Adequate Debridement Research Articles

Retrospective analysis of dental implants immediately placed in extraction sockets with periapical pathology: immediate implant placement in infected areas

BackgroundThe aim of this study is to examine the survival rates of immediate implants placed in extraction sockets with chronic periapical pathology.Methods69 patients and 124 immediate implants were included in the study. The patients included in the study were examined in 3 groups. Group 1: Patients who underwent tooth extraction with periapical pathology and immediate implant placement. Group 2: patients who underwent tooth extraction with periapical pathology, immediate implant placement and guided bone regeneration. Group 3: Patients who underwent tooth extraction with periapical pathology, sinus lift procedure and immediate implant placement. In statistical analysis, t-test and Anova analysis were used in the evaluation of quantitative data, cross-tables and chi-square (χ2) test were used in the evaluation of classified qualitative data. Statistical significance was determined as p < 0.05.ResultsIt was observed that 116 (95.55%) of 124 implants were successful and 8 (4.45%) failed. The success rate was 97.2% in Group 1, 93.5% in Group 2 and 81.8% in Group 3. A significant correlation was found between the study groups and implant success in terms of χ2 test (p = 0.037). A significant relationship was found between smoking and success in terms of the χ2 test (p = 0.015).ConclusionsHigh survival rates are observed for immediate implant placement in sockets with periapical pathology. The success rates observed in guided bone regenerations simultaneously with immediate implant placement are at satisfactory levels. In cases where simultaneous sinus lifting procedures are required, the success rates were observed to be significantly lower. In case of adequate curettage and debridement in sockets with periapical pathology, high implant survival rates are observed. As the complexity of the surgical procedure increases, treatment protocols may progress in safer ways.

Two rare cases of management of proximal phalanx spina ventosa

Tubercular dactylitis or spina ventosa is the tubercular infection of phalanges, metacarpals and metatarsals termed after cystic swelling of short tubular bones by tubercular infection. Here we presented two rare cases of spina ventosa in a 10 years old female and a 16 years old male patients. In both cases there was swelling of digits with stiffness. The radiographs were suggestive of chronic osteolytic infection with cortical destruction and diffuse sclerosis. We managed them with adequate surgical debridement, splintage and anti-tubercular therapy with good functional recovery. Spina ventosa or tubercular dactylitis is a rare condition and is often missed on diagnosis due to vague non-specific presentation, unavailability of rapid diagnostic tests and can be confused with other mimicking diseases. Any swelling over small tubular bones of hand or feet should raise the suspicion of spina ventosa, especially in endemic countries for tuberculosis. In neglected chronic infections, surgical debridement, curettage and splintage followed by anti-tubercular therapy based on histo-pathological reports is the treatment of choice with high protein diet and vitamin D supplementation ensures good outcome.

FUNCTIONAL OUTCOME OF COMPOUND FRACTURES OF TIBIA TREATED BY EXTERNAL FIXATION

Tibial fractures are among commonly occurring long bone fractures which frequently present as open fractures due to subcutaneous nature of tibia and increasing high velocity trauma in road trafc accident. The precarious blood supply and lack of soft tissue cover of the shaft of tibia and increased incidence of open fracture make it difcult for treatment and high rate of non-union and infection. So aggressive treatment with adequate wound debridement and IV antibiotics and fracture stabilization is necessary. Various methods for fracture stabilization include plating , intra-medullary nailing or external xator application. This prospective study was done among 39 patients who sustained compound tibial fractures(Gustilo grade II , IIIa and IIIb) and were admitted in Department of Orthopaedics, Government Medical College, Thrissur. Functional and clinical outcome is assessed at 1st and,2nd week followed by 1st , 3rd &amp; 6th months using modied johner and wruh's criteria.The post operative outcomes- intermediate and nal, were assessed and analysed for statistical signicance using Microsoft Word, Microsoft Excel and statistical software IBM-SPSS (International Business Machines- Statistical Product and Service Solutions) ver18, using appropriate statistical tests. The patients were in the age group of 23 to 63 years and with a mean age of 41.59 years. Males were predominant. Most common mode of injury is road trafc accident which accounts for 71.8% of cases. Majority of injury were type 2 (61.5%) Gustilo-Anderson classication. There were 12.8% Excellent results, 38.5% Good results, 10.3% Fair results and 38.5% Poor results according to Modied Johner and wruh's criteria. External xation is a simple and effective means of treating of open tibial shaft fractures especially in type 2 , type 3A &amp; type 3B fractures, the external xator as a treatment in open tibia fracture is a valuable tool as it gives advantage to less operative time and intra-operative blood loss. There is easy access to the soft tissue and easy wound management with a stable xation can be obtained

