Tissue Tension Research Articles

SPONTANEOUS CORRECTION OF EXTERNAL TIBIOFEMORAL ROTATION AND TIBIAL TUBEROSITY-TROCHLEAR GROOVE DISTANCE OCCURS AFTER MEDIAL PATELLOFEMORAL LIGAMENT RECONSTRUCTION IN FIXED OR OBLIGATORY DISLOCATORS

Background:Tibial tubercle to trochlear groove distance (TT-TG) and external tibiofemoral rotation (TFR) through the knee joint have been identified potential contributing factors to patellar instability. In patients with a fixed or obligatory lateral patella dislocation (FOD), the normal force vector of the extensor mechanism is altered, so instead of a direct axial pull to cause extension, it exerts a lateralizing and external rotatory force on the tibia via the tibial tubercle.Hypothesis/Purpose:The purpose of this study is to investigate postoperative changes in TT-TG and TFR after medial patellofemoral ligament reconstruction (MPFLR) in two clinical cohorts: standard traumatic patellar instability (SPI) patients and FOD patients. We hypothesized that by surgically relocating the patella in the trochlea, and re-establishing medial sided soft tissue tension, the increased medializing force vector on the patella may exert enough force to alter resting rotation of the tibia in relation to the femur in the FOD group.Methods:A retrospective study was performed from April 2009 to February 2019. FOD and SPI patients under 18 years with available magnetic resonance imaging (MRI) of the knee before and after MPFLR were eligible. All FOD patients in the time frame were analyzed and SPI patients were randomly selected. Exclusion criteria were outside institution MRI, concomitant alignment procedures done at the time of MPFLR, and prior MPFLR or tibial tubercle osteotomy. TT-TG and TFR (using the posterior femoral and tibial condylar lines) were measured blindly on initial axial MRI. Statistical analysis using a paired sample t-test was performed with significance set at p<0.05.Results:A total of 30 patients were included, 14 in the FOD group and 16 in the SPI group. The mean age at time of surgery was 13.9 years (range 10-17 years), 53% of the cohort was female, and the mean time from surgery to follow-up MRI was 2.0 years. Demographics by group are shown in Table 1. TT-TG and TFR were not significantly different preoperatively versus postoperatively in the SPI group (Table 2). In the FOD group, both TT-TG (17.7 vs 13.7, P=.019) and TFR (8.6 vs 3.1, P=.025) decreased significantly on postoperative MRI.Conclusion:The postoperative decrease in TT-TG and TFR in the FOD group suggests that MPFLR in fixed or obligatory dislocators can improve the external rotation deformity through the level of the joint, and thus may help normalize the forces acting through the extensor mechanism.Tables/ Figures

Endoscopic submucosal dissection using a detachable assistant robot: a comparative in vivo feasibility study (with video).

Appropriate tissue tension and clear visibility of the dissection area using traction are essential for effective and safe endoscopic submucosal dissection (ESD). We developed a robotic assistive traction device for flexible endoscopy and compared its safety and efficiency in ESD between experienced and novice endoscopists. Robotic ESD was performed by experienced and novice endoscopist groups (n = 2, each). The outcomes included time to complete each ESD step, total procedure time, size of the dissected mucosa, rate of en bloc resection, and major adverse events. Furthermore, incision and dissection speeds were compared between groups. Sixteen gastric lesions were resected from nine live pigs. The submucosal incision speed was significantly faster in the expert group than in the novice group (P = 0.002). There was no significant difference in the submucosal dissection speed between the groups (P = 0.365). No complications were reported in either group. When the robot was assisting in the ESD procedure, the dissection speed improved significantly, especially in the novice surgeons. Our robotic device can provide simple, effective, and safe multidirectional traction during ESD.

Displacement Error Propagation From Embedded Markers to Brain Strain.

