Donor Site Pain Research Articles

Examining Various Graft Substrates and Their Clinical Evidence in the Treatment of Tibial Plateau Fractures

Tibial plateau fractures (TPF) are complex injuries of the tibia that involve the articular surface and commonly have depression of subchondral and metaphyseal bone. Common sequelae of this injury include arthritis and gait disturbances. A popular surgical strategy for this fracture calls for elevation of subchondral bone to restore the joint line, in turn leaving a metaphyseal bone void; this is then commonly secured with plates and screws. Autologous bone has been the gold-standard graft option to fill these voids, but other filling agents such as allografts, biologic grafts, and xenografts are gaining popularity TPF surgery. This is because bone graft substitutes provide predictable outcomes in the treatment of TPF and avoid complications such as donor site pain, infection, increased blood loss, and increased operative time that is seen with autografts. This review explores the benefits, complications, and outcomes of clinically researched graft substrates used for TPF reconstruction. Secondarily, we aim to find potential graft candidates for future clinical research that will progress the treatment of TPF. Internet searches with specific keywords were conducted on different journal databases to find clinically researched graft options in the treatment of TPF within the last 10 years. Multiple studies of various bone graft substitutes achieved similar, if not better results than autologous bone grafts in the treatment of TPF. A summary of each clinically researched graft in this review can be found in Table 1. Establishing a graft selection protocol remains a challenge for fracture surgeons, as well as choosing the best graft material. Future studies should aim to establish a superior graft substrate based clinical outcomes, while minimizing the cost and morbidity to the patient.

Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone–Patellar Tendon–Bone and Hamstring-Tendon Autografts

Background: Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone–patellar tendon–bone (BPTB), hamstring tendon (HT), and QT is still debatable. Hypothesis: The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. Study Design: Meta-analysis; Level of evidence, 2. Methods: A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. Results: Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .45), Lachman test (P = .76), pivot-shift test grade 0 (P = .23), pivot-shift test grade 0 or 1 (P = .85), mean Lysholm score (P = .1), mean subjective IKDC score (P = .36), or graft failure (P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .75), Lachman test (P = .41), pivot-shift test grade 0 (P = .53), Lysholm score less than 84 (P = .53), mean subjective IKDC score (P = .13), donor-site pain (P = .40), or graft failure (P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). Conclusion: QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.

Cartilage Graft Donor Site Morbidity following Rhinoplasty and Nasal Reconstruction.

Although surgical techniques for rhinoplasty and nasal reconstruction are well established, prospective research on postoperative morbidity remains limited. The aim of this pilot study was to assess costal and auricular cartilage donor site pain and morbidity in patients undergoing rhinoplasty and nasal reconstruction. In this prospective cohort study, we enrolled 55 patients undergoing nasal surgery that required costal or auricular cartilage harvest from February 2015 through May 2016. Each patient was given a symptom-specific patient survey that assessed general pain, nasal pain, graft donor site pain, graft donor site itching, color variation, skin stiffness and thickness, and graft donor site appearance at 1, 4, and 12 weeks after surgery. Our patient group was 55% female ( n = 30); the mean age was 47 years. Rib cartilage graft patients had significantly greater nasal pain than cartilage donor site pain. There was no significant difference in rib versus ear cartilage donor site pain. Nearly all patients reported that they were not at all concerned about their scar appearance or ear shape and appearance. No prior studies compare cartilage donor site morbidity in patients undergoing nasal surgery. Our findings challenge the conventional wisdom that utilizing auricular and costal cartilage results in high levels of donor site pain. Surgeons should have a low threshold to harvest rib or ear cartilage when it can improve surgical outcome.

Donor-Site Morbidity After Osteocutaneous Free Fibula Transfer: Longitudinal Analysis of Gait Performance