Treatment of Fracture-Related Infections with Bone Abscess Formation after K-Wire Fixation of Pediatric Distal Radius Fractures in Adolescents—A Report of Two Clinical Cases

Closed reduction and K-wire fixation of displaced distal radius fractures in children and adolescents is an established and successful surgical procedure. Fracture-related infections after K-wire fixation are rare but can have significant consequences for the patient. There is a lack of literature on the treatment of K-wire-associated fracture-related infections in children and adolescents. Herein, we report two cases of fracture-related infection after initial closed reduction and Kirschner wire fixation in two adolescents. One 13-year-old boy and one 11-year-old girl were seen for fracture-related infections 4 and 8 weeks after closed reduction and percutaneous K-wire fixation of a distal radius, respectively. X-ray and magnetic resonance imaging (MRI) revealed a healed fracture with osteolytic changes in the metaphyseal radius with periosteal reaction and abscess formation of the surrounding soft tissue structures. A two-staged procedure was performed with adequate debridement of the bone and dead space management with an antibiotic-loaded polymethyl methacrylate (PMMA) spacer at stage 1. After infection control, the spacer was removed and the defect was filled with autologous bone in one case and with a calcium sulphate-hydroxyapatite biomaterial in the other case. In each of the two patients, the infection was controlled and a stable consolidation of the distal radius in good alignment was achieved. In one case, the epiphyseal plate was impaired by the infection and premature closure of the epiphyseal plate was noted resulting in a post-infection ulna plus variant. In conclusion, a fracture-related infection after Kirschner wire fixation of pediatric distal radius fractures is a rare complication but can occur. A two-stage procedure with infection control and subsequent bone defect reconstruction was successful in the presented two cases. Premature closure of the epiphyseal growth plate of the distal radius is a potential complication.

Successful Multimodal Therapy with Intracerebral Liposomal Amphotericin B and Systemic High-Dose Isavuconazole in Proven Disseminated Aspergillosis

We report the case of a 32-year-old man receiving chemotherapeutics for an acute B-lymphoblastic leukemia who developed proven cerebral and pulmonary aspergillosis with Aspergillus flavus. Because of progressive fungal disease with neurological deterioration despite adequate systemic antifungal therapy and surgical debridement, intracerebral administration of liposomal amphotericin B was initiated at 5 mg twice weekly. This led to improvement of the cerebral infection. Surgical debridement of a pleural Aspergillus empyema was necessary, and pleural trough level of isavuconazole was found to be subtherapeutic despite adequate blood trough levels, which led us to increase the dose of isavuconazole. We conclude that intralesional amphotericin B might be beneficial at 5 mg twice weekly in cerebral aspergillosis if systemic antifungals and surgical debridement fail. In Aspergillus empyema, measurement of pleural isavuconazole trough levels should be considered.

Reconstruction of Upper Extremity Using Pedicled Latissimus Dorsi Myocutaneous Island Flap and Skin Graft after Necrotizing Fasciitis: A Case Report

Necrotizing fasciitis of the upper extremities is a severe, life-threatening condition, potentially resulting in amputation or death in the absence of prompt and aggressive surgical treatment. Reconstruction is eventually required after adequate surgical debridement, and patients are often referred to a plastic surgeon for this purpose. Herein, we present the case of a patient with extensive soft tissue defects on the upper extremity after fasciotomy for necrotizing fasciitis. We successfully performed a pedicled latissimus dorsi myocutaneous island flap, full-thickness skin graft, and split-thickness skin graft for this patient. After 2 months, the patient did not have any wound problems and could carry out adequate upper extremity motion.

