Successful Management of Post-Excisional Biopsy Dehisced Wound with 1% Framycetin Sulphate and Ozonated Oil Adjuvant: A Case Report

Wound dehiscence after spinal instrumentation presents a challenging problem to the surgeon.[1][1]–[8][2] Soft-tissue complications after operation are most commonly seen in patients with poor nutritional status, in the presence of injury to the spinal cord, following multiple operations and in

Modern war ballistics and blast injuries inflict devastating extremity injuries, violating soft tissue, bone, and neurovascular structures. Despite advances in complex wound management, appropriate timing of war wound closure remains subjective. In addition, the pathophysiology of acute wound failure is poorly defined. Patients with penetrating extremity wounds sustained during combat were prospectively studied and followed for 30 days after definitive wound closure. The primary outcome was wound healing. Wound dehiscence was defined as spontaneous partial or complete wound disruption after closure. Serum, wound effluent, and wound bed tissue biopsy were collected at each surgical wound debridement. Serum and wound effluent were analyzed with a multiplex array of 22 cytokines and chemokines, and wound tissue for corresponding gene transcript expression. Fifty-two penetrating extremity war wounds in 33 male patients were investigated. Nine (17%) wounds dehisced. Concomitant vascular injury, increased wound size, and higher injury severity score correlated with wound dehiscence. Both serum and wound effluent cytokine and chemokine protein profiles were statistically associated with healing outcome at various time points. Wound biopsy gene transcript expression demonstrated increased tissue inflammation associated with wound failure. Multiple protein and gene transcript biomarkers predictive of wound healing were identified. The cytokine and chemokine protein and gene transcript expression patterns demonstrate a condition of inflammatory dysregulation associated with war wound failure. A molecular biomarker panel may predict combat wound healing outcome and warrants prospective validation.

