Device related tangential excision in burns

Soot-Embedded Extruded Talus Fracture After a 5-Story Fall: A Case Report

CASE

A 17-year-old boy presented with an open talus fracture complicated by soot contamination after a chimney-related accident. Standard irrigation and debridement (I&D) methods were used, but complete removal of soot was not possible. At the latest follow-up, there was no evidence of infection, hardware failure, or avascular necrosis.

CONCLUSION

There is a lack of well-established guidelines regarding I&D of traumatic wounds contaminated with fine particulates. A review of potential debridement methods is discussed. Orthoapedic surgeons should be aware of hydrosurgical debridement as a potential treatment approach in these unique scenarios.

Efficacy of Versajet hydrosurgery system in chronic wounds: A systematic review

Studies demonstrating the effectiveness of hydrosurgery for chronic wounds are extremely limited. This systematic review aimed to evaluate the efficacy of hydrosurgery compared with conventional debridement in chronic wounds, skin ulcers, and non‐acute wounds. This PROSPERO‐registered review was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases. Abstracts of all studies were screened independently by two reviewers. The bias of prospective randomised controlled studies was assessed using the Cochrane Collaboration's tool for assessing the risk of bias and RevMan 5.4 software, whereas the bias of retrospective comparative studies was evaluated using the Risk of Bias Assessment Tool for Non‐randomised Studies. Two prospective randomised controlled trials, two retrospective comparative studies, and three prospective non‐comparative studies were included. Hydrosurgery enabled rapid debridement. The Versajet Hydrosurgery System saved 8.87 minutes compared with the conventional methods. Similarly, the debridement quality was high with this system. The debridement number needed to achieve adequate wound beds was fewer in the hydrosurgery group than in the conventional group. These superiorities lead to subsequent success and cost‐effectiveness. As there were only two prospective randomised controlled studies, and much information was missing, the risk of bias was unclear. This review confirmed that hydrosurgery is useful for the debridement of chronic wounds, considering the procedural speed and quality.

Evidence and Trends in Burn Wound Debridement: An Evidence Map

Treatment of the burn wound is crucial in care of severely burned patients. Surgical strategies differ in technique and timing of wound excision and are considered to have an impact on morbidity and mortality of burn patients. Most techniques and strategies have been established during the last century and are still standard of care. Nonetheless, several newer techniques have been presented and evaluated recently. To summarize the evidence and trends for eschar removal by burn wound debridement currently available, an evidence map as variant of the systematic review, was prepared. For this purpose, a systematic literature search was performed in the PubMed databases until December 2016. While overall evidence in this domain is low, recent publications focus on optimal timing of wound excision, enzymatic debridement, and hydrosurgery. Several studies report the benefit of an early wound excision in terms of shorter hospital stay, lower wound infection rate, and reduction of postburn metabolic changes. Enzymatic debridement has been shown to be an effective tool for early eschar removal and in addition reduces the need for autografting of the debrided burn wound with a relatively high level of evidence (LoE 2-). Wound debridement by means of hydrosurgery is more precise compared to conventional wound excision and preserves viable dermis, but a positive effect on wound healing or scar formation could not been shown (LoE 2). Furthermore, rarely reported techniques comprise larvae therapy, debridement by laser, and other technical adjuncts, but the level of evidence is limited (LoE 4-/5).

Reconstruction of Lower Limb Necrotizing Fasciitis by Hydrosurgical Debridement and Multiperforator Anterolateral Thigh Flap

The authors describe a surgical treatment that optimally combined the use of the hydrosurgical system and a free multiperforator anterolateral thigh flap to prevent lower limb amputation in a severe case of necrotizing fasciitis. A 43-year-old woman was diagnosed with necrotizing fasciitis, and amputation was performed at the level of the metatarsal shafts with an emergency debridement using the hydrosurgical system. In the second reconstructive surgery, a free anterolateral thigh flap measuring 28 × 8 cm² was harvested using the left thigh as the donor site and the vascular pedicle was made up of a total of 3 vessels, 2 perforating arteries from the descending branch of the lateral circumflex femoral artery, and 1 oblique branch from the lateral circumflex femoral artery. To thin the flap, we first resected as much subcutaneous fat as possible in the distal part of the flap (which would eventually cover the ankle joint) and ensured adequate residual volume of the proximal part of the flap (which would cover the metatarsal stumps). We then sutured the flap to the tissue defect on the left foot and then end-to-side anastomosing the lateral femoral circumflex artery and posterior tibial artery while the 2 veins were anastomosed to the posterior tibial veins under a microscope. Six months after the surgery, adequate flap volume was maintained over the metatarsal stumps with no postoperative complications such as infection or ulcer formation, and there were no other complications such as motor dysfunction at the donor site on the left thigh.

