Initial Debridement Research Articles

The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IVantibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544-53.

Management of septic arthritis after arthroscopic anterior cruciate ligament reconstruction using a standard surgical protocol

BackgroundTo report the incidence of septic arthritis after anterior cruciate ligament (ACL) reconstruction and management of this complication using a specific treatment protocol. MethodsAll primary ACL reconstructions performed in our institution between January 2002 and January 2014 were included in this study. Time to presentation, clinical symptoms, and culture results of all infected patients were analyzed. According to our protocol, an arthroscopic debridement and irrigation of the knee joint was performed immediately after a diagnosis of infection was made. In case of recurrence, knee irrigation with hardware and graft removal and later re-implantation was performed. Patients were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) Form, KT 1000 arthrometer and radiographic evaluation. ResultsPostoperative septic arthritis occurred in seven of 1242 patients (0.56%). After initial arthroscopic debridement, infection recurred in six out of seven cases (85%). Graft and hardware removal was performed in these patients. Graft re-implantation was performed in four patients at an average five months after infection. At the final follow-up (mean 6.3years) all patients had full range of motion, while in patients with graft re-implantation the mean Lysholm score was 92, and the mean IKDC score was 87. Radiographs demonstrated that three patients had normal knees and one patient had a grade one, knee arthritis according to Kellgren–Lawrence classification. ConclusionsManagement of septic arthritis after ACL reconstruction using a specific surgical protocol which includes graft removal in case of infection recurrence with later re-implantation, can provide good and excellent results. Level of evidenceLevel IV, case series.

Is hyperbaric oxygen therapy indispensable for saving mutilated hand injuries?

Mutilated hand injuries are a profound challenge to the plastic surgeon, and such injuries often lead to limb loss and severe functional impairment. Hyperbaric oxygen therapy (HBOT) appears to counteract tissue hypoxia and stimulate acute wound healing. This study was performed to evaluate the efficacy of HBOT as an adjunctive therapy in patients with a mutilated hand injury. Between January 2006 and December 2014, 45 patients with a mutilated hand injury were enrolled. After reconstruction or revascularisation, patients underwent 120 minutes of HBOT with oxygen at 2·5 atmospheres absolute while breathing 100% oxygen. Outcomes such as amputee survival and surgery-related complications were recorded. The patients were 38 men and 7 women with average age of 37·2 years (range 18-62). The mean defect area was 131·5 cm2 (range 40-300). Most patients experienced a pure crush injury (53%). The average number of operations from the initial debridement to the first reconstruction was 3·8 (range 1-6). A total of 33 patients (73%) underwent replantation during the initial reconstruction. For flap coverage, most patients received a free flap using an anterolateral thigh flap (18 patients) or local flap using an abdomen/groin flap (nine patients). The average time from the first reconstruction or revascularisation to the first HBOT was 6·5 hours (range 2-12). The average number of HBOT sessions was 9·1 (range 6-14 sessions). The survival rate of the replanted fingers was 81%, and the survival rate of the palms was 100%. Most complications in the initial reconstruction involved partial loss of an avulsed flap, and most complications in the chronic stage (≥3 months) involved scar contracture. When combined with delicate microsurgery, early intervention using adjunctive HBOT was effective in preserving partially viable tissue and restoring hand function in patients with a mutilated hand injury.

Postoperative wound infections : Diagnosis, classification and treatment

Surgical site infections are afrequent complication of surgery and asevere burden for the patient as well as for the healthcare system. Sound knowledge of the disease pattern is an essential prerequisite for effective therapy. This article presents an overview of the diagnosis, classification and treatment options for surgical site infections. Based on the existing experience, the currently available evidence and pathophysiological considerations, an overview of the diagnostic possibilities, the existing classification systems and the treatment options is presented. The diagnosis of surgical site infections is based on the clinical symptoms and can particularly be supported by the microbiological analysis of wound samples. There is no validated classification system but the definition of the Centers for Disease Control and Prevention is most commonly used. After initial bedside processing, debridement and wound cleansing are the basis for the further treatment, which is supplemented by the rational use of antiseptics and antibiotics. The use of modern dressings with the aim of maintaining aphysiological moist wound environment promotes wound healing. The negative pressure wound therapy is an available treatment option. Rare diseases need to be considered. The low level of evidence and critical consideration of the treatment options have been discussed in many guidelines, consensus documents and systematic reviews on the basis of which this article was written. Strengthening the evidence situation through intensive, targeted research should be the goal.

