Adjacent Wound Research Articles

Surgical intervention on the wound channels of gunshot non-penetrating craniocerebral injuries

Objective – to optimize of surgical approaches to damaged tissues of the head and methods of primary surgical treatment for gunshot non-penetrating gunshot craniocerebral injuries in accordance with the principles of comprehensive and single-stage surgical treatment accepted in military field surgery. Materials and methods. An analysis of the surgical treatment of 155 wounded people with non-penetrating gunshot wounds of the skull vault and brain for the period from 2014 to 2020 was carried out. Anatomical and morphological features of wound canals were studied depending on the traumatic agent. Variants of surgical approaches for the primary surgical treatment of non-penetrable gunshot wounds of the skull and brainwere developed based on the clinical X-ray and computed tomography characteristics of the affected head tissues. Results. The choice of surgical approaches depends on the nature of the wound canals (single fragment blind, multiple fragment blind, ball and fragment tangent) and the presence of concomitant epidural and subdural hematomas. Primary plasty of the skull defect with a titanium plate during primary surgical treatment is indicated for gunshot impenetrable craniocerebral injuries with a single fragmental blind wound channel. Such plastic surgery was performed in 33.5% of cases with a favorable postoperative course. Peculiarities of surgical approaches to damaged tissues of the head in case of single fragmentary, blind wound canal; with multiple blind fragmental wound canals, the adjacent wound canal and the sequence of their surgical treatment were established. Conclusions. Planning of surgical approaches to damaged tissues of the head in case of gunshot impenetrable craniocerebral wounds in modern local wars should be carried out taking into account clinical and computed tomography data. The high proportion of comprehensive and one-time early primary surgical treatments (92.9%) performed on the first day after the injury testifies to the high efficiency of the system of providing specialized medical care during the local war.

A prospective study on application of human umbilical cord mesenchymal stem cells combined with autologous Meek microskin transplantation in patients with extensive burns

Objective: To investigate the effects of human umbilical cord mesenchymal stem cells (hUCMSCs) combined with autologous Meek microskin transplantation on patients with extensive burns. Methods: The prospective self-controlled study was conducted. From May 2019 to June 2022, 16 patients with extensive burns admitted to the 990th Hospital of PLA Joint Logistics Support Force met the inclusion criteria, while 3 patients were excluded according to the exclusion criteria, and 13 patients were finally selected, including 10 males and 3 females, aged 24-61 (42±13) years. A total of 20 trial areas (40 wounds, with area of 10 cm×10 cm in each wound) were selected. Two adjacent wounds in each trial area were divided into hUCMSC+gel group applied with hyaluronic acid gel containing hUCMSCs and gel only group applied with hyaluronic acid gel only according to the random number table, with 20 wounds in each group. Afterwards the wounds in two groups were transplanted with autologous Meek microskin grafts with an extension ratio of 1∶6. In 2, 3, and 4 weeks post operation, the wound healing was observed, the wound healing rate was calculated, and the wound healing time was recorded. The specimen of wound secretion was collected for microorganism culture if there was purulent secretion on the wound post operation. In 3, 6, and 12 months post operation, the scar hyperplasia in wound was assessed using the Vancouver scar scale (VSS). In 3 months post operation, the wound tissue was collected for hematoxylin-eosin (HE) staining to observe the morphological changes and for immunohistochemical staining to observe the positive expressions of Ki67 and vimentin and to count the number of positive cells. Data were statistically analyzed with paired samples t test and Bonferronni correction. Results: In 2, 3, and 4 weeks post operation, the wound healing rates in hUCMSC+gel group were (80±11)%, (84±12)%, and (92±9)%, respectively, which were significantly higher than (67±18)%, (74±21)%, and (84±16)% in gel only group (with t values of 4.01, 3.52, and 3.66, respectively, P<0.05). The wound healing time in hUCMSC+gel group was (31±11) d, which was significantly shorter than (36±13) d in gel only group (t=-3.68, P<0.05). The microbiological culture of the postoperative wound secretion specimens from the adjacent wounds in 2 groups was identical, with negative results in 4 trial areas and positive results in 16 trial areas. In 3, 6, and 12 months post operation, the VSS scores of wounds in gel only group were 7.8±1.9, 6.7±2.1, and 5.4±1.6, which were significantly higher than 6.8±1.8, 5.6±1.6, and 4.0±1.4 in hUCMSC+gel group, respectively (with t values of -4.79, -4.37, and -5.47, respectively, P<0.05). In 3 months post operation, HE staining showed an increase in epidermal layer thickness and epidermal crest in wound in hUCMSC+gel group compared with those in gel only group, and immunohistochemical staining showed a significant increase in the number of Ki67 positive cells in wound in hUCMSC+gel group compared with those in gel only group (t=4.39, P<0.05), with no statistically significant difference in the number of vimentin positive cells in wound between the 2 groups (P>0.05). Conclusions: The application of hyaluronic acid gel containing hUCMSCs to the wound is simple to perform and is therefore a preferable route. Topical application of hUCMSCs can promote healing of the autologous Meek microskin grafted area in patients with extensive burns, shorten wound healing time, and alleviate scar hyperplasia. The above effects may be related to the increased epidermal thickness and epidermal crest, and active cell proliferation.

