Wound Healing Problems Research Articles

Ginsenoside Rg5 promotes wound healing in diabetes by reducing the negative regulation of SLC7A11 on the efferocytosis of dendritic cells

Background: ginsenoside Rg5 is a rare ginsenoside with known hypoglycemic effects in diabetic mice. This study aimed to explore the effects of ginsenoside Rg5 on skin wound-healing in the Leprdb/db mutant (db/db) mice (C57BL/KsJ background) model and the underlying mechanisms. MethodsSeven-week-old male C57BL/6J, SLC7A11-knockout (KO), the littermate wild-type (WT), and db/db mice were used for in vivo and ex vivo studies. ResultsGinsenoside Rg5 provided through oral gavage in db/db mice significantly alleviated the abundance of apoptotic cells in the wound areas and facilitated skin wound healing. 50 μM ginsenoside Rg5 treatment nearly doubled the efferocytotic capability of bone marrow-derived dendritic cells (BMDCs) from db/db mice. It also reduced NF-κB p65 and SLC7A11 expression in the wounded areas of db/db mice dose-dependently. Ginsenoside Rg5 physically interacted with SLC7A11 and suppressed the cystine uptake and glutamate secretion of BMDCs from db/db and SLC7A11-WT mice but not in BMDCs from SLC7A11-KO mice. In BMDCs and conventional type 1 dendritic cells (cDC1s), ginsenoside Rg5 reduced their glycose storage and enhanced anaerobic glycolysis. Glycogen phosphorylase inhibitor CP-91149 almost abolished the effect of ginsenoside Rg5 on promoting efferocytosis. Conclusion: ginsenoside Rg5 can suppress the expression of SLC7A11 and inhibit its activity via physical binding. These effects collectively alleviate the negative regulations of SLC7A11 on anaerobic glycolysis, which fuels the efferocytosis of dendritic cells. Therefore, ginsenoside Rg5 has a potential adjuvant therapeutic reagent to support patients with wound-healing problems, such as diabetic foot ulcers.

The Infero-Central Mound Reduction Mammoplasty: A Single Surgeon, 20-year Experience.

Reduction mammoplasty (RM) remains one of the most common plastic surgeries worldwide. Many different techniques have been described in the literature, each with its advantages and limitations. Nipple-areolar complex necrosis remains a daunting complication, regardless of the chosen surgical approach. We describe the senior author's (HYK) unique reduction mammoplasty technique, employing the infero-central (IC) pedicle throughout the last two decades. A retrospective chart review of 520 patients undergoing breast reduction was performed. After exclusion criteria, 360 were included in the study. These patients underwent RM with the IC technique, with stabilization of the breast mound and plication of the inferior pole dermis to prevent bottoming out. Demographics, operative data, and complications were recorded. Pre- and postoperative photographs were evaluated by a specialists' panel. The BREAST-Q questionnaire was utilized to assess satisfaction rates. BREAST-Q questionnaire-satisfaction with breast score was 84.19, and outcome score was 91.67. Aesthetic outcome evaluation, reviewed by four plastic surgeons, yielded a high score in all parameters (1.64-2; range 0-2). On a per-breast basis for all patients, the following complications were analyzed: dehiscence (3.61%), infection (2.22%), hematoma (1.66%), superficial wound healing problems (1.38%), seroma (0.83%), skin flap ischemia (1.52%), hypertrophic scar (1.38%), fat necrosis (0.97%), and partial nipple ischemia (0.27%). Infero-central mound technique can be applied to breast reductions of nearly all sizes, allowing for consistently satisfactory aesthetic outcomes for most patients. Due to robust vascularity of the pedicle, complication rates are kept at a minimum. IC mound technique is an essential tool in the plastic surgeon's armamentarium. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

