Nutritional status and wound healing in open fractures of the lower limb

Etiological spectrum and treatment outcome of wound infection in patients with open tibia and fibula fractures

OBJECTIVE

To explore the etiology of wound infections in patients with open tibia and fibula fractures and the treatment effects.

METHODS

In this retrospective study, a total of 76 patients with open tibia and fibula fractures were included in this research. These patients were divided into the control group (n=38) and the observation group (n=38) according to the treatment methods for wound infection. The distribution and drug resistance of pathogenic bacteria in wound infections were analyzed. Clinical effects, time for body temperature returning to normal, time for disappearance of exudates, time for clearance of pathogenic bacteria, recovery effects and patients' satisfaction rate were also compared between two groups.

RESULTS

A total of 152 strains of pathogenic bacteria were separated. The main pathogenic bacterium was Acinetobacter baumannii, accounting for 30.92% (47/152). Pathogenic bacteria were demonstrated to be highly sensitive to vancomycin and imipenem. The proportion of wound healing by first intention and the Johner-Wruhs scores in observation group were significantly higher than those in control group, while recurrent infection rate, the time to restore normal body temperature, the time for exudates to disappear, the time to remove pathogenic bacteria, hospital stays and VAS scores in observation group were obviously shorter or lower than those in control group (all P<0.05). Moreover, the satisfaction rate of patients in the observation group was significantly higher than that in the control group (P<0.05).

CONCLUSION

Understanding pathogenic characteristics and drug resistance of wound infection in patients with open tibia and fibula fractures is helpful to subsequent treatment. Comprehensive control measures should be taken to decrease incidence of wound infection.

Nutritional Status in Patients with Medication-Related Osteonecrosis of the Jaw (MRONJ)

Medication-related osteonecrosis of the jaw (MRONJ) is a potentially severe side effect of mostly antiresorptive drugs. The aim of this prospective clinical study was to evaluate the nutritional status in MRONJ patients scheduled for surgical treatment (intraoral soft tissue closure). The following parameters were evaluated: body weight, body height, BMI, nutritional risk index (NRI), bioelectric impedance analysis (BIA), vitamins A, B12, D3, E, K1, folic acid, iron, total protein, transferrin, ferritin, prealbumin, albumin, and zinc. All subjects were admitted to hospital four to five days before surgery and sip-fed with Nutritia Fortimel Compact Protein in addition to regular oral food intake. During surgery, a nasogastric tube was inserted and only removed on hospital discharge five days postoperatively. A total of 58 patients could be included. Half of the MRONJ patients were identified to be at risk for malnutrition. Deficiencies regarding protein levels were revealed, whereas hardly any relevant deficits of micronutrients were noted. The intraoral wound healing four weeks post-surgery was highly satisfactory with a low dehiscence rate of intraoral mucosal sites. Of all parameters analyzed, the dehiscence rate at the last follow-up four weeks post-surgery was significantly influenced by vitamin K, transferrin, and ferritin levels (p = 0.030, p = 0.004, and p = 0.023, respectively). In conclusion, perioperative dietary counselling and appropriate nutritional therapy are important supportive measures in MRONJ patients scheduled for intraoral soft tissue closure.

Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine

BACKGROUND

Hospital-based studies have shown that mortality rates in individuals with diabetic foot ulcers are about twice those observed in individuals with diabetes without foot ulcers.

OBJECTIVE

To assess the etiology and management of chronic diabetic foot ulcers.

STUDY DESIGN

Literature review.

METHODS

Systematic review of the literature discussing management of diabetic foot ulcers. Since there were only a few randomized controlled trials on this topic, articles were selected to attempt to be comprehensive rather than a formal assessment of study quality.

RESULTS

Chronic nonhealing foot ulcers occur in approximately 15% of patients with diabetes. Many factors contribute to impaired diabetic wound healing. Risk factors include peripheral neuropathy, peripheral arterial disease, limited joint mobility, foot deformities, abnormal foot pressures, minor trauma, a history of ulceration or amputation, and impaired visual acuity. With the current treatment for nonhealing diabetic foot ulcers, a significant number of patients require amputation.