Head injury model validation has evolved from against pressure to relative brain-skull displacement, and more recently, against marker-based strain. However, there are concerns on strain data quality. In this study, we parametrically investigate how displacement random errors and synchronization errors propagate into strain. Embedded markers from four representative configurations are used to form unique and nonoverlapping tetrahedrons, triangles, and linear elements. Marker displacements are then separately subjected to up to ±10% random displacement errors and up to ±2 ms synchronization errors. Based on 100 random trials in each perturbation test, we find that smaller strain errors relative to the baseline peak strains are significantly associated with larger element sizes (volume, area, or length; p < 0.05). When displacement errors are capped at the two extreme levels, the earlier "column" and "cluster" configurations provide few usable elements with relative strain error under an empirical threshold of 20%, while about 30-80% of elements in recent "repeatable" and "uniform" configurations are considered otherwise usable. Overall, denser markers are desired to provide exhaustive pairwise linear elements with a range of sizes to balance the need for larger elements to minimize strain error but smaller elements to increase the spatial resolution in strain sampling. Their signed strains also provide unique and unambiguous information on tissue tension and compression. This study may provide useful insights into the scrutinization of existing experimental data for head injury model strain validation and to inform how best to design new experiments in the future.

Neglected сlubfoot treated by Ilizarov and Ponseti methods

The Ponseti method has revolutionized clubfoot treatment. Though completely neglected clubfeet are now rare, partially or incompletely and improperly treated feet are not uncommon. Relapses after successful correction may occur due to non-compliance with bracing. In scarred soft tissues due to previous surgery, soft tissue distraction using external fixation helps achieve correction. The Ilizarov fixator permits us to follow the Ponseti protocol, using correction methods that may either be constrained or unconstrained by hinges. Applying force vectors perpendicular to the moment arm allows us to correct the еquinus without damaging the ankle joint. All of the above is possible when the talus is round. Full correction of the deformity is possible. However, longterm follow-up of these patients has revealed stiffness of the ankle setting and frequently with tibio-talar osteophytes anteriorly. They are probably a reaction to excessive pressure developed in the joint due to the tight soft tissues. Hence the author has now added a mild shortening of the tibia and fibula to reduce soft tissue tension, rather than resorting to further soft tissue releases through scarred tissues. This allows faster correction with the Ponseti-Ilizarov protocol and allows good ankle range of motion to persist.

Influence of the femoral offset on the muscles passive resistance in total hip arthroplasty.

BackgroundSoft tissue tension is treated as a crucial factor influencing the post-THA dislocation. The femoral offset is regarded as one of the major parameters responsible for the stabilization of the prosthesis. It is unclear which soft tissue is mostly affected by the offset changes.MethodsA finite element model of the hip was created. The model comprised muscles, bones, a stem, the acetabular component and a liner. The muscles were modelled as a Hill-type musculo-tendon nonlinear springs. Nonlinear analyses of the hip flexion and internal rotation were performed for the two values of the femoral stem offset.ResultsWe observed that the quadratus femoris and gluteus medius produce the largest resisting moment opposing the external load excreted by the surgeon during the intraoperative hip dislocation test.ConclusionsAn increased femoral offset increases the stretching of the quadratus femoris muscle significantly and provides the growth of its initial passive force. This muscle serves as a stiff band, providing stabilisation of the hip prosthesis, measured during the simulated intraoperative test.

Radiographic outcomes of patients undergoing reverse shoulder arthroplasty using inlay versus onlay components: is there really a difference?

IntroductionAchieving soft tissue tension in RSA occurs by displacement of the humerus from the glenoid. We compared the lateral and inferior humeral displacement of two RSA systems radiographically. Each system utilized a humeral implant with a 135-degree neck-shaft angle and offered lateralized glenospheres. One had an onlay component and the other an inlay. Our primary hypothesis was that an alteration of surgical technique would negate the differences in their geometries radiographically. Secondarily, we sought to determine if a difference in complications or revisions occurred with these different designs. MethodsTwo hundred and eleven patients underwent RSA by a single surgeon with either an inlay or onlay prosthesis over a 2-year period. A true AP Grashey radiograph was utilized to measure: 1) Glenohumeral offset (GHO); 2) Acromiohumeral distance (AHD); 3) Pivot point (PP); 4) Humeral head cut surrogate (HHC) and 5) Humeral Socket Depth (HSD). Complications recorded included postoperative acromial fractures, revision for any reason, instability, and infections. ResultsThere was no significant difference in GHO or AHD between the two groups. There was a difference in PP and HHC between the groups (P < .001). The onlay group had an HHC 1.8 mm larger than inlay. Of the inlay group patients, 66% had their humeral tray placed above the level of the humeral osteotomy. DiscussionA larger HHC in the onlay group and implanting the inlay above the humeral osteotomy negates differences in AHD and GHO. Level of evidenceLevel III; Retrospective Comparative Study