EVALUATION OF THERAPEUTIC EFFICACY OF ALOE VERA GEL FOR EXCISIONAL WOUND HEALING MECHANISM USING ANIMAL MODEL

Wound-healing diseases are considered significant clinical issues in patients, which become more complicated in association with obesity, diabetes mellitus, and high blood pressure conditions. Various therapeutic options were available for the wound-repairing process. The current study project evaluated the healing properties of Aloe Vera gel on epidermal wounds in rats. Experimental animals (adult rats) were divided into groups A, B, and C with equal distribution. These groups represent treatment, without treatment, and control, respectively. A pair of wounds measuring 2cm x 2cm each was created hygienically on the back of each rat lateral to the spinal cord. The wounds were treated with homogenized Aloe Vera gel, while the injuries in the second group were treated with normal saline. Blood samples were collected on days 21 for hematology analysis with a standard method. Animals in group ‘A’ had significantly faster healing with shorter days of skin fall-off than the control and untreated group. Further biochemical changes in the packed cell volume, mean corpuscular volume, lymphocyte and neutrophil counts also showed significant results compared to the control group. The study concluded that Aloe Vera effectively treated epidermal wounds in adult rat models. An improvement occurred in the hematological profile of the experimental animals. These findings will go a long way in expanding the horizon of the clinical application of this plant in solving wound-healing problems in humans and other animal species.

Topical tranexamic acid reduces postoperative hematomas in reduction mammaplasties

BackgroundPostoperative bleeding requiring reoperation is an untoward event in breast surgery. Topical tranexamic acid (TXA) has been routinely used to reduce the risk of postoperative bleeding in some surgical fields. In breast surgery, it is not routinely used owing to scarce information. We investigated whether the intraoperatively applied topical TXA reduces the incidence of postoperative hematoma in reduction mammaplasty surgeries. MethodsThis retrospective, single-center cohort study comprises of 415 consecutive patients who underwent reduction mammaplasty between 2019 and 2021. The prophylactic use of topically applied TXA (20 mg/ml) was implemented as a part of the hospital protocol in November 2020. The patients who were rinsed with TXA before the wound closure were compared with those who were not rinsed. The results were analyzed using statistical tests, two-sided Pearson’s Chi-Square and Fisher’s exact tests. ResultsTopical TXA significantly reduced the number of postoperative hematomas requiring evacuation (p = 0.008). In the non-TXA control group, 12 (5.8%) hematomas were observed out of 208 patients. In the topical TXA group, only one (0.6%) hematoma occurred among the 168 patients. A tendency towards fewer wound infections, seromas, and other minor wound-healing problems can also be seen in the topical TXA group (ns). No adverse events of topical TXA were detected. ConclusionsThe incidence of postoperative hematomas decreased to a tenth after the introduction of topical TXA in reduction mammaplasty surgeries. This simple procedure may save patients from reoperations owing to bleeding. Randomized controlled trials are warranted.

Treatment of tracheoesophageal fistulas following laryngectomy by customized prostheses-A bicentric case series.

Tracheoesophageal fistulas (TEF) following laryngectomy cause immense restrictions due to the inability of oral feeding, loss of voice rehabilitation, penetration of saliva, and permanent need of inflatable tracheal cannulas. Patients are consistently in threat of fatal aspiration pneumonias. The failure rate of surgical approaches to close the fistulas is high and an ultima ratio option by customized silicone prostheses can be considered. A retrospective analysis of 26 patients with a TEF was performed. The fistulas occurred in average 40 months after laryngectomy caused by an enlargement of the voice fistula in 17 patients and problems in wound healing in 6 patients. The mean diameter of the fistula was 32 × 18 mm. Eight patients were treated by a button-shaped and 18 by a tube-shaped prosthesis. Complete oral feeding was possible in 8 and additional feeding by percutaneous endoscopic gastrostomy tube in 16 patients. Voice rehabilitation by voice prostheses was possible in 18 cases. Fifteen patients died in the course of the treatment either due to oncological progression or other reasons. The median follow-up time of the patients alive was 36 months (max 88 months) with 2.2 protheses replacements in mean (max 11). The treatment of TEF by customized prostheses can be considered as an ultima ration option if other approaches had failed. At least, partial oral nutrition and voice rehabilitation as well as protection from aspiration can be achieved in the majority of the patients. 4-Case series.

