Soft Tissue Destruction Research Articles

Reconstructive challenges in war wounds

War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds.

An unusual presentation of a dental abscess

AbstractDentoalveolar abscesses are common squeal to microorganisms reaching the periapical area of a tooth. If the infection remains localised, it may drain intraorally through a sinus. If the infection spreads, fascial planes determine the path that the bacteria will follow and may result in cellulites affecting different tissue spaces in the head and neck. Either way, diagnosis is usually straight forward.In very rare situations, these abscesses can present in an unusual way and can be diagnostically misleading. In addition, they may cause more serious conditions such as necrotising fasciitis, which is an uncommon, progressive, destructive soft tissue infection caused by a mixture of aerobic and anaerobic organisms. Other serious consequences of dental abscesses depending on their anatomical location are cavernous sinus thrombosis, osteomyelitis, and Ludwig's angina.

Expression levels of novel cytokine IL-32 in periodontitis and its role in the suppression of IL-8 production by human gingival fibroblasts stimulated with Porphyromonas gingivalis

BackgroundIL-32 was recently found to be elevated in the tissue of rheumatoid arthritis and inflammatory bowel disease. Periodontitis is a chronic inflammatory disease caused by polymicrobial infections that result in soft tissue destruction and alveolar bone loss. Although IL-32 is also thought to be associated with periodontal disease, its expression and possible role in periodontal tissue remain unclear. Therefore, this study investigated the expression patterns of IL-32 in healthy and periodontally diseased gingival tissue. The expression of IL-32 in cultured human gingival fibroblasts (HGF) as well as effects of autocrine IL-32 on IL-8 production from HGF were also examined.MethodsPeriodontal tissue was collected from both healthy volunteers and periodontitis patients, and immunofluorescent staining was performed in order to determine the production of IL-32. Using real-time PCR and ELISA, mRNA expression and protein production of IL-32 in HGF, stimulated by Porphyromonas gingivalis (Pg), were also investigated.ResultsContrary to our expectation, the production of IL-32 in the periodontitis patients was significantly lower than in the healthy volunteers. According to immunofluorescent microscopy, positive staining for IL-32 was detected in prickle and basal cell layers in the epithelium as well as fibroblastic cells in connective tissue. Addition of fixed Pgin vitro was found to suppress the otherwise constitutive expression of IL-32 mRNA and protein in HGF. However, recombinant IL-32 in vitro inhibited the expression of IL-8 mRNA by HGF stimulated with Pg. Interestingly, anti-IL-32 neutralizing antibody upregulated the IL-8 mRNA expression in non-stimulated HGF, indicating that constitutive expression of IL-32 in HGF suppressed IL-8 mRNA expression in the absence of bacterial stimulation.ConclusionThese results indicate that IL-32 is constitutively produced by HGF which can be suppressed by Pg and may play a role in the downregulation of inflammatory responses, such as IL-8 production, in periodontal tissue.

The In Vivo Linear and Volumetric Wear of Hip Resurfacing Implants Revised for Pseudotumor

Metal-on-metal arthroplasty-related pseudotumors can cause severe local destruction of bone and soft tissues. The cause of pseudotumors is unknown, although some authors have implicated metal wear debris. The aim of this study was to measure the location and magnitude of wear on resurfacing devices that were retrieved during revision procedures for pseudotumor (the pseudotumor group) and for other reasons (the control group). We examined thirty-six hip-resurfacing implants, which were divided into two groups: eighteen implants from patients with a diagnosis of pseudotumor and eighteen control implants. Implant orientation and patient demographics were recorded. Three-dimensional, contactless metrology was used to scan the surface of the femoral and acetabular components to a resolution of 20 nm. Linear and volumetric wear were measured, and the components were examined for evidence of edge wear. There was three times more total linear wear and over six times more total volumetric wear of the femoral and acetabular components in the pseudotumor group as compared with that in the control group. The mean linear wear rate and standard deviation of the femoral components in the pseudotumor group (8.4 ± 8.7 μm/yr) were significantly greater than those in the control group (2.9 ± 3.9 μm/yr; p = 0.01). The mean volumetric wear rate of the femoral components was also significantly greater in the pseudotumor group (3.3 ± 5.7 mm3/yr) than it was in the control group (0.8 ± 1.2 mm3/yr; p = 0.009). Seventeen of eighteen subjects in the pseudotumor group had edge wear, compared with six of eighteen in the control group (p < 0.001). Implants that were retrieved because of pseudotumor had a significantly higher wear rate and prevalence of edge wear than the control implants did. There was a strong association between pseudotumor and the high levels of wear debris that are generated during edge-loading. However, not all patients with high wear developed pseudotumors, and not all pseudotumors had high wear; therefore, other factors are most likely involved in the cause of pseudotumors.

