eyes then were enucleated and studied histologically. We also performed ultrasound biomicroscopy at various time points postoperatively in patients who received a scleral self-sealing incision during cataract surgery. RESULTS: In rabbit eyes, on days 1 and 2 postoperatively, we detected the scleral wound; thereafter, detection became increasingly difficult. On day 7 postoperatively, the wound was undetectable. By light-microscopic observation, the scleral wound was open at 1 day postoperatively. On day 2 postoperatively, fibrovascular tissue barely extended into the wound; on day 5 postoperatively, connective tissue extended through the full thickness of the wound. On day 7 postoperatively, the connective tissue became dense and aligned with the lamella. In human eyes, using ultrasound biomicroscopy, the scleral incision was detectable until 5 days postoperatively, but undetectable at 7 days postoperatively. CONCLUSIONS: Ultrasound biomicroscopy demonstrates the stages of wound healing of scleral self-sealing incisions. We believe that careful observation is necessary for approximately 7 days following self-sealing incision cataract surgery.     

Suicidality and aggressive behaviour

Delayed wound healing is one of the complications of diabetes mellitus, exhibited by increased wound collagenase and decreased granulation tissues. The current study compared wound healing in normal and diabetic rats, and the effects of topically applied 1% or 3% concentrations of chemically modified tetracycline-2 (CMT-2) on 6-mm circular full-thickness skin wounds healed by secondary intention. On day 7 after wounding, tissues were removed for biochemical analysis and histology. The wound granulation tissue hydroxyproline was less in the untreated diabetic rat with increased collagenase and gelatinase. Treating the diabetic rat wounds with 3% CMT-2 increased the wound hydroxyproline and decreased activities of gelatinase and collagenase. There was a delay in wound filling by granulation tissue in diabetic rats. In CMT-2-treated diabetic rats, the volume of granulation tissue was greater than that in untreated diabetic rats. CMT-2 appears to normalize wound healing in diabetic rats and may be a valuable adjunct in the treatment of chronic wounds.     

Using wound care products to promote a healing environment

Healing is characterized by the synthesis of new tissue and scar formation. Despite the complexity of healing with full-thickness injury, the repair process occurs in a predictable manner. There are four basic principles of wound care: (1) debride necrotic tissue and cleanse the wound to remove debris, (2) provide a moist wound healing environment through the use of proper dressings, (3) protect the wound from further injury, and (4) provide nutritional substrates essential to the healing process. Most importantly, any underlying pathophysiology must be treated or the wound will not heal. Products selected to create a healing environment must be chosen thoughtfully and scientific rationale must support their use. Intensive care nurses have the opportunity to get the patient off to the right start by attending to the basic principles elucidated in this article. Accurate wound assessment and appropriate product choices can promote a healing environment. Intensive care of patients includes differentiating wound types and making appropriate wound care product decisions that ultimately affect patient outcomes.     

Basics of cutaneous wound repair

BACKGROUND: Cutaneous wound repair consists of multiple integrated networks of cell-matrix-cytokine interactions. It is generally believed that a better understanding of these networks will lead to improved care of cutaneous wounds, whether freshly made by the surgeon's scalpel or previously existing and not healing secondary to underlying abnormalities. OBJECTIVE: This review is intended to update the readership in some of the salient aspects of wound repair networks. METHODS: To facilitate the review of multiple integrated networks, cutaneous wound repair was arbitrarily divided into three phases: inflammation, tissue regeneration including re-epithelialization and granulation tissue formation, and tissue reorganization. RESULTS: Throughout the entire process of wound repair it is clear that cells produce or alter various cytokines and extracellular matrix. The cytokines and matrix in turn alter the behavior of the producer cells (autocrine response) or neighbor cells (paracrine response). CONCLUSION: The dynamic reciprocity among cells, cytokines, and matrix material helps explain how integrated wound healing networks are sequential as well as tightly controlled.     

Management of a maxillary canine with dens invaginatus and a vital pulp

A case is presented that demonstrates successful management of a maxillary canine with dens invaginatus (Oehlers' type 3 invagination) with associated chronic periradicular periodontitis and a vital pulp. Debridement and obturation of the invaginated space resulted in resolution of the associated periradicular radiolucency. Pulp vitality was retained after endodontic treatment of the invagination.     