The purpose was to evaluate donor-site clinical morbidity and changes in kinematic gait parameters after the harvest of a vascularized free fibula flap for facial reconstruction. We enrolled 14 patients (aged 50±15years) in a longitudinal study. Every patient underwent a double evaluation in which a presurgical assessment and 6-month postsurgical assessment were performed. Subjective donor-site evaluation was carried out through unstructured clinical questioning about pain, paresthesia, walking ability, and restrictions in activity. Further subjective evaluations were assessed through the Western Ontario and McMaster Universities Osteoarthritis Index and the Point Evaluation System for Lower Extremity Fibulectomy. A clinical evaluation of the donor site assessed muscular deficits, sensibility disturbance, and wound healing. Temporal and spatial kinematic parameters were measured through gait analysis during overground walking at a comfortable speed. Postsurgical clinical examinations detected 1 patient affected by a neurologic disorder and 3 patients with donor-site pain, whereas 10 patients (71%) declared no residual alterations in the operated leg. On average, the Western Ontario and McMaster Universities Osteoarthritis Index score was 367 of 2,400, and the Point Evaluation System for Lower Extremity Fibulectomy score was 19 of 24. Presurgical versus postsurgical gait analysis comparison showed no significant differences in gait parameters except for a 6% reduction in the double-support phase.Stance values were higher for the operated limb in both evaluations (+1.3% before surgery,+1.8% after surgery). No alterations were detected in the range of motion of the lower-limb joints. Considering the slight modification of the gait pattern, which is not usually perceived by patients, vascularized free fibula flap harvest was generally associated with successful functional and subjective outcomes of the donor site.

Current Clinical Recommendations for Use of Platelet-Rich Plasma.

This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications. Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.

Transversus Abdominis Plane Blocks in Microsurgical Breast Reconstruction: Analysis of Pain, Narcotic Consumption, Length of Stay, and Cost.

Transversus abdominis plane blocks are increasingly being used in microvascular breast reconstruction. The implications of these blocks on specific reconstructive, patient, and institutional outcomes remain to be fully elucidated. Patients undergoing abdominally based microvascular breast reconstruction from 2015 to 2017 were reviewed. Length of stay, complications, narcotic consumption, donor-site pain, and hospital expenses were compared between patients who did and did not receive transversus abdominis plane blocks with liposomal bupivacaine. Outcomes were subsequently compared in patients with elevated body mass index. Fifty patients (43.9 percent) received blocks [27 (54.0 percent) under ultrasound guidance] and 64 patients (56.1 percent) did not. Patients with the blocks had significantly decreased oral and total narcotic consumption (p = 0.0001 and p < 0.0001, respectively) and significantly less donor-site pain (3.3 versus 4.3; p < 0.0001). There was no significant difference in hospital expenses between the two cohorts ($21,531.53 versus $22,050.15 per patient; p = 0.5659). Patients with a body mass index of 25 kg/m(2) or greater who received a block had a significantly decreased length of stay (3.8 days versus 4.4 days; p = 0.0345) and decreased narcotic consumption and postoperative pain compared with patients without blocks. Patients with a body mass index less than 25 kg/m(2) did not have a significant difference in postoperative pain, narcotic consumption, or length of stay between groups. Transversus abdominis plane blocks with liposomal bupivacaine significantly reduce oral and total postoperative narcotic consumption and donor-site pain in all patients after abdominally based microvascular breast reconstruction without increasing hospital expenses. The blocks also significantly decrease length of stay in patients with a body mass index greater than or equal to 25 kg/m(2). Therapeutic, III.

Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines.

Background:Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites.Methods:A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores.Results:A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings.Conclusion:The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.

Pedicled Vascularized Bone Graft Versus Induced Membrane Technique for Reconstruction of Forearm Medium-Size Bone Defects

There is no financial information to disclose. Induced membrane technique has proven satisfactory results for reconstruction of infected nonunion. However, more complex techniques such as vascularized bone grafts (VBG) are usually indicated in the presence of prior graft failure or a poor soft tissue bed. The purpose of this study is to compare the clinical and radiological outcomes of a series of patients treated for ulnar nonunion with medium-size bone defects. Patients were treated with either pedicled distal radius VBG (Figure 68-1) or induced membrane technique (IMT). Twelve patients who underwent surgery for reconstruction of infected forearm nonunion with bone defects up to 6 cm (minimum follow-up, 2 years) were selected retrospectively. Seven patients underwent distal radius pedicled VBG (group A) and 5 patients underwent reconstruction with the induced membrane technique (group B) (Figure 68-2). Mean follow-up was 34 months. The time between the original injury and the index procedure was 16 months (range, 11–20). The mean age was 42 years (range, 26–64). Patients were evaluated clinically and radiographically. The number of previous surgeries was recorded. Elbow and wrist range of motion, visual analog scale (VAS) for pain, the Quick-DASH questionnaire, and Mayo Elbow Perfomance Score (MEPS) were assessed. Complications and the need for reoperations were recorded. All nonunion were healed at final follow-up. The average defect size was 5.3 cm (range, 4.2–6). The average number of previous surgeries in the VBG group was 4.2 (range, 3–7) and in the IMT group was 2.8 (range, 2–5). The average time to union was 3.8 months (range 3–6) for group A, and 4.6 (range 4–6) for group B. Active ROM did not differ significantly between groups. Average QuickDASH was 13, and average MEPS was 83. At the 2-year follow-up, there were no significant differences in the VAS pain score (1.3 in group A; 0.9 in group B). There were 2 complications. In the VBG group, one patient required implant removal, and in the IMT group, 1 nonunion required autogenous iliac crest bone graft. Final results were satisfactory for both. No fracture or persistent donor site pain was observed in the VBG group. •In this limited series, both techniques showed favorable results and could be considered surgical alternatives for the treatment of infected ulnar nonunion.•Pedicled VBG showed a shorter time to union compared with induced membrane.Figure 68-2Intraoperative photographs of an ulnar defect reconstructed with a pedicled radius VBG (A) and with iliac crest bone graft, during the second stage of the induced membrane technique (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Total Finger Arthroplasty Using Costal Osteochondral Autograft for Finger Joint Ankylosis: Mid- to Long-Term Clinical Outcomes Up to 11 Years of Follow-Up