The clinical and histopathological study, the effects of platelet-rich fibrin on skin pedicle graft healing

Background: Tissue engineering aims to repair or replace damaged tissue in response to various injury circumstances. One of these sectors is platelet-rich fibrin (PRF), extensively employed for soft tissue regeneration in recent years. Objective: The research aimed to examine the clinical and histological effects of allogenic PRF on skin pedicle grafts used to treat experimental avulsion wounds. Materials and method: Fifteen adult female goats were used for this study. Under heavy sedation and complete aseptic conditions, 2 skin marks (2×2 cm) were created on both sides of the trunk region of the animal. Two total thicknesses of the blotchy skin are cut carefully. Advancement (sliding) flaps (2×6 cm) are harvested parallel to the lines of most minor tension and slid over the adjacent wound. These wounds are allocated into two groups, the first one as the control group and the second group treated with autogenic platelet-rich fibrin. Each goat has two groups represented. The edges of the wounds were closed by 2-0 nylon monofilament sutures with a simple interrupted pattern. Results: Clinical examination showed the amount of wound exudation in the treated group significantly increased compared to the control group.

Effects of platelet-rich fibrin on skin pedicle graft healing

Objective: Avulsion injuries mostly lead to serious lesions. and those wounds become a challenge to be repaired by surgeons. The aim of the study was to evaluate the effect of autogenic PRF on skin pedicle graft to treat experimental avulsion wounds including clinical and hydroxyproline evaluations. Materials and methods: The experiment was performed on 15 adult female goats, aged between 7-8 months and weighted 18-20 Kg. Surgery was performed under heavy sedation and complete aseptic conditions, 2 skin marks (2×2 cm) were created on both sides of the trunk region of the animal. Two full thickness of the marked skin is cut carefully. A sliding flap (2×6 cm) are harvested parallel to the lines of least tension and are then slid over the adjacent wound which were closed by 2-0 nylon monofilament suture. These wounds are classified into two groups, the first one as the control group and the second group treated with autogenic platelet-rich fibrin. The two groups are represented in each goat. Results: Clinical examination showed the amount of wound exudation in the treated group was a significant increase compared to the control group.

725 Case Series: New Porcine Placental ECM for Burn Injuries

IntroductionHuman amniotic membrane (HAM) has been used as a biologic dressing for burn wounds since 1955 but limited due to availability, size, and processing costs. In 2021 a new porcine placental product was FDA-approved overcoming challenges with human-sourced products. Our study is the first case series to report outcomes using porcine placental extracellular matrix (PPECM) in the use of adult burn patients.MethodsAdults with thermal burns resulting in partial-thickness burn wounds (PTBW) were consented and included in the study from 03/2021 to 09/2021. Patients with full-thickness injures, concomitant trauma, or adverse beliefs to porcine products were not included in the study. Serial still images and initial wound measurements were obtained intraoperatively and post-operatively. PPECM trial product processed with a proprietary decellularization method to produce single sheets up to 15x20cm was approved by the facility value assessment committee. Adverse events were defined a priori as infection, increased pain or itching relative to adjacent autografts, or failure to heal. Infection was defined as a PPECM treatment site requiring any change from standard of care or initiation of local or systemic antibiotics. Pain was assessed using a visual analogue scale. Itching was assessed at discharge and follow-up. Healing was assessed using the FDA guidance for wound closure with 2 consecutive visits 2 weeks apart demonstrating 100% epithelialization without drainage or dressing requirements.ResultsFour patients were treated during the study period with wounds involving the torso and major joints such as the hands/wrists and knees. None of the PPECM wounds demonstrated failure to heal or required revision excision, or autograft. None of the PPECM wounds had evidence of infection. PPECM wounds had decreased pain/itching relative to adjacent burn wounds which were treated with split-thickness autograft, autologous skin cell suspension, or allogeneic cultured skin substitute (VAS mean 1 vs 3.1). Healing was noted in all wounds at 1-week primary dressing removal with confirmation at 2-week interval follow-up.ConclusionsPPECM treatment of PTBW was not associated with adverse events and resulted in favorable outcomes clinically. The large size, ease of use, and lower costs relative to HAM is an intriguing alternative for PTBW. Comparative studies are needed in the field to determine best practices and overall value.

