Leg Wound Research Articles

Lowering the pivot point of sural neurofasciocutaneous flaps to reconstruct deep electrical burn wounds in the distal foot

Due to the thinness of the skin and soft tissues in the foot, tendons and bones tend to become exposed and necrotic after injury; therefore, it is difficult to reconstruct foot injuries, especially distally. Reconstruction with free skin flaps is highly risky as it demands technologies and equipment, while patients suffer greatly from the use of cross-leg skin flaps. Sural neurofasciocutaneous flaps are often used for reconstruction of wounds in the lower leg, malleolus, and the proximal end of the foot but are not feasible for wound repair in the distal foot; this is because, with the pivot point of 5–7cm above the tip of the lateral malleolus, the flaps are not able to cover defects in the distal foot. In this study, we used a sural neurofasciocutaneous flaps with a lowered pivot point for reconstruction of distal foot wounds caused by electrical burns. An ultrasound flow detector and Doppler flow imaging were used to detect the diameter, the perforating point and the blood flow of the lateral retromalleolar perforator. Twelve patients with the perforator diameter greater than 0.6mm and the peak systolic flow more than 0.15m/s were included. The pivot point of sural neurofasciocutaneous flaps was lowered to 0–3cm above the tip of the lateral malleolus and the size of the flaps ranged from 6cm×5cm to 12cm×18cm. Eleven of the 12 flaps survived completely. One flap developed necrosis approximately 1cm at the far point but was managed successfully by daily dressing. We demonstrated that lowering the pivot point of sural neurofasciocutaneous flaps is feasible for reconstruction of distal foot injury with the advantages of reliable blood supply and easy operation. The use of Doppler flow imaging provides useful information for the design of the flaps.

157 Surgical Management of Infant Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis: Nikaidoh Versus Rastelli

stream regulator of KLF4 mediated VSMC differentiation, in SVGs harvested using the CON (vs. NT) technique. Selfreported functional recovery of the NT leg at 3 months was reduced compared to the CON leg (p 0.0005) and harvest site wound complications greater (p 0.13). There were 4 harvest site infections in the NT leg vs. 0 in the CON leg (p 0.05); all infected patients had diabetes. CONCLUSIONS: SVGs harvested using the NT technique exhibit a molecular and morphological pattern consistent with decreased VSMC activation. Self-reported functional recovery was decreased in the NT leg at 3 months. Prospective clinical trials (SUPERIOR-SVG) will evaluate whether these early biological signals translate into improved patency in SVG harvested using the NT technique. CIHR

Clostridium celerecrescens, often misidentified as “Clostridium clostridioforme group,” is involved in rare human infection cases

Misidentification of rare Clostridium species often originated from the environment as clinically relevant species is problematic. A strain isolated from a traumatic leg wound first identified as C. clostridioforme was finally identified as the rare Clostridium celerecrescens. Two similar misidentifications are reported in the literature. In order to help the phenotypic differentiation of C. celerecrescens from the close species of the “C. clostridioforme group”, an identification table and differential susceptibilities to 4 selected antibiotics are proposed. Once a clinical isolate is referred to this group, identification should be definitively confirmed by unambiguous methods such as 16s rDNA sequencing.

Perceived learning needs of Yemeni patients after coronary artery bypass graft surgery

To explore the information needs of Yemeni patients who have undergone coronary artery bypass graft surgery before hospital discharges and to examine the differences in the patients' learning needs according to age, gender, level of education and working condition. Postcoronary artery bypass graft (CABG) patients need more information before their discharge from the hospital. This need of information must be assessed and provided for them before their discharge from hospital to help them with adequate care and recovery at home. Design. A descriptive, correlational design. Data were collected from 120 CABG patients before their discharge from Al- Thawra Hospital, Sana'a, Yemen, by using modified Cardiac Patients Learning Needs Inventory (CPLNI) instrument. The Statistical Package for the Social Sciences was used to analyse the collected data. The information about chest and leg wound care, medication information, other pertinent information and complications were indicated to be the most valued by CABG patients prior to discharge. There was a statistically significant difference between patients' total learning needs according to their socio-demographic characteristics. Male patients needed more information than female patients (p=0.004). Younger (p=0.021) and middle-aged (p=0.032) patients needed more information than older ones. Highly educated (p=0.000) and school-level (p=0.002) patients needed more information than those in the uneducated group. Working patients needed more information than non-working ones (p=0.000). This study suggests that CABG patients have high information needs within 24-48 hours before hospital discharge. In addition, the results of this study showed that there are statistically significant differences in patients' learning needs according to their demographic characteristics. Assessment of CABG patients' information needs before their discharge from hospital helps in developing effective educational programme that will help these patients in their recovery at home.

