Repair Of Trauma Research Articles

Editorial introductions

Editorial introductions

Team Management of a Young Adult with a Traumatic Cleft Repair

The orthodontist role in a cleft palate craniofacial team is undebatable. For satisfactory results, close coordination among team members is mandatory. This interactive, evidence-based and patient-centered care should provide the basis for a rational approach to diagnosis and treatment planning. The ultimate goal is to have fully rehabilitated patient who is satisfied with the treatment outcomes in terms of speech, occlusion, facial and dental esthetics and function. This case report describes management of an adult patient with a traumatically repaired cleft. The maxilla was deficient in all three planes and the mandible appeared protrusive. The patient's speech had nasalance and articulation problems. The patient was informed about the possibility of speech deterioration post-surgery and was explained about the options available. After appropriate presurgical orthodontics, maxilla was surgically expanded and was also advanced by 5 mm. After surgery, speech was more intelligible because of improved articulation. It was possible to get optimum esthetic and functional result due to coordinated team approach.

Bone marrow mesenchymal stem cells can be mobilized into peripheral blood by G-CSF in vivo and integrate into traumatically injured cerebral tissue

The efficacy of granulocyte colony-stimulating factor (G-CSF) in mobilizing mesenchymal stem cells (MSCs) into peripheral blood (PB) and the ability of PB-MSCs incorporated into injured brain were tested. Colony forming, cell phenotype and differentiation potential of mouse MSCs mobilized by G-CSF (40μg/kg) were evaluated. Mortality and pathological changes in mice with serious craniocerebral trauma plus G-CSF treatment (40μg/kg) were investigated. Bone marrow (BM) cells derived from GFP mice were fractionated into MSCs, hematopoietic stem cells (HSCs), and non-MSC/HSCs using magnetic beads and adherent culture. The resultant cell populations were transplanted into injured mice. The in vivo integration and differentiation of the transplanted cells were detected immunocytochemically. The expression of SDF-1 in injured area of brain was tested by Western blot. G-CSF was able to mobilize MSCs into PB (fourfold increase). PB-MSCs possessed similar characteristics as BM-MSCs in terms of colony formation, the expression pattern of CD73, 44, 90, 106, 31 and 45, and multipotential of differentiation. Accumulative total mice mortality was lower in TG group (5/14) than that in T group (7/14). It was MSCs, not HSCs or non-MSC/HSC cells integrated into the damaged cerebral tissue and differentiated into cells expressing neural markers. Increased SDF-1 expression in injured area of brain was confirmed, which could facilitate the homing of MSCs to brain. G-CSF can mobilize MSCs into PB and MSCs in PB can integrate into injured cerebral tissue and transdifferentiated into neural cells and may benefit the repair of trauma.

Blunt pediatric anterior and posterior urethral trauma: 32-year experience and outcomes

ObjectiveTo analyze our experience with delayed repair of pediatric urethral trauma. Materials and methodsFrom 1978 to 2007, 26 boys <18 years old (mean age 15.0) presented for delayed repair of urethral stricture after blunt trauma. Anterior and posterior urethral injuries were separately stratified. ResultsThere were 8 anterior and 18 posterior urethral strictures. All patients presented in a delayed fashion. Mean follow up of the anterior cohort was 2.9 years. All repairs were performed via a ventral onlay buccal graft or anastomotic approach. The mean follow up of the posterior cohort was 1.1 years, and all posterior urethral injuries were repaired via an anastomotic approach.Overall success for anterior stricture disease was 88.9% and for posterior stricture disease was 89.5%. All three urethroplasty failures responded favorably to internal urethrotomy; however, one failed anterior repair and one of the two failed posterior repairs required two internal urethrotomy operations for success. No secondary urethroplasty operations were required and ultimately all patients were voiding per urethra without need for urethral dilation. ConclusionDelayed, definitive repair of pediatric urethral trauma via open urethroplasty has a high success rate.