Gunshot wounds to the leg causing neurovascular compromise—A case study

Summary Background Gunshot wounds are responsible for considerable damage to the body and its structures. Between 1995 and 2005, Gunshot wounds were the second most common cause of murders in NSW, although in comparison to other countries, are uncommon in Australia. However, they do produce high velocity injuries and are associated with numerous potential complications including bony, vascular and nerve injuries, soft tissue destruction, compartment syndrome, delayed wound healing, potential for infection and, a number of psycho-social complications. Methods The following paper is a case study based on a de-identified patient who presented following a gunshot injury, focussing on neurovascular assessment and communication. Results This case study generates numerous discussion points including pre-hospital notification, efficient in-hospital trauma team response, effective primary and secondary surveys, intravenous fluid use in penetrating injuries, regular nursing observations and methods for neurovascular assessment, potential causes of vascular compromise in limb injuries, communication and assertiveness, analgesia, and forensic considerations in the emergency department. Conclusion The importance of neurovascular observations cannot be understated and must be effectively conducted and reported upon in a timely manner when results are not within the normal parameters. Further, patient advocacy and effective inter-disciplinary communication is essential to ensure the patient is provided with a recovery that is uncomplicated and with as minimal morbidities as possible.

Paper # 200: Posteromedial Portal In Knee Arthroscopy: A New Safe Parameter to do it

Paper # 200: Posteromedial Portal In Knee Arthroscopy: A New Safe Parameter to do it

Adverse reaction to metal release from a modular metal-on-polyethylene hip prosthesis

A 70-year-old man with an uncemented metal-on-polyethylene total hip prosthesis underwent revision arthroplasty 33 months later because of pain, swelling and recurrent dislocation. There appeared to be corrosion and metal release from the prosthetic head, resulting in pseudotumour formation and severe local soft-tissue destruction. The corrosion occurred at the junction between the titanium-molybdenum-zirconium-iron taper and the cobalt-chrome-molybdenum head, but the mechanism was unproven.

The Dislocator, Early and Late: The 3 am Phone Call

Hip dislocation is one of the most common causes of patient and surgeon dissatisfaction following hip replacement. To correctly treat dislocation, the causes must first be understood. Patient factors include age older than 70 years, medical comorbidities, female sex, musculoligamentous laxity, revision surgery, issues with the abductors and trochanter, and lack of education. Issues related to the surgeon and technique are surgical volume and experience, surgical approach and repair, adequate restoration of femoral offset and leg length, correct component position, and avoidance of soft tissue or bony impingement. Chief among implant-related factors is the design of the head and neck region. Is the femoral head diameter sufficient, and, in concert with the prosthetic neck, is there an adequate head-neck ratio? Skirts on longer neck lengths greatly reduce the head-neck ratio and should be avoided if possible. There must be available offset choices to restore soft tissue tension. Lipped liners aid in gaining stability, yet may result in impingement and dislocation if improperly placed. Late dislocation may result from polyethylene wear, soft tissue destruction, trochanteric or abductor disruption and weakness, or infection. Understanding the causes of hip dislocation allow prevention in a majority of instances. Proper preoperative planning includes the identification of high-offset patients in whom inadequate restoration of offset will reduce soft tissue tension and abductor efficiency. Component position must be accurate to achieve stability without impingement. Finally, patient education cannot be overemphasized, as most dislocations occur early and are preventable with proper instructions.

Imaging of Metal-on-Metal Hip Prostheses

AJR:197, September 2011 metal THA and resurfacing failure are small acetabular or femoral head size, implant malposition, female sex, metal ion–mediated adverse inflammatory reactions, implant loosening, femoral neck fractures, and others [1]. In the Australian registry, loosening (presumably acetabular) is the most common cause of resurfacing and metal-on-metal THA failure [3]. Clinically, pain is the most common symptom of metal-on-metal THA and resurfacing failure. Adverse inflammatory reactions accompanying metal-on-metal hip prostheses are well documented. The biologic cascade leading to adverse inflammatory reactions as a result of metal-on-metal bearing metallic debris has not been completely elucidated. Adverse inflammatory reactions can present as microscopic foci of asymptomatic aseptic lymphocyte-dominated vasculitic lesions found at the time of metal-on-metal hip revision, asymptomatic or symptomatic cystic structures (i.e., pseudotumor) found on imaging of metal-on-metal hip prostheses, or aggressive cystic lesions causing bone and soft-tissue destruction around metal-on-metal hip prostheses [1]. The exact incidence of clinically significant adverse inflammatory reactions secondary to metal-on-metal hip prostheses has been reported to be as low as 0.1% [5] and as high as 4% [6].