Advanced Subscapularis Repair Techniques

The subscapularis muscle plays an essential role in full, pain-free shoulder function. Injuries to the subscapularis tendon exist on a spectrum of severity. In the evaluation of the injured and/or painful shoulder, careful scrutiny of the subscapularis tendon on advanced shoulder imaging in all planes facilitates detection of subscapularis pathology. Specific surgical techniques of subscapularis tendon repair, including arthroscopic and open approaches, are tailored to tear size, pattern, retraction, tissue quality and concomitant pathologies. Smaller, upper border tears of the subscapularis tendon may be treated with a single-row repair construct while tears greater than 2cm are typically treated with a double-row repair. Surgical pearls include adequate debridement of the rotator interval, identification of the comma tissue in retracted tears, use of a lateral viewing portal during arthroscopic repair, and gentle decortication of the lesser tuberosity footprint. While unrecognized subscapularis tendon tears is associated with worse clinical outcomes in the setting of multi-tendon tears, further study is needed to identify additional strategies to improve rotator cuff tendon healing following surgical repair.

Current scenario of traditional medicines in management of diabetic foot ulcers: A review.

Diabetic foot infections and diabetic foot ulcers (DFU) cause significant suffering and are often recurring. DFU have three important pathogenic factors, namely, microangiopathy causing local tissue anoxia, neuropathy making the foot prone to injuries from trivial trauma, and local tissue hyperglycaemia favouring infection and delaying the wound healing. DFU have been the leading cause for non-traumatic amputations of part or whole of the limb. Western medicines focus mainly on euglycaemia, antimicrobials, debridement and wound cover with grafts, and off-loading techniques. Advances in euglycaemic control, foot care and footwear, systemic antimicrobial therapy, and overall health care access and delivery, have resulted in an overall decrease in amputations. However, the process of wound care after adequate debridement remains a major cost burden globally, especially in developing nations. This process revolves around two basic concerns regarding control/eradication of local infection and promotion of faster healing in a chronic DFU without recurrence. Wound modulation with various dressings and techniques are often a costly affair. Some aspects of the topical therapy with modern/Western medicines are frequently not addressed. Cost of and compliance to these therapies are important as both the wounds and their treatment are "chronic." Naturally occurring agents/medications from traditional medicine systems have been used frequently in different cultures and nations, though without adequate clinical base/relevance. Traditional Chinese medicine involves restoring yin-yang balance, regulating the 'chi', and promoting local blood circulation. Traditional medicines from India have been emphasizing on 'naturally' available products to control wound infection and promote all the aspects of wound healing. There is one more group of chemicals which are not pharmaceutical agents but can create acidic milieu in the wound to satisfy the above-mentioned basic concerns. Various natural and plant derived products (e.g., honey, aloe vera, oils, and calendula) and maggots are also used for wound healing purposes. We believe that patients with a chronic wound are so tired physically, emotionally, and financially that they usually accept native traditional medicine which has the same cultural base, belief, and faith. Many of these products have never been tested in accordance to "evidence-based medicine." There are usually case reports and experience-based reports about these products. Recently, there have been some trials (in vitro and in vivo) to verify the claims of usage of traditional medicines in management of DFU. Such studies show that these natural products enhance the healing process by controlling infection, stimulating granulation tissue, antimicrobial action, promoting fibroblastic activity and collagen deposition, etc. In this review, we attempt to study and analyse the available literature on results of topical traditional medicines, which are usually advocated in the management of DFU. An integrated and 'holistic' approach of both modern and traditional medicine may be more acceptable to the patient, cost effective, and easy to administer and monitor. This may also nevertheless lead to further improvement in quality of life and decrease in the rates of amputations for DFU.