Emerging drugs for treating skeletal muscle injury and promoting muscle repair

Introduction: Musculoskeletal injuries represent a major global public health problem and muscle injury contributes significantly to the burden of disability and suffering. Drugs that can attenuate muscle trauma and/or hasten muscle repair to restore function can help reduce the economic burden and alleviate personal suffering and financial hardship.Areas covered: This review provides an update on some emerging drugs with therapeutic potential for muscle injury including those that could attenuate damage or improve regeneration. Although there are few (if any) drugs in development specifically for muscle injury, there are numerous drugs in development for cardiovascular complications, such as ischemia-reperfusion, that might also have efficacy for promoting regeneration after similar events in skeletal muscle.Expert opinion: Drugs in development for muscle wasting or inflammatory diseases should also be considered within the context of modulating the events associated with muscle degeneration and regeneration. More rigorous pre-clinical evaluations, especially of a drug's efficacy for improving function, would help minimize false leads and hasten development of effective approaches for treating muscle damage and promoting repair after injury.

Endovascular and open repair for blunt aortic injury, treated in one clinical institution in Brazil. A case series

OBJECTIVE:The objective of this retrospective study is to analyze and compare the results of conventional surgical repair and endovascular treatment of blunt aortic injury over the past 8 years.METHODS:Twenty‐eight patients (25 male; mean age, 35 years) were treated for blunt aortic injury between April 2001 and March 2009 in a university hospital in Brazil. Twenty‐six patients were included in the study: five were treated with operative repair (OR) and 21 with endovascular treatment (TEVAR). Two patients were excluded from analysis: one was managed conservatively, and one was treated with endovascular treatment for chronic dissection related to aortic trauma.RESULTS:Mean age was lower in the OR group than in the endovascular treatment group (17.8 vs. 38 years, P = .003). There was one death in the OR group and four deaths in the endovascular treatment group. Mean follow‐up for the overall group was 33.6 months, with 48.7 months (range 8‐83 months) for the OR group, and 29.8 months (range 2‐91 months) for the TEVAR group. Mean time elapsed from injury to repair was 23.4 hours (range 8‐48 h, median 20 h) for the OR group and 30.3 hours (range 2‐240 h, median 18 h) for the TEVAR group (P = .374). The duration of surgery was shorter in the endovascular treatment group (142 versus 237 minutes; P = .005). There were no significant differences with respect to the number of postoperative days requiring mechanical ventilation, duration of ICU stay or duration of hospital stay.CONCLUSION:In this retrospective analysis, endovascular treatment was a safe method for repair of blunt aortic trauma, with immediate and midterm results that were comparable to those results obtained with operative repair. No complications from the stent graft were identified during follow‐up. Nevertheless, long‐term follow‐up is necessary to confirm the effectiveness of this treatment.

Nanobots as Therapeutic Devices

Current medicine is limited both by its understanding and by its tools. In many ways, it is still more an art than a science. Today’s drug therapies can target some specific molecules, but only some, and only on the basis of type. Doctors today can’t affect molecules in one cell while leaving identical molecules in a neighboring cell untouched because medicine today cannot apply surgical control to the molecular level. To understand what nanotechnology can do for medicine, we need a picture of the body from a molecular perspective. There are opportunities to design nanosized, bioresponsive systems able to diagnose and then deliver drugs, and systems able to promote tissue regeneration and repair (in disease, trauma and aging), circumventing chemotherapy. The long term goal is the development of novel and revolutionary bimolecular machine components that can be assembled and form multi-degree-of freedom nano devices that will apply forces and manipulate objects in the nanoworld, transfer information from the nano to the macro world, and travel in the nano environment. These machines are expected to be highly efficient, controllable, economical in mass production, and fully operational with minimal supervision. The emerging field of medical nanorobotics is aimed at overcoming these shortcomings. Molecular manufacturing can construct a range of medical instruments and devices with greater abilities. Ongoing developments in molecular fabrication, computation, sensors and motors will enable the manufacturing of nanobots. These are theoretical nanoscale biomolecular machine systems within a size range of 0.5 to 3 microns with 1-100 nm parts. Work in this area is still largely theoretical, and no artificial non biological nanobots have yet been built. These ultra miniature robotic systems and nano-mechanical devices will be the biomolecular electro-mechanical hardware of future biomedical applications.