Lisfranc and Chopart amputation: A systematic review.

Lisfranc and Chopart amputations are historically controversial procedures. To obtain evidence for the pros and cons we performed a systematic review to analyze wound healing, the need for re-amputation at a higher level, and ambulation after a Lisfranc or Chopart amputation. A literature search was performed in 4 databases (Cochrane, Embase, Medline, and PsycInfo), using database-specific search strategies. Reference lists were studied to include relevant studies that were missed in the search. Of the 2881 publications found, 16 studies could be included in this review. Excluded publications concerned editorials, reviews, letters to the editor, no full text available, case reports, not meeting the topic, and written in a language other than English, German, or Dutch. Failed wound healing occurred in 20% after Lisfranc amputation, in 28% after modified Chopart amputation, and 46% after conventional Chopart amputation. After Lisfranc amputation, 85% of patients were able to ambulate without prosthesis for short distances, and after modified Chopart 74%. After a conventional Chopart amputation, 26% (10/38) had unlimited household ambulation. The need for re-amputation because wound healing problems occurred most frequently after conventional Chopart amputation. All 3 types of amputation levels do, however, provide a functional residual limb, with the remaining ability to ambulate without prosthesis for short distances. Lisfranc and modified Chopart amputations should be considered before proceeding to a more proximal level of amputation. Further studies are needed to identify patient characteristics to predict favorable outcomes of Lisfranc and Chopart amputations.

Kampo herbal ointments for skin wound healing.

The management of skin wound healing problems is a public health issue in which traditional herbal medicines could play a determining role. Kampo medicine, with three traditionally used ointments, provides interesting solutions for these dermatological issues. These ointments named Shiunkō, Chuōkō, and Shinsen taitsukō all have in common a lipophilic base of sesame oil and beeswax from which herbal crude drugs are extracted according to several possible manufacturing protocols. This review article brings together existing data on metabolites involved in the complex wound healing process. Among them are representatives of the botanical genera Angelica, Lithospermum, Curcuma, Phellodendron, Paeonia, Rheum, Rehmannia, Scrophularia, or Cinnamomum. Kampo provides numerous metabolites of interest, whose content in crude drugs is very sensitive to different biotic and abiotic factors and to the different extraction protocols used for these ointments. If Kampo medicine is known for its singular standardization, ointments are not well known, and research on these lipophilic formulas has not been developed due to the analytical difficulties encountered in biological and metabolomic analysis. Further research considering the complexities of these unique herbal ointments could contribute to a rationalization of Kampo's therapeutic uses for wound healing.

Seasonal Impact on Free Flap Surgery in Terms of Flap Loss and Wound Healing Disorders: A Retrospective Cohort Study of 158 Free Flaps.

(1) Background: Postoperative flap loss and wound healing disorders are severe complications after microsurgical free flap surgery. Despite multiple clinical observations, a possible influence of season and external temperature on outcome are largely missing. (2) Methods: Retrospectively, data were collected from 151 patients receiving microsurgical free flaps from March 2018 to August 2019. Patients were divided into two cohorts. The winter group includes all patients who underwent surgery from October 2018 to March 2019 and the summer group al those who underwent surgery from April 2018 to September 2018. Data included demographic information, pre-existing conditions, flap characteristics, and postoperative complications like flap losses and wound healing problems. External temperatures during the first 14 postoperative days were documented and the predictor of flap loss and wound healing disorders was detected. (3) Results: In the winter group (October-March; Ø 7.24 °C) 72 patients (46 female, 24 males; Ø 57.0 years) and in the summer group (April-September; Ø 18.79 °C) 81 patients (48 female, 33 males; Ø 56.0 years) received free flap surgery. There were no significant differences in demography (age: p = 0.593; gender: p = 0.419; BMI: p = 0.141). We found a significant increase in flap loss during summer (χ2(1) = 6.626; p = 0.010; V = 0.209) strengthened by logistic regression analysis (p = 0.037; Exp(B) = 9.655). Additionally higher average temperatures 14 days postoperatively represents another main driver (p = 0.023, Exp(B) = 1.161) for postoperative flap loss. (4) Conclusions: The data confirm a significantly higher postoperative flap loss in the summer group. This information may potentially contribute to optimization of perioperative management and planning of elective and semi-elective surgeries.