Review of Clinical and Functional Outcome of Prosthetic Salvage for Infected Total Knee Replacement

We have retrospectively studied the infected total knee replacement cases treated by open irrigation and debridement from 1996 to 2006 at NHS Tayside hospitals. Case notes of 18 (17 patients) were reviewed and looked into factors such as criteria chosen for surgery, timing of debridement, organism cultured and antibiotic duration. A success rate of 94% was noted (only 1 case of failure). Failure of the procedure included those which were re-infected or underwent some other treatment after initial debridement. The clinical and functional outcome amongst the successful cases was noted to be good as evidenced by knee society scores. The median follow-up was 3 years. The commonest organism found was staphylococcus aureus (27%). The single case of failure was a 77 year old female with no significant co-morbidities and had mixed organisms in culture. No relation was found between success and failure with regard to age, sex, pre-operative diagnosis and co-morbidity. However, timing of surgery and the length of antibiotic administration were considered relevant to the success of this method. Despite the hesitant and not so encouraging results of some previous studies concerning prosthetic salvage by this method, we believe that this procedure has a role in immediate post-operative period in carefully chosen cases within 4 weeks of index surgery.

The use of locked plate as a definitive fixation for open supracondylar fracture of the femur with partial bone loss in polytraumatized patients

Background Open supracondylar fractures of the femur are complex injuries usually presenting in a polytraumatized patient. Partial circumferential bone loss may result at the time of injury or during debridement. The way in which the fracture is treated has a substantial influence on the local mechanical and biological environment, which in turn will influence the quantity and quality of the osteogenic response. Although early skeletal stabilization can stop the cycle of injury, remove nidus for infection, and halt ongoing hemorrhage, it may be prudent to delay definitive surgery until the patient’s general condition is optimized. Meanwhile, debridement and a preliminary spanning external fixator is used to stabilize the fracture. The use of a locked plate for the fixation of supracondylar fracture of the femur with partial bone loss creates a rigid biomechanical environment needed for healing and maintenance of alignment until fracture healing. Patients and methods Eighteen patients with open supracondylar fracture of the femur were treated between January 2009 and June 2011. All patients were treated surgically within the first 24 h. Radical soft tissue and bone debridement was performed. Thirteen patients underwent definitive fracture fixation using a laterally placed locked distal femur plate. Five patients had their fractures primarily stabilized by an external fixator until improvement of their general condition. Results Bone healing was obvious on follow-up radiographs in 10 patients without the need for supplementary surgical procedures at a mean of 16 (12–20) weeks. Seven patients with no progressive radiologic healing by 20 weeks’ follow-up underwent an iliac crest cancellous bone graft; healing was then realized radiologically after a mean of 12 (8–18) weeks. Using the IOWA knee functional score for final patient assessment, we found excellent results in 14 patients, good results in three patients, and fair results in one patient. Conclusion Generally stable polytraumatized patients should be treated with thorough initial debridement, local antibiotics, and early definitive fracture fixation using a locked distal femur plate. Critically unstable patients with hemorrhagic shock are to be treated with damage control until improvement in their general condition. Bone graft is to be delayed for 20 weeks as many fractures would successfully heal by that time, even with partial bone loss.

Results of open fractures of tibia treated by external fixator as primary and definitive procedure

Unilateral AO external fixator was used as primary and definitive procedure for treatment of open fractures of both bones of leg. There were 37 patients, and according to Gustilo and Anderson classification there were 20 patients in Type II and 9 in type III A and 8 in type III B. Type I and Type II C were excluded from the study. Males were 30 and females were 7. Maximum cases were in the age group 31-40 years (12 patients). The most common level of injury was at middle 1/3 of tibia. There were associated injuries in seven patients. In all the cases initial debridement and unilateral external fixation was applied. In 31 cases primary closure was done after ensuring the viability of the soft tissues and skin. Secondary closure was done in six cases. Flap cover was given in three cases and skin grafting in three cases. Release incision was done in two cases. The patients were followed for union of fracture; function of the limb and for complications. Fractures in 36 patients united by 10 to 24 weeks with an average of 16 weeks. The complications encountered were, non-union in one, loss of reduction in three, Pin track infection in 8, osteomyelitis in one patient.