An Update of the Role of Endovascular Repair in Blunt Carotid Artery Trauma

An Update of the Role of Endovascular Repair in Blunt Carotid Artery Trauma

Nailbed repair and patient satisfaction in children

We performed an audit to assess frequency of injury to the nail bed and outcomes after repair in a busy paediatric hand trauma clinic. This retrospective study examines 46 consecutive nail bed repairs over a 6-month period. All notes were reviewed for patient demographics, details of the injury including the operation and aftercare. Telephone interviews were used to assess patient/parent satisfaction and complications. The commonest mechanism of injury was trapping a finger in a door. The accident usually occurred indoors and most frequently affected the middle finger. The majority of repairs were carried out under general anaesthetic, by registrars, using absorbable synthetic sutures, within 24 h of the injury as a day-case. Outcome data with a minimum of 15 months follow-up, showed a high satisfaction rate (8.9/10) and low complication rate (7%), none of which required further surgery. There was a high failure rate of attendance in the follow-up clinic whilst the outcomes of those attending were good. Outcomes and patient satisfaction were good with a low complication rate resulting in a change of practice in our unit to an 'opt-in' system for follow-up.

Double-edged effects of neuropeptide substance P on repair of cutaneous trauma

To explore further the role of substance P (SP) in wound healing and scar formation, SP concentrations in wounds of scalded rats were assayed. Expressions of apoptosis-associated genes in fibroblasts cultured with SP were detected. SP concentrations in superficial wounds increased earlier than those in deep wounds. SP was associated with an increased proliferation and a decreased apoptosis of fibroblasts. It had a greater influence on keloid fibroblasts than on hypertrophic scar fibroblasts by elevating the expression of proliferating cell nuclear antigen and BCL-2 in fibroblasts. Spantide completely suppressed the effects of SP on hypertrophic scar fibroblasts, and partly inhibited its effects on keloid scar fibroblasts. SP may play an important role in wound healing by promoting wound fibroblast proliferation and inhibiting apoptosis. It may also participate in pathological scar formation by modulating the expression of apoptosis-associated genes. SP is postulated to play a dual role in wound repair.

Endovascular stenting of blunt thoracic aortic injury in an 11-year-old

Blunt traumatic thoracic aortic injury in children is very rare. Open surgical repair is the definitive treatment. Thoracic endovascular aortic repair (TEVAR) for trauma has been performed in adults with good outcomes. Its use has been adopted in pediatric population, and its role is evolving. We report a successful TEVAR in a critically injured 11-year-old boy. To our knowledge, this is the youngest patient to be successfully treated with TEVAR.

PErineal Assessment and Repair Longitudinal Study (PEARLS): protocol for a matched pair cluster trial

BackgroundThe Perineal Assessment and Repair Longitudinal Study (PEARLS) is a national clinical quality improvement initiative designed to improve the assessment and management of perineal trauma. Perineal trauma affects around 85% of women who have a vaginal birth in the UK each year and millions more world-wide. Continuous suturing techniques compared with traditional interrupted methods are more effective in reducing pain and postnatal morbidity, however they are not widely used by clinicians despite recommendations of evidence based national clinical guidelines. Perineal suturing skills and postnatal management of trauma remain highly variable within and between maternity units in the UK as well as worldwide. Implementation of a standardised training package to support effective perineal management practices could reduce perineal pain and other related postnatal morbidity for a substantial number of women.Methods/DesignPEARLS is a matched pair cluster trial, which is being conducted in maternity units across the UK. Units within a matched pair will be randomised to implement the study intervention either early or late in the study period. The intervention will include the cascading of a multi-professional training package to enhance midwifery and obstetric skills in the assessment, repair and postnatal management of perineal trauma. Women who have had an episiotomy or second degree perineal tear will be eligible for recruitment. Prior to developing the intervention and deciding on study outcomes, a Delphi survey and a consensus conference were held to identify what women, who previously suffered perineal trauma during childbirth, considered to be important outcomes for them. Findings from this preliminary work (which will be reported elsewhere) and other outcomes including women's experiences of perineal pain and pain on activity, breastfeeding uptake and duration and psychological well-being as assessed using the Edinburgh Postnatal Depression Scale (EPDS) will be assessed at 10 days and three months post-birth.DiscussionImplementation of evidence-based perineal assessment and management practices, could lead to significantly improved physical and psychological health outcomes for women in the UK and world-wide.Trial registrationPEARLS is registered with the Current Controlled Trials Registry (no: ISRCTN28960026). NIHR UKCRN portfolio no: 4785.