Morphological Changes In Bone Tissue In Chronic Osteomyelitis On The Background Of Application Of Plate Concentrate

The method of laser osteoperforation developed experimentally was approved in 142 patients with chronic osteomyelitis of different forms. A diode laser was used in which wavelength was 970 nm and power – 30 W. Laser osteoperforation was performed transcutaneously in a contact way with a quartz light guide of 0, 4 mm diameter in the projection of bone destruction foci with formation of 2-20 holes. Normalization of temperature and blood indices as well as pain decrease, reduce of soft tissue tension and edema was observed in all the patients in the immediate days after surgery. As a rule, fistulae closed by 4-10 day. In case of chronic osteomyelitis persistent remission is noted during 2-5 years by the objective data (roentgenography, flowmetry, densitometry). Thus, the experience of laser osteoperforation clinical use demonstrates its high effectiveness in treatment of osteomyelitis different forms. The method is of little invasiveness and it allows to reduce the periods of treatment and rehabilitation to a great extent.

Mechanical control of tissue shape and morphogenetic flows during vertebrate body axis elongation

Shaping embryonic tissues into their functional morphologies requires cells to control the physical state of the tissue in space and time. While regional variations in cellular forces or cell proliferation have been typically assumed to be the main physical factors controlling tissue morphogenesis, recent experiments have revealed that spatial variations in the tissue physical (fluid/solid) state play a key role in shaping embryonic tissues. Here we theoretically study how the regional control of fluid and solid tissue states guides morphogenetic flows to shape the extending vertebrate body axis. Our results show that both the existence of a fluid-to-solid tissue transition along the anteroposterior axis and the tissue surface tension determine the shape of the tissue and its ability to elongate unidirectionally, with large tissue tensions preventing unidirectional elongation and promoting blob-like tissue expansions. We predict both the tissue morphogenetic flows and stresses that enable unidirectional axis elongation. Our results show the existence of a sharp transition in the structure of morphogenetic flows, from a flow with no vortices to a flow with two counter-rotating vortices, caused by a transition in the number and location of topological defects in the flow field. Finally, comparing the theoretical predictions to quantitative measurements of both tissue flows and shape during zebrafish body axis elongation, we show that the observed morphogenetic events can be explained by the existence of a fluid-to-solid tissue transition along the anteroposterior axis. These results highlight the role of spatiotemporally-controlled fluid-to-solid transitions in the tissue state as a physical mechanism of embryonic morphogenesis.

Comparison and appraisal of techniques for the determination of material loss from tapered orthopaedic surfaces

This review examines the challenges associated with quantifying material loss at modular junctions. Determination of material loss from retrieved orthopaedic surfaces is regarded as a prerequisite for the evaluation of long-term implant performance. Methods previously adopted to overcome the challenges associated with determining material loss from non-articular surfaces will be presented and discussed in this paper.Total Hip Replacement (THR) is regarded as one of the most successful and cost-effective surgical interventions for the treatment of advanced osteoarthritis. The use of modular components offers surgeons an array of possible implant combinations to intraoperatively optimise range of motion and soft tissue tension. However, the taper interface used to connect modular components has been suggested to contribute to premature implant failure through the release of metal debris and corrosion products. Geometrical and topographical measurement of explanted modular interfaces has been used to correlate multifarious variables with an absolute volumetric value for material loss. To improve modular implant performance, medical device manufacturers have adopted numerous design philosophies, each presenting a unique set of challenges for the measurement of material loss. This review summarises the approaches used in previous studies to overcome these challenges and identifies future work required in this area. This field of research is currently the subject of discussion within standards bodies to create recommended best practices for centres to follow.