Skin wound healing assessment via an optimized wound array model in miniature pigs

An appropriate animal wound model is urgently needed to assess wound dressings, cell therapies, and pharmaceutical agents. Minipig was selected owing to similarities with humans in body size, weight, and physiological status. Different wound sizes (0.07–100 cm2) were created at varying distances but fail to adequately distinguish the efficacy of various interventions. We aimed to resolve potential drawbacks by developing a systematic wound healing system. No significant variations in dorsal wound closure and contraction were observed within the thoracolumbar region between boundaries of both armpits and the paravertebral region above rib tips; therefore, Lanyu pigs appear suitable for constructing a reliable dorsal wound array. Blood flow signals interfered with inter-wound distances ˂ 4 cm; a distance > 4 cm is therefore recommended. Wound sizes ≥ 4 cm × 4 cm allowed optimal differentiation of interventions. Partial- (0.23 cm) and full-thickness (0.6 cm) wounds showed complete re-epithelialization on days 13 and 18 and strongest blood flow signals at days 4 and 11, respectively. Given histological and tensile strength assessments, tissue healing resembling normal skin was observed at least after 6 months. We established some golden standards for minimum wound size and distance between adjacent wounds for effectively differentiating interventions in considering 3R principles.

The Effect of Fluence on Neutrophil Kinetics in Zebrafish Wounds Using Real-time In Vivo Imaging

Background: Neutrophils participate in a cooperative defense strategy with macrophages following tissue injury. Application of low dose electromagnetic radiation via 635 nm wavelength can enhance macrophage recruitment to the wound, decrease tissue levels of ROS and speed healing. The impact of this wavelength on neutrophil activity in vivo is not well-described. Given that wound healing can be enhanced if collateral damage by neutrophils within the wound is decreased, we investigated how neutrophil kinetics changed during these accelerated reparative responses. Methods: Zebrafish, transgenic for the fluorescent neutrophil marker, mpx-dendra2, underwent defined fin tissue injury, and were randomized to one of two laser treatment groups, 3 J/cm2 (n=57), or 18 J/cm2 (n=69) or to the control group, 0 J/cm2 (n=164). Electromagnetic wave exposures were administered by a 635-nm continuous 5mW He:Ne laser with recipients randomized by dose delivered. Fish were three-dimensionally time-lapse imaged 30-120 minutes post injury (mpi) and wound healing documented at 24 hours post-injury. Individual neutrophil movement was tracked according to distance from wound center. Results: The lower treatment fluence, 3 J/cm2, significantly decreased neutrophil migration speed into the wound, increased reverse migration, and promoted stasis outside the adjacent wound area when compared to control and higher energy doses. The 3 J/cm2 treatment groups also exhibited more rapid wound closure when compared to control or higher fluence. Conclusions: Unlike our previous work in macrophages in which low fluence treatment enhanced the speed of forward directed migration into the wound, the response of neutrophils was decreased speed into the wound, increased reverse migration, and stasis outside the areas of the wound edges. These findings advance the notion that low fluence treatments reduce neutrophil inflammatory responses within the wound by their reduced presence within the wound. Reduced neutrophil-mediated collateral damage may work in concert with enhanced macrophage wound activity to promote faster wound healing.

Immune tolerance of allogeneic haematopoietic cell transplantation supports donor epidermal grafting of recessive dystrophic epidermolysis bullosa chronic wounds.

