Degloving lower leg injury - the importance of additional treatment: negative pressure and hyperbaric oxygen therapy

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy

Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

Therapeutic efficacy of dose-reduced adjuvant chemotherapy with S-1 in patients with pancreatic cancer: a retrospective study

BACKGROUND

S-1 adjuvant chemotherapy is the standard treatment in Asia for resectable pancreatic ductal adenocarcinoma. The relative dose intensity of adjuvant chemotherapy influences survival in pancreatic cancer but does not precisely reflect treatment schedule modifications. We investigated the effects of total dose intensity of S-1 adjuvant chemotherapy on the survival of patients with pancreatic cancer and the permissible dose reduction.

METHODS

Patients who underwent surgical resection during 2011-2019 for pancreatic cancer were selected. We determined the total dose intensity cut-off value that predicted tumor recurrence within 2 years postoperatively using receiver operating characteristic curves and compared the outcomes between the high and low total dose intensity groups.

RESULTS

Patients with total dose intensity ≥ 62.5% (n = 53) showed significantly better overall survival than those with total dose intensity < 62.5% (n = 16) (median survival time: 53.3 vs. 20.2 months, P < 0.001). The median survival of patients without adjuvant chemotherapy (total dose intensity = 0, n = 28) was 24.8 months. Univariate analysis identified lymphatic involvement (P = 0.035), lymph node metastasis (P = 0.034), and total dose intensity (P < 0.001) as factors affecting survival. On multivariate analysis, total dose intensity (P < 0.001) was an independent predictor of worse survival.

CONCLUSIONS

Maintaining a total dose intensity of at least 60% in S-1 adjuvant chemotherapy seems important to achieve a long postoperative survival in patients with pancreatic cancer.

Hyperbaric oxygen therapy in low extremity trauma: A case series

Introduction

Trauma to the extremities is a common major health problem that requires special attention because it can have a dangerous impact on both the viability of the limb and the patient's life. Hyperbaric oxygen therapy is an alternative therapy hypothesized to improve the prognosis in lower extremity trauma.

Case presentation

We present a series of 7 cases of lower extremity trauma treated with hyperbaric oxygen therapy: soft tissue loss, neglected chronic burn injury, high-voltage electrical burn, gas gangrene, crush injury, chemical burn, and excoriation with skin loss.

Discussion

Hyperbaric oxygen therapy involves giving 100% oxygen in a chamber at pressures above atmospheric pressure (2–3 atm absolute [ATA]). It can increase oxygen delivery to peripheral tissues with vascular compromise, cytogenic and vasogenic edema, and cellular hypoxia caused by limb trauma.

Conclusion

Hyperbaric oxygen therapy has many benefits in lower extremity trauma for wound recovery, preventing complications, and helping patients return to daily activities.

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Hyperbaric oxygen therapy is an alternative therapy believed to improve the prognosis in cases of lower extremity trauma.

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We present 7 cases: soft tissue loss, chronic burn, high-voltage burn, gangrene, crush, chemical burn, and excoriation.

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Hyperbaric oxygen therapy has benefits for wound recovery, preventing complications, and return to daily activities.

Degloving Soft Tissue Injuries of the Extremity: Characterization, Categorization, Outcomes, and Management

Background:

We aimed to identify degloving soft tissue injury (DSTI) patient characteristics, injury and reconstruction patterns, and factors affecting outcomes of DSTI injuries to propose a reconstructive protocol for these injuries.

Methods:

A retrospective analysis of consecutive patients with DSTIs of an extremity over a 22-year period has been done.

Results:

188 patients with 201 extremity DSTIs were included. Mean patient age was 37 years, with follow-up of 19.6 months. In total, 96% of injuries were related to motor vehicles or machinery, and 74.6% of DSTIs had injuries to structures deep to skin/subcutis. The avulsed tissue was utilized in reconstruction in 71.6% of cases and 86.8% of these experienced some loss of the used avulsed tissues. Of the total cases, 82% employed skin grafting in reconstruction. Dermal regeneration templates were used in 32% of patients. An estimated 86.5% of patients had negative pressure wound therapy utilized. Of the injured patients, 21% required flap reconstruction and 22% required some form of amputation. Age, body mass index, and tobacco use did not increase perioperative complications or amputation. DSTIs with injury to structures deep to skin/subcutis were associated with negative pressure wound therapy use (P = 0.02). DSTIs with underlying fractures required more procedures to reach reconstruction completion (P = 0.008), had more minor (P = 0.49) and major perioperative complications (P = 0.001), longer time to heal (P = 0.002), and increased need for amputation (P = 0.02).

Conclusions:

Factors affecting the reconstructive management and outcome of DSTIs include injury to structures deep to the skin/subcutis. We categorized DSTIs based on the level of injury and proposed a systematic approach to extremity DSTIs which may be utilized by plastic surgeons and other surgical services to manage these complex injuries.

Chronic wound biofilms: diagnosis and therapeutic strategies

OBJECTIVE

To review the diagnosis of chronic wound biofilms and discuss current treatment approaches.

DATA SOURCES

Articles included in this review were obtained from the following databases: Wanfang, China National Knowledge Infrastructure, PubMed, and the Web of Science. We focused on research published before August 2019 with keywords including chronic wound, biofilm, bacterial biofilms, and chronic wound infection.

STUDY SELECTION

Relevant articles were selected by carefully reading the titles and abstracts. Further, different diagnosis and clinical treatment methods for chronic wound biofilm were compared and summarized from the selected published articles.

RESULTS

Recent guidelines on medical biofilms stated that approaches such as the use of scanning electron microscopy and confocal laser scanning microscopy are the most reliable types of diagnostic techniques. Further, therapeutic strategies include debridement, negative pressure wound therapy, ultrasound, antibiotic, silver-containing dressing, hyperbaric oxygen therapy, and others.

CONCLUSION

This review provides the identification and management of biofilms, and it can be used as a tool by clinicians for a better understanding of biofilms and translating research to develop best clinical practices.