Analysis of the tissue movements of embryonic wound healing--DiI studies in the limb bud stage mouse embryo

The tissue movements of epithelial spreading and mesenchymal contraction play key roles in many aspects of embryonic morphogenesis. One way of studying these movements in a controlled manner is to make an excisional skin wound to an embryo and watch the wound heal. In this paper we report our studies of healing of a simple excisional lesion made to the limb bud stage mouse embryo. The wounded, living embryo is cultured in a roller bottle; under such conditions the wound heals with a highly reproducible time course and is completely closed by 24 hr. During the healing period the environment bathing the wound can be simply manipulated by adding drugs or factors to the culture medium. We have used DiI to label mesenchymal cells exposed at the margin of the initial wound and, by following their fate and measuring the area of mesenchyme remaining exposed at various time points during the healing process, we have quantified both the extent of mesenchymal contraction and the extent of reepithelialisation by movement of epidermis over mesenchyme. We show that the two types of tissue movement contribute almost equally (50:50) to the total wound closure rate. We have gone on to investigate the cell machinery underlying these processes. In adult wounds the epidermis migrates by means of lamellipodial crawling, but we show that reepithelialisation in the embryo is achieved instead by purse-string contraction of a cable of filamentous actin which assembles in the basal layer of cells at the free edge of the epidermis. Addition of cytochalasin D to the culture medium blocks formation of this actin cable and leads to failure of reepithelialisation. Contraction of adult wound connective tissue appears to be driven by conversion of dermal fibroblasts into a specialist smooth muscle-like fibroblast, the myofibroblast. However, using an antibody recognising the alpha-isoform of smooth muscle actin and specific for smooth muscle cells and myofibroblasts, we show that a similar conversion into myofibroblasts does not occur at any stage during the embryonic wound healing process. These observations indicate that both of the tissue movements of embryonic wound healing utilise cell machinery fundamentally different from that driving the analogous tissue movements of adult healing.     

Complications with infection and foreign body reaction after silicon implant arthroplasty in the second metatarsophalangeal joint in an adolescent: a case report

A 21-year-old otherwise healthy male was referred to our clinic due to severe pain, deformation, development of fistules, and swelling of the second metatarsophalangeal joint of the right foot. He presented a history of two previous operations. At the age of 13, a 2-cm. resection of the distal part of the proximal phalanx was performed due to severe hammertoe deformity. At the age of 19, a partial phalanx resection and implantation of a silicon elastomer ball-shaped joint spacer was performed due to second metatarsophalangeal joint instability. After this operation, the patient suffered from fistules that appeared in the second metatarsophalangeal region. Following referral to our clinic, the patient was operated on. The proximal phalanx was removed along with the prosthesis which had slipped from the metatarsophalangeal joint into the proximal phalanx with the ends of the prosthesis perforating the skin. Debridement of infected tissue and implantation of gentamicin containing beads were performed. Bacterial specimens revealed growth of coagulase-negative staphylococci. Microscopic examination of the debrided tissue showed signs of acute and chronic inflammation. Postoperatively, the patient was treated with antibiotics and healing was uneventful. This case advocates the need for proper selection criteria and strict indications in patients with joint disease needing an arthroplasty.     

Wound healing microbiology

The relationship between wound healing and cutaneous microbiology is a complex one mediated by the type of wound, its treatment, and the defense mounted by the injured individual. Acute wounds harbor microflora similar to that of noninjured skin. "Dirty" traumatic wounds or chronic wounds with devitalized tissue offer more opportunity for microflora colonization, with the potential for bacterial adherence to the host cells and ultimate invasion into viable tissue or infection. The alterations of these wound environments can be brought on by topical treatments. Occlusive dressings with various moisture vapor transmission rates can provide a wound environment suitable for microflora proliferation. In spite of this increase in numbers of organisms, most wounds do not become infected, as shown by a survey of published trials. Infection requires the proper pathogenic microorganism, its attachment, and subsequent multiplication. To cause an infection, an organism must invade viable tissue and evade the host defense response. The many occlusive dressing types available offer an opportunity to select a wound therapy tailored for the microenvironment most suitable for healing. Wounds can be protected from exogenous microfloral contamination with dressings. Some dressing types, such as hydrocolloid dressings with no moisture vapor transmission, should not be used on chronic wounds suspected of harboring anaerobic organisms. Other typical treatments, such as antiseptics, can injure tissue and make infection more probable, providing devitalized tissue for bacterial adhesion. Povidone-iodine solution has been shown not be efficacious, whereas povidone-iodine cream effectively limits bacteria and infection.(ABSTRACT TRUNCATED AT 250 WORDS)     