Transcaruncular medial orbitotomy: A globe sparing intervention in management of COVID associated mucormycosis [CAM

To describe a novel method of transcaruncular medial orbitotomy, local debridement and amphotericin B irrigation into orbit for COVID-19-associated rhino-orbital mucormycosis. Also to evaluate its its outcome in controlling the disease, increasing the survival rate and as a globe-sparing intervention in them. A total of ten COVID-19-associated mucormycosis patients with clinical and radiological evidence of orbital involvement with necrotic tissue localized in medial orbit were considered for our study. A transcaruncular modified medial orbitotomy with medial and inferomedial orbit debridement was done along with placement of scalp vein catheter by a single surgeon. Postoperatively 3.5 mg/ml liposomal amphotericin B irrigation through the catheter was done for 5 sittings. Correction of underlying systemic conditions and intravenous antifungals were given. Clinical response to the procedure was noted on postoperative week 1, week 4, and 3rd month (week 12). The mean age group was noted to be 49.9 years with a male: female ratio of 2.3:1. All patients were diabetics with 5 being newly detected diabetes after COVID infection. All the ten patients showed significant clinical improvement at the first follow-up (week 1). Five patients at 1st month showed clinical and radiological improvement, while one patient had worsening of orbital disease for which exenteration was done. Three patients succumbed to the disease due to altered cardiopulmonary status and 1 patient was lost to follow-up. All 6 survived patients were stable till the last follow-up. Hence, mortality rate accounted to 30% and globe survival of 40% in the current study. Transcaruncular approach to orbit for adequate debridement combined with amphotericin irrigation is a novel technique that can be considered for compartmental involvement of orbit in mucormycosis. Debridement removes the necrotic tissue, while local amphotericin irrigation directly reaches the target tissues that effectively halts the disease progression and hence can be considered an effective globe-sparing intervention without affecting the disease outcome.

A Comparison of Parenteral and Per-Oral Antibiotic Usage in Pyogenic Flexor Tenosynovitis: A Retrospective Study.

Introduction Pyogenic flexor tenosynovitis (PFT) is a common hand infection that can cause significant morbidity. Although treatment involves surgical debridement and inpatient intravenous (IV) antibiotics, there is a paucity of literature guiding antibiotic use. This study aims to determine if the use of postoperative outpatient oral antibiotics leads to poor outcomes compared to IV antibiotics given in an institutional setting. Methods A retrospective review of 110 patients treated post-operatively with either outpatient oral or inpatient IV antibiotics at our institution from 2016-2019 was performed. All patients underwent surgical debridement. Primary outcomes analyzed included readmission, repeat surgery, and amputation. Clinical parameters including age, diabetes, smoking, duration of symptoms, involvement of surrounding structures (felon, dorsal abscess, osteomyelitis, septic arthritis), culture growth, Michon classification, and duration of antibiotics were analyzed as possible risk factors for poor outcome. The level of evidence of this study isLevel 3Retrospective Cohort Study. Results Seventy-five patients were treated with outpatient oral antibiotics and 35 patients were treated with inpatient IV antibiotics. The oral antibiotics group received antibiotics for 13.1 +/- 9.9 days compared to 18.1 +/-10.4 days in the IV antibiotic group. Patients in the oral antibiotic group had a significantly shorter length of hospitalization at 0.6 +/-1.8 days compared to 3.6 +/-1.8 days in the IV antibiotic group. The readmission rate for the oral antibiotic group was 10.7% compared to 5.7% in the IV antibiotic group.This difference was not statistically significant except in patients who had involvement in surrounding structures. There was no significant difference in repeat surgeries or amputationsbetween the groups. Conclusions The use of outpatient oral antibiotics after surgical debridement for PFT does not significantly increase rates of readmission, repeat surgery, or amputation, except in cases with the involvement of surrounding structures. On subgroup analysis, anaerobic infection and diabetes were significantly associated with amputations. Post-operative oral antibiotics and immediate discharge may be considered for PFT after adequate surgical debridement with close outpatient follow-up in the absence of surrounding structure involvement and diabetes.