Chronic wounds, a common morbidity in recessive dystrophic epidermolysis bullosa (RDEB), lack definitive therapies. To assess allogeneic epidermal skin grafts in terms of wound healing and durability over time. In a prospective, open-label clinical trial for postallogeneic haematopoietic cell transplantation (post-alloHCT) patients with RDEB, up to nine chronic wounds per patient were grafted over 1year. Epidermal grafts measuring 5 cm2 were obtained from related alloHCT donors in the outpatient setting using the CELLUTOMETM Epidermal Harvesting System. Wounds were photographed and symptom inventories completed at baseline and 6, 12 and 52weeks after grafting. The trial was registered at ClinicalTrials.gov (NCT02670837). Between August 2016 and January 2019, eight patients with RDEB received a total of 35 epidermal allografts at a median of 1157days (range 548-2884) post-alloHCT. The median (interquartile range) percentage reductions in wound surface area were 75% (52-94), 95% (72-100) and 100% (97-100) at 6, 12 and 52weeks postgraft, respectively, each significantly reduced from baseline (P<0·001). Donor harvest sites healed quickly without scarring. Biopsy evaluation at 1year of an epidermal allograft site revealed wildtype type VII collagen (immunofluorescence), anchoring fibrils (electron microscopy), and full-thickness skin whole-DNA donor chimerism of 42% (compared with 16% in concurrently biopsied native skin). This strategy subsequently supported release of RDEB pseudosyndactyly. The immune tolerance established by alloHCT supports successful adoptive transfer of donor epidermal grafts. Persistence of donor grafts in a single patient beyond 1year and observed migration of donor-grafted cells into adjacent wound suggest that epidermal allografts include nonterminally differentiated cells and/or trigger recruitment of donor bone-marrow-derived cells to mediate wound healing.

A Human-Derived, Collagen-Rich Hydrogel Augments Wound Healing in a Diabetic Animal Model.

Application of collagen products to wounds has been shown to improve wound healing. Using a collagen-based hydrogel (cHG) capable of cellular support previously developed by our laboratory, we hypothesize that our hydrogel will increase the speed of wound healing by providing a 3-dimensional framework for cellular support, increasing angiogenesis and cell-proliferation at the wound bed. Two, 10-mm excisional wounds were created over the dorsum of 12 male, genetically modified Zucker diabetic rats. Wounds were splinted open to limit healing by wound contracture. One wound was treated with an occlusive dressing (OD), whereas the adjacent wound was treated with an OD plus cHG. Occlusive dressings were changed every other day. Hydrogel was applied on day 2 and every 4 days after until complete wound closure. Rate of wound closure was monitored with digital photography every other day. Wounds were harvested at days 10 and 16 for histological and immunohistochemical analysis. Wound closure was significantly faster in cHG-treated wounds compared with OD-treated wounds. By day 10, cHG-treated wounds achieved 63% wound closure, compared with 55% wound closure in OD-treated wounds (P < 0.05). By day 16, cHG-treated wounds achieved 84% wound closure, compared with 68% wound closure in OD-treated wounds (P < 0.05).Histologically, wound depth was not different between the cHG and OD groups on days 10 and 16. However, wound length was significantly less in the cHG group compared with the OD group (P < 0.05) consistent with digital photographic analysis. Immunohistochemical analysis for RECA-1 demonstrated that blood vessel density in the wound bed was 2.3 times higher in the cHG group compared with the OD group (P = 0.01) on day 16. Cell proliferation was 3.8 times higher in the cHG group versus the OD group (P < 0.05) on day 10. Collagen-based hydrogel-treated wounds demonstrated significantly improved healing compared with control. The thermoresponsive feature of collagen hydrogel and its structural stability at body temperature demonstrate promising clinical potential as a vehicle for the delivery of therapeutic cells to the wound bed.

Repair of resurfacing soft tissue defect of hand with radial collateral artery polyfoliate perforator flap

