Primary Intention Healing Research Articles

A Prospective cohort study of functional outcomes after primary closure versus secondary intention healing with collagen dressing in partial glossectomy for early-stage tongue cancer

A Prospective cohort study of functional outcomes after primary closure versus secondary intention healing with collagen dressing in partial glossectomy for early-stage tongue cancer

Repair of Tracheo-Cutaneous Fistula Following Tracheostomy

Tracheo-cutaneous fistula is a relatively uncommon complication that can occur after tracheotomy. The possibility of fistula increases in proportion to the duration of intubation and it occurs due to the transposition of stratified squamous epithelium in the passage between the tracheal mucosa and the skin. There are several surgical techniques to repair trachea-cutaneous fistula, such as primary suture, fistulectomy and primary suture, fistulectomy and secondary intention healing, and using local or regional flap. In addition to these techniques, we would like to introduce a technique used in our hospital.

Multidisciplinary Approach to the Management of Diabetic Foot Complications

Background: According to the International Working Group on the Diabetic Foot (2015), 28 % of diabetic foot ulcers result in major amputations. Over 30 % of patients with diabetic foot undergo major amputations that result in death in 13.0 %-14.0 % of the cases. Clinical case: In our experience of treating a female patient with diabetic foot complications, we observed that such cases require a multidisciplinary approach to determine management strategies, as well as strict surgery staging. Early plastic and reconstructive surgery demonstrated its positive impact on postoperative wound closure. Conclusions: We managed the infection and achieved the complete closure of the major wound and primary intention healing through the multidisciplinary approach and strict adherence to surgical staging (debridement, revascularization, reconstruction). Thus, patient quality of life and rehabilitation potential significantly improved.

A novel tension relief technique to aid the primary closure of traumatic equine wounds under excessive tension.

To achieve an excellent functional and cosmetic result, primary closure is preferred over leaving wounds to heal by secondary intention. However, traumatic wounds are often under excessive tension during wound closure and incorrect suture technique can compromise microcirculation, leading to skin necrosis and impaired wound healing. To describe an inexpensive and effective tension relief technique that helps the successful primary closure of a variety of equine wounds at high risk of dehiscence. Retrospective case series. All wounds that were managed with the Tension Tile System (TTS) at four Equine Hospitals between March 2017 and May 2021 were evaluated. The wounds were classified according to various criteria including anatomical location, time elapsed prior to surgery, depth of wound and post-surgical use of immobilisation. Outcome criteria were based on the success of primary intention healing. The duration of convalescence (weeks) after surgery was also recorded. During the study period, the TTS was used in 191/860 (22%) wounds repaired under general anaesthesia or standing sedation. Overall, primary intention healing (Group A) was achieved in 132 of 191 cases (69%, CI 62%-75%), with partial dehiscence (Group B) in a further 30/191 cases (16%, CI 11%-22%). Severe dehiscence (Group C) was recorded in 29/191 cases (15%, CI 11%-21%). The median convalescence time was 4 weeks (Range 3-15, interquartile range 4-6) in Group A. Retrospective nature of the study and subjective outcome assessment. The technique was applied to wounds under significant tension; however, this was based on a subjective assessment by the surgeons involved. The Tension Tile System is an economical and effective technique for challenging equine wounds under tension, in a variety of anatomical locations.

Osseous topography in biologically driven flap design in minimally invasive regenerative therapy: A classification proposal.

Minimally invasive periodontal regenerative surgical procedures are a paradigm shift that demands a unique approach encompassing specialized armamentarium, magnification tools, knowledge of handling properties of biomaterials, and specific flap designs. Biologically driven flap design is dictated by optimal soft and hard tissue handling, flap perfusion, and wound stability, all in the pursuit of primary intention healing. The unique architecture of the infrabony defect is a determining factor on incision tracing, boundaries of flap extension, and biomaterial selection. The purpose of this article is to propose a flap design classification based on the osseous topography of infrabony defects during biologically driven minimally invasive surgical periodontal regenerative therapy.

Ingrown Toenail Treated by the Modified Howard-Dubois Technique: Long-Term Follow-Up Results.