Single-Stage Revision Reverse Shoulder Arthroplasty: Preoperative Planning, Surgical Technique, and Mixed Reality Execution.

Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.

Specialty specific quality measures needed to improve outcomes in wound care.

Despite the health care community's best efforts, 20% of diabetic patients who develop a diabetic foot ulcer will require some form of amputation. Those undergoing a major lower extremity amputation risk an increase in their five-year mortality rate to 56.6%, which is comparable to or higher than many forms of cancer. Given this perspective, quality measures need to be considered at each patient inflection point to drive increased compliance with best practices in order to redirect patients whose therapies fail. Medicare limited datasets (October 2015 through October 2019) retrospectively analyzed patients with diabetes receiving care for chronic lower extremity diabetic ulcers (LEDUs). The analysis demonstrated that only 21% of Medicare patients with hard-to-heal LEDUs received sharp debridement at intervals of every 7 days and less, while only 40% received sharp debridement at intervals of every 8 to 14 days. This is despite landmark prospective randomized controlled trials showing the benefits of frequent sharp debridement to patients with LEDUs. According to the Medicare data, when patients received debridement at intervals of 7 days or less with concurrently applied skin substitutes, observed amputation rates dropped by 65% to the lowest levels identified among Medicare LEDU episodes (2.1%). Optimal use of debridement and adjunctive use of skin substitutes significantly improves outcomes and lowers the use of healthcare resources. Another unexpected finding highlighted in the Medicare data analysis was that wound care providers have not been applying skin substitutes early enough. Clinical guidelines related to LEDUs have long relied on the seminal Sheehan marker study, which identified that diabetic ulcers that have not progressed to at least 53% healing after four weeks of conservative care have only a 9% chance of proceeding to closure by 12 weeks. It is therefore vital that patients move to advanced therapies within 30 to 45 days after initiation of failed conservative care; however, the Medicare claims data shows this is not happening regularly enough (average time to first skin substitute application >69 days) to benefit both the patient and the healthcare system. There is a demonstrable need for quality measures that encourage (1) frequent and adequate debridement throughout wound treatment, (2) earlier adoption of advanced treatments, such as skin substitutes, for LEDUs to align with clinical guidelines, (3) the application of skin substitutes to better align with medical evidence, which is associated with improved patient outcomes, as well as (4) expansion of best practices across all demographic and socioeconomic populations.

Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study

The timing of definitive fixation of open ankle malleolar fractures is still controversial. This study intended to evaluate the outcome of patients who were managed by immediate definitive fixation in comparison to delayed definitive fixation following open ankle malleolar fractures. This was an IRB approved retrospective case control study of 32 patients who were treated with open reduction and internal fixation (ORIF) for open ankle malleolar fractures at our Level I trauma center 2011-2018. Patients were divided into 2 groups; immediate ORIF group (within 24 hours) and delayed ORIF group (first stage included debridement and external fixator or splinting followed by second stage of delayed ORIF). Outcomes assessed were postoperative complications (wound healing, infection, nonunion). Logistic regression models were used to access the unadjusted and adjusted associations between post- operative complications and selected co factors. The immediate definitive fixation group included 22 patients while the delayed staged fixation group included 10 patients. Gustilo type II and III open fractures were associated with higher complications rate (p-value = 0.012) in both groups. Comparing the 2 groups, There was no increase in complication in the immediate fixation group compared to the delayed group. Complications following open ankle malleolar fractures are usually associated with Gustilo type II and III open fractures. Immediate definitive fixation after adequate debridement was not found to increase complication rate compared to staged management.