Cutaneous Mucormycosis in a Trauma Patient with a New Diagnosis of Diabetes Mellitus

Background: Mucormycosis is an uncommon, but life-threatening fungal infection caused by the order Mucorales, family Mucoraceae. It is difficult to diagnose and manage, and it has a high fatality rate because of its rapid progression. Methods: We present a 34-year-old male trauma patient admitted following a motor vehicle accident. Results: While he had no medical history of diabetes mellitus, his admitting glycosylated hemoglobin (HbA1c) was 12.7%. On hospital day eight the patient developed an ecchymotic lesion on his left flank associated with surrounding erythema and edema. The edges of the lesion became necrotic and surrounding erythema expanded on hospital day ten. A white cotton-like appearance formed over the ecchymotic wound. An extensive surgical debridement was performed, extending to healthy bleeding tissue. A skin biopsy showed broad, large and non-separated fundal hyphae. On the same day, liposomal amphoteracin B at 5 mg/kg/day was started. The tissue culture was positive for Rhizopus species. The patient underwent multiple subsequent debridements and received a total course of 4 wks of liposomal amphoteracin B. Fifteen days from the initial surgical incision debridement, a split thickness skin grafting was performed. Conclusion: No mucormycosis relapse was noted 3 mo after initial fungal infection presentation.

Variation in practice preferences in management of open injuries of extremities-an international survey by SICOT research academy.

Open fractures are challenging injuries and there is a lot of variation in practice preferences which may reflect the wide variations in outcome in different units across the world. A survey was done amongst the international community of SICOT membership to document the practice preferences and variations. An online questionnaire containing 23 questions which were sub-divided into three sections covering the various aspects of open injury management was sent by email to orthopaedic trauma surgeons across the world. A total of 358 responses were evaluated and presented in this manuscript. The SICOT study confirmed wide variation in practice protocols. About 94.7% of orthopaedic surgeons around the world use the Gustillo Anderson scoring system for assessment of open injury and 50.6% of surgeons prefer lavage in operation theatre. For lavage, 84.6% of surgeons preferred normal saline and for antibiotic prophylaxis, 48.3% used a combination of second generation cephalosporin, metronidazole and an aminoglycoside for a minimum of three to fivedays. In 88% of patients, orthopaedic surgeons performed the initial debridement and 69.2% surgeons aimed for debridement within sixhours. Regarding wound management, 43.9% units preferred and were capable of soft tissue cover within 72hours and about 26.3% surgeons combined definitive fixation along with plastic procedure. Our study documented wide variations in practice preferences across the world and showed that information and awareness about current guidelines and practices will help many to update themselves in terms of basic questions about open fracture care.

Negative pressure wound therapy for Gustilo Anderson grade IIIb open tibial fractures.

Background:Traditionally, Gustilo Anderson grade IIIb open tibial fractures have been treated by initial wide wound debridement, stabilization of fracture with external fixation, and delayed wound closure. The purpose of this study is to evaluate the clinical and radiological results of staged treatment using negative pressure wound therapy (NPWT) for Gustilo Anderson grade IIIb open tibial fractures.Materials and Methods:15 patients with Gustilo Anderson grade IIIb open tibial fractures, treated using staged protocol by a single surgeon between January 2007 and December 2011 were reviewed in this retrospective study. The clinical results were assessed using a Puno scoring system for severe open fractures of the tibia at the last followup. The range of motion (ROM) of the knee and ankle joints and postoperative complication were evaluated at the last followup. The radiographic results were assessed using time to bone union, coronal and sagittal angulations and a shortening at the last followup.Results:The mean score of Puno scoring system was 87.4 (range 67–94). The mean ROM of the knee and ankle joints was 121.3° (range 90°–130°) and 37.7° (range 15°–50°), respectively. Bone union developed in all patients and the mean time to union was 25.3 weeks (range 16–42 weeks). The mean coronal angulation was 2.1° (range 0–4°) and sagittal was 2.7° (range 1–4°). The mean shortening was 4.1 mm (range 0–8 mm). Three patients had partial flap necrosis and 1 patient had total flap necrosis. There was no superficial and deep wound infection.Conclusion:Staged treatment using NPWT decreased the risks of infection and requirement of flap surgeries in Gustilo Anderson grade IIIb open tibial fractures. Therefore, staged treatment using NPWT could be a useful treatment option for Gustilo Anderson grade IIIb open tibial fractures.

Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers

Category: Diabetes Introduction/Purpose: With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers. Methods: Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD. Results: Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. Thirty-six of 51 (70.59%) state boards of nursing responded to the survey with 33 of 36 (91.67%) defining CSWD as within the nursing scope of practice. The estimated cost savings by having nurses perform CSWD over a 6 week treatment period, with all other factors being equal, was $774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to $2.1 billion in potential annual healthcare savings. Conclusion: CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings.

Treatment of Turtle Shell Ulcerations Using Photopolymerizable Nano-Hybrid Dental Composite

Shell ulcerations are commonly observed lesions in chelonians, with treatment typically required for disease resolution. In this study, photopolymerizable nano-hybrid dental composite was used as a closure material for ulcerative lesions affecting chelonian shells. Shell ulcerative lesions were diagnosed in 33 different species of turtles: 14 red-eared sliders (Trachemys scripta elegans), 5 yellow bellied sliders (Trachemys scripta scripta), 11 Sicilian pond turtles (Emys trinacris), 2 Florida red bellied cooters (Pseudemys nelsoni), and 1 Mississippi map turtle (Graptemys pseudogeographica kohnii). Turtles were premedicated with tramadol and meloxicam administered intramuscularly; anesthesia was induced using a combination of ketamine and diazepam administered intramuscularly, and maintained on a surgical plane of anesthesia using isoflurane. The patient’s shells were washed with a povidone iodine solution before being placed on a heating pad to maintain a normothermic condition. After the initial lesion debridement, surgical curettage was performed with a tungsten carbide burr. The surgical curettage was necessary to generate an appropriate cavity and suitable surface for applying the photopolymerizable dental composite (PDC). During the curettage procedure, sterile saline solution, containing 3mL/L of 2% lidocaine, was continuously applied onto the lesions. After the curettage procedure, an EDTA solution, followed by a dehydrating potassium-based solution, was applied on the prepared shell sites. An etching gel was painted on the areas where the PDC was to be placed and maintained for approximately 1 minute. After the etching gel dried, a bonding agent was applied, and it was polymerized with single cycle of curing light. Cavities were filled using a light-curing nano-hybrid composite, which was polymerized using a light-emitting diode curing light. On average, 10 minutes was required to fill the cavities with the PDC. After the shell repair procedure, the turtles were placed in dry hospital holding units for 24 hours, after which they were moved to several hospitalization water tanks. Antibiotic treatment and postsurgical analgesia were performed for 6 days. After 7 days of hospitalization, treated turtles were discharged to their owners. On the follow-up examinations, 30 days posttreatment lesions had healed in 48.4% of treated turtles; 60 days posttreatment lesions had healed in 78.7% of treated turtles; and 90 days posttreatment lesions had healed in 100% of treated turtles. Treatment of shell ulcers with photopolymerizable nano-hybrid dental composite appears to eliminate shell ulceration relapses, long and expensive antimicrobial treatment, and dry docking hospitalization, while promoting rapid healing of the shell along with fast and excellent recovery of the turtle patients.

Marine Omega3 wound matrix for the treatment of complicated wounds

Summary Introduction Complicated wounds in the lower extremity can arise as a consequence of insufficient soft-tissue coverage after amputations in diabetic patients. The Kerecis® Omega3 wound matrix is a decellularized skin matrix derived from codfish and represents an alternative treatment option to achieve wound healing. Methods 5 patients with diabetes mellitus and complicated wounds in the lower limb with exposed bony segments were treated with the Omega3 wound matrix between November 2014 and November 2015. Following initial debridement in the operating room, the wound matrix was applied and covered with a silicone mesh. In the further course, wound treatment was conducted on outpatient setting. Results In total, 7 wounds were treated with localization at the level of the thigh (n=2) and the forefoot (n=5). For the wounds at the thigh, it took 26 weeks to achieve wound closure, whereas the wounds at the level of the forefoot showed healing times between 13 and 41 weeks. In all patients, a reduction of analgetics intake was noted when the treatment with the Omega3 wound matrix was initiated. Conclusion The Kerecis® Omega3 wound matrix represents a viable treatment option in complicated wounds in the lower limb of diabetic patients to circumvent an otherwise necessary proximalization of amputation level. Further studies comparing the Omega3 wound matrix with appropriate control groups of standard therapies for soft-tissue conditioning/coverage like negative pressure therapy, biosurgery and other acellular dermal matrices are warranted.