According to the Mozena classification system, stage IIb and stage III ingrown toenail cases are considered as severe ones; however, limited options are available for treatment. To lower the recurrence rate and achieve primary intention healing in severe ingrown toenail cases by the modified Howard-Dubois technique. Forty patients were included in this study. In this procedure, a fish-mouth like soft tissue along the nail groove to the tip of the toe was resected, the upper surface of the distal phalanx was flattened and the nail bed matrix was remodelled. The European Quality of Life (EuroQol) questionnaire and Surgical Satisfaction Questionnaire were used to assess the outcomes. There were no recurrences observed during the follow-up period. Healing time from surgery to back to school or work was 10.82 days on an average (range: 7-23 days). According to the results of EuroQol questionnaire, improvements were achieved in the areas of mobility (50%), looking after myself (10%), doing usual activities (35%), having pain or discomfort (95%) and feeling worried, sad, or unhappy (55%). According to the results of Surgical Satisfaction Questionnaire, 38 (95%) patients indicated that they would undergo the surgery again if they 'had to do it all over again' and 36 (90%) patients said that they would recommend the procedure to others. This modified Howard-Dubois technique was an effective, safe and cosmetic alternation for the treatment of ingrown toenail in severe or relapsed cases.

Simultaneous operation in a patient with recurrent varicosity and recurrent inguinal hernia in a one-day hospital. Case report

Introduction . Currently, despite the use of modern and high-tech methods of surgical treatment of patients with varicose veins and hernias of the anterior abdominal wall in the long-term period, relapses of the disease occur in 1.7-14% of cases. The combination of postoperative recurrence of inguinal hernia and varicosis is an infrequent type of multiple surgical pathology. Case report . The article presents a clinical observation of a patient with a relapse of varicosis and an inguinal hernia, who underwent a total of three surgical interventions before admission to the clinic. Detailed ultrasound diagnostics made it possible to establish the cause of the relapse and develop optimal surgical tactics, taking into account the individual characteristics of the disease and the nature of previous operations. Taking into account the anatomical proximity and one-sided localization of pathological processes, the patient underwent a simultaneous operation from one access. A day later, the postoperative pain intensity was rated with a visual analogue scale at 4.2 scores, a patient administered analgesics to relieve pain within two postoperative days. Class 2 compression stockings were used for the compression therapy. The patient was discharged from the clinic in satisfactory condition the following day after the intervention, complaining of minor pain in the surgical wound area. The postoperative period was uneventful, without complications. Pain, restriction of movement were observed within 4 days after surgery. The sutures were removed after 7 days, the wound healed by primary intention healing. Conclusions . The use of a simultaneous operation allows a radical correction of both diseases, to reduce the psychological burden on the patient, to improve the aesthetic result of the intervention, to avoid thrombotic complications and hernia infringement in the postoperative period.

Supra-auricular and post-auricular resection of pre-auricular and post-auricular sinuses.

This study aimed to classify the pre-auricular sinus before performing radical dissection, so as to achieve optimal aesthetic results. The recent five-year clinical data of 53 patients with a congenital pre-auricular sinus and infection treated in the hospital were reviewed. According to the sinus course, pre-auricular and post-auricular types were defined, and regional dissection was performed using the modified supra-auricular or post-auricular approach. All patients achieved primary intention healing of the incision, and were followed up for six months to five years. No recurrence was found, and the incision scar was completely concealed. Surgical approaches for regional dissection might be adopted based on the different types of pre-auricular sinuses, and further radical dissection might be performed to achieve optimal aesthetic results.

Supra-alveolar attachment gain in the treatment of combined intra-suprabony periodontal defects by non-incised papillae surgical approach.

To assess the effectiveness of non-incised papillae surgical approach (NIPSA) in periodontal reconstructive surgery of combined intra-suprabony defects. Patients with deep periodontal defects treated with NIPSA (n=20) were analysed. Defects were treated with enamel matrix derivative plus xenograft. Clinical outcomes were assessed before surgery and at 12months. Wound closure was assessed one week post-surgery. Supra-alveolar attachment gain (SUPRA-AG) was recorded at 12months post-surgery. Non-incised papillae surgical approach showed significant improvements in clinical attachment gain (5.9±2.38mm; p<0.001), recession reduction (0.25±0.44; p<0.05) and tip of the papillae coronal displacement (0.4±0.5; p<0.05). It also showed complete wound closure of the apical mucosal incision in the 85% of the cases, with no interproximal tissue necrosis. SUPRA-AG (1.9±1.74) showed a positive tendency, associated with complete intrabony defect resolution. Non-incised papillae surgical approach promoted primary intention healing, wound stability and space provision for optimal periodontal reconstruction, preserving supra-alveolar soft tissue integrity.