Fibula Nail versus Locking Plate Fixation-A Biomechanical Study.

In the treatment of ankle fractures, complications such as wound healing problems following open reduction and internal fixation are a major problem. An innovative alternative to this procedure offers a more minimally invasive nail stabilization. The purpose of this biomechanical study was to clarify whether this method was biomechanically comparable to the established method. First, the stability (range of motion, diastasis) and rotational stiffness of the native upper ankle were evaluated in eight pairs of native geriatric specimens. Subsequently, an unstable ankle fracture was created and fixed with a locking plate or a nail in a pairwise manner. The ankles showed significantly less stability and rotational stiffness properties after nail and plate fixations than the corresponding native ankles (p < 0.001 for all parameters). When comparing the two methods, both showed no differences in their range of motion (p = 0.694) and diastasis (p = 0.166). The nail also presented significantly greater rotational stiffness compared to the plate (p = 0.001). However, both fixations remained behind the native stability and rotational stiffness. Due to the comparable biomechanical properties of the nail and plate fixations, an early weight-bearing following nail fixation should be assessed on a case-by-case basis considering the severity of fractures.

Review: Ethnomedicinal plants used for wound healing and dermatological problem in the North-Eastern Hill Region of India

Abstract. Das G, Thou K, Mondal P, Meeran SM. 2022. Review: Ethnomedicinal plants used for wound healing and dermatological problem in the North-Eastern Hill Region of India. Asian J Ethnobiol 5: 102-119. Wound healing is a complex process that facilitates tissue cohesion and homeostasis renewal. Medicinal plants have several bioactive compounds and play a principal role in healing and curing human and animal diseases. In our review, we collected ethnobotanical information mostly from Nagaland, a North-Eastern state of India, from various ethnic groups through personal communication, articles, surveys, and sources. In this study, we selected 26 plant species belonging to 20 families categorized as herbs (15 species), shrubs (5 species), trees (4 species), and climbers (2 species) with scientifically demonstrated medicinal properties or reported from ethnic groups on wound healing, dermatological problem, other numerous diseases and disorders relating to the urinary system, inflammation, tumors, diabetes, diarrhea, gastritis, scabies, skin sores, animal/insect bites, parasitic related problems, and rheumatism. They have been compiled and reviewed. Medicinal plants are considered efficacious adjuvants or alternatives to conventional therapies to treat various diseases, and the use of medicinal plants and their products to cure different ailments was reported and recorded. Our review will help create awareness about using medicinal plants and alternative medicine to ameliorate dermatological problems and treat various diseases in humans and animals.

Reduction of the scar burden at the donor area of the radial forearm flap with the aid of an endoscopic pedicle preparation.