Autologous engineering of cartilage

Treatment of full-thickness damage to hyaline cartilage is hampered by the limited availability of autologous healthy cartilage and the lengthy, cost-prohibitive cell isolation and expansion steps associated with autologous cartilage implantation (ACI). Here we report a strategy for de novo engineering of ectopic autologous cartilage (EAC) within the subperiosteal space (in vivo bioreactor), through the mere introduction of a biocompatible gel that might promote hypoxia-mediated chondrogenesis, thereby effectively overcoming the aforementioned limitations. The EAC is obtained within 3 wk post injection of the gel, and can be press-fit into an osteochondral defect where it undergoes remodeling with good lateral and subchondral integration. The implanted EAC showed no calcification even after 9 mo and attained an average O'Driscoll score of 11 (versus 4 for controls). An "on demand" autologous source of autologous cartilage with remodeling capacity is expected to significantly impact the clinical options in repair of trauma to articular cartilage.

Damage control surgery in abdominal trauma

The damage control laparotomy is an advancement in the management of massively injured trauma patients. Massive liver injuries, pelvic trauma and some retroperitoneal injuries are some of the indications for this approach. The damage control laparotomy is the phased approach to severe abdominal injury that might best be described with the acronym STIR (Staged Trauma Injury Repair). The initial procedure requires rapid abdominal exploration with hemorrhage and contamination control, using suture repair combined with abdominal packing. Temporary abdominal wall closure without tension is recommended. After abrevated initial surgical procedure, the patient is transferred to the intensive care unit where continued resuscitation is performed. Careful replacement of blood and blood products along with correction of hypothermia, acidosis and optimalization of oxygen transport represents a critical phase in this management approach. Once the coagulation profile has normalized, planned re-intervention, with repeat abdominal exploration to remove the packs and perform definitive surgical repair and reconstruction takes place. When applied judiciously, the damage control laparotomy with the staged abdominal repair and reconstruction for severe trauma is associated with an improved outcome in the selected group of patients.

Clinical application of miniature tissue transplantation in hand surgery

Objective To explore the concept,denomination and technique of miniature tissue transplantation in hand clinic. Methods In 537 cases,local skin or composite tissue defect in 756 thumbs or fingers were repaired with 4 kinds of miniature island flap and 10 kinds of miniature vascularized composite tissue.Some of them were created in clinic practice.The precess,main points and indication of the operation were expounded and compared. Results In 639 fingers covered with miniature island flap,the transferred flaps were surviverd completely in 621 fingers(97.2%),survivered partly in 11 fingers(1.7%)and necrosised in 7 fingers(1%).In 117 fingers repaired with miniature vascularized composite tissue,all the transplanted tissues were survivered.In all the injuried fingers,beautiful outlook were recovered and no fat and clumsy were found,two-point difference was 6-8 mm,effctive sensibility and good function were restored,and all the patients were satisfied. Conclusion Miniature tissue transplantation were good methods to cover the local defect in fingers or thumbs,worth of generalization and aplication in hand clinic,and have an important significance for improve the trauma repair quality and treatment level in hand surgery. Key words: Surgical flap; Transplantation; Thumb; Micmsurgery

Philip L. Maloney Lecture: Soft Tissue Injuries—Repair and Revision

This presentation will provide an overview of soft tissue trauma repair in oral and maxillofacial surgery— where we began—where we are today, and the opportunities that soft tissue traumatic reconstruction has brought to our specialty.