Chronic wounds affect more than 6 million people annually in the Unites States alone, and the cost to the healthcare system is an estimated $25 billion 1. Despite recent technology advances in tissue engineering and drugs, more cost-effective treatments are needed. With approximately 5 million hair follicles (HF) 2 continuously generating hair over the body, is it possible to harness this growth potential in wound management? Jimenez et al. 3 Exp Dermatol 2014 provide compelling reasons to engender hope, guiding us first through basic science research supporting the role of HF in wound healing, the influence of hair cycling, follicular stem cells (FSC) and signalling to HF neogenesis, and then providing examples of currently available hair-related therapies in wound management. Hair follicles display a unique, lifelong cycling process, regulated by complex ectodermal–mesenchymal interactions. HF phases include the anagen (rapid growth), catagen (apoptosis driven regression) and telogen (relative resting), and FSC play an important role in this process. FSC reside in different parts of the HF, and the importance of FSC in wound re-epithelization has been described as a dichotomic process, at least in mice. Initially, a rapid and transient influx of bulge FSC (Krt15+) contribute to early re-epithelization; these are later replaced by a long-lasting population from the isthmus (Lgr6+, Gli1+ and Lrig1+) 4. For more details, see Table 1 and Fig. 1. Additionally, Reynolds et al. in a previous issue of Exp Dermatol found that dermal sheath cells also have a FSC role. Both upper and lower dermal sheath cells are incorporated into the neodermis after skin wounding, but only dermal sheath cells from the lower dermis are assimilated into HF 5. Recently, HF neogenesis in the centre of large wounds has been described after wound re-epithelization. Despite the fact that neo-HF have a prominent Krt15+ population, the origin of these neo-HF and their stem cells (SC) does not appear to come from Krt15+ bulge SC of pre-existing hairs. The exact origins of these neo-HF and from which particular SC populations they originate are not clear, but cellular and molecular markers suggest that they are derived from Lgr6+ FSC 7. As generation of neo-HF is not solely an epithelial process, an intact dermal papillae is required for HF neogenesis, suggesting complex mesenchymal–epithelial interactions are at play 5. These complex mesenchymal–epithelial interactions are the types of interactions seen during wound repair. Plikus et al. 8 recently reported in Exp Dermatol that as opposed to the epigenetic regulation of the interfollicular epidermis, FSC exhibit a greater degree of flexibility in the generation of different hair cell types. This malleability supports the role of FSC in wound healing and highlights their potential for therapeutic benefit. As pointed out by Jimenez et al. 9, despite the increasing knowledge regarding the role of HF in wound healing and clinical observations that wounds in high hair density areas heal faster than those in nonhair-bearing or less hairy areas, only selected reports utilizing hair-derived treatments exist. Among these, the generation of epidermal autografts derived from outer root sheath (Epidex®; EurodermBiotec& Aesthetics, Stutgart, Germany) found comparable efficacy in treatment of recalcitrant leg ulcers to the well-established method of split-thickness-meshed skin grafting, with fewer patients having treatment failure 10. More recently, Lough et al. 11, using a murine model, transplanted Lgr6+ FSC in a hydrogel vehicle, comparing this to hydrogel alone, and found that wound beds that received Lgr6 FSC demonstrated increased epithelization, hair growth and angiogenesis. Although promising and supportive of the HF potential for wound healing, these technologies are not necessarily simple or inexpensive. In a more practical approach, Jimenez et al. 9 previously compared punch skin grafts derived from hair-bearing skin to nontreated areas in refractory leg ulcers. They reported superior healing with greater wound size reduction (27% vs. 7% at 18 weeks), improved granulation tissue appearance and wound border reactivation in the areas that received hair-bearing skin grafts. We have also seen improved healing with hair-bearing skin grafts, observing increased healing in wounds treated with skin grafts derived from hair-bearing areas (scalp) compared with skin grafts derived from nonhair-bearing (back) skin, and control areas (Baquerizo Nole et al. Submitted for Publication). Autologous skin grafts, often used in the treatment of refractory wounds, have a variable success. Never subjected to testing in a randomized fashion, meshed split-thickness skin grafts, for instance, have been reported to achieve healing in 50% to 75% of cases in large clinical series 12. Improvement of skin grafting techniques such as use of optimal donor tissue such as hair-bearing skin with high density of HF and FSC might be able to better promote healing rates without increasing donor site morbidity. HF may be ideal as skin grafting donor areas, given that hair-bearing skin heals rapidly with minimal scarring, and their potential superiority due to the presence of FSC. Given the perceived importance of FSC in healing, it is not surprising that the hair cycle phase influences wound healing, with faster healing with the use of HF in anagen phase as opposed to telogen phase 3. This suggests follicular grafting may be optimized to even a greater extent by taking hairs in anagen phase for grafting, perhaps identified by dermoscopy or other imaging techniques. As wounds increase in incidence and prevalence with age, it is important to note that ageing does not alter the density of FSC, nor does it decrease the bulge cell DNA content per hair follicle; this compares favourably to the likely reduced proliferative capacity of the interfollicular epidermis 10. Emerging technologies may improve cellular persistence of currently available allogeneic cellular tissue-engineered products, but this prolonged persistence may allow graft rejection to occur. Graft rejection is not typically a consequence of the current products. However, using lower dermal sheath cells may present a mechanism to bypass immune surveillance, as these cells are thought to be immune privileged 5. Thus, the use of allograft fibroblasts derived from the lower dermal sheath potentially may allow enhanced persistence without rejection. Given the great availability of FSC, easy access to tissue containing FSC and the advantages over interfollicular SC, therapeutic potential exists for a variety of conditions, including non/slow healing wounds, large wounds and epidermal depigmenting disorders, among others 2. Emerging research will further elucidate the role of HF in wound healing and perhaps create innovative technologies to improve healing or optimize existing therapies already in use. KLBN wrote the initial draft and RSK reviewed the manuscript. None reported. The authors have declared no conflicting interests.

Exposure of the tibialis anterior (TA) tendon with wound dehiscence after total ankle arthroplasty (TAA) with the anterior approach is a problematic complication, especially in rheumatoid arthritis (RA) patients. Once the TA tendon is exposed, the duration of wound healing is prolonged, and it could be a risk factor for deep infection. Thus, early resection of the TA tendon was evaluated for tendon exposure with wound dehiscence after TAA in RA patients. In this case report, three rheumatoid ankles that showed wound dehiscence with exposure of the TA tendon after TAA with the anterior approach are presented. Early resection of the TA tendon and debridement under local anesthesia were performed within two days after wound dehiscence. In all cases, wound healing was completed within two weeks after the treatment. Drop foot was not seen in any patients, and there was no difference between the preand postoperative (1 year after TAA) range of dorsiflexion. Muscle strength for ankle dorsiflexion was also maintained. In conclusion, early resection of the TA tendon appears to be a useful option for undesirable tendon exposure with wound dehiscence to prevent deep infection and prolonged wound healing after total ankle arthroplasty in RA patients.