Evaluation of preliminary anti-microbial efficacy of curcumin and chitosan nanoparticles with and without photoactivation against – An invitro study

: The success of endodontic treatment lies in adequate debridement of the root canal. There are various microorganisms responsible for the failure of root canal treatment, one among them is . Sodium hypochlorite is considered as the gold standard. Since it has various disadvantages newer irrigants like Curcumin and Chitosan nanoparticles have been tried.: The aim of this study was to evaluate the preliminary anti-microbial efficacy of Curcumin and Chitosan nanoparticles with and without photoactivation against : The antimicrobial activity of Curcumin, Chitosan nanoparticles with and without Photoactivation, Saline and Sodium hypochlorite was assessed. MIC was done with serial dilution method, incubated for 48-72 hours and observed for turbidity.MBC was done from the MIC dilutions tubes, first 3 tubes were plated, incubated for 24 hrs and the colony was counted. For Time kill assay broth with the compound was mixed, plated and inoculated at 1hr, 2hrs and 4hrsinterval and colony count was noted. Results were tabulated and statistical analysis was done using Analysis of Variance (ANOVA) and Tukey multiple comparison test.Photoactivated Curcumin has shown the best antimicrobial results as compared to Curcumin, Chitosan nanoparticles (photoactivated and nonphotoactivated) and 3% Sodium hypochlorite.: Curcumin with and without photo activation and Chitosan nanoparticles can be considered as an alternate endodontic irrigants against sodium hypochlorite.

The role of hyperbaric oxygen therapy in Fournier's Gangrene: A systematic review and meta-analysis of observational studies.

ABSTRACTPurpose:Management of Fournier’s Gangrene (FG) includes broad-spectrum antibiotics with adequate surgical debridement, which should be performed within the first 24 hours of onset. However, this treatment may cause significant loss of tissue and may delay healing with the presence of ischemia. Hyperbaric oxygen therapy (HBOT) has been proposed as adjunctive therapy to assist the healing process. However, its benefit is still debatable. Therefore, this systematic review and meta-analysis aimed to evaluate the effect of HBOT as an adjunct therapy for FG.Materials and Methods:This study complied with the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol to obtain studies investigating the effect of HBOT on patients with FG. The search is systematically carried out on different databases such as MEDLINE, Embase, and Scopus based on population, intervention, control, and outcomes criteria. A total of 10 articles were retrieved for qualitative and quantitative analysis.Results:There was a significant difference in mortality as patients with FG who received HBOT had a lower number of deaths compared to patients who received conventional therapy (Odds Ratio 0.29; 95% CI 0.12 – 0.69; p = 0.005). However, the mean length of stay with Mean Difference (MD) of -0.18 (95% CI: -7.68 – 7.33; p=0.96) and the number of debridement procedures (MD 1.33; 95% CI: -0.58 – 3.23; p=0.17) were not significantly different.Conclusion:HBOT can be used as an adjunct therapy to prevent an increased risk of mortality in patients with FG.

The Pull-Through Technique: Surgical Augmentation for Debriding Mid- and Forefoot Diabetic Foot Infections