There is no financial information to disclose. Costal osteochondral grafting is a technique for providing anatomical and biological reconstruction of articular disorders. We have applied this procedure to the treatment of finger joint ankylosis. The purpose of this study was to clarify the mid- to long-term clinical outcomes of total finger arthroplasty using costal osteochondral autograft for finger joint ankylosis. The metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were approached dorsally through a longitudinal incision. The periosteum and capsule were elevated concurrent with the collateral ligaments and the volar plate all around the joint (Figure 62-1A). The ankylosed joint was separated at the original joint level. The ends of the phalanx and metacarpus were step-cut for the graft floor (Figure 62-1B). Two pieces of osteochondral graft were harvested from the fifth and sixth ribs and then manually trimmed to form a new MCP/PIP joint with adequate contours using a scalpel (Figure 62-1C). The bony part of the graft was step-cut and stabilized using low-profile screws (Figure 62-1D). Twenty-three finger joints (3 MCP joints and 20 PIP joints) in 23 patients with ankylosis were treated with costal osteochondral autograft with at least 5 years of follow-up. Participants were composed of 19 males and 4 females ranging in age from 18 to 55 years (mean, 33 years). Clinical outcomes including range of finger motion, the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder, and Hand (DASH-JSSH) score, donor-site disturbances, and radiographic outcomes were evaluated after a mean follow-up of 77 months (range, 60–138 months). Significant improvement in active finger extension-flexion was seen from a preoperative mean of –24°/26° (arc: 2°) to –12°/75° (arc: 63°) at 1 year postoperatively (P < .001) and to –13°/75° (arc: 62°) at latest follow-up (P < .001). Mean preoperative DASH-JSSH score was initially 23.6, improving significantly to 6.6 at 1 year postoperatively, and to 5.2 by latest follow-up (P < .001) (Figure 62-2). Donor-site pain persisted only 1 to 2 weeks after surgery and raised no particular problems. One patient injured the operated finger while playing rugby football 2 years after surgery and needed additional costal osteochondral grafting. Other additional surgeries were collateral ligament reconstruction in 4 patients, corrective osteotomy of the phalanx in 2, and tenolysis in 1. •Total finger arthroplasty using costal osteochondral autograft for finger joint ankylosis showed anatomical and biological reconstruction and provided stable improvement of clinical outcomes with a mean follow-up of 77 months.Figure 62-1BAfter exposure of the ankylosed joint, the bone is separated with a chisel at the original PIP joint. The cut-off ends of the middle and proximal phalanx are step-cut.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-1CTwo pieces of osteochondral graft are harvested from the fifth and sixth ribs through an ipsilateral transverse sub-mammary incision. The harvested grafts are trimmed by hand to form the head of the proximal phalanx and base of the middle phalanx. The cartilaginous area of the graft is trimmed using a scalpel. Careful trimming is necessary to form adequate contours.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-1DThe bony part of the graft is step-cut and stabilized using low-profile screws. In closure, the central slip is reattached to the base of middle phalanx, and the collateral ligament, periosteum, and volar plate are repaired with 5-0 nylon sutures. A continuous distracting device is applied to the PIP joint to decrease friction between the joint surfaces.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-2Comparing range of motion preoperatively, at 1 year postoperatively, and at latest follow-up. *P < .001.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Marine Collagen/Apatite Composite Scaffolds Envisaging Hard Tissue Applications.