The radial forearm flap is one of the most commonly used flaps of reconstructive microsurgery with its long pedicle and thin structure. The donor site at the forearm is a visible anatomic region that has high mobility and functional importance. In this study, a longitudinal and large scar was avoided on the forearm during pedicle dissection of the conventional radial forearm flap with the utilization of an endoscope. Furthermore, arterial, venous, and nervous injuries were avoided by performing a separate inci-sion of 2-3 cm at the cubital fossa to reduce flap failure and donor site morbidity. The patients who underwent pedicle dissection of the radial forearm flap with the aid of an endoscope for head-neck reconstruction between 2014 and 2021 were included in this study. The flap was harvested from the subfascial plane. The cephalic vein was used in all of the patients. When the pedicle dissection reached the antecubital region, an incision of 2-3 cm was performed from the skin. Two vein anastomoses were performed for each patient. This retrospective study consists of 51 patients. While 45 of the patients were the result of head and neck cancer, six of them had a defect caused by trauma. The average area of skin islands was 40.3 cm2, while the full-thickness skin graft size was 24.2 cm2. An average of 2.6 cm of scar tissue was formed at the antecubital region. No venous or arterial compromise was observed in the post-operative period. There was no partial or total flap loss in any patient. Localized numbness persisted in the skin area where the superficial sensory branch of the radial nerve is located in 6 (11.7%) patients. With endoscopic radial forearm flap harvesting, the longitudinal incision in the forearm and wound healing prob-lems are avoided. The absence of partial or total flap loss has shown that endoscopic harvesting of the radial forearm flap is a safe and reliable method.

The Ethnobotanical Significance of Allium stracheyi in Uttarakhand: From Tradition to Conservation

High-altitude ecosystems are considered to be hotspots of medicinal plant diversity. The government has declared Uttarakhand as herbal state due to the highest diversity of medicinal plant species. Allium stracheyi belonging to the family Alliaceae and locally known as Jamboo or Faran has been practiced by the Bhotiya communities of Niti and Milam valleys since the past several years. It was originally brought from Tibet decades ago. Traditionally, the plant has been known for its uses as spices, pickles and medicines for jaundice, cold, cough, wound healing and other stomach problems. Besides, it is used as a traditional vegetable. The plant is in endangered status and has been included in the Red Data Book of Indian plants due to its indiscriminate collection and resulting threat to its existence. The present study aimed to provide a general review of the Allium stracheyi on its ethnopharmacological uses, climatic distribution and Habitat, chemical constituents, pharmacological activities, threat and conservation status, cultivation practices, future perspectives and its commercialization.

A Novel Mouse Model for Investigating the Effects of Gender-affirming Hormone Therapy on Surgical Healing.

Wound healing problems are a major cause of morbidity for gender-affirming surgery (GAS) patients. Prior studies have shown sex differences in wound healing may exist. We hypothesized exogenous testosterone supplementation may impair post-GAS wound healing and developed a model to investigate this phenomenon. Mice were randomized by hormone regimen and gonadectomy (OVX). Gonadectomy or sham occurred on day 0 and mice were assigned to no testosterone (-T), mono- or bi-weekly (T/2T) testosterone groups. Dorsal splinted wounding occurred on day 14 and harvest on day 21. Serum testosterone levels were quantified with mass spectrometry. Tissue underwent analysis with planimetry, qPCR, ELISA, and immunofluorescence. Mean testosterone trough levels for bi-weekly regimen were higher compared to mono-weekly (397 versus 272 ng/dL; P = 0.027). At POD5, 2T injections led to 24.9% and 24.7% increases in mean wound size relative to SHAM and OVX/-T, respectively (P = 0.004; 0.001). Wounds in OVX/+2T mice demonstrated increased gene expression for inflammatory cytokines and macrophage marker F4/80 (P < 0.05). ELISA confirmed elevated wound TNFα levels (P < 0.05). Quantitative multiplex immunofluorescence with F4/80/NOS2/ARG1 showed significant increases in macrophage prevalence in OVX/+2T (P < 0.05). We developed a novel model of GAS hormonal milieu to study effects of exogenous testosterone on wound healing. Optimized twice-weekly dosing yielded serum levels comparable to clinical therapy. We showed exogenous testosterone administered to XX/OVX mice significantly impairs wound healing. A hyperinflammatory wound environment results in increased macrophage proliferation and elevated cytokines. Future efforts are directed toward mechanistic investigation and clinical validation.