A National Study of the Impact of Initial Débridement Timing on Outcomes for Patients with Deep Sternal Wound Infection.

Excisional débridement for patients with deep sternal wound infection is a main component of treatment. This study aims to evaluate the impact of delayed excisional débridement on mortality and associated outcomes. The authors analyzed the MarketScan database from 2009 to 2013 to identify patients with deep sternal wound infection who received surgical intervention. A logistic regression model was created to model mortality. Poisson regression models were used to model number of procedures, number of hospitalizations, and length of stay. A log-linear regression model was used for cost analysis. All analyses were adjusted for patient risk factors. The final cohort included 1335 patients with 12 percent in-hospital mortality. There was considerable variation in timing of débridement among patients with deep sternal wound infection, with more than 25 percent undergoing initial débridement 4 or more days after diagnosis, and 10 percent undergoing débridement more than 1 week after diagnosis. Patients undergoing delayed débridement had progressively higher risk for greater number of admissions and total hospital days compared with those undergoing early débridement. Patients undergoing débridement on the day of diagnosis of deep sternal wound infection had a predicted 34 total hospital days, compared with 49 total hospital days for patients undergoing débridement more than 7 days after diagnosis. Patients treated with early surgical intervention had fewer hospital admissions and fewer hospital days than patients undergoing delayed surgical treatment. Protocols to facilitate early débridement have the potential to improve quality and efficiency of deep sternal wound infection care. Therapeutic, III.

A Skin-Sparing Approach to the Treatment of Necrotizing Soft-Tissue Infections: Thinking Reconstruction at Initial Debridement

A Skin-Sparing Approach to the Treatment of Necrotizing Soft-Tissue Infections: Thinking Reconstruction at Initial Debridement

Reconstructive Surgical Repair of a Forth Degree Iatrogenic Burn in a Dog

Background: Burns are uncommon in small animal surgery routine and represents a real therapeutic challenge. Skin can be affect in different degrees of deepness as superfcial, partial thickness, full thickness and full thickness affecting underlying tissues. Each degree has individual features. Progression through degrees can occur in the frst 24 h or if treatment is inadequate. This paper aims to describe therapeutic approach and surgical technique to treat a huge dorsal iatrogenic thermal burn injury. Case: A 4-year-old female German Shepard was referred to veterinary hospital after 11 days of elective ovariosalpingohisterectomy. The patient presented a severe skin injury with crusts, eschars, purulent discharge and myiasis on dorsal cervical, thoracic and lumbar region. Beside severity of the wound, animal present good general status and normal vital signs. Complete blood count and biochemical analysis were within normal ranges. Histopathologic analysis of a wound tissue sample revealed the presence of coagulation necrosis and inflammatory response. The absence of traumatic events, histopathologic result and wound features increased suspicious of an iatrogenic burn injury from a poorly regulated thermal mattress used during surgical intervention. “Rule of Nines” was estimated as 25% of total body surface area. Systemic antibiotics and topical treatment with 0.05% chlorhexidine digluconate and 2.5% silver sulfadiazine ointment followed by wet-wet bandage was performed after initial surgical debridement. Muscle and vertebral bone explosion were evident. Topical treatment with Silver Sulfadiazine and chlorhexidine persisted twice daily until granulation tissue formation. Pain killers and sedation were often necessary during bandage changes. At 65th day proceeded to en bloc excision of scar tissue and surgical reconstruction with skin advancement and recruitment technique. Tie-over dressing was applied to cover the fnal wound. After 14 days animal received hospital discharge, and was assessed bi-weekly for 60 days. Discussion: Besides great extension of the burn injury, patient’s age, absence of systemic involvement and fluid therapy or critical care the prognosis was good. Modifed “rule of nine” are used to estimate wound size in dogs. The wound was classifed as forth degree or full thickness injury due to exposed muscular layer and bone. Early debridement, standard topical and systemic treatment protocol applied granted good recovery of wound bed. Due to be uncommon in small animal routine, main diagnosis and therapeutic recommendations for veterinary patients are based on human data. Systemic antimicrobial drugs are usually not recommended due to low concentration in burned tissues, however, prophylactic use was necessary due to highly infected tissues and possible bacterial absorption from devitalized tissues. Delayed primary closure technique was necessary due to highly infection site and extension, which turns surgical approach hard to perform. After formation of a granulation tissue bed for wound reconstruction, surgical treatment was performed. Surgical reconstruction is indicated in large full thickness defects and for better cosmetic appearance. The correct use and regulation of thermal mattress can avoid burns that can be life threatening. This case report rises the important concept that even low contact temperatures when persistent for long time can cause burn injuries. Keywords: thermal, mattress, injury, dogs, plastic.