The high prevalence of bone defects has become a worldwide problem. Despite the significant amount of research on the subject, the available therapeutic solutions lack efficiency. Autografts, the most commonly used approaches to treat bone defects, have limitations such as donor site morbidity, pain and lack of donor site. Marine resources emerge as an attractive alternative to extract bioactive compounds for further use in bone tissue-engineering approaches. On one hand they can be isolated from by-products, at low cost, creating value from products that are considered waste for the fish transformation industry. One the other hand, religious constraints will be avoided. We isolated two marine origin materials, collagen from shark skin (Prionace glauca) and calcium phosphates from the teeth of two different shark species (Prionace glauca and Isurus oxyrinchus), and further proposed to mix them to produce 3D composite structures for hard tissue applications. Two crosslinking agents, 1-[3-(dimethylamino)propyl]-3-ethylcarbodiimide hydrochloride/N-Hydroxysuccinimide (EDC/NHS) and hexamethylene diisocyanate (HMDI), were tested to enhance the scaffolds’ properties, with EDC/NHS resulting in better properties. The characterization of the structures showed that the developed composites could support attachment and proliferation of osteoblast-like cells. A promising scaffold for the engineering of bone tissue is thus proposed, based on a strategy of marine by-products valorisation.

Reconstruction of iliac crest defect after autogenous harvest with bone cement and screws reduces donor site pain

BackgroundThe iliac crest is the most common autogenous bone graft donor site, although associated with postoperative pain, functional disability, cosmesis, morphology and surgical satisfaction. We assessed each aspect above by comparing iliac crest reconstruction with bone cement and screws following harvest with no reconstruction.MethodsWe evaluated patients who underwent large iliac crest harvesting, including ten patients who underwent iliac crest defect reconstruction with bone cement and cancellous screws (R group) and ten randomly matched patients without reconstruction (NR group) were evaluated prospectively in the same period. Local pain, cosmesis and other complications were assessed postoperatively at 1 week, 6 weeks, 3 months and 6 months.ResultsPain, cosmesis and satisfaction of patients significantly differed between the two groups. The R group exhibited less complications and lower pain visual analogue scores at postoperative 1 week (p < 0.001), 6 weeks (p < 0.001) and 3 months (p < 0.01) but not at 6 months, at which time patients reported almost no pain. One patient reported pain for more than 1 year in the NR group. The R group exhibited better cosmesis, morphology and satisfaction than the NR group. In the NR group, one patient suffered pain when sitting up and another when wearing a belt.ConclusionPostoperative pain can be reduced and cosmesis can be improved through reconstructing the iliac crest defects after autogenous harvesting with bone cement and cancellous screws. The technique is simple, safe and easy to implement.

Novel, vacuum-assisted method for harvesting autogenous cancellous bone graft and bone marrow from the proximal tibial metaphysis

Category: Other Introduction/Purpose: Autogenous cancellous bone graft and bone marrow aspirate are commonly used in lower extremity fusion procedures. Autologous graft is considered the gold standard as it is osteogenic, osteoinductive, and osteoconductive, and is without the potential risks of graft-associated infection and immunologic reaction. Disadvantages include graft harvest time and donor site morbidity due to the surgical incision, approach and bone corticotomy. This study evaluated the safety and efficacy of a novel vacuum-assisted bone graft harvesting device which was able to obtain both cancellous bone and bone marrow for insertion into the arthrodesis sites of patients undergoing complex primary and revision lower extremity fusion procedures. Methods: Between March and November 2017, 9 patients had a foot and/or ankle complex primary or revision arthrodesis performed, with autogenous cancellous graft and bone marrow harvested from the ipsilateral proximal tibia. All patients were 18 years or older with no prior history of knee pain, injury, or surgery at the proximal tibia. Following a circular corticotomy, cancellous bone was harvested using a novel suction-powered, hand-driven bone curettage system (Avitus Orthopaedics, Farmington, CT). The donor site was backfilled with bone graft substitute. Incision length was recorded as well as surgical time from donor site incision to completion of graft acquisition. The volume of cancellous graft and bone marrow were separately recorded. All patients were non-weight bearing on the involved extremity for a minimum of 6 weeks post-operatively and all were evaluated at 2 and 6 weeks post-operatively for donor site pain and associated complications. Results: There were five male and four female patients with an average age of 51 years and 8 months. Procedures included six complex primary fusions and three revision subtalar or tibio-talar-calcaneal fusions for nonunion. Mean incision length was 2 cm (range 1.80-2.75 cm). Mean volume of obtained graft material included 25 cm3 of cancellous bone (range 9-30 cm3) and 21 cm3 bone marrow aspirate (range 10-40 cm3). Mean procedure time was 5 mins (range 4-8 mins), and average blood loss was less than 1 mL. Two patients had mild pain at 2 week follow-up; however, no patients reported donor site pain at 6 week follow-up. There were no major or minor complications including fracture, infection, hematoma formation, sensory changes, or wound healing issues. Conclusion: The use of an innovative, vacuum-assisted bone harvesting device allows large volumes of autogenous cancellous bone graft and marrow to be rapidly and readily obtained from the ipsilateral proximal tibia with minimal donor site morbidity.