Definitive Wound Closure Techniques in Fournier's Gangrene

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885-11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727-0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

Treatment of coxofemoral luxation in a mature Welsh pony by femoral head ostectomy: Long‐term outcome

SummaryA 233 kg, 4‐year‐old Welsh pony stallion presented with a unilateral coxofemoral luxation and a history of previous upward fixation of the patella. This condition was surgically managed by femoral head ostectomy using a craniodorsal approach to the luxated coxofemoral joint, without greater trochanteric osteotomy. Immediate improvement in weightbearing was observed after surgery and primary intention healing was recorded. Long‐term outcome, 4 years after surgery, was assessed by radiographic, ultrasonographic and lameness examination. The pony was in good body condition and the initial weight of this patient was restored. Despite fetlock hyperlaxity of the contralateral hindlimb, amyotrophy and mechanical lameness of the affected hindlimb, the pony showed evident comfort without apparent signs of pain and was able to trot and gallop. Bone callus was observed at imaging examination.

Incisional hernia following closure of loop ileostomy: The main predictor is the patient, not the surgeon

BackgroundIncisional hernia at the ileostomy site occurs in 0–48% of patients undergoing loop ileostomy closure. Risk factors for ileostomy-site hernia are not currently well understood. We explored the predictive value of patient and clinical factors for ileostomy-site hernias. MethodLoop ileostomy reversals undertaken between 1st January 2009 and 31st December 2013 were retrospectively evaluated. Preoperative patient data (BMI, age, gender, blood pressure, diabetes), surgical variables (preoperative ileostomy marking, intraoperative management (suture type, closure method), postoperative complications (≤30 days), approach, urgency, and chemotherapy, hospital stay, stoma closure interval, follow-up duration) were collected. Patients were followed up by clinical examination and postoperative imaging. Results193 loop ileostomy reversals were identified. Operative indications included: colorectal cancer (n = 102, 52.8%); inflammatory bowel disease (n = 47, 24.3%); diverticulosis (n = 20, 10.4%); assorted indications (n = 19, 9.8%); and inflammatory fistulae (n = 5, 2.6%). Median duration of clinical follow-up was 20.5 months (0–69). Hernia occurred in 26 patients (13.5%), detected at a median of eight months post-reversal. Radiological follow-up occurred in 72% of patients and, as a reference standard, in 100% of patients diagnosed with a hernia. Concordance between clinical and radiological findings was 88.5%. Postoperative complications predicted higher hernia risk. BMI and preoperative blood pressure were significant hernia predictors. Differences in the type of suture material to close the defect (absorbable vs. non-absorbable) and stoma skin closure method (primary vs. secondary intention healing) were non-predictive of hernia. ConclusionWhilst BMI and patient comorbidity are the major hernia predictors, variability in surgical practice does not constitute a significant risk factor for ileostomy-site incisional hernia.

Wound healing following surgical and regenerative periodontal therapy.

Clinical studies have evaluated the effect of conventional periodontal surgical therapy. In general, although some clinical gain in tissue support may be attained, these therapies do not support regeneration of the periodontal attachment. Even though the biological possibility of periodontal regeneration has been demonstrated, the clinical application of this intrinsic potential appears difficult to harness; thus also conceptually most intriguing candidate protocols face clinical challenges. In this review, we explore the bioclinical principles, condiciones sine quibus non, that unleash the innate potential of the periodontium to achieve clinically meaningful periodontal regeneration (i.e. space-provision, wound stability and conditions for primary intention healing). Moreover, limiting factors and detrimental practices that may compromise clinical and biological outcomes are reviewed, as is tissue management in clinical settings.

Evaluation of a compression resistant matrix for recombinant human bone morphogenetic protein‐2