We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February2021. We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data. Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute. Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure. This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.

Abstract. between the morphological and functional state of spinal ganglia neurons and the dynamics of healing of a purulent wound in an experimental animal during its natural course and complex therapy with hydropulse sanitation (HIS) and the addition of platelet-rich blood plasma (PRP). Material and methods. In an experiment on 100 white outbred rats, a purulent wound on the lateral surface of the thigh was modeled by introducing a daily culture of Staphyllococcus aureus. Two groups were formed: natural healing and healing after therapy with hydropulse sanitation of the wound with an isotonic NaCl solution followed by the addition of platelet-enriched autoplasma. The material for the study was taken on the 1st, 3rd, 5th, 7th, 14th, and 21st days. The area of the wound and the dynamics of its healing were assessed using the planimetric method. For the study, lumbar spinal ganglia (SG) of segments LIII–LV. were taken. At the light-optical level, after staining with cresyl violet according to Nissl and azure B according to the S. Shea method, the area of nerve cells was measured, photometry of RNA content was carried out, and the number of satellite gliocytes was counted. The obtained data were processed using statistical analysis methods. Results. The healing process of a purulent skin wound ended with the formation of a scar on days 7–14 for both experimental groups. The use of GIS and PRP demonstrated better dynamics of defect closure - a reduction in wound area by 59.35±3.4% (p=0.018) in the period from 3 to 5 days, compared with 40.05±2.9% (p=0.009) with natural healing. The response of SG neurons during healing was characterized by pronounced polymorphism. The maximum number of cells with reactive changes during natural healing was observed on the 5th day of the experiment (17.2±3.2% for A-neurons and 36.7±4.3% for B-neurons). Complex therapy led to a decrease in the proportion of both reactively altered and destructive neurons. The cell area, RNA content, and the number of satellite glia increased on average by the 7th day of the experiment. Separate close correlations were identified between the dynamics of changes in the wound area and the studied quantitative characteristics. Conclusion. A purulent wound causes a complex of nonspecific reactions in the neurons of the SG. In the dynamics of wound healing, neurons with reactive changes more often demonstrated biphasic dynamics, more pronounced for B-type cells with a primary reaction on days 1–3 and a further transition to regenerative hypertrophy or destruction. Regenerative changes in SG neurons had a close correlation with the processes of regeneration of the wound defect.

Hyperbaric oxygen therapy for complex wound management following breast cancer treatment: Single institution 10-year experience.

The effectiveness of different fasciotomy wound management treatment options following acute compartment syndrome: A systematic review protocol

The incidence of wound infection and dehiscence following childbirth-related perineal trauma: A systematic review of the evidence

Background: Dehiscence of the wound is an infrequent complication following total knee arthroplasty (TKA); numerous risk factors are responsible for this. This study aims to represent a case who underwent TKA, was infected with coronavirus disease-2019 (COVID-19) soon afterward, took corticosteroid as an immunosuppressive agent to resolve COVID-19 symptoms, and presented with wound dehiscence with minor trauma in early postoperative follow-ups.
 Case Report: A 62-year-old man underwent TKA, and soon after discharge from the hospital, he was hospitalized with COVID-19. A corticosteroid was started for the patient, and a traumatic impaction occurred on his operated knee after he fell in the hospital. As a result, wound dehiscence was performed on the operated knee.
 Conclusion: Numerous risk factors such as diabetes mellitus and corticosteroid consumption are implicated as known risk factors for wound dehiscence after TKA, which must be followed precisely to prevent the unfortunate development of such complications. Postoperative care must be considered in patients at risk for wound dehiscence. In the presented case, wound management was fulfilled with proper timing of irrigation and debridement without any prosthesis component exchange.