English

BACKGROUND Skeletal class II division 1 malocclusion is an antero posterior discrepancy between maxilla and mandible which is usually treated by functional appliances when the patient is in the growing phase. It has been shown that these functional orthodontic appliances may lead to pressure on the oral mucosa, soft tissue tension, oral constriction, toothache and pain. They may also lead to fatigue or to functional speech and respiratory disorders, and they may affect the appearance of the face. All of these undesired consequences affect the patients’ degree of compliance in a negative manner, and may in turn affect the patients’ perception towards the treatment. This study was conducted to investigate patient perception of treatment need, appliance acceptance, expectations of treatment influence on oral health, value of dental aesthetics and information concerning treatment procedures. METHODS Total 30 samples were selected 15 samples were cases treated with twin block appliance and other 15 samples were treated with clear block appliance. After 8 months of treatment, a questionnaire survey was conducted assessing discomfort, expectations and experiences of all patients being treated with clear block appliance and twin block appliance. RESULTS Clear block seemed to be better with regard to all the parameters used in the study but on statistical analysis the difference between the two groups was insignificant. CONCLUSIONS Clear block appliance was designed to increase the compliance of the patient. However, clear block and twin block appliance have similar effects. KEY WORDS Class II, Clear Block, Twin Block

Simplified magnetic anchor-guided endoscopic submucosal dissection: an ex vivo porcine model.

Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. A total of 15 en bloc ESDs (five with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.

Simplified magnetic anchor-guided endoscopic submucosal dissection: an ex vivo porcine model

Introduction and aimsEndoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. Materials and methodsAn experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. ResultsA total of 15 en bloc ESDs (5 with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90min. Lesion size ranged from 15 to 50mm (mean 30mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). ConclusionsOur study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.

Highlights from Recent Cancer Literature

Highlights from Recent Cancer Literature

L233P mutation in the bovine leukemia virus Tax protein has impact on annexin A3 and type I collagen secretion by host cells

Bovine leukemia virus (BLV) is the causative agent of enzootic bovine leukosis (EBL) and can be classified into two types based on the amino acid at position 233 in Tax protein, which probably plays crucial roles in leukemogenesis. We previously revealed that L233-Tax-expressing cells secreted chemoattractants for endothelial cells and formed significantly larger tumors accompanying neovascularization than P233-Tax-expressing cells in athymic mice. In the present study, comparative proteomic analysis of the culture medium of Tax-expressing cells revealed that annexin A3 and probably extracellular matrix protein 1 served as chemoattractants. Conversely, L233-Tax-expressing cells were impaired in the secretion of collagen alpha-1 (I) chain precursor, which participates in tissue tension homeostasis, leading to tumor mass development. The analysis also demonstrated that both L233-Tax- and P233-Tax-expressing cells had deficits in the secretion of potentially antiangiogenic molecules, including pigment epithelium-derived factor and collagen alpha-1 (VIII) chain, and they produced complement component 3, which might participate in tumor cell proliferation, metastasis, and immune evasion. These findings provided novel insights into prognostication of EBL and the function of Tax in leukemogenesis induced by BLV.

Effect of Ulnar Head Offset on Distal Radioulnar Joint Stability

A complete ulnar head replacement may be indicated in cases of distal radial ulnar joint (DRUJ) dysfunction to address bony pathology in lieu of using a constrained total DRUJ prosthesis. Complete ulnar head implants are simple, but they may be unstable if soft tissue tension is not adequately restored. We hypothesized that incorporating an increased offset in the complete ulnar head replacement would lead to increased tension on the distal oblique interosseous ligament, increased contact force at the DRUJ, and improved joint stability. Using a specially designed jig, we measured instability by comparing displacement under load (stiffness) of the DRUJ in 10 cadaveric specimens under 4 different conditions: (1) intact, (2) native head after excision of the triangular fibrocartilage complex, (3) replacement of the ulnar head with a standard offset ulnar head, and (4) replacement of the ulnar head with an increased offset ulnar head. No soft tissue repair was done. We measured anteroposterior displacement under load with maximum translation of 10 mm or maximum loads of 50 N. We tested all specimens with the forearm positioned in neutral, supination, and pronation. Excising the triangular fibrocartilage complex decreased the average stiffness of the DRUJ to 46% of the intact state, creating a simulated state of DRUJ instability. Replacing the ulnar head with the standard offset head increased average stiffness to 54% of the intact state. Increasing the ulnar head offset with the simulated total ulnar head replacement increased average stiffness to 77% of the intact state. An increased offset ulnar head replacement improves DRUJ stability compared with a standard anatomic offset ulnar head replacement. Understanding DRUJ morphology and offset is important in the treatment of DRUJ arthritis and instability.

