Repair of soft tissue defect of the middle and lower leg with island flap / 中华医学美学美容杂志

Objective:To investigate the methods and effect of wound repair after partial skin and soft tissue necrosis of middle and lower leg fracture surgery.Methods:Three kinds of island flaps were used to repair the wound after skin and soft tissue necrosis of middle and lower leg fracture surgery in 22 patients. Nine patients were repaired with sural neurotrophic fascial flaps, 7 patients with posterior tibial artery perforator flaps, and 6 patients with peroneal artery perforator flaps. The area of wound defect was 3.0 cm×3.8 cm to 12.0 cm×9.0 cm. The donor area was directly sutured, or free skin grafted.Results:All patients were the cases after partial skin and soft tissue necrosis of middle and lower leg fracture surgery, with bone, internal fixation plate or tendon exposed. The skin flaps in 21 patients were survived, and the wound healed by first intention. The sural neurotrophic fascial flap necrosis in one patient was due to hematoma and entrapment in vascular pedicle. After 5 to 24 months (mean 9 months) follow-up, texture of flaps was good, no ulcer occured, and outlook of the repaired wound was satisfied. The sutured wound of donor site and skin-grafting had healed by first stage intention.Conclusions:Repair with island flap is an ideal way to the defect wound after skin and soft tissue necrosis of middle and lower leg fracture surgery.

Unusual Severe Soft Tissue Necrosis Following Exposure of Metal Implants in Total Knee Replacement: A Case Report

Introduction: Complications, such as thromboembolism, infection, periprosthetic fracture, and soft-tissue necrosis are commonly encountered in cases of total knee arthroplasty. The risk of developing complications is higher in patients with comorbidities, including diabetes mellitus (DM) and hypertension. Soft tissue necrosis can be managed through local wound care, frequent dressing change, surgical debridement, and tissue flap accordingly. Case report: In this report, we describe the case of an obese, 65-year-old bed-ridden female, a known case of hypertension, DM and hypothyroidism with stable vital signs. She underwent bilateral total knee replacement for severe osteoarthritis of her knees. During the 8th week post-operatively of her left knee, the patient developed sloughing of the wound and was admitted through the emergency under orthopedic care. She was diagnosed with soft tissue necrosis and treated with irrigation and debridement. She also administered a course of intravenous antibiotics. During her hospitalization, the orthopedic and plastic surgery teams were involved and the patient underwent multiple irrigation and debridement and implant removal followed by coverage of the wound with a partial thickness skin graft. Conclusion: Extensive antibiotics course, multiple irrigation and debridement, and arthrodesis over a period of less than 3 months has successfully salvaged the patient’s limb.

Gangrena gaseosa / Gangrène gazeuse / Gas gangrene

Se presenta un paciente masculino de 29 años, mestizo, recluso, quien 7 días antes de haber sido remitido al servicio de urgencias del Hospital Universitario Amalia Simoni se había inoculado, en autoagresión, heces fecales en la pierna y el muslo derechos. Refirió dolor y presentaba gran toma del estado general. A la exploración física se constató aumento de volumen generalizado del miembro inferior derecho, con zonas de eritema marcado que alternaban con áreas de necrosis que incluso afectaban el abdomen bajo, aumento de la temperatura local; a la palpación, dolor intenso con amplia zona de crepitación subcutánea, además de bulas de contenido serohemático, pútrido, de olor fétido. La radiografía reveló aumento marcado de la opacidad de las partes blandas, bandas de gas a nivel del tejido celular subcutáneo y presencia de numerosas bulas sin toma ósea. Se decidió tratamiento quirúrgico multidisciplinario que incluyó la desarticulación en guillotina del miembro inferior derecho a nivel de la cadera y toilette amplia, medidas de soporte vital, y la combinación de clindamicina, vancomicina y meronem. La gangrena gaseosa es una infección fulminante de los tejidos blandos con una mortalidad elevada; la sospecha diagnóstica y el entendimiento de la fisiopatología mejoran el pronóstico. El soporte vital, el equilibrio del medio interno, el uso de antimicrobianos de amplio espectro y un tratamiento quirúrgico agresivo, disminuyen la mortalidad(AU)

A case of a 29-year convict mestizo male patient is presented here. This patient is referred to the emergency department of Traumatology at Amalia Simoni University Hospital, seven days after having self-inoculated with stool in his right leg and thigh as self-harm. The patient complained of pain and his general was very poor. Physical examination revealed generalized increase in volume of the right lower limb, with marked erythema areas alternating with areas of necrosis that were even affecting the lower abdomen; increased local temperature, tenderness, pain with subcutaneous crepitus in wide area were found, as well as bulls serohematic bulls, putrid, foul-smelling. Radiography reveals marked increase in opacity of the soft tissues, bands of gas at the level of subcutaneous tissue and the presence of numerous bulls without bone involvement. Multidisciplinary surgical treatment was decided including the guillotine disarticulation of the right leg to hip level and wide toilette, life support, and the combination of clindamycin, vancomycin, and meronem. Gas gangrene is a fulminant soft tissue infection with high mortality; the suspected diagnosis and understanding of the pathophysiology improve prognosis. Life support, balance the internal environment, the use of broad-spectrum antimicrobials and aggressive surgical treatment, reduce mortality(AU)