Is the Anterolateral Thigh Flap the Solution for Orthopedic Trauma Complication Reconstructions?: A Case Series.

The anterolateral thigh (ALT) flap, which can be applied as a free or pedicled flap, is supplied by musculocutaneous or septocutaneous perforators belonging to the descending branch of the lateral circumflex femoral artery. Because local or regional flap options that can be used for the reconstruction of large tissue losses in the distal third of the tibia and foot are limited, ALT and other free flaps are frequently used when needed. The aim of this report is to present our experience with and clinical results of free ALT flaps in a tertiary health-care institution. Between June of 2017 and April of 2020, lower extremity reconstruction with free ALT flaps was performed in seven patients. In the preoperative period, dominant perforators were determined in each patient by Doppler ultrasonography, and surgery was planned considering the size and localization of the defect. All the patients were men, with an average age of 41.7 years. Three patients were operated on for implant exposition on the distal-medial third of the tibia after fracture repair, one patient for posttraumatic calcaneal deformity with osteomyelitis, and two patients because of localized posttraumatic tissue loss in the anterior aspect of the tibia and one patient in the dorsum of the foot. Secondary recovery was achieved in two patients and localized linear necrosis was observed at the flap suture line. No infection was observed in the donor or recipient site. In all patients, the donor site was closed primarily and no wound healing problem was encountered. This is one of the primary reconstruction options for the free ALT flap, especially in cases of large tissue losses in which local and/or regional flap alternatives are insufficient.

Successful use of minimal invasive debridement plus negative pressure wound therapy under skin flap and axillary region for refractory postmastectomy seroma: A STROBE-compliant retrospective study.

Seroma is the most common wound complication due to dead space remaining after mastectomy and axillary dissection. Seroma formation, which causes pain and tension, together with the limitations of shoulder and arm movements, can cause wound healing problems that can progress to wound dehiscence and flap necrosis. The aim of our study was to investigate the effects of continuous drainage and negative pressure wound therapy (NPWT) in breast cancer patients with refractory postmastectomy seroma. This retrospectively designed study was conducted with 27 patients who were referred to our center between 2018 and 2021 due to refractory seroma after mastectomy. The inclusion criteria of the study were the cases who were planned minimally invasive debridement and NPWT due to having refractory seroma formation with at least 200 cc and having interventions more than 1 month after modified radical mastectomy (MRM), despite conventional treatment methods. All patients' demographics, disease stage, history of possible neoadjuvant therapy, comorbidities, body mass index (BMI), number of wound dressings with NPWT, and total amount of NPWT accumulation were enrolled and compared statistically. Twenty-seven patients included in the study underwent continuous drainage after debridement, and 5 (3-9) dressings were treated with NPWT. None of the patients experienced complications after debridement and NPWT administration. In refractory seroma cases seen after postmastectomy, NPWT especially for the management of debridement and dead space can be evaluated as an appropriate treatment method in patients with high flow rate seroma.

Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study.

Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People’s Hospital, Beijing, China, was searched for all patients (aged 14‐70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.