To explore the feasibility and effectiveness of radial collateral artery polyfoliate perforator flap in repair of resurfacing soft tissue defect of hand. Between September 2017 and September 2018, the radial collateral artery polyfoliate perforator flaps were transplanted to repair 5 cases of two adjacent wounds of hand and wide or irregular wounds. All patients were male, aged from 27 to 52 years, with an average of 42.5 years. The time from injury to admission was 4 hours to 3 weeks, with an average of 7.3 days. Causes of injury included traffic accident in 2 cases, crushing injury in 2 cases, and paint injection injury in 1 case. The wounds were located at the dorsum of hand in 3 cases, the dorsum of finger in 1 case, and the thumb and thumb web in 1 case. The area of wound ranged from 8 cm×6 cm to 10 cm×8 cm. The area of skin flap ranged from 6.0 cm×3.0 cm to 11.0 cm×4.5 cm, all of which carried the posterior cutaneous nerve of the arm, and the donor site was closed directly. All flaps survived and healed by first intention. All patients were followed up 3-11 months (mean, 6.5 months). The patients were satisfied with the appearance of hands. The flaps were not bulky, and the color and texture were similar to the hand. There was only linear scar in the donor site, no radial nerve injury occurred, and elbow joint function was not affected. One patient underwent finger-splitting and skin flap thinning at 6 months after operation. The radial collateral artery polyfoliate perforator flap is a good method for repairing two adjacent wounds and wide or irregular wounds of hand.

577 Successful allogeneic epidermal grafting of chronic recessive dystrophic epidermolysis bullosa wounds from hematopoietic cell donors in the outpatient setting

Chronic wounds, or non-healing epidermal erosions present >6 weeks, are common, contribute to morbidity, and lack definitive therapy in recessive dystrophic epidermolysis bullosa (RDEB). The immune tolerance established by allogeneic hematopoietic cell transplantation (HCT) permits adoptive transfer of donor epidermal grafts and establishment of induced mosaicism. In a prospective, open label clinical trial for post-HCT RDEB patients with stable peripheral blood donor chimerism of ≥5%, up to 3 chronic wounds were grafted. Epidermal skin grafts measuring 5 cm2 were obtained from related HCT donors in the outpatient setting using the CelluTomeTM Epidermal Harvesting System. Wound size was measured at baseline, 6, 12, and 52 weeks. Nine patients received a total of 23 epidermal grafts at a median of 1207 days (range 267-3111) post-HCT. The mean (±SD) percent reduction in wound surface area achieved was 61.8% (±31.3), 85.1% (±20.3), and 90.9% (±16.8), at 6, 12, and 52 weeks, respectively, each significantly reduced compared to baseline (p < 0.0001). Donor harvest sites healed quickly with no scarring, though mild hypopigmentation was noted in 5 of 9. Recipient reported benefits include absence of blistering, touch sensation equivalent to native skin, and normal temperature regulation at donor sites. Evaluation of one graft following completion of the study at 1 year revealed wild-type type VII collagen staining by immunofluorescence, normal ultrastructure including intact anchoring fibrils at the dermal-epidermal junction by electron microscopy, and full thickness skin whole DNA donor chimerism of 42% (compared to 16% in concurrently biopsied native skin). Persistence of the donor graft beyond 1 year and observed migration of donor-grafted cells into adjacent wound suggest the epidermal grafts include non-terminally differentiated cells.

Free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound

Objective To explore the surgical method and clinical effects of free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound. Methods From June 2010 to June 2015, 9 cases of thumb defect and adjacent finger soft tissue defects were treated using free second toe transplantation with the first dorsal metatarsal artery flap. The area of the first dorsal metatarsal artery flap ranged from 3.3 cm×2.0 cm to 5.2 cm×3.0 cm. Free skin grafts were used to repair donor site. Results Postoperatively tension blister at the distal end of the flap occurred in 1 case which were healed after removal of stitches and change of dressing. Other reconstructed fingers, flaps and skin grafts achieved primary healing. All the patients were follow-up for 6 to 32 months with an average of 15 months. All the flaps presented good appearance and elasticity with soft texture. The appearance and function of the reconstructed thumbs were good. There was no obvious effect on foot load walking. No skin ulcer occurred in donor site. Conclusion Free second toe transplantation with the first dorsal metatarsal artery flap in reconstruction of thumb and repair of adjacent finger wound is an ideal method for repairing due to the reliable blood supply, safe operation and accordance to repair principle. Key words: Surgical flaps; Microsurgery; Tissue defects; Repair