Basic fibroblast growth factor (b-FGF) in the perimatrix of cholesteatoma

The growth of a cholesteatoma requires angioneogenesis in the connective tissue of the perimatrix. Angioneogenesis is also needed for wound healing as a host response to tissue injury. Normal wound repair is conducted through a wide number of growth factors. Basic fibroblast growth factor (b-FGF) plays a pivotal role in wound repair. This cytokine exerts its effects through stimulation of a wide range of target cells. B-FGF is chemotactic and mitogenic for fibroblasts, endothelial cells and keratinocytes. In addition, b-FGF can stimulate the production of collagenase and plasminogen activators to enhance fibroblast proliferation and angioneogenesis. Its necessity for normal wound repair has been confirmed by several workers. METHOD: In order to demonstrate angioneogenesis in the cholesteatoma perimatrix the distribution of b-FGF as the pivotal cytokine of the process was investigated in the perimatrix of 18 cholesteatoma specimens. RESULTS: B-FGF could be observed in 12 of 18 specimens (66%) in close approximation to histological signs of inflammation and wound healing. Areas with b-FGF also exhibited proliferation of the covering squamous epithelium. Cholesteatoma matrix tissue without inflammation or any sign of wound healing did not express b-FGF (6 of 18). CONCLUSION: Histological changes and distribution pattern of b-FGF in the perimatrix of cholesteatoma in the present study indicate that the perimatrix cells and substances of the wound healing cascade may play an important role in cholesteatoma development, angiogenesis and growth.     

Reduction of wound healing problems after median sternotomy by use of retention sutures

Obese people have a higher risk of sternal wound dehiscence resulting from traction of suprasternal tissue. In such patients we recommend the use of retention sutures with extracorporeal plates to improve tissue connection and to disburden fascia and skin sutures. This augmented closure is simple and effective and, since 1996, has prevented wound healing problems in more than 50 patients with a body mass index greater than 27.     

Human wound contraction: collagen organization, fibroblasts, and myofibroblasts

The closure of ungrafted sacrococcygeal pilonidal sinus excisional wounds was studied in 15 patients. Wound punch biopsies were taken on a regular basis, and histologic sections were made. To document changes, computer-assisted morphometric image analysis was employed. Initial average wound depth was 37.8 +/- 4.6 mm, and complete closure (0 wound depth) was reached by 68 days. Wound contraction contributed 88 percent to wound closure, whereas the deposition of scar only contributed 12 percent. Maximum cells density within granulation tissue was reached by day 18. Myofibroblasts, identified by alpha-smooth muscle actin immunostaining, first appeared on day 11. Unlike those observed in laboratory animals, myofibroblasts were a minor cell population of granulation tissue, never exceeding 10 percent of the cells. The pattern of collagen fiber organization was documented by polarized light microscopy of Sirius red-stained sections. Early granulation tissue collagen fibers demonstrated a fine greenish birefringence, whereas more mature granulation tissue collagen fibers were thicker, displaying orange-yellowish birefringence. Myofibroblasts were associated exclusively with thicker collagen fibers, whereas fibroblasts were associated with both fine and thick collagen fibers. It is proposed that human wound contraction involves a volume change whereby normal dermal and adipose tissues are pulled into the defect by forces generated within fibroblasts.     

Doppler velocimetry of growth-restricted fetuses in an ovine model of placental insufficiency

Crush syndrome is the severe systemic manifestation of prolonged muscle compression and compartment syndrome. Careful patient assessment, early diagnosis, and aggressive treatment are vital to prevent multiorgan failure and death. Medical management of systemic complications, along with operative procedures of fasciotomy and debridement, are indicated with accompanying compartment syndrome. Debridement of necrotic and nonviable tissue is necessary; significant risks of infection and hemorrhage remain until the wounds can be subsequently closed or covered with skin graft. Crush syndrome and muscle necrosis in a closed injury without compartment syndrome may be followed clinically until healing or demarcation of a gangrenous part occurs, providing the patient's general medical condition, including renal function, can be maintained. Fasciotomy and hyperbaric oxygen will not reverse necrosis of muscle in the absence of compartment syndrome and therefore do not affect outcome of the extremity. Overall, prognosis is improved by early diagnosis and treatment, but outcome of the crushed extremity is poor and Volkmann's contracture often results.     

Bite injuries in the head and neck area

In Germany about 8500 dog-bite injuries in the face occur every year; more than 50% of the victims are infants and schoolchildren. Besides dogs, other animals such as cats or horses may be responsible for these accidents. Even human bites are reported. The predominant areas are the nose and the auricles. The tissue defects may be superficial, but they can even cause amputations, including severe vascular and nerve or bony destruction. Systemic antibiotic therapy is needed when the wound is infected. The surgical approach to bite injuries includes local wound cleansing, careful excision of necrotic tissue and primary closure of the wound whenever possible. Regarding the importance of surgery in the head and neck area plastic-reconstructive techniques including autologous transplantations and various local or regional flaps should be used at the time the wound is first repaired.