Arthroscopic needle knife for knee video arthroscopic surgical portals

Introduction: A new era of orthopedic surgery is happening nowadays. innovative procedures like video surgery; Ultrasound Guided Interventions; Pain interventionist orthopedics procedures; plastic surgery (cellulites subcision treatment); hydrodissection injections; dry needling; thermography assisted pain procedures and acupuncture started to be widely performed [3]. Objective: The aim of the research is to assess the possibility of a needle knife surgical device to perform portals of knee video arthroscopic surgical interventions and to evaluate the two diferentes needle-knife surgical devices [7-9]. Method: 200 consecutive knee Video Arthroscopies performed by the same team were divided in two groups: A and B. Group A: the lateral portal used a hypodermic needle 40X12 (18Gx 1’1/2) for portal performance. Group B submitted a lateral portal using a metal guide for intravenous catheter 14Gx2’’. The medial portal, a 11 blade knife, was used for both cases.Comparison of two groups by assessing wound healing time; superficial and deep infection; pain, cosmesis by a third person nurse.A surgeon’s opinion for friendly use comparing group A or B was made [8, 9]. Results: There were nor superficial or deep knee infections. No wound healing problems, same time of healing. No difference in pain related to the wound. Cosmesis were similar. The surgeon’s choice was the metal guide for intravenous catheter 14Gx2’’ is more friendly due to the rigidity in comparison to a hypodermic needle 40X12 (18Gx 1’1/2). Conclusion: The two needles seem suitable for knee video arthroscopy surgical interventions. The surgeon’s choice was the metal guide for intravenous catheter 14Gx2’’ is more friendly due to the rigidity in comparison to the 40x12 needle [7-9].

A Novel Technique for Tarsal Metatarsal Joint (TMTJ) Fusion using Calcaneal Precision Bone Graft: Reducing Morbidity Associated with Bone Graft Donor Site

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Other Introduction/Purpose: TMTJ fusion has long been used as a treatment for TMTJ disease. Bone grafting has been shown to potentially improve union rates and often the iliac crest as a donor site has been used to achieve this. Indications for bone grafting include severe disease with greater bone loss and deformity, multiple joints being fused or revision surgery. In our paper we report on our experience of TMTJ fusion using localised bone grafting from either the calcaneum or cuneiform. This incorporates a novel operative technique for graft placement which increases contact area for healing and restores foot biomechanics. This may also therefore reduce non-union rate. Additionally, this localised form of bone grafting avoids the morbidity associated with iliac crest donor sites providing a better tolerated procedure. Methods: Twenty patients were included between 2016 and 2019 who underwent fusion of 39 TMTJs in total. Of these 39 joints 9 were first, 16 were second and 14 were third TMTJ. Two of the first TMTJ Fusions were revisions with double plating and bone grafting for non union. Fourteen patients had standard bone grafting and donor sites were as follows; 7 calcaneal, 1 cuneiform, 6 iliac crest. Seven patients had excision of OA joint and bone graft using precision instruments and surgery using our described technique. Locking plates were used in all twenty patients. Post-operative care included a wound check at two weeks, non-weight- bearing in a cast for 6 weeks and then weight-bearing cast for a further 6 weeks. Patients were followed up in clinic to observe radiological and clinical union. Ct scanning employed when delayed union was suspected. Complications with wound healing and infection were also recorded. Results: 15 of patients were female with a mean age of 59. 38 out of 39 fused joints went on to unite. 10 patients were initially assessed in the Specialist Limb Service (SLS) clinic with gait analysis prior to surgery. One non-union was diagnosed on CT scan in the traditional bone graft technique group. Graft was harvested from iliac crest in this case. All other graft sites resulted in fusion of the joint. All seven patients (100%) who had excision and bone graft using precision bone instruments with the new technique had union without delay. One patient underwent removal of metalware due to prominence. This was a revision double plating case. There were no wound healing problems and no postoperative infections. 80% of patients were satisfied with the results of surgery and reported improvement in quality of life. Conclusion: TMTJ fusion with looking plates remains an appropriate treatment for TMTJ disease providing high rates of successful union. Local donor site for bone grafting does not generate inferior outcomes whilst avoiding the morbidity associated with iliac crest harvesting. Additionally, this work presents a novel technique using precision bone graft instruments and cylindrical bone graft to fuse the TMTJ in the presence of OA. This technique generates increased fusion surface area and may provide better restoration of normal foot biomechanics.