İntraperitoneal adezyonlar: Patogenezi, klinik önemi ve önleme stratejileri

Postoperative peritoneal adhesion is an important clinical challenge in gastrointestinal, colorectal, and gynecologic surgery. Adhesions are the most frequent cause of long-term complications, including chronic abdominal pain, female infertility, mechanical small bowel obstruction, and injury at reoperations. Postoperative adhesion formation is a natural consequence of peritoneal irritation by surgical tissue trauma or infection, and may be considered as the pathological part of healing following any peritoneal injury. In the search for effective methods for preventing postoperative adhesions, several clinical techniques and agents have been investigated. Strategies for reduction of adhesions are based on their natural pathophysiological mechanisms of origin, including activating fibrinolysis, hampering coagulation, diminishing the inflammatory response, inhibiting collagen synthesis or creating a barrier between adjacent wound surfaces. Despite initial promising results of different measures in postoperative adhesions prevention, none of them have become a standard application and achieved mostly in animal model. Until additional information and findings from future clinical investigations, only a meticulous surgical technique can be recommended to reduce morbidity and mortality rates from these undesirable and troublesome effects of surgery. In the current state of knowledge, further pre-clinical and clinical investigations are necessary to evaluate the prevention strategies of postoperative peritoneal adhesions.

Assessment of platelet-derived growth factor using A splinted full thickness dermal wound model in bearded dragons (Pogona vitticeps).

Wounds in reptiles are a common reason for presentation to a veterinarian. At this time there is limited information on effective topical medications to aid in wound closure. The objectives of this study were to translate the splinted, full-thickness dermal wound model, validated in mice, to the bearded dragon (Pogona vitticeps) and to determine the effect of topical becaplermin (BP), a platelet-derived growth factor (0.01%), on the rate of wound closure. Ten bearded dragons were anesthetized and two full-thickness cutaneous wounds were made on the dorsum of each lizard. Encircling splints were applied surrounding each wound and subsequently covered by a semi-occlusive dressing. Five lizards had one wound treated with BP and the adjacent wound treated with a vehicle control. Five additional lizards had one wound treated with saline and the second wound treated with a vehicle control. Wounds were imaged daily, and the wound area was measured using digital image analysis. The change in percentage wound closure over 17 days and the time to 50% wound closure was compared among the four treatment groups. There was no significant difference in wound closure rates between BP-treated and saline-treated wounds or in the time to 50% wound closure between any treatments. Vehicle-treated wounds adjacent to saline-treated wounds closed significantly slower than did BP (P < 0.010), saline (P < 0.001), and vehicle-treated wounds adjacent to BP-treated wounds (P < 0.013). Our preliminary study indicates that the splinted wound model, with modifications, may be used to determine wound closure rates in bearded dragons. When compared with saline, BP did not have a significant effect on wound closure rates, while the vehicle alone delayed wound closure. Histologic analysis of experimentally created wounds throughout the wound healing process is needed to further evaluate the effects of these treatments on reptile dermal wound healing.

Management of complex abdominal wall defects associated with penetrating abdominal trauma

IntroductionThe paradigm of Damage Control Surgery (DCS) has radically improved the management of abdominal trauma, but less well described are the options for managing the abdominal wall itself in an...

Indicators for Detection of Septic Arthritis in the Acutely Swollen Joint Cohort of Those Without Joint Prostheses

Differentiating septic arthritis from culture-negative, acute atraumatic joint effusion is difficult. Studies have attempted to elucidate factors that herald infection, but, due to overlap, most conclude that the diagnosis ultimately relies on clinical judgment. Furthermore, studies are limited by broad inclusion criteria. The current retrospective case study sought to examine (1) which markers differentiate a culture-positive septic joint from culture-negative effusion in patients suspicious for infection despite no growth on Gram stain and without previous surgery in the affected joint and (2) whether threshold values of these markers exist that predict septic arthritis. The study was performed by reviewing records of those who underwent operative irrigation and debridement involving the shoulder, elbow, wrist, hip, knee, and ankle. Patients were included if they were older than 18 years and had an acutely swollen/painful joint and no organisms on initial Gram stain. Exclusion criteria were lack of serum markers or synovial fluid aspirate, antibiotics within 1 week, adjacent wound or skin infection, recent trauma to the joint, and previous joint infection or surgery to the joint. Several clinical, serological, and synovial parameters were collected and analyzed using paired t test with Bonferonni correction. Serum C-reactive protein was the only significantly different variable between groups. Serum C-reactive protein greater than 10.5 mg/dL was predictive of infection. In those suspicious for infection despite no growth on Gram stain and without previous surgery in the affected joint, C-reactive protein greater than 10.5 mg/dL is suspicious for joint sepsis and should warrant consideration for urgent irrigation and debridement.