Autologous Costal Cartilage Harvesting Technique and Donor-Site Pain in Patients Undergoing Rhinoplasty-Reply.

Autologous Costal Cartilage Harvesting Technique and Donor-Site Pain in Patients Undergoing Rhinoplasty-Reply.

Autologous Costal Cartilage Harvesting Technique and Donor-Site Pain in Patients Undergoing Rhinoplasty

Autologous Costal Cartilage Harvesting Technique and Donor-Site Pain in Patients Undergoing Rhinoplasty

Alternatives to Autologous Bone Graft in Alveolar Cleft Reconstruction: The State of Alveolar Tissue Engineering.

Alveolar cleft reconstruction has historically relied on autologous iliac crest bone grafting (ICBG), but donor site morbidity, pain, and prolonged hospitalization have prompted the search for bone graft substitutes. The authors evaluated bone graft substitutes with the highest levels of evidence, and highlight the products that show promise in alveolar cleft repair and in maxillary augmentation. This comprehensive review guides the craniofacial surgeon toward safe and informed utilization of biomaterials in the alveolar cleft.A literature search was performed to identify in vitro human studies that fulfilled the following criteria: Level I or Level II of evidence, ≥30 subjects, and a direct comparison between a autologous bone graft and a bone graft substitute. A second literature search was performed that captured all studies, regardless of level of evidence, which evaluated bone graft substitutes for alveolar cleft repair or alveolar augmentation for dental implants. Adverse events for each of these products were tabulated as well.Sixteen studies featuring 6 bone graft substitutes: hydroxyapatite, demineralized bone matrix (DBM), β-tricalcium phosphate (TCP), calcium phosphate, recombinant human bone morphogenic protein-2 (rhBMP-2), and rhBMP7 fit the inclusion criteria for the first search. Through our second search, the authors found that DBM, TCP, rhBMP-2, and rhBMP7 have been studied most extensively in the alveolar cleft literature, though frequently in studies using less rigorous methodology (Level III evidence or below). rhBMP-2 was the best studied and showed comparable efficacy to ICBG in terms of volume of bone regeneration, bone density, and capacity to accommodate tooth eruption within the graft site. Pricing for products ranged from $290 to $3110 per 5 mL.The balance between innovation and safety is a complex process requiring constant vigilance and evaluation. Here, the authors profile several bone graft substitutes that demonstrate the most promise in alveolar cleft reconstruction.

56 Regional Anesthetic Blocks for Donor Site Pain in Burn Patients: A Meta-Analysis on Efficacy, Outcomes and Cost

56 Regional Anesthetic Blocks for Donor Site Pain in Burn Patients: A Meta-Analysis on Efficacy, Outcomes and Cost

Pain and the unstable knee

Causes of knee pain in the unstable knee can be multifactorial and complex and often misdiagnosed. Commonly ligamentous injury, such as anterior cruciate ligament (ACL) tears can lead to knee pain that can be secondary to hemarthrosis, articular injuries, meniscal pathology and/or patellofemoral pain. Controversy exits regarding the role bone bruising plays in ACL injured and knee instability patients. Patient factors such as sex, age, BMI, and type of sport play a role as well. When ligamentous reconstruction is chosen, prehabilitation is essential to decrease the risk of arthrofibrosis which is a common cause of post-operative knee pain. Autograft donor site pain, as well as painful hardware, also is relevant. Post-operative therapies are critical as well. Posterior cruciate ligament (PCL) injury can lead to asymptomatic instability which also can be a cause of pain. As with the ACL, this instability can lead to further cartilage damage and osteoarthritis and subsequently to knee pain. Further, multi-ligamentous knee injuries are complex and causes of knee pain are even more numerous. Special attention must be paid to the vascular and neurologic status of the patient as conditions such as complex regional pain syndrome can be devastating. Commonly, injury and surgical complications, and arthrofibrosis can cause acute and chronic pain and no superior treatment scheme has been well established. The authors recommend an individualized approach with a thorough exam, appropriately indicated treatments, and post-operative care to prevent further injury and debilitating pain to allow the best outcomes.