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Diabetic foot infections (DFI) are complications of poorly controlled diabetes and are the proximate cause of lower extremity amputations. Wounds lead to bacterial colonization, the development of a biofilm and antibiotic resistance. Management requires aggressive debridement, maximizing vascularity and preserving viable soft tissues. Large dorsal and plantar incisions may be necessary for adequate debridement. The purpose of this paper is to discuss a technique that allows both dorsal and plantar approaches, using smaller incisions, for the management of diabetic foot infections and to evaluate complications and outcomes with this technique. Methods: From January 2015 through January 2022, diabetic patients with osteomyelitis or abscesses were identified. Exclusion criteria were osteomyelitis or abscesses of the tibia, ankle, fibula, talus, calcaneus, or navicular; gangrene; or patients who underwent an amputation of their toe(s) or foot as primary treatment. Inclusion criteria were patients with abscesses or osteomyelitis of the mid- or forefoot who underwent a pull-though technique. This Technique uses dorsal and plantar incisions, sterile betadine scrub (soap) and RAY-TEC sponges (Johnson and Johnson, Dublin, Ohio, U.S.A). After plantar wound debridement, a small dorsal incision is made over the plantar wound. The betadine soaked sponges are then individually passed, one time, from dorsal to plantar (pull-through), mimicking the face of a clock (12-1-2, 3, etc.), followed by formal irrigation solutions. Demographics and complications were recorded. Results: 155 patients were diagnosed with osteomyelitis or abscess of the foot or ankle. 82 patients had excluded areas of infection. 29 patients underwent a primary amputation as index procedure. 34 patients only had debridements leaving 10 patients, with 18 procedures, utilizing the pull-through technique. All pull-though patients presented with plantar wounds in the forefoot or midfoot. The 7 males, 3 females averaged 62.8 years (29-81). BMI averaged 34.1(25-48.8), with an A1C of 8.1 (6.3-12.9). Plantar wound duration was 11.4 months (3-36) and only one patient accurately detected a 5.07 monofilament. One patient had a positive smoking history, 6 patients had peripheral arterial disease. No skin or wound problems occurred as a result of the pull-through technique and no patient required an amputation. Of the 18 procedures (n=36, incisions plus plantar wounds) only one plantar wound (3%) failed to completely heal. Conclusion: DFI leads to production of biofilms and bacterial tissue adherence by various organisms. Surgical debridement is a key part of the treatment. Plantar wounds need larger incisions for acceptable debridement but may not adequately reach dorsal areas of involvement. The addition of a pull-through technique allows for the placement of small dorsal incisions to augment the plantar debridement, providing more debridement of the involved DFI. This technique did not produce any skin necrosis or additional wound problems, with 97% of wounds plus incisions completely healing. The authors feel this is an adequate adjunct for the management of mid-and forefoot DFI.

Single-Stage Reconstruction of Maxillectomy and Midfacial Defects in Cases of Covid Associated Mucormycosis.

ObjectiveTo advocate a single stage reconstruction in cases of maxillectomy and midfacial defects operated for covid associated mucormycosis to enable a favorable overall outcome within a shorter duration in terms of survival, quality of life, speech, deglutition and aesthetics.MethodIn our series of six patients with signs and symptoms suggestive of covid associated mucormycosis with diabetes as a predisposing factor had undergone Contrast enhanced CT and MRI with biopsy confirming the diagnosis, were then subsequently posted for resection and reconstruction depending upon extent of disease and defect left behind. Out of six, three were revision cases and the other three were primary cases. All had undergone single stage reconstruction using free flap (5/6) and pedicle (1/6) after intra-operative margins and distal most part of recipient vessels was found negative for mucormycosis on histopathology. Post-operative Liposomal Amphotericin B with Oral Posaconazole along with antibiotics and supportive treatment were given and were then followed up.ResultsAll the cases have complete flap survival after a mean follow-up of 90 days with no recurrence of mucormycosis. We had a survival rate of 100% with patients having good quality of life, speech, deglutition and acceptable aesthetical outcome.ConclusionStepping up on the reconstruction ladder to provide a single stage management in patients of covid associated mucormycosis by adequate surgical debridement, intraoperative negative margins on histopathology and subsequent reconstruction using autologous flaps is the need of the hour to provide within a shorter duration, favourable overall outcome in terms of survival, quality of life, speech, deglutition and aesthetics.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12070-022-03121-1.

The influence of adequate debridement and placental-derived allografts on diabetic foot ulcers.