CONCLUSION

Diabetic foot ulcers are optimally managed by a multidisciplinary integrated team. Offloading and preventative management are important. Dressings play an adjunctive role. There is a critical need to develop novel treatments to improve healing of diabetic foot ulcers. The goal is to have wounds heal and remain healed.

CLINICAL RELEVANCE

Diabetic neuropathy and peripheral arterial disease are major factors involved in a diabetic foot ulcer. Despite current treatment modalities for nonhealing diabetic foot ulcers, there are a significant number of patients who require amputations. No known therapy will be effective without concomitant management of ischemia, infection, and adequate offloading.

Body mass index (BMI) at diagnosis is associated with surgical wound complications in patients with localized osteosarcoma: a report from the Children's Oncology Group

BACKGROUND

Malnutrition is common at diagnosis and during treatment for sarcoma patients. Poor nutritional status is associated with increased risk of complications, particularly infections. We investigated the role of body mass index (BMI) on the incidence of surgical wound complications in patients with localized osteosarcoma treated on the Children's Oncology Group (COG) legacy trial, INT-0133.

PROCEDURE

Patients considered in this report had localized osteosarcoma, enrolled on COG trial INT-0133, remained on protocol therapy to have definitive surgery 6-16 weeks after study entry, and had adequate height, weight, and surgical complication data for analysis. By protocol design, definitive surgical resection was planned for 10 weeks after induction chemotherapy. Wound complications within 30 days after definitive surgery were considered post-operative. BMI was calculated at the start of neoadjuvant chemotherapy and expressed as age- and gender-adjusted percentile. The incidence of wound complications was evaluated by logistic regression or Fisher's exact test.

RESULTS

A total of 498 patients met criteria for analysis. Low BMI (≤10th percentile) was seen in 73 (14.7%), middle BMI (11th-94th percentile) in 382 (76.7%), and high BMI (≥95th percentile) in 43 (8.6%) patients. Wound infection or slough was seen in low BMI patients (OR = 2.0, P = 0.07) although the results did not reach statistical significance. Arterial thrombosis was more common in high BMI patients (OR = 9.4, P = 0.03).

CONCLUSIONS

Abnormal BMI at the start of treatment for localized osteosarcoma is associated with increased risk of post-operative wound complications such as arterial thrombosis. Future studies should evaluate whether maintenance of age-appropriate BMI reduces the risk of surgical complications.

Nutritional assessment of bariatric surgery patients presenting for plastic surgery: a prospective analysis

BACKGROUND

Assessment of nutritional status in the growing postbariatric patient population remains controversial. Previous literature suggests that these patients have poor nutrition that may have adverse effects on surgical outcomes. The authors sought to determine the optimal method of nutritional assessment in postbariatric patients.

METHODS

One hundred patients presenting for body contouring after bariatric surgery were consecutively enrolled in an institutional review board-approved prospective study. A trained nutritionist assessed protein and calorie intake. All patients underwent baseline laboratory assessment.

RESULTS

Eighteen percent of subjects had less than the recommended daily protein intake. Hypoalbuminemia was observed in 13.8 percent of subjects, with hypoprealbuminemia in 6.5 percent. Nearly forty percent of all patients had evidence of iron deficiency, with vitamin B12 deficiency present in 14.5 percent. Ten percent of subjects (all women) were confirmed to have iron deficiency anemia. Impaired fasting glucose was seen in 6.2 percent of subjects, whereas 3.6 percent had hemoglobin A1c levels greater than 6.5. Increasing age (odds ratio, 1.07) and greater change in body mass index (odds ratio, 1.11) were predictors of low protein intake. Dumping syndrome led to 13.3 times increased odds of low albumin levels.

CONCLUSIONS

The results suggest that inadequate nutrition is common among postbariatric patients presenting for body contouring. The lack of correlation between methods of nutritional assessment supports the combination of multiple methods in determining overall nutritional status. The presence of dumping syndrome, a large change in body mass index, and advanced age may help to identify patients with an increased risk of nutritional deficiency.