Triclosan-coated sutures do not reduce leg wound infections after coronary artery bypass grafting

Leg wound infection is a common complication after coronary artery bypass grafting (CABG). Suture contamination has been suggested as a mechanism of surgical site infections. Vicryl Plus(®) is a polyglacitin suture coated with the antiseptic chemical substance Triclosan, which has been shown to inhibit the growth of Staphylococcus aureus in vitro. The first aim of the present study was to compare Vicryl Plus with conventional Vicryl(®) sutures with regard to leg wound infections following CABG. The second aim was to examine patient- and operative characteristics, which are assumed to predict leg wound infections. After statistical calculations a priori, 328 CABG patients were prospectively randomized to leg wound closure with Vicryl Plus (164 patients) or conventional Vicryl sutures (164 patients). Incidences of leg wound infection and predictors of infection related to patient- and operative characteristics were examined. The incidence of leg wound infections was 10.4% (17/163) in the Vicryl group, and 10.0% (16/160) in the Vicryl Plus group (P = 1.00). Patients with leg wound infections had increased body mass index and prolonged extracorporeal circulation and aortic clamping time compared with patients without infections. In the present study, we report for the first time that Vicryl Plus did not reduce the incidence of leg wound infections in patients undergoing CABG. Obesity and prolonged time of extracorporeal circulation were both associated with the increased risk of infections. Currently, the clinical role and indication for the use of Vicryl Plus have yet to be defined.

Wound coverage considerations for defects of the lower third of the leg.

Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles, vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Free flaps continue to be the gold standard for the coverage of lower third leg wounds because of their ability to cover large defects with high success rates and feasibility of using it in acute situations by choosing distant recipient vessels. Reverse flow flaps are more useful for the coverage of the ankle and foot defects than lower third leg defects. The perforators in the lower third leg on which these flaps are based are often damaged during the injury. In medium-sized defects of less than 50 cm2 size, local transposition flaps, perforator flaps, or propeller flaps can be used. Preoperative identification by the Doppler is essential before embarking on these flaps. Of the muscle flaps, the peroneus brevis flap can be used in selected cases with small defects. In spite of all recent developments, cross-leg flaps continue to remain as a useful technique. In rare occasions when other flaps are not possible or when other options fail it can be a life boat. In the author's practice free flaps continue to be the first choice for coverage of wounds in the lower third leg with gracilis muscle flap for small and medium defects, latissimus dorsi muscle flap for large defects and anterolateral thigh flap when a skin flap is preferred.

Closed Suction Drainage Improves Clinical Outcome in Patients Undergoing Endoscopic Vein Harvesting for Coronary Artery Bypass Grafting

Endoscopic vein harvesting (EVH) is a widely accepted technique for coronary artery bypass grafting, with well-reported benefits. However, EVH is associated with severe hematoma formation at incision sites, resulting in postoperative pain. We hypothesized that the use of a leg wound drain at the incision site may reduce these comorbidities. One hundred consecutive patients were prospectively randomly allocated into two groups of 50: group 1 with leg wound drains, and group 2 without drains. Group 1 patients underwent EVH followed by closure with a size 10 high vacuum leg wound drain (20 kPa), whereas group 2 underwent EVH followed by closure without a leg wound drain. Patients were assessed for postoperative pain, wound infection, and satisfaction using validated scoring systems immediately after surgery. Pain at rest (p < 0.001) and with movement (p < 0.001), incidence of hematoma (p < 0.001), and patient satisfaction (p < 0.001) were significantly improved in the drain group at days 1 to 7 and remained significant at week 6 after surgery. Interestingly, the use of antibiotics (6% versus 24%, p = 0.012) and the number of general practitioner visits (6% versus 26%, p = 0.012) were lower in the drain group compared with the no-drain group. However, there were no differences in the length of hospital stay between the two groups after surgery. Our findings indicate that the use of a high vacuum leg drain after EVH for long saphenous vein is of clear therapeutic benefit in the early postoperative period. We also report that this technique may reduce antibiotic administration and general practitioner visits after patient discharge.