Previous studies document the therapeutic potential of recombinant human bone morphogenetic protein-2 (rhBMP-2) in an absorbable collagen sponge (ACS) carrier for indications in the axial and appendicular skeleton. Nevertheless, the ACS does not comprise structural integrity to adequately support bone formation for onlay indications. The objective of this study was to evaluate local bone formation and osseointegration following surgical implantation of rhBMP-2 soak-loaded onto a compression resistant matrix (CRM). Routine, contralateral, critical-size, supraalveolar, peri-implant defects in five adult male Hound Labrador mongrel dogs received 0.8mg rhBMP-2 soak-loaded onto either the ACS (benchmark control) or a CRM (collagen/β-TCP/hydroxyapatite) followed by submerged wound closure for primary intention healing. The animals were euthanized at 8weeks for histologic/histometric evaluation. Healing was uneventful albeit considerable initial swelling was observed for either treatment. Sites receiving rhBMP-2/CRM showed significantly increased bone area (20.0±0.9 versus 12.3±2.6mm(2) , p=0.03) and bone density (24.1±1.4% versus 14.6±2.0%, p=0.04) compared with those receiving rhBMP-2/ACS. There were no significant differences between treatments for new bone height and osseointegration. Woven and lamellar trabecular bone lined with abundant osteoid was observed for all sites. Inconsistent cortex formation confirmed the immature nature of the newly formed bone. Seroma formation was observed for both treatments (80-100% of the animals/implants). Sites receiving rhBMP-2/CRM showed residual ceramic granules undergoing biodegradation, including accumulation of foamy macrophages. rhBMP-2/CRM supports bone formation of clinically relevant geometry. Longer observation intervals as well as dose variations appear necessary to capture maturation of the newly formed bone, elimination of residual ceramic granules and resolution of seroma formation(s).

Periodontal repair in dogs: space‐provision supports alveolar bone and cementum formation

Clinical criteria for periodontal wound healing/regeneration include wound stability, space-provision and conditions for primary intention healing. However, wound stability/space-provision may be difficult to obtain in non-contained periodontal defects. The objective of this study was to; using a limited, space-providing device as a conduit, evaluate a concept of space-provision sans tissue occlusion for periodontal wound healing/regeneration. Bilateral, critical-size, supraalveolar, periodontal defects were created in eight young adult Beagle dogs. One jaw quadrant received a limited, space-providing titanium mesh device, the contra-lateral jaw quadrant served as sham-surgery control followed by submerged wound closure for primary intention healing. The animals were euthanized at 8weeks for histometric analysis of the surgical sites. Clinical healing was generally uneventful; minor late exposures observed for some defects. Experimental sites exhibited significantly enhanced mean (±SE) bone and cementum regeneration compared with control (1.10±0.20 and 1.32±0.10mm versus 0.34±0.18 and 0.66±0.15mm; p<0.01). A cellular mixed (extrinsic/intrinsic) fibre cementum and functionally oriented collagen fibres were routinely observed. Wound exposures were significantly associated with reduced bone formation (p<0.05). Using a limited, space-providing device to support periodontal wound healing/regeneration appears a promising clinical approach for non-contained periodontal defects.

Secondary intention healing in skin surgery: our own experience and expanded indications in hidradenitis suppurativa, rhinophyma and non‐melanoma skin cancers

There are many situations in integument surgery in which secondary intention healing (SIH) may bring results comparable or even superior to those obtained with primary intention healing. To present our own methods of employing SIH in surgical treatment of different skin lesions. Moreover, to delineate the extended indications for SIH as a first-line method of wound treatment. Between 1999 and 2009, we conducted 236 operations followed by SIH in the group of 195 patients. Two independent investigators and the patients carried out post-operative assessment (at 12 months) of both cosmetic and functional results of operations (data for 142 patients). Moreover, at 3 and 12 months, patients were asked for self-evaluation of the outcomes of surgical procedures using the visual analogue scale (VAS). The most frequent indications for SIH were defects after the excision of non-melanoma skin cancers and hidradenitis suppurativa lesions. Depending on localization, the mean extent of the post-operative wounds prepared for SIH ranged from 0.8to 85.7 cm(2). The healing lasted 2-12 weeks. The most important factor was the size of the wound (r = 0.59; P < 0.001). The assessment at 12 months revealed that cosmetic/functional outcomes were evaluated as 'good' or 'excellent' in 89/83% and 72/70% cases, according to patients and physicians respectively. VAS showed that evaluation scores at 3 months post-surgery were significantly lower than at 12 months (P < 0.0001). SIH is a safe and efficient form of treatment for various post-operative skin defects. In certain areas of the body, SIH shows favourable cosmetic and functional effects. In these cases, it may even be regarded as the method of choice.