Un patient âgé de 29 ans, métis, reclus, référé au service d'urgences à l'hôpital universitaire "Amalia Simoni" dû à une automutilation (inoculation de selle dans la jambe et la cuisse droites), est présenté. Il a exprimé une douleur et une sensation de mal-être. Dans l'examen physique, on a pu constater une inflammation du membre inférieur droit; des zones érythémateuses très marquées alternant avec des zones nécrosées, même arrivant à l'abdomen bas; une augmentation de la température locale; une douleur violente avec une zone de crépitements à la palpation, et des bulles à contenu séro-hématique, putréfié et fétide. La radiographie a révélé une augmentation significative de l'opacité des parties molles, des bandes gazeuses au niveau du tissu cellulaire sous-cutané, et une présence de nombreuses bulles sans prise osseuse. On a décidé un traitement chirurgical pluridisciplinaire consistant à une désarticulation en guillotine du membre inférieur droit au niveau de la hanche et un curettage profond; des soins intensifs, et une combinaison de clindamycine, vancomycine et méropénème. La gangrène gazeuse est une infection fulminante des tissus mous avec un taux de mortalité très haut. Le diagnostic suspecté et la compréhension de la physiopathologie améliorent le pronostic. Les soins intensifs, l'équilibre du milieu intérieur, l'emploi d'antimicrobiens à large spectre et un traitement chirurgical agressif font réduire le taux de mortalité(AU)

Necrose tecidual causada por alúmen de potássio / Tissue necrosis caused by potassium alumina: case report

O objetivo do presente trabalho foi relatar um caso clínico de necrose tecidual causada por alúmen de potássio. Paciente do sexo feminino realizou procedimento de enxerto de tecido conjuntivo para tratamento de defeito de rebordo classe I. Aos sete dias do período pós-operatório, observou-se extensa necrose da área receptora e do tecido enxertado. A paciente relatou que utilizou bochechos diários de alúmen de potássio para controle de edema e sangramento. O alúmen de potássio interferiu negativamente no processo de reparo tecidual.

The aim of this present study is to describe a case report of tissue necrosis caused by potassium alumina. Subepithelial connective tissue graft was used in the treatment of class I alveolar ridge defect. After seven days an extensive necrosis of the tissue graft and the receptor area was observed. The patient related that used potassium alumina solution as mouthrinse daily to control edema and bleeding. Potassium alumina had a negative influence in the tissue repair process.

Complicaciones severas por el uso parenteral del Kerosene en intento de autólisis: a propósito de tres casos / Severe complications due to the parenteral use ofKerosene in autolysis intends: a propose of three cases

El suicidio o intento suicida es un proceder muy antiguo, realizado por el ser humano en contra de sí mismo. Se presentó un estudio descriptivo de tres pacientes, que en intento suicida se auto inocularon kerosene, combustible doméstico, lo que desencadenó severa necrosis tisular y lesión pulmonar aguda en uno de ellos. La falta de previsión desde su inicio en el personal facultativo sobre la envergadura de las complicaciones que posteriormente aparecieron, se puso de manifiesto en el estudio. Se realizaron sugerencias para futuros afectados por esta causa.

Suicide or suicidal intend is a very old procedure, carried out by the human being against himself. We presented the descriptive study of three patients who inoculated themselves kerosene, a domestic combustible, in a suicidal intend, unleashing severe tissue necrosis and acute pulmonary lesion in one of them. In the study it was clear the lack of prevision on the reach of the complications that lately appeared, from the part of the medical staff. We made suggestions for the persons injured for this cause in the future.