In the case of transmission of &lt;i&gt;Mycobacterium ulcerans&lt;/i&gt; in Buruli ulcer disease &lt;i&gt;Acanthamoeba &lt;/i&gt;species stand accused

Buruli ulcer disease caused by Mycobacterium ulcerans results in extensive destruction of skin and soft tissue and long-term functional disabilities that ultimately require surgery and rehabilitation. The disease is associated with aquatic and swampy environments with the mycobacterium occurring in biofilms, soil, aquatic insects, fish and wildlife however, the mode of transmission to humans remains an enigma. Current transmission ideas including bites from predatory water bugs and mosquitoes, do not explain satisfactorily the spasmodic disease distribution in human populations. Here we argue that Acanthamoeba species are the natural hosts of M. ulcerans and are mainly responsible for disease transmission because; (i) Acanthamoebae are known natural hosts of several microbial pathogens including M. marinum, M. avium and Legionella pneumophila, (ii) culture of slow-to-grow microbial pathogens hosted in nature by Acanthamoeba spp is enhanced when the media is seeded with the protozoa, (iii) acanthamoebae and M. ulcerans share similar bio-ecological and epidemiological settings, (iv) documented evidence that prior growth of L. pneumophila and M. avium in acanthamoebae influences entry mechanisms, intracellular growth and virulence in human monocytes, (v) Acanthamoeba spp also infect humans and cause diseases via routes of openings including broken skin and sites of trauma similar to M. ulcerans and (vi) M. ulcerans is rather a fastidious intracellular organism as recent analysis of the genome indicate. We argue further that temperature plays a significant role in transmission determining the fate of either the intracellular microbe or the host cells. Also, Acanthamoeba-pathogen association has a long evolutionary history because the same set of bacterial genes and gene products e.g. in L. pneumophila are required for survival in both mammalian and protozoan host cells. We suggest that the involvement of Acanthamoeba in the transmission of M. ulcerans to humans better explains the disease's epidemiology.

Gunshot wound in skeletonised human remains with partial adipocere formation

We present a case of skeletonised human remains. In the present case report, a body was exhumed from the ground above a cemetery. On exhumation, the body was partially-skeletonised with adipocere formation on the upper part of the body. Autopsy of the body showed two bullets in the right thigh muscle and lumbar vertebrae between L4 and L5. Postmortem changes and destruction of soft tissue made it impossible to determine direction of fire through the body, even in a careful complete autopsy.

Maxillary brown tumour: unusual presentation of parathyroid carcinoma

AbstractThis is a report of a maxillary brown tumour caused by primary hyperparathyroidism (HPT) secondary to parathyroid carcinoma. A 62-year-old man presented with a large swelling in the right maxilla, which caused right-sided nasal obstruction, intermittent bleeding and diplopia. A computed tomography scan demonstrated an expansible, destructive soft tissue mass centred on the right ethmoid sinus, extending from the maxilla to the orbital floor. Histology showed a central giant cell granuloma of bone, thought to be a brown tumour of HPT and this was supported by serum calcium of 3.0 mmol/l and serum parathyroid hormone of 880 ng/l (normal 7 to 40 ng/l). Parathyroid imaging was consistent with a left lower parathyroid adenoma. The patient underwent removal of the parathyroid gland, left hemithyroidectomy and central node dissection. Histology confirmed parathyroid carcinoma. Surgical removal of the brown tumour was offered but declined. The symptoms improved and the maxillary swelling gradually reduced...

Endoprothetische Versorgung der rheumatischen Fingergelenke

Resection arthroplasty, arthrodesis and prosthetic reconstruction are able to guarantee the maintenance of good functional ability of finger joints even in late stages and with severe destruction. Destruction of soft tissues of the finger joints cannot be corrected by prosthetic measures alone. A stabile situation of the wrist joint is one of the most important prerequisites for a normal performance of daily life activities. Silastic endoprostheses are still the gold standard for finger replacement in rheumatoid arthritis.