To determine the role of debridement when patients are using placental-derived allografts (PDAs), data from two prospective, multicentre, randomised controlled trials (RCTs) were evaluated for the quality or adequacy of debridement on diabetic foot ulcers (DFUs) treated with PDAs. Results were compared with real-world findings via a retrospective analysis of 2015-2019 Medicare claims for DFUs. Debridement adequacy in the prospective RCTs was adjudicated by three blinded wound care specialists. Treatments included two PDAs, dehydrated human amnion/chorion membrane (DHACM, n=54) or dehydrated human umbilical cord (DHUC, n=101), compared with standard of care (SOC, n=110). The key outcome was the influence of adequate debridement on rates of complete closure within 12 weeks. Additionally, a retrospective analysis of 2015-2019 Medicare claims for DFUs that received routine debridement at intervals ranging from every 1-7 days (18,900 total episodes), 8-14 days (35,728 total episodes), and every 15 days or greater (34,330 total episodes) was performed. Within the RCTs, adequate debridement occurred in 202/265 (76%) of patients, 90/110 (82%) SOC ulcers, 45/54 (83%) of DHACM-treated ulcers, and in 67/101 (66%) of DHUC-treated ulcers. Complete closure occurred in 150/202 (74%) of adequately debrided ulcers, and in only 13/63 (21%) of ulcers without adequate debridement, p<0.0001. Debridement was the most significant factor for closure even when controlling for other clinical characteristics. Within the Medicare claims data 21% (18,900/88,958) of episodes treated with SOC only had debridement intervals of ≤7 days. Short debridement intervals in combination with the use of DHACM demonstrated statistically significant better outcomes than SOC including: 65% fewer major amputations (p<0.0001), higher DFU resolution rates (p=0.0125), 42% fewer emergency room visits (p<0.0001) and reduced usage of other hospital resources (admissions and readmissions). Prospectively collected data examining the quality of debridement and retrospectively analysed data examining the frequency of debridement supports routine adequate wound debridement, particularly at intervals of seven days, as an essential component of wound care. Optimal use of placental-derived allografts improves outcomes and lowers the use of healthcare resources.

Acute fulminant rhino-orbito-cerebral mucormycosis: Our experience with open approach in the COVID era

Objectives: Rhino-orbito-cerebral mucormycosis (ROCM) is a quite rare and an extremely aggressive infection which can cause profound destruction of tissues. A high index of suspicion is required to diagnose and treat this infection. Although mostly occurring in diabetic or immunosuppressed patients, a sudden surge of these patients has been observed in the COVID era. Mortality is extremely high in neglected cases and can range from 40%–85% or even more. In this article, we aim to highlight patient demographics, clinical features, diagnosis, management, and outcome of fulminant ROCM in patients managed jointly by plastic surgeons and maxillofacial surgeons by the open approach. Materials and Methods: Between May 2021 and August 2021, there was a sudden upsurge of mucormycosis patients admitted in our institute (IPGME and R, Kolkata). Less severe fulminant forms of the disease were managed by the department of otorhinolaryngology by endoscopy, whereas fulminant cases with extensive involvement were managed by the department of plastic surgery in conjunction with the department of maxillofacial surgery. The surgical management involved open access to the involved tissues and resection under direct vision combined with appropriate medical management. Results: In total, we operated on eight cases of fulminant ROCM of which 4 patients were male and 4 females. Apart from this, two male patients and one female patient were also planned for extensive debridement surgery but the same could not be performed because of poor anesthetic risk. Biopsies were taken in all of these patients. Therefore, out of a total of 11 patients with fulminant ROCM, 9 patients did not survive taking the mortality rate in fulminant cases to 82%. Conclusion: ROCM can be an extremely difficult disease to treat and is associated with a very high mortality rate in fulminant cases. Early diagnosis coupled with adequate debridement and systemic amphotericin B has the prospect of salvaging patients with this dreaded disease.

Management of frontal sinus fungal osteomyelitis in the COVID 19 era: A case series

The aim of this study was to review different approaches and outcomes in the management of post-COVID-19 frontal sinus fungal osteomyelitis.The study included 19 patients with frontal sinus fungal osteomyelitis. The main line of treatment was surgical debridement (sequestrectomy). Approaches included combined external and endoscopic approaches (n = 15) and pure endoscopic approaches (n = 4) according to the extent and accessibility of the sequestrum. Postoperative healing was satisfactory in all patients. All patients returned to their normal daily activity within 4–6 weeks, without residual or recurrent frontal sinus infection, osteomyelitis or need for revision procedures.Within the limitation of this case series, it seems that there is no need to adopt a new therapy regimen for treatment of frontal sinus fungal osteomyelitis because the conventional and well-known treatment approach combining surgery and antifungal drugs seems to work well. However, early, and adequate debridement and sequestrectomy is crucial. Furthermore, an open approach may be required according to the extent of osteomyelitis.