Endovascular Treatment of a Blunt Aortic Injury in Iraq: Extension of Innovative Endovascular Capabilities to the Modern Battlefield

The management of blunt descending thoracic aortic injury remains controversial. Despite emerging evidence touting the advantage of endovascular repair in civilian trauma, there have been no reports on the application of this management strategy in the austere environment of war. We provide a case report from the 332nd EMDG/Air Force Theater Hospital, Balad Air Base, Iraq. An Iraqi policeman presented with traumatic aortic disruption following blunt trauma. The patient arrived with hemoperitoneum, a Le Fort III facial fracture, a left humerus fracture, and a thoracic aortic disruption. Following facial packing, fracture stabilization, and damage control laparotomy, aortography was performed, confirming aortic disruption beyond the left subclavian artery. The injury was treated with three aortic cuffs (Gore Excluder AAA Aortic Extender Endoprostheses) placed in sequence from the origin of the left subclavian across the disruption. A type III endoleak was successfully managed with placement of one additional aortic cuff. The patient was discharged after 1 month following the successful treatment of his other injuries. Computed tomography angiography at 10 and 30 days following the procedure revealed no endoleak and a resolved periaortic hematoma. This report details the first endovascular treatment of blunt aortic injury in wartime and represents a sustained commitment to advance innovative endovascular capability closer to the time of injury. Although controversial, this less invasive approach is appealing in patients with high injury severity scores, making its availability in wartime especially germane.

Fresh research progress in repair of extremity trauma with flaps

Fresh research progress in repair of extremity trauma with flaps

Effect of extracellular matrix of xenogenic femoral fascia in repair of renal trauma

Objective To study the effect of extracellular matrix(ECM)of xenogenic femoral fascia which is a tissue-engineering material in repair of renal trauma.Methods Twenty-four experiment dogs were divided into 3 groups:group 1(n=10),the kidneys were repaired using ECM of xenogenic femoral fascia;group 2(n=10),the kidneys were repaired using self-omentum;group 3(n=4),xenogenic femoral fascia was used as repair materials.The animals were sacrificed separately at 1,2 weeks and 1,2,4 months after renal repair operations in group 1,2.In group 3,the animals were sacrificed separately at 2 weeks and 2 months after renal repair operations.The examinations of blood routine were performed before and after operations immediately,blood creatinine and serum renin were measured before operations and before death.The creatinine clearances of affected and contralateral normal kidneys were evaluated before death and the local areas of renal repair were studied by light and scan electron microscopy.Results In group 1,bleeding stopped rapidly and completely after the entire patch was sutured,only mild adhesions to surrounding tissues were found in various times after operations.As time passed,the repair patch was replaced by smooth neocapsule just like a normal one.In group 2,the bleeding volume in the operations was larger than the other 2 groups.It was diffieult tO separate the kidneys from the surrounding tissues.The wounds gradually contracted because of the scar forming.In group 3,there were severe immunological reactions in the patchs.Conclusion ECM of xenogenic femoral fascia is an ideal tissue-enginee rjng material for renal repair. Key words: Extracellular matrix; Renal trauma; Repairt Tissue engineering

Clinical Decision-Making for Repair of Spontaneous Childbirth Trauma: Validation of Cues and Related Factors

From recalled childbirth cases, a series of cues and related factors were previously identified that were used by midwives when making decisions to suture or not suture perineal and associated trauma incurred during spontaneous vaginal delivery. This study aimed to determine the validity of these cues and related factors. A panel of 18 experienced midwives evaluated their content validity using the criteria of "necessity" and "sufficiency." The two main cue categories-"bleeding" and "birth trauma"-were considered by 18 (100%) of the panel members to be necessary to assess. At least 16 (89%) panel members considered the following specific cues necessary to assess: in the bleeding category-type, flow, amount, and effect of application of pressure or ice; in the birth trauma category-trauma sites, trauma types, dimensions of trauma, types of tissue, alignment of tissue, edema, and bruising. Seventeen (94%) panel members considered seven woman-centred related factors that were necessary to assess and 14 (78%) considered the combination of all cues in bleeding, birth trauma, and related factors sufficient for making the decision to suture or not. The availability of these validated cues and related factors has the potential to guide a comprehensive assessment on which the decision to suture or not suture depends. This addition to the domain of midwifery knowledge enables educational preparation of midwives who will have the capacity to more adequately support women in childbirth.