Hip Resurfacing and Pseudotumour

Metal on metal hip resurfacing has been used widely over the last ten years but there has been recent concern about destructive soft tissue reactions, which have been called pseudotumours by some authors. This has generated considerable controversy. This review explains why pseudotumours occur after resurfacing and how they can be prevented. It also supports the continued use of resurfacing in appropriate patients by appropriately trained surgeons.

Advances in Resuscitation in the Setting of Vascular Injury

Damage control surgery with the principles of expeditious control of hemorrhage and contamination, followed by predominant crystalloid resuscitation in the intensive care unit has saved the lives of many severely injured trauma patients. Unfortunately, crystalloid resuscitation has too often led to worsening of coagulopathy in the setting of vascular injury. The recent conflicts in Iraq and Afghanistan have created injured patients with severe vascular injury and massive soft tissue destruction creating early and profound coagulopathy associated with high rates of mortality. An alternative strategy, known as damage control resuscitation, with the principal resuscitation of a 1:1 ratio of packed red blood cells and fresh frozen plasma has been developed during these conflicts. This method is associated with decreased mortality and improved limb salvage in military and civilian trauma patients.

Rheumatoid arthritis and periodontitis; a possible link via citrullination

Rheumatoid Arthritis (RA) and chronic and aggressive periodontitis are chronic inflammatory disorders characterized by deregulation of the host inflammatory response. Increased secretion of pro-inflammatory mediators results in soft and hard tissue destruction of the synovium and periodontium respectively. Both diseases share risk factors and have pathological pathways in common, resulting in loss of function and disability as a final clinical outcome. This article discusses possible interactions, particularly related to the periodontal pathogen Porphyromonas gingivalis, which could explain the observed association between these two prevalent diseases.

Primary cutaneous mucormycosis at sites of insulin injection

To the Editor: Mucormycosis is an uncommon saprophytic infection classically affecting immunocompromised individuals. Particularly susceptible are those with uncontrolled diabetes, organ transplantation, or hematologic malignancy.1 The disease is characterized by angioinvasion with soft tissue destruction and may be rapidly progressive and fatal, with overall mortality exceeding 65%.1 Mucormycosis manifests in one of five clinical forms: rhinocerebral, pulmonary, gastrointestinal, cutaneous, or disseminated disease.

Dangers of bone graft substitutes: lessons from using GeneX

BackgroundBone graft substitutes are widely used in spinal surgery. Here, serious complications associated with the bone graft substitute GeneX are presented. GeneX contains tri-calcium phosphate and calcium sulphate.MethodsGeneX was used...

Necrotizing Streptococcal Myositis of an Extremity: A Rare Case Report

Necrotizing myositis is a severe and very rare streptococcal soft tissue infection involving the superficial fascia and muscle. Its clinical symptoms are nonspecific until the appearance of a fulminant clinical course with soft tissue destruction and septic shock. A high mortality and morbidity rate has been reported in the few cases over the last century. Despite several attempts to better define the different entities causing this necrotizing soft tissue infection, no clear treatment has been outlined. We present the case of a 47-year-old woman who had an acute necrotizing myositis after a stab wound. The diagnosis of necrotizing myositis was only established after surgical treatment with a pathology report. We reviewed the literature to highlight the clinical difficulty of a preoperative diagnosis and surgical treatment.

Host‐derived diagnostic markers related to soft tissue destruction and bone degradation in periodontitis

A major challenge in clinical periodontics is to find a reliable molecular marker of periodontal tissue destruction with high sensitivity, specificity and utility. The aim of this systematic review is to evaluate available literature on 'the utility of molecular markers of soft and hard periodontal tissue destruction'. Based on the focused question, 'What is the utility of molecular markers of soft and hard periodontal tissue destruction', an electronic and manual search was conducted for human studies presenting clinical data for the potential of molecular markers of tissue destruction in biofluids; gingival crevicular fluid (GCF), saliva, and serum. Papers fulfilling the inclusion criteria were selected. All relevant data from the selected papers were extracted and recorded in separate tables for molecules in GCF, saliva, and serum. Within the defined limits of the Problem/Population, Intervention, Comparison, Outcome, the present analysis reveals that (a) no single or combination of markers exists that can disclose periodontal tissue destruction adequately; (b) while the most fruitful source of biomarkers for periodontal destruction appears to be in molecules tightly related to bone and soft tissue destruction, this remains to be objectively demonstrated. Currently, clinical measurements are still the most reliable.