Hydrosurgical debridement versus conventional surgical debridement for acute partial-thickness burns

BACKGROUND

Burn injuries are the fourth most common traumatic injury, causing an estimated 180,000 deaths annually worldwide. Superficial burns can be managed with dressings alone, but deeper burns or those that fail to heal promptly are usually treated surgically. Acute burns surgery aims to debride burnt skin until healthy tissue is reached, at which point skin grafts or temporising dressings are applied. Conventional debridement is performed with an angled blade, tangentially shaving burned tissue until healthy tissue is encountered. Hydrosurgery, an alternative to conventional blade debridement, simultaneously debrides, irrigates, and removes tissue with the aim of minimising damage to uninjured tissue. Despite the increasing use of hydrosurgery, its efficacy and the risk of adverse events following surgery for burns is unclear.

OBJECTIVES

To assess the effects of hydrosurgical debridement and skin grafting versus conventional surgical debridement and skin grafting for the treatment of acute partial-thickness burns.

SEARCH METHODS

In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people of any age with acute partial-thickness burn injury and assessed the use of hydrosurgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

One RCT met the inclusion criteria of this review. The study sample size was 61 paediatric participants with acute partial-thickness burns of 3% to 4% total burn surface area. Participants were randomised to hydrosurgery or conventional debridement. There may be little or no difference in mean time to complete healing (mean difference (MD) 0.00 days, 95% confidence interval (CI) -6.25 to 6.25) or postoperative infection risk (risk ratio 1.33, 95% CI 0.57 to 3.11). These results are based on very low-certainty evidence, which was downgraded twice for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in operative time between hydrosurgery and conventional debridement (MD 0.2 minutes, 95% CI -12.2 to 12.6); again, the certainty of the evidence is very low, downgraded once for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in scar outcomes at six months. Health-related quality of life, resource use, and other adverse outcomes were not reported.

AUTHORS' CONCLUSIONS

This review contains one randomised trial of hydrosurgery versus conventional debridement in a paediatric population with low percentage of total body surface area burn injuries. Based on the available trial data, there may be little or no difference between hydrosurgery and conventional debridement in terms of time to complete healing, postoperative infection, operative time, and scar outcomes at six months. These results are based on very low-certainty evidence. Further research evaluating these outcomes as well as health-related quality of life, resource use, and other adverse event outcomes is required.

Hydrosurgical Debridement Allows Effective Wound Bed Preparation of Pressure Injuries: A Prospective Case Series

Background:

Pressure injuries (PIs) are common in hospitalized patients, with incidence exceeding 50% in high-risk patients. Immobilization causes a prolonged compression of vascular networks in tissues overlying bony prominences, leading to ischemia and ulceration. Traditionally, PIs are treated with a combination of surgical debridement and reconstruction. This approach can be invasive for debilitated patients who cannot tolerate prolonged surgeries and extensive tissue resection. Hydrosurgery uses high-pressure irrigation to low-invasively debride and cleanse wounds; its use has shown positive outcomes in burn and chronic wounds care. Here, we hypothesize that hydrosurgery allows low-invasive yet effective wound bed preparation in truncal PIs.

Methods:

We conducted a single-center, prospective, uncontrolled case series. Inclusion criteria for this study were presence of a truncal PI (stage III or IV) and an American Society of Anesthesiologists physical status of ≥2 (no exclusion criteria). Measured outcomes included duration of hydrosurgery, postsurgical local (dehiscence, infection, seroma) or systemic complications in the first 30 days, and PI recurrence rate (6-month follow-up).

Results:

Seven patients (3 sacral, 2 greater trochanteric, and 2 ischial tuberosity PIs) were enrolled for this study. Average duration of hydrosurgery was 12 minutes (±3.1). No local or systemic complications were observed at a 30-day follow-up (0/7, 0%). All flaps (6/7, 86%) and graft (1/7, 14%) reconstructions successfully survived, and no PI recurrence was reported within a 6-month follow-up (0/7, 0%).

Conclusions:

Hydrosurgery seems to allow safe, low-invasive, and effective wound bed preparation in truncal PIs. Larger controlled trials are needed to confirm this preliminary evidence, to guide its broader adoption for improved care of high-risk patients with PIs.

Hydrosurgical debridement as an approach to wound healing: an animal thermal burn model

OBJECTIVE

This study investigates the advantages of hydrosurgical debridement compared with surgical debridement.

METHOD

Thermal skin burns were created on the backs of male Wistar rats. Surgical debridement was used to treat one wound and hydrosurgical debridement (Versajet Hydrosurgery System, Smith&Nephew, UK) used to treat the second wound. Debridement time, blood loss volume, time-to-heal and histologic changes in the wound areas were compared.