POSTCOITAL RUPTURE OF VAGINAL VAULT AND PROLAPSE OF BOWEL FOLLOWING HYSTERECTOMY- A CASE REPORT

Hysterectomy is one of the commonest major gynecological surgical procedure performed all over the world. It is performed either for benign or malignant gynecological conditions, through abdominal or vaginal route. Hemorrhage,accidental injury to the adjacent organs, wound dehiscence and sepsis are some of the major complications associated with this procedure . We report a rare case of a young woman, who presented with post coital rupture of vaginal vault and prolapse of bowel loop, three months following abdominal hysterectomy for benign condition. Her condition was stable at admission. A rent in the vaginal vault, measuring 4 to 5 centimeters was sutured by vaginal route, in two layers under general anesthesia, after reposition of bowel. She had uneventful postoperative period. She was followed up for a period of one year following repair, for re occurrence of this rare complication. Incidence, causative factors and preventive measures for this condition are discussed in the report.

Pathophysiology and prevention of postoperative peritoneal adhesions

Peritoneal adhesions represent an important clinical challenge in gastrointestinal surgery. Peritoneal adhesions are a consequence of peritoneal irritation by infection or surgical trauma, and may be considered as the pathological part of healing following any peritoneal injury, particularly due to abdominal surgery. The balance between fibrin deposition and degradation is critical in determining normal peritoneal healing or adhesion formation. Postoperative peritoneal adhesions are a major cause of morbidity resulting in multiple complications, many of which may manifest several years after the initial surgical procedure. In addition to acute small bowel obstruction, peritoneal adhesions may cause pelvic or abdominal pain, and infertility. In this paper, the authors reviewed the epidemiology, pathogenesis and various prevention strategies of adhesion formation, using Medline and PubMed search. Several preventive agents against postoperative peritoneal adhesions have been investigated. Their role aims in activating fibrinolysis, hampering coagulation, diminishing the inflammatory response, inhibiting collagen synthesis or creating a barrier between adjacent wound surfaces. Their results are encouraging but most of them are contradictory and achieved mostly in animal model. Until additional findings from future clinical researches, only a meticulous surgery can be recommended to reduce unnecessary morbidity and mortality rates from these untoward effects of surgery. In the current state of knowledge, pre-clinical or clinical studies are still necessary to evaluate the effectiveness of the several proposed prevention strategies of postoperative peritoneal adhesions.

Modifying the Burow's triangles of traditional transposition flaps for the repair of adjacent nasal defects

Adjacent defects are commonly encountered during Mohs micrographic surgery for nasal skin cancers and often present a formidable reconstructive challenge. This article will describe similar modifications of both the bilobed and nasolabial transposition flaps' Burow's triangles that allow for the repair of two adjacent defects of the distal nose using a single flap. This is a report of two similar reconstructive cases after Mohs micrographic surgery requiring the repair of adjacent nasal defects. Both cases demonstrate the feasibility of this technique. This technique is based on two case reports. Traditional transposition flaps' Burow's triangles can be effectively modified for the repair of properly selected adjacent wounds of the distal nose.

IGF signaling between blastema and wound epidermis is required for fin regeneration

In mammals, the loss of a limb is irreversible. By contrast, urodele amphibians and teleost fish are capable of nearly perfect regeneration of lost appendages. This ability depends on direct interaction between the wound epithelium and mesenchymal progenitor cells of the blastema. It has been known for decades that contact between the wound epithelium and the underlying blastema is essential for successful regeneration. However, the underlying mechanisms are poorly understood. Here, we show that upon amputation the blastema induces expression of the ligand Igf2b, which then activates IGF signaling specifically in cells of the adjacent apical epithelium. Inhibition of IGF signaling by either morpholino antisense technology, or by specific chemical inhibitors of Igf1 receptor function NVP-AEW541 and NVP-ADW742, impairs fin regeneration. At the cellular level, this block in regeneration is reflected by a lack of the distinctive basal epithelium, increased apoptosis in the wound epidermis and reduced proliferation of blastema cells. Furthermore, induction of the blastemal and wound epidermal markers cannot be supported in the absence of IGF signaling. These data provide evidence that Igf2b expressed in the blastema promotes the properties of the adjacent wound epidermis, which subsequently are necessary for blastema function. Thus, IGF signaling upregulated upon fin amputation represents a signal from the blastema to the wound epithelium, a crucial step in appendage regeneration.