Clinical Outcomes of Posterior Hindfoot Endoscopic Surgery using 1.9-mm Diameter Needle Arthroscopy for Posterior Ankle Impingement in Athletes

Category: Arthroscopy; Ankle; Hindfoot; Sports Introduction/Purpose: Posterior hindfoot endoscopy is a safe and effective treatment for posterior ankle impingement syndrome (PAIS). However, wound-healing problems following hindfoot endoscopy have been still reported. Recently, a novel 1.9- mm diameter needle-arthroscopic system has been introduced. Its small features can help reduce the risk of wound complications and can have the potential to make it earlier to return to play sports due to its minimally invasiveness. To our knowledge, no studies have been reported regarding PAIS treatment using a 1.9-mm diameter needle-arthroscopy. The purpose of this study was to report the clinical outcomes including return to sports following hindfoot endoscopic surgery using 1.9-mm diameter needle- arthroscopy for PAIS. Methods: Six patients who engaged in athletic activity (mean age 21.7 [range 16-34] years) and were treated by a hindfoot endoscopic surgery using a 1.9-mm diameter arthroscopic system (NanoScopeTM, Arthrex) for PAIS were included. In all patients, os trigonum was resected and flexor hallucis longus (FHL) tenosynovitis was debrided. American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score was evaluated and Visual analog scale (VAS) at 1 day and 2 weeks after surgery were recorded. Time to return to sports activity at preinjury level was also evaluated. Engaged sports included soccer (3 patients), ballet (2 patients), and lacrosse (1 patient). Results: The mean AOFAS score improved significantly from 77.7 to 100 after surgery (p&lt;0.001). Mean VAS score at 1 day and 2 weeks were 1.5 (range 0-3) and 0.3 (range 0-1). respectively. All patients were able to return to full sports activities and the mean time to return to sports activities at preinjury level was 4.8 weeks (range 3-7 weeks). No complications were reported. Conclusion: Posterior hindfoot endoscopy using a 1.9-mm diameter needle-arthroscopy provided excellent clinical outcomes in the treatment of PAIS with relatively earlier return to play sports compared to conventional arthroscopy surgery, although this is not a comparative study. Minimum invasiveness with less postoperative pain using needle-arthroscopy may contribute to its early recovery. Further studies are required to support our results.

A Clinical and Economic Evaluation of ORIF Management for Calcaneal Fractures with and without Adjunctive Umbilical Cord

Category: Hindfoot Introduction/Purpose: The number of calcaneus fractures per year continues to increase in the United States, resulting in an increased number of open reduction and internal fixation (ORIF)procedures to repair these injuries. These surgeries are notorious for post-operative complications, including post-surgical wound healing problems that occur in 16 to 43% of patients. Umbilical cord (UC) allograft has anti-inflammatory and anti-scarring properties and has been shown to promote healing of cutaneous wounds. The objective of this study was to evaluate the clinical and economic outcomes related to wound complications after ORIF management of calcaneal fractures with and without adjunctive UC. Methods: A clinical and economic evaluation was performed based on information pertaining to ORIF management obtained from the published literature and our previous clinical data of ORIF for calcaneal fractures with (n=20) and without adjunctive UC (n=20). Results: After ORIF for calcaneal fractures, 10% of patients that received adjunctive UC required wound care compared to 35% of patients didn't receive the adjunctive treatment. Similarly, the readmission and reoperation rate were higher in the control group compared to the UC treatment group (30% vs 10%, respectively). Available cost-effectiveness data demonstrated that treatment with UC results in an average cost-savings of $2,775.50 per person over a five-year period (total cost of $330, 500 vs. $386,010 in the UC and control group, respectively). Using available data that includes costs incurred from time off work, adjunctive UC allograft treatment resulted in an average cost-savings of $14,377.50 per patient over a four-year period (total cost of $704,260 vs. $991,810 in the UC and control group, respectively). Conclusion: Wound complications remain a significant burden to patient recovery and an economic burden to payors and providers. Based on our observed complications rates, adjunctive use of UC during ORIF management of calcaneal fractures may not only decrease wound complications but also reduce socioeconomic costs.