RESULTS

A total of 23 rats were used in the study. Debridement time and time-to-heal were significantly shorter with hydrosurgical debridement than with surgical debridement (p<0.01 and p<0.05, respectively). Blood loss volume was significantly less with hydrosurgical debridement (p<0.01), and the wound surface area was significantly smaller on days two (p<0.01), four (p<0.05) and seven (p<0.05). Dense inflammatory cell infiltration into dermal muscle was deeper after surgical debridement (p=0.017). Reactive fibrotic tissue at the wound surface was significantly thinner (p<0.001) and the vascular endothelial cell count was significantly higher (p<0.001) after hydrosurgical debridement.

CONCLUSION

The hydrosurgical system used appears to provide for minimally invasive debridement that can be performed in a relatively short period of time. Use of the device appears to minimise injury to healthy tissue and ameliorate inflammation, which in turn promotes early wound healing and reduces scar contracture. Hydrosurgical debridement appears to cause less damage to normal tissues. Furthermore, it is easier and requires less time.

Radical treatment of axillary osmidrosis using the VERSAJET™ II Hydrosurgery System or traditional open excision: A prospective cohort study

BACKGROUND

Axillary osmidrosis, characterized by an unpleasant odor, renders social life difficult for young adults. This study aimed to compare traditional open excision and use of the VERSAJET™ II Hydrosurgery System for effectiveness and treatment complaints in the treatment of axillary osmidrosis.

AIM

The current study aimed to assess the curative effect of VERSAJET™ for axillary osmidrosis in a prospective cohort study, comparatively to traditional open excision.

METHOD

In this prospective cohort study, from October 2016 to March 2018, 31 and 34 patients treated with the VERSAJET™ II Hydrosurgery System and traditional open excision, respectively, were recruited and followed up for 6 months post-treatment. Treatment outcomes were assessed, including surgical field size, operation time, postoperative complications, odor elimination, hair growth reduction, scarring, and patient satisfaction.

RESULTS

The VERSAJET™ group had significantly shorter operation (P < .001) and lower rates of complications, including hematoma (P = .014), wound dehiscence (P = .048), and epidermal erosion (P = .022) compared with the open excision group. A similar rate of good odor elimination (P = .925) was observed in both groups (96.77% and 97.05% in the VERSAJET™ and open excision groups, respectively). Most patients experienced sparsity of armpit hair following both procedures. Based on a comprehensive consideration of the whole operation process, recovery process, postoperative odor and scar, patients in the VERSAJET™ group were more satisfied compared with those in the open excision group (P = .008).

CONCLUSION

The VERSAJET™ II procedure is shorter, with less postoperative scarring and fewer postoperative complications, compared with the traditional method. Therefore, the VERSAJET™ II procedure is superior to traditional open excision, as a new, radical treatment method for axillary osmidrosis.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial

Background

Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns.

Methods/design

A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm², total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale.

Discussion

This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds.

Trial registration

Dutch Trial Register, NTR6232. Registered on 23 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2599-2) contains supplementary material, which is available to authorized users.

Burr Hole Surgery for Chronic Subdural Hematoma with Extensive Scalp Burn

BACKGROUND

Neurosurgical intervention for a patient with an extensive scalp burn is rare, but it may be associated with a high risk of surgical site infection.

CASE DESCRIPTION

An 80-year-old man had a severe and extensive scalp burn. A chronic subdural hematoma (CSDH) was observed on a computed tomographic view of the head, performed for the assessment of bacteremia during treatment in the intensive care unit. To evaluate whether the CSDH might underlie the patient's prolonged fever and sepsis, we urgently evacuated the hematoma using 1 burr hole. The surgery was uneventful. We made a skin incision through the deep burn wounds covering the right temporal muscle. We removed necrotic tissue from scalp burns continuously to avoid wound complications and intracranial infection.

CONCLUSIONS

Temporal muscle with a constant blood supply served as an effective tissue for surgical wound closure. By use of this multidisciplinary approach, the CSDH resolved completely, and surgical wound complications were avoided.

Lasers and ancillary treatments for scar management: personal experience over two decades and contextual review of the literature. Part I: Burn scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for the plastic surgeon. We aim to explore new approaches to the management of such scarring. The senior authors current use of laser technology, chemotherapeutic agents, pharmacotherapy and cryosurgery will be reviewed. This is placed in the context of the current literature and evidence base and is illustrated with case studies, starting with burns scars in part I, and focusing on keloid and hypertrophic scars in part II, acne scars in part III and finally pigmented scars in part IV. In Part I we focus on burns scar treatment with fractional ablative 10,600 nm wavelength carbon dioxide (CO2) laser therapy.