Histological evaluation of human intrabony periodontal defects treated with an unsintered nanocrystalline hydroxyapatite paste

The aim of the study was to clinically and histologically evaluate the healing of human intrabony defects treated with open flap surgery (OFD) and application of a new, resorbable, fully synthetic, unsintered, nanocrystalline, phase-pure hydroxyapatite (nano-HA). Six patients, each of them displaying very advanced intrabony defects around teeth scheduled for extraction due to advanced chronic periodontitis and further prosthodontic considerations, were included in the study. Following local anaesthesia, mucoperiosteal flaps were reflected; the granulation tissue was removed, and the roots were meticulously debrided by hand and ultrasonic instruments. A notch was placed at the most apical extent of the calculus present on the root surface or at the most apical part of the defect (if no calculus was present) in order to serve as a reference for the histological evaluation. Following defect fill with nano-HA, the flaps were sutured by means of mattress sutures to allow primary intention healing. At 7 months after regenerative surgery, the teeth were extracted together with some of their surrounding soft and hard tissues and processed for histological analysis. The postoperative healing was uneventful in all cases. At 7 months following surgery, mean PPD reduction and mean CAL gain measured 4.0 ± 0.8 and 2.5 ± 0.8 mm, respectively. The histological analysis revealed a healing predominantly characterized by epithelial downgrowth. Limited formation of new cementum with inserting connective tissue fibers and bone regeneration occurred in three out of the six biopsies (i.e. 0-0.86 and 0-1.33 mm, respectively). Complete resorption of the nano-HA was found in four out of the six biopsies. A few remnants of the graft particles (either surrounded by newly formed mineralized tissue or encapsulated in connective tissue) were found in two out of the six biopsies. Within their limits, the present results indicate that nano-HA has limited potential to promote periodontal regeneration in human intrabony defects. The clinical outcomes obtained following surgery with OFD + nano-HA may not reflect true periodontal regeneration.

Periodontal regeneration: experimental observations—clinical consequences

Biologic evidence thus far points to the presence of cells originating from the periodontal ligament, wound stability, space‐provision, and primary intention healing as central biologic and clinical factors that must be afforded to a site to obtain periodontal regeneration. Only profound appreciation of these biological and clinical variables affecting the outcome of periodontal regenerative procedures will allow clinicians to proficiently manipulate them to optimize the clinical result and elevate predictability of periodontal regenerative therapy.

Single‐Flap Approach for Surgical Debridement of Deep Intraosseous Defects: A Randomized Controlled Trial

The single-flap approach (SFA) consists of the elevation of a limited mucoperiosteal flap to allow surgical access to periodontal defects from either the buccal or oral aspect only, leaving the interproximal supracrestal gingival tissues intact. The aim of the present randomized controlled trial is to assess the effectiveness of a buccal SFA used for the surgical debridement of deep intraosseous defects compared to the double-flap approach (DFA). Fourteen patients were treated according to SFA principles and 14 patients received the DFA. In all patients, root surfaces and defects were thoroughly debrided, and conditions for the primary intention healing and blood clot stability were ensured by a proper flap design and suture technique. The clinical attachment level (CAL), probing depth (PD), and gingival recession (REC) were assessed immediately before surgery and at 6 months post-surgery. The results of the study indicate that: 1) the SFA and DFA resulted in significant CAL gains and PD reductions at 6 months post-surgery; and 2) the SFA was similarly effective compared to the DFA in terms of CAL gain and PD reduction. The surgical debridement of intraosseous periodontal defects resulted in comparable, substantial CAL gains and PD reductions as well as limited postoperative REC increases when defects were accessed with the SFA or DFA.

Flap designs for periodontal healing

The surgical reconstruction of the lost periodontal attachment apparatus is a highly technique‐sensitive procedure, where the choice and the technical performance of the flap design in a specific patient with a specific defect plays a key role. When considering the technical aspects of periodontal reconstructive procedures, the selection of a specific flap design and related suture technique must be based on the predictability to achieve optimal primary closure of the healing wound, thus creating an essential biologic prerequisite for periodontal regeneration. The clinical value to adapt the selection of the surgical approach to the anatomy of the treated area as well as the physical and biological characteristics of the regenerative materials adopted has been emphasized by several Authors. Along with the use of the appropriate regenerative technology, the surgical procedures should provide conditions for primary intention healing supporting adequate wound stability allowing uneventful tissue formation and maturation. In this respect, flap design and suture technique appear of paramount importance to maximize the reconstructive potential of membrane, graft biomaterials and biological agents. The purpose of the present article is to critically revise the surgical options which have been described in the literature, outlining the technical steps as well as the indications and contraindications for each flap design when used to correct the periodontal intraosseous defect.