Pancreatic cancer is suppressed by fibroblast-derived collagen I.

Clinical implementation of anti-stromal therapies in pancreatic cancer has been delayed by unanticipated tumor-restraining properties of the desmoplastic stroma. In confronting these challenges, Chen etal. demonstrate in this issue of Cancer Cell that fibroblast-specific deletion of collagen I, in the background of oncogenic Kras-induced spontaneous murine pancreatic ductal adenocarcinoma, enhances immune suppression and accelerates progression of disease.

Use of Dual Mobility Acetabular Component and Anterior Approach in Patients With Displaced Femoral Neck Fracture

BackgroundAlthough the antidislocation effect of total hip arthroplasty (THA) via the direct anterior approach (DAA) with dual mobility cup (DMC) for displaced femoral neck fracture (FNF) has already been reported, the clinical result of DMC-DAA-THA for displaced FNF in terms of mortality, complications, and walking ability are still unclear. Methods106 cases with DMC-DAA-THA for displaced FNF were investigated of dislocation; perioperative complications; 3-, 6-, and12-month mortality rate; and pre/early postoperative walking ability. The walking ability was stratified into the following four categories: (1) use of a wheelchair (no walking), (2) walking alongside a support (including walkers designed for the elderly), (3) walking using one stick, and (4) unaided walking. ResultsThere was no dislocation withing one-year postoperative. The 3-, 6-, and 12-month mortality rate was 2.8%, 4.7%, and 5.7%. Total complications occurred in 14 cases (14.7%). Although there was no revision surgery, two cases (1.9%) of intraoperative fracture treated without additional fixation, and one case of postoperative fracture was occurred. Among patients with preinjury walking category 2, 3, and 4 (total 94 cases), the number of patients who recovered same walking category at two-week postoperation was 56 cases (59.6%). ConclusionsOur study demonstrated that DMC-DAA-THA for displaced FNF offered quick recovery of walking ability with no dislocation and low one-year mortality rate. We believe that the combination of early postoperative recovery due to the minimal invasiveness of the DAA and decreased dislocation rate due to increased range of motion by DMC and adequate soft tissue tension by DAA contributed to null dislocation.

Küntscher nails with static cement spacer: A simple technique in periprosthetic knee infections with massive bone loss and instability

BackgroundTwo-stage revision for periprosthetic knee infection is challenging in cases of massive bone loss and instability. The present study aims to describe our experience with an alternative technique of reinforced cement spacer, usually necessary in these situations, focusing on its advantages and clinical results. MethodsWe retrospectively identified all patients who underwent a two-stage revision for periprosthetic knee infection using two intramedullary Küntscher nails as reinforcement from January 2010 to September 2018. From each medical record, we extracted the type of explanted prosthesis, isolated micro-organism, number of cement spacers before index procedure (and related episodes of spacer dislocation) and final treatment. ResultsTwelve patients were identified, mean age of 64.0 years (range 39–85). In four of them, the reinforced spacer was used twice for persistent infection, with a total of 16 procedures performed and no cases of dislocation. Ten patients were finally treated with reimplantation or arthrodesis with intramedullary nails, whereas an above-knee amputation was necessary for two patients. Infection was eradicated in 10 patients out of 12 (83%) at a mean follow up of 34.3 months (range 10–62). ConclusionsThis technique is an effective alternative to traditional spacers in cases of massive bone loss, producing a mechanically stable joint and preserving adequate tissue tensions. The construct is technically easy to perform and, not less importantly, to remove during stage 2. Further studies, with larger groups, are necessary to determine its validity.