Efficiency of Antibacterial Suture Material in Cardiac Surgery: A Double-Blind Randomized Prospective Study

Postoperative surgical site infections (SSI) still greatly affect mortality and morbidity in cardiovascular surgery. SSI may be related to the suture material. In this prospective, randomized, controlled, and double-blinded study, the effect of antibacterial suture material on SSI in cardiac surgical patients was investigated. We randomly allocated 510 patients into 2 groups. Antibacterial suture materials were used for wound closure in 170 patients (triclosan-coated suture group), and routine suture materials were used in 340 patients (noncoated suture group). All patients were evaluated for SSI on days 10, 20, and 30 following cardiac surgery. Preoperative risk factors and laboratory findings were comparable for the 2 groups. Sternal infection occurred in 4 (2.4%) of the patients in the triclosan-coated suture group and in 3.5% of the noncoated suture group (P > .05). Leg wound infection occurred in 5 (3.5%) of the patients in the triclosan-coated suture group and in 3.8% of the noncoated suture group (P > .05). Only diabetes mellitus was an independent predictor of SSI. Both noncoated and triclosan-coated suture materials are safe. Larger studies may be needed to show the benefit and cost-effectiveness, if any, of triclosan-coated materials over noncoated materials.

A deep wound in left leg as a result of skin traction in 81‐old‐year woman with hip fracture in orthopaedic ward

A deep wound in left leg as a result of skin traction in 81‐old‐year woman with hip fracture in orthopaedic ward

Endoscopic vein harvesting improves leg wound related morbidity and might impair graft patency: A systematic literature review with meta-analysis

Objective: Recent reports seriously question the value of endoscopic vein harvesting techniques for coronary bypass grafts. Therefore, we determined the current strength of evidence for or against (EVH) in patients undergoing coronary artery bypass grafting (CABG).

Association of gender with morbidity and mortality after isolated coronary artery bypass grafting. A propensity score matched analysis

IntroductionThere is conflicting evidence about the impact of gender on outcomes after coronary artery bypass grafting (CABG). MethodsWe performed a multivariate logistic regression and propensity score matched analyses in 13,115 patients (75% men) who underwent CABG between January 1, 1995 and December 31, 2009. The primary outcome was in-hospital mortality. Secondary outcomes included post-operative respiratory failure, stroke, myocardial infarction, sternal and leg wound infections, atrial fibrillation (AF), renal failure, need for postoperative intra-aortic balloon pump (IABP) support, and length of hospital stay. ResultsA higher proportion of women (184; 5.6%) suffered in-hospital death compared to men (264; 2.7%), p<0.0001. After propensity score matching (n=3600 total, 1800 in each group), female gender was an independent predictor of mortality after isolated CABG (odds ratio [OR]=1.84; 95% confidence interval [CI] 1.22–2.78). Women also experienced a higher incidence of postoperative complications including stroke (3.8% vs. 2.3%, OR 1.37; 95% CI 1.08–1.73) and leg wound infection (3.4% vs. 1.7%, OR 1.75; 95% CI 1.36–2.54) on multivariate regression analyses. However, these differences were not significant after propensity score matching. We also observed a lower risk of post-operative AF (21.2% vs. 22.1%, OR 0.78; 95% CI 0.70–0.86) in women that remained significant after propensity matching (O.R. 0.76; 95% C.I. 0.65–0.90). Length of hospital stay was longer in women compared with men (11.9±9.0 vs. 10.4±9.2days, p<0.0001). ConclusionsFemale gender is an independent predictor of increased mortality and a lower incidence of post-operative AF after isolated CABG.