Relevance. The choice of the method for purulent wound management (open or closed) is a relevant problem in surgery. The way of drainage is the fundamental factor of the effect on the wound. The open-drainage systems are most frequent in maxillofacial surgery, and the drain is passive, combined with various drug administration. It has significant drawbacks: the short action of the injected substances, painful dressing changes, long wound healing time, etc. The instillation drainage therapy is not widely available and is used only in clinics with appropriate equipment. Active draining (negative pressure suction drainage system) allows closed wound management. Though, it is still rarely used in maxillofacial surgery.Purpose. The study aimed to increase the effectiveness of the treatment of maxillofacial purulent wounds formed after the incision of odontogenic soft tissue purulent inflammatory processes using negative pressure wound therapy.Material and methods. The study was a comparative analysis of clinical and laboratory indicators of 303 patients with purulent wounds formed after incision of superficial cellular spaces’ abscesses and phlegmons. The patients formed two groups: the main group had negative pressure wound therapy (NPWT), and the comparison group had wound treatment with the traditional open method. NPWT methodology included the tubular drain placement into the purulent cavity formed after the incision and administration of a surgical film on the wound. The distal tube end was attached to a vacuum source that simultaneously was a canister for exudate collection and analysis. We followed up on clinical manifestations and endointoxication indicators and studied the wound content toxicity and the dynamics of the respiratory enzyme succinate dehydrogenase activity.Results. The negative pressure system appears to allow fast and atraumatic wound management, reducing the inflammatory stage of the wound healing process, promoting quick normalization of endointoxication parameters, which improves the patient’s general condition (fast resolution of the clinical signs), and the effect of vacuum-assisted closure allows avoiding secondary wound closure.Conclusion. Low-dose negative pressure provides the wound healing process with specific characteristics. Continuous exudate aspiration promotes rapid elimination of bacteria and detoxification of the wound and surrounding tissues, normalization of endointoxication parameters, provides anti-oedematous and analgesic effects, early restoration of impaired functions, and the time of wound healing process reaches that of healing by primary tension, which allows us to reduce the number of medications, as well as treatment and rehabilitation time.

Dear Editor: I read the article “The influence of lifestyle (smoking and body mass index) on wound healing and long-term recurrence rate in 534 primary pilonidal sinus patients” by Sievert and coworkers published in International Journal of Colorectal Disease (2013; November 28: 1555–62) with interest [1]. They concluded that the lifestyle parameters, smoking and body weight statistically do not complicate wound healing or long-term recurrence rates for primary pilonidal sinus disease surgery. Moreover, they commented that body mass index over 25 may have a beneficial influence on wound healing in primary open and primary midline closure. I believe some clarifications about these results and comments are needed. First of all, this was a retrospective analysis, and in order to make a clear comment, both arms of the groups (smoker vs. non-smoker and obese vs. non-obese) should have been comparable. There are lots of factors on wound healing process including (i) patient (age, co-morbid diseases, alcohol, smoking, body mass index, personal hygiene, compatibility to the treatment), (ii) pilonidal disease (existing abscess, number and distance of lateral openings, the size of the excised area, preoperative amount of hair, and its preoperative cleaning time and way), (iii) surgery (wound drainage, suture techniques, suture materials, using scalpel or diathermy, hemostasis techniques, local injections) and (iv) postoperative complications (fluid collection under the closed wound, hematoma, surgical site infection). In this study, there were no data about those parameters for the homogeneity of the groups. For a reliable analysis, both groups should be comparable. If the groups are not homogenous for comparison, a likely bias can completely change all the comments. Secondly, the only parameter for wound healing in this study was the number of wound dehiscence. Other factors such as wound collections or infections were very prone to wound dehiscence and none of them is talked about. Wound healing time could be a good parameter for both primary closed and lay open groups to compare the effects of obesity and smoking, but there was no data about them. Singleparameter examination for wound healing can result with bias again. Thirdly, authors mentioned total 39 wound dehiscence in 192 primary closures. They reported that “105 patients with a BMI of <25 kg/m were submitted to primary midline closure. N=38 of them had wound dehiscence (36 %). On the opposite, 87 patients with a BMI of 25 kg/m and above had primary midline closure, and 27 experienced wound dehiscence (21 %; p=0.9)”. When I calculate the sum of the wound dehiscence of both groups, the total number reaches to 65, not 39. Another point, 27×100/87 results with 31% but not 21%. I think there are some misprinting and calculation errors. Authors, with those results, commented that “as the BMI of 25 and above may have a beneficial influence on wound healing in primary open and primary midline closure”. I think, there is no evidence to make this comment with those numbers. Lastly, while examining the effects of smoking and obesity, the severity level of both parameters should be taken care. One of the generally accepted classifications for the obesity (e.g., 25–29.9=overweight, 30–34.9=class I obesity, 35–39.9=class II obesity, and 40≤class III obesity) was necessary. In this study, patients were only separated into two groups up to body mass index (BMI) level 25. In the <25 group, there were also underweighed patients (BMI<18.5) and the 25<group covers all the patients who had BMI between 26 and 41. When the authors concluded that obesity had no role on wound healing C. Kayaalp (*) Department of General Surgery, Turgut Ozal Medical Center, Inonu University, Malatya 44315, Turkey e-mail: cuneytkayaalp@hotmail.com