Defining deformity thresholds for the use of augmented glenoids in arthritic shoulders with posterior glenoid bone loss

BackgroundDespite increasing utilization, little guidance is offered regarding appropriate indications for posterior augmented glenoid implants. The purpose of this study is to virtually assess the effect of implant selection on glenoid resurfacing and joint line restoration in osteoarthritic shoulders with posterior glenoid wear. MethodsThirty-three CT scans were randomly selected from a cohort of osteoarthritic shoulders with Walch B2 or B3 deformities. Imascap SAS (Wright Medical, Memphis, TN) was used to assess bony deformities and plan glenoid resurfacing. Implants simulated included: standard Pegged Cortiloc, and 15° and 25° half-wedge augments. Each component was planned for a version correction to neutral and 10° retroversion, inclination was maintained within 5° of neutral and the component was medialized until bony support reached 80%. Implantation failure was defined as: greater than 20% cancellous bone support, central peg perforation, or joint line medialization relative to the pathologic joint (accounting for polyethylene thickness). Excessive lateralization was defined as creation of a joint-line >4 mm lateral to the pathologic joint-line. ResultsThe mean retroversion deformity in this cohort was 23.7° (range: 13°-37°). When correcting to neutral, the corrective reaming alone failed in 72.7% (24/33) of cases compared to 15.2% (5/33) when correcting to 10° of implant retroversion. When correcting to neutral version failure was decreased with a 15° (27.3%; 9/33; P < .001) and 25° augment (15.2%; 5/33; P < .001). Receiver operating characteristic (ROC) analysis found that an augment is useful to resolve standard implant failure for retroversion deformities greater than 27° (area under the curve [AUC] = 0.91) and 22° (AUC = 0.77) for correcting version to neutral and 10° retroversion, respectively. When placing a 25° augment, there was high risk of overstuffing the joint for both correction to neutral (27.3%) and 10° retroversion (66.7%). Overstuffing was likely to occur when correcting deformities less than 19° (AUC = 0.96) to neutral with a 25° augment. Likewise, implanting 15° or 25° augmented glenoids in 10° of retroversion is likely to overstuff the joint for pathologic retroversion deformities smaller than 18° (AUC = 0.94) and 28° (AUC = 0.69), respectively. ConclusionThis study helps to clarify the severity of glenoid deformities more appropriately addressed with the use of a half-wedged augmented glenoid. Both the severity of glenoid deformity and the desired implant version affect appropriate indications for the use of augmented glenoids. The risk of excessive joint-line lateralization in shoulders with less severe deformities should not be ignored. These considerations, in addition to individual soft tissue tension should be considered when planning and performing glenoid resurfacing. Level of evidenceLevel III; Treatment Study

A Case report-Ayurvedic Management of Dushta vrana

The break/loss/rupture of contuinity of body tissue or part of body is called Vrana(Wound). Normally wounds are healed by itself if kept clean.Contamination of bacteria, insufficient blood supply, tissue tension and radiation are the local factors for delay in wound healing. Whereas general factors include malnutrition, malignant disease,diabetes and long term consumption of steroids and cytotoxic drugs.[i]Acharya Shushruta mentioned 60 upakrama for management of Vrana. Acharya charaka classified vrana into 20 types among them dustha vrana is one of them.[ii]In the case 35 yr female presented at opd with complain of non healing wound since 6 months at bilateral lower limbs with signs and symptoms of slough,pus discharge and pain.Ayurvedic management was done for 30 days which cured all the sign and symptoms. Ayurvedic management includes prakshalana by panchavalkal kwath, nimba taila for local application and arogyabardini vati,mahamanjistha kwath and kaishor guggulu per oral.&#x0D; Conclusion: Dustha vrana can be treated by ayurvedic management like panchavalkal kwatha, nimba taila,Arogyavardini vati kaishor guggulu, mahamanjistha kwath.&#x0D; &#x0D; [i] RAINS A.J.HARDING, RITCHIE H DAVID in Bailey and Loves Short Practice of Surgery 19th Edition Chapter 1 pg 3&#x0D; [ii] Acharya Bidhyadhar Shukla,Prof.Rabidutta Tripathi in Charak Samhita Uttarardha Reprinted 2010 chapter 25 pg606