Topical simvastatin gel as a novel therapeutic modality for palatal donor site wound healing following free gingival graft procedure

Objective: Autogenous soft-tissue grafting is a commonly used procedure nowadays in dentistry. However, the prolonged healing time needed for the donor site leads to increase the patient’s pain and discomfort. Statin has been observed to be beneficial in reducing bacterial burden, improving epithelization and wound healing. The aim of this study was to evaluate intra-oral topical application of simvastatin/chitosan gel (10 mg/mL) over the palatal donor site following free gingival graft (FGG) procedure.Material and methods: Subjects indicated for FGG procedure were divided into four groups. Group I: Simvastatin suspension (S), group II: simvastatin/chitosan gel (SC), group III: chitosan gel (C), group IV: petroleum gel (P). Treatment was applied three times/day for the following 7 days. Wound healing was evaluated at day 3, 7 and 14 post-surgery. A visual analogue scale (VAS) was used to measure the experienced discomfort at 1, 3, 5, 7 and 14 days.Results: Statistical significant reduction in wound-healing scores was observed after 3 and 7 days for group II compared to other groups (p = .015). A significant reduction was also observed in VAS score for group II compared to other groups at day 1, 3, 5 and 7.Conclusion: Topical application of S/C gel could be used as a novel therapeutic modality that improved healing and reduced pain in the palatal donor site following FGG procedure.

Feasibility and Advantages of Full Thickness Skin Graft from the Anterolateral Thigh.

Full thickness skin graft (FTSG) gives better outcomes than split thickness skin graft (STSG), but it has the drawback of limited donor sites. Anterolateral thigh (ALT), a popular donor site of STSG, is also a popular donor site of perforator flaps. This area has the advantage of large flap size available with primary closure. Based on this we harvested FTSG instead of STSG from the ALT. We retrospectively reviewed 10 cases of FTSG from the ALT, with the recipient site of foot in 3, ankle in 2, lower leg in 2, forearm in 2, and wrist in 1 patient. In all cases elliptical full thickness skin was harvested from the ALT, and the donor site was closed primarily. The skin was defatted and placed onto the defect with vacuum-assisted closure (VAC). The skin size ranged 7-30 cm in length and 3-12 cm in width. Mean follow up period was 7 months (range, 3-13). FTSG from the ALT provided durable wound coverage, with excellent color and texture matching. Partial (< 20%) graft failure was observed in 1 case, but no additional surgery was necessary. No patient reported donor site pain at postoperative 2 weeks. No donor site complications were encountered. No patient complained a feeling of tension in the thigh at final follow-up. FTSG from the ALT is feasible with the aid of VAC. Considering the skin quality, large skin size available, early pain relief, and little donor site morbidity, the ALT should be revisited as a donor site of FTSG.

Treating pain on skin graft donor sites: Review and clinical recommendations.

Split-thickness skin grafting is the most common reconstructive procedure in managing burn injuries. Harvesting split-thickness skin creates a new partial thickness wound referred to as the donor site. Pain at the donor site is reported to be one of the most distressing symptoms during the early postoperative period. Here, we (a) identify strategies for managing donor site pain, (b) assess the quality of individual studies, and (c) formulate evidence-based recommendations based on the amount and consistency of evidence. Our analysis revealed five distinct approaches to minimize donor site pain. These include: continuous subcutaneous local anesthetic infusion (three studies), subcutaneous anesthetic injection (five studies), topical agents (six studies), nonpharmacological interventions (three studies), and wound dressings (18 studies). Available randomized control trials typically evaluated pain on standardized scales (i.e. Visual Analog Scale, Numerical Rating Scale), and compared the experimental group with standard care. Recommended treatments include: (a) subcutaneous anesthetic injection of adrenaline-lidocaine; (b) ice application; (c) topical agents, such as lidocaine and bupivacaine; and (d) hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant. Methodologically sound randomized control trials examining the efficacy of modified tumescent solution, ropivacaine, plasma therapy, noncontact ultrasound, and morphine gels are lacking and should be a priority for future research.