Hemostasis is an emergency medical treatment to reduce pain and patient mortality, therefore research is being developed to find effective hemostasis. The utilization of natural materials for hemostasis and wound healing is rapidly expanding, including chitosan found in shell extracts. Chitosan is obtained from chitin found in the soft shells of marine animals such as squid, shrimp, and crabs, or from hard shells such as clams, crabs, and lobsters. Chitosan offers advantages such as good biodegradability, biocompatibility, and non-toxicity, and has been widely used in biomedical, chemical, food, and cosmetic industries. This literature review aims to investigate the potential of shell extracts, particularly the characteristics of chitosan, in wound healing across hemostasis, inflammation, proliferation, and remodeling stages. The study results indicate that extracts from shells containing chitosan exhibit varying characteristics in terms of molecular weight and degree of deacetylation. Chitosan with higher molecular weight and degree of deacetylation tends to yield better outcomes in hemostasis and wound healing. The material is effective in reducing antithrombin, enhancing blood clotting processes, and aiding clot formation. Increased molecular weight contributes to stimulating various cytokines, such as TNF-α, TGF-ß1, and FGF2, which play a key role in the wound healing process. Additionally, higher degree of deacetylation chitosan is effective in stimulating fibroblast proliferation. Chitosan also influences VEGF in inducing angiogenesis and enhancing neovascularization in bone healing. Chitosan from shell extracts with certain molecular weight characteristics and degree of deacetylation has the potential to be the material of choice for accelerating hemostasis and wound healing.

IL-1 blockade in Schnitzler syndrome: Ex vivo findings correlate with clinical remission

To assess risk factors for perineal tears, wound infection and dehiscence among primiparous women. A prospective cohort study at four Danish hospitals (Odense, Esbjerg, Aarhus and Kolding) among 603 primiparous women sampled in three groups: 203 with none/labia/1st degree, 200 with 2nd degree, and 200 with 3rd/4th degree tears included between July 2015 and January 2018. Baseline data were obtained and a clinical examination of perineal wound healing was performed 11-21days postpartum. Main outcome measurements were as follows: degree of perineal tear, 1st to 4th, analyzed with a case-control approach, infection (purulent drainage or wound abscess), and wound dehiscence (a gap between wound edges > 0.5cm). Instrumental delivery and birthweight > 4000g increased the risk of 3rd/4th degree tears (adjusted Odds Ratio [aOR] 13.7, 95% confidence interval [CI] 5.48-34.1 and aOR 3.27, 95% CI 1.52-7.04, respectively). BMI > 35kg/m2 increased the risk of wound infection and dehiscence (aOR 7.66, 95% CI 2.13-27.5 and aOR 3.46, 95% CI 1.10-10.9, respectively). Episiotomy tripled the risk of infection (aOR 2.97, 95% CI 1.05-8.41). Treatment with antibiotics during delivery and postpartum seemed to decrease the risk of dehiscence (aOR 0.32, 95% CI 0.15-0.70). Instrumental delivery and high birth weight increased the risk of perineal tears. Severe obesity and episiotomy increased the risk of perineal wound complications. More focus on these women may be warranted postpartum. The use of prophylactic antibiotics among women in high risk of wound complications should be further investigated in interventional studies.