Antibacterial Activity of Honey and Erytlaria Acualis against Bacteria Isolated From Burnt Wound Sepsis

The growing threat and spread of antibiotic resistance by a wide range of common pathogens has lead to increased investigations into traditional medicinal plants as alternatives. Honey has been used as a medicine since ancient times in many cultures and is still used in 'folk medicine'. It is used widely for healing burnt wounds, but nowadays due to antibiotic resistance organisms honey also took back seat. The present study shows the antibacterial activity of Erytlaria acualis lindau against the bacteria (multidrug resistant bacteria like Pseudomonas aeroginosa, E.coli, and methicillin resistant Staphylococcus aureus) isolated from burnt wound sepsis. Since it was used only for healing and deworming cattle wounds, the present study shows that it can also be used by the humans for the same purpose. Hence it is proved by my grandfather who used the plant extract for his operated wound in leg infected with worms and germs and it also has an efficient healing property. Thus Erytlaria acualis was effective than both honey and antibiotics.

Split thickness skin grafts for the treatment of non-healing foot and leg ulcers in patients with diabetes: a retrospective review

We retrospectively reviewed 107 diabetic patients who received a split thickness skin graft (STSG) for treatment of a non-healing diabetic foot or leg ulcer to describe healing times based on patient characteristics, comorbidities or complications. The minimum follow-up was 6 months from the time of STSG application. The mean time to healing among all patients was 5.1 weeks (3 to 16 weeks). The mean healing time for patients with complications was 12.0 weeks (10 to 16 weeks) while the mean healing time for those without complications was 4.9 weeks (3 to 10 weeks). Overall complication rate was 2.8%. Patients with a STSG take of less than 95% had a mean healing time of 7.9 weeks compared to 4.8 weeks for those with a STSG take of 100% (p<0.001). The use of autologous STSG for treatment of non-healing diabetic foot and leg wounds is a viable method for soft tissue closure and may present a low complication rate and a satisfactory rate of healing.

Postischemic Lower Extremity Wounds Treated with and without Negative Pressure Dressing

Background: Vacuum-assisted dressing is a noninvasive closure system of the wound, which makes localized and controlled negative pressure. Its mechanical tension reduces edema, stimulates granulation tissue formation and angiogenesis, and prepares the wound bed for closure. In this study, a patient has been presented, who suffered from serious lower extremity wounds due to arterial emboli, one of her wounds has been treated with vacuum-assisted dressing and the other with conventional dressing to evaluate the efficacy of vacuum-assisted dressing in acute ischemic wounds. Methods: A 65-year-old female patient was admitted to the emergency clinic, due to complaint of severe pain in her right lower extremity which suggested an acute arterial occlusion. She immediately underwent an embolectomy operation; however, a few days later, severe ischemia on the leg and foot became appearant. All of the necrosis was sharply debrided under sterile conditions in the operating room, and then lower leg wound was covered with vacuum-assisted dressing, also calcaneal wound was dressed with silver sulphadiazine. Results: Eighteen days after the first dressing with negative pressure, distal leg wound became ready for closure, whereas, enough granulation tissue over the calcaneal area developed merely thirty-four days later. Calcaneal wound closed spontaneously within fifty-three days. Conclusions: When dealing with this experience, using the negative pressure dressing in patient with severe lower limb wounds following arterial emboli, accelerates wound healing by means of developing the granulation tissue, and rapidly prepares the wound for closure, so it may reduce the risk of amputation.

Cross-Leg as Salvage Procedure after Free Flaps Transfer Failure: A Case Report

Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.

Outcome of Tight Versus Standard Glycemic Control in Coronary Artery Bypass Patients

Abstract Objectives : To compare the outcome of tight versus standard glycemic control and its impact on post oper-ative morbidity and short term mortality in patients undergoing Coronary Artery Bypass Grafting (CA-BG). Patients and Methods : A prospective surveillance of 124 patients undergoing isolated CABG surgery (on pump) was included in the study, 62 patients in each group were randomly assigned to tight and standard glucose control group. The main exposure was insulin in respect to level of blood glucose and the primary outcome measures were Sternotomy wound infection, Leg wound infection and new Myocardial Infarction. Surgical Site infection was assessed on a daily basis during the patient's stay in the Department of Cardio-thoracic Surgery, Sheikh Zayed Hospital, Lahore or within 30 days of operation prompting the patient to return to the hospital. Chi-square test or test was used to identify the significance of various short term morbidities and mortality. Results: In this study, 12 patients in the standard group and 4 patients in the tightly controlled group developed Sternal wound infection (p value 0.046). Similarly, 9 versus 2 patients in the standard and tight group respectively developed Leg wound infection (p-value 0.035). Test of proportion was applied and it was found that there was significant difference in the pro-portion of infection in the two groups (p value 0.05). However, there were no significant differences in other morbidities and the short term mortality. Conclusion: Study confirmed that tight glucose con-trol post operatively in CABG patient's results in redu-ced sternal and leg wound infection rates; however, there was no effect on other morbidities and short term mortality. Key words: Glycemic control, Coronary artery by-pass grafting, Surgical Site Infections.