Wound Healing Society 2015 update on guidelines for pressure ulcers.

Wound Healing Society 2015 update on guidelines for pressure ulcers.

Negative-pressure wound therapy for deep groin vascular infections

Infection of synthetic graft in the groin is a rare but devastating complication. When it occurs, several possibilities of treatment are available. Extra-anatomic reconstruction and in-situ implantation of new, infection resistant grafts are associated with high mortality and morbidity. Therefore, more conservative approach is needed in some cases. Negative-pressure wound therapy is one of the options in treating such patients. The aim of this study was to assess the outcome for deep groin vascular graft infection treated with negative-pressure wound therapy. Seventeen patients (19 wounds), treated for Szilagyi grade III groin infections between October 2011 and June 2014, were enrolled into this observational study. Majority of the wounds (11/19) were healed by secondary intention, and the rest of the wounds (8/19) were healed by primary intention after initial negative-pressure wound therapy and graft substitution with silver-coated prostheses or autologous artery/vein implantation. No early mortality was observed. Minor bleeding was observed in one patient. Reinfection was noted in three wounds. Only one graft occlusion was noted. Late mortality was observed in three patients. Negative-pressure wound therapy seems to be safe for groin vascular graft infections and comfortable for both patient and surgeon. However, the rate of persistent infection is high. This technique, in our opinion, can be used as a “bridge” from initial wound debridement to definitive wound management, when good local conditions are achieved for graft substitution, either with new synthetic graft with antimicrobial properties or autologous artery/vein. In selected cases of deep groin infections it can be used as the only therapeutic approach in wound treatment.

Results of intraocular foreign body removal from the posterior segment by direct approach

Objective: to evaluate early and remote complication of intraocular foreign body (FB) removal by direct approach, and to determine indications for splinter removal through the wound. Material and methods. Case history analysis was performed in 31 patients with missile eye injuries. In all patients, FB was removed by direct approach at initial surgical debridement. Results. Foreign body penetration was accompanied with injuries of different eye segments, which were manifested by vitreous hemorrhage, hyphema, subretinal hemorrhage, retinal detachment, traumatic cataract. In 12 patients, there was a need in additional surgical treatment consisting in retinal laser barrage, vitrectomy, cataract extraction. As a result of treatment, visual acuity increased in 58.06% of injured. At the remote post-op period, retinal detachment developed in 16.13% cases, and vitreoretinal procedures were performed. Conclusions. Intraocular foreign body removal from the posterior eye segment using direct approach is appropriate if the FB is in the wound or in its immediate proximity. Most serious complications of missile injury are proliferative vitreoretinopathy and retinal detachment, demanding vitreoretinal surgery.

SYNCHRONOUS SQUAMOUS CELL CARCINOMA OF EXTERNAL ACOUSTIC MEATUS FOLLOWING PIGMENTED BASAL CELL CARCINOMA OF CHEEK -A RARE OCCURRENCE

Introduction: A synchronous second primary malignancy as squamous cell carcinoma of external acoustic meatus following basal cell carcinoma of cheek is reported with their management and review of literature.&#x0D; Case Report: Pigmented basal cell carcinoma of cheek was managed successfully by wide local excision followed by flap reconstruction and subsequently diagnosed squamous cell carcinoma of external acoustic meatus by concurrent chemoradiation after initial surgical debridement.&#x0D; Conclusion: Second primary malignancy as squamous cell carcinoma of external ear canal is rare after basal cell carcinoma of cheek though there is anatomical vicinity. Surgery in case of basal cell carcinoma and concurrent chemoradiotherapy in case of external ear canal squamous cell carcinoma is the mainstay of treatment.