Dermabond Protape (Prineo) for Wound Closure in Plastic Surgery

Dermabond Protape (2-octyl-cyanoacrylate and pressure sensitive adhesive mesh; Prineo, Closure Medical Corporation) is a topical mesh and skin adhesive that forms a strong polymeric bond across opposed wound edges allowing the normal healing process to occur. No published studies have already compared the use of a topical mesh en skin adhesive in wound closure. This study evaluated the possible applications of a combined mesh-adhesive system in 100 plastic surgery operations (14 different surgical procedures) with a mean follow-up of 85.5 days. The rate of allergic reaction, infection, wound dehiscence and hypertrophic scar formation were recorded in relation to patient co-morbidities, medication and tobacco consumption. No technical restrictions were found during the Dermabond Protape application. The average time for the topical mesh and skin adhesive application was 2 minutes. The Dermabond protape was removed 7 through 10 days after the operation. Three patients (3/100 or 3%) reported an allergic reaction without increased scar formation. Hyper-inflammation in one or more wound areas with a micro-abscess were noted in 11 different patients probably due to polyglactin 910 (vicryl) sutures at their scheduled follow-up visit 1 week after their operation. Increased tissue inflammation and scar formation were found in these patients with hypertrophic scars in 1 patient (1/11 or 9.1%). One upper leg wound dehiscence was seen in a diabetes mellitus patient using corticosteroids. Two patients (2/100 or 2%) with a history of tobacco abuse showed a partial wound dehiscence after an abdominoplasty and a partial areola dehiscence after mamma reduction respectively (Table 2).

Experience With Reverse Sural Flap to Cover Defects of the Lower Leg and Foot

Background:Coverage of traumatic soft-tissue defects in the lower limb is a common procedure.Objectives:The purpose of this prospective case series study was explore the capacity of the perforator-based sural flap in reconstruction surgery of patients with high velocity gunshot wounds in the distal third of the leg and heel pad of the foot.Patients and Methods:A prospective case series study was undertaken to assess the sural fasciocutaneous flap carried out in our hospital, from 2010 to 2011. This case series study comprised eight patients, seven men and one woman with an average age of 35 years (19-55) and with a mean follow-up duration of 13 months (6-24 months). All patients had a history of a gunshot wound in distal part of the leg and heel pad of the foot with large soft-tissue defects; treatment was done using the reverse sural flap.Results:We performed reverse sural flaps in eight gunshot patients, to cover the defects of the lower leg and foot. Surgical site infection observed in one patient (12.5%) was treated successfully with antibiotic therapy. The reverse sural flap provided a satisfactory coverage for gunshot defects in all the patients.Conclusions:Reverse sural flap is a useful and versatile reconstructive method in patients with gunshot wounds of the lower leg and foot.

Endoscopic Saphenous harvesting with an Open CO2 System (ESOS) trial for coronary artery bypass grafting surgery: study protocol for a randomized controlled trial

BackgroundIn coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature.Methods/DesignEndoscopic Saphenous harvesting with an Open CO2 System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre.DiscussionThe goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting.The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery.Trial registrationwww.clinicalTrials.gov NCT01121341.

Kerstersia similis sp. nov., isolated from human clinical samples

Analysis of gyrB gene sequences, (GTG)(5)-primed PCR fingerprinting and biochemical characteristics determined in the Biolog GEN III microtest system were used to differentiate an unnamed Kerstersia species from Kerstersia gyiorum, the type and only named species in this genus. The inability to oxidize D-galacturonic and D-glucuronic acids and the ability to oxidize D-serine, along with gyrB gene sequence analysis and (GTG)(5)-PCR fingerprints, readily differentiated the unnamed taxon from the type species. Therefore, we propose to formally classify this unnamed taxon as Kerstersia similis sp. nov. with strain LMG 5890(T) (= CCUG 46999(T)), isolated from a leg wound in the USA in 1983, as the type strain.