Experimental poisoning by Baccharis megapotamica var. weirii in buffalo / Intoxicação experimental por Baccharis megapotamica var. weirii em búfalos

Five male 6-8 month-old Murrah buffalo calves were orally dosed with the fresh aerial parts of Baccharis megapotamica var. weirii at doses of 1, 3, 4, 5 and 10g/kg body weight (bw) (~1-10mg macrocyclic trichothecenes/kg/bw). The B. megapotamica used for the experiment was harvested on a farm where a recent spontaneous outbreak of poisoning caused by such plant had occurred. Clinical signs appeared 4-20 hours and 4 buffaloes died 18-49 hours after the ingestion of the plant. Clinical signs were apathy, anorexia, and watery diarrhea, fever, colic, drooling, muscle tremors, restlessness, laborious breathing and ruminal atony, and dehydration. The most consistent gross findings were restricted to the gastrointestinal (GI) tract consisted of varying degrees of edema and reddening of the mucosa of the forestomach. Histopathological findings consisted of varying degrees of necrosis of the epithelial lining of the forestomach and of lymphocytes within lymphoid organs and aggregates. Fibrin thrombi were consistently found in sub-mucosal vessels of the forestomach and in the lumen of hepatic sinusoids. It is suggested that dehydration, septicemia and disseminated intravascular coagulation participate in the pathogenesis of the intoxication and play a role as a cause of death. A subsample of B. megapotamica var. weirii was frozen-dried and ground and analyzed using UHPLC (Ultra High Performance Liquid Chromatography) with high resolution Time of Flight mass spectrometry and tandem mass spectrometry, it was shown that the plant material contained at least 51 different macrocyclic trichothecenes at a total level of 1.1-1.2mg/g. About 15-20% of the total trichothecenes contents was found to be monosaccharide conjugates, with two thirds of these being glucose conjugates and one third constituted by six aldopentose conjugates (probably xylose), which has never been reported in the literature.

As partes aéreas verdes de Baccharis megapotamica var. weirii foram administradas oralmente a cinco búfalos da raça Murrah de 6-8 meses de idade nas doses de 1, 3, 4, 5 e 10g/kg de peso corporal (pc) (~1-10mg de tricotecenos macrocíclicos/kg/pc). A planta usada no experimento foi colhida numa fazenda onde um surto recente de intoxicação espontânea por essa planta havia ocorrido. Nos búfalos deste experimento, os sinais clínicos apareceram 4-20 horas e 4 búfalos morreram 18-49 horas após a ingestão da planta. Os sinais clínicos consistiram de apatia, anorexia, diarreia aquosa, febre, cólica, salivação, tremores musculares, inquietação, respiração laboriosa, atonia ruminal e desidratação. Os achados macroscópicos mais consistentes estavam restritos ao trato gastrointestinal (GI) e consistiram de graus variados de edema e avermelhamento da mucosa dos pré-estômagos. Os achados histopatológicos consistiam de vários graus de necrose do epitélio de revestimento dos pré-estômagos e de linfócitos em agregados e órgãos linfoides. Trombos de fibrina foram consistentemente encontrados nos vasos da submucosa dos pré-estômagos e na luz dos sinusoides hepáticos. É sugerido que desidratação, septicemia e coagulação intravascular disseminada participem da patogênese da intoxicação e sejam fatores responsáveis pela morte dos animais afetados pela intoxicação. Uma subamostra de B. megapotamica var. weirii foi congelada a seco, moída e analisada usando UHPLC (Cromatografia Líquida de Ultra Alta Performance) com espectrometria de tempo-de-vôo de alta resolução e espectrometria de massa em tandem. Foi demonstrado que o material de planta analisado continha pelo menos 51 tricotecenos macrocíclicos diferentes num nível total de 1,1-1,2mg/g. Cerca de 15-20% do conteúdo total de tricotecenos eram conjugados de monossacarídeos, sendo dois terços desses, conjugados de glicose e um terço constituídos por seis conjugados de aldopentose (provavelmente xilose), o que nunca tinha sido antes relatado na literatura.

Study on mechanism behind of tissue necrosis following injection of hyaluronic acid filler / 第二军医大学学报

Objective To investigate the mechanism of tissue necrosis following injection of hyaluronic acid. Methods Twenty New Zealand white rabbits (40 ears) were used to establish ear complex tissue flap models with blood supply only from the central pair of artery and vein by ligating the anterior pair and other branches. Then the animal models were randomly divided into 4 groups. Group A, B and C were injected with 0. 2 ml hyaluronic acid into the periphery of the root portion of the central artery, central vein and central artery, respectively; Group D received cutting and ligation of the central artery (control group). The visual findings, microcirculation changes, skin temperature and percutaneous oxygen saturation were examined at 1, 7, and 14 days after injection. The animals were sacrificed on the 14th day and the ears were studied pathologically. Results All the groups showed different degrees of tissue ischemia. In Group A and D the skin temperature and oxygen saturation were not significantly different before and after injection of hyaluronic acid. The skin temperature and oxygen saturation were decreased one day after injection in Group B, and they gradually increased thereafter (P<0. 05). All the ears in Group A, B and D survived. The skin temperature and oxygen saturation in Group C were significantly decreased after injection of hyaluronic acid (P < 0. 05), and all the ears in Group C developed skin ulceration and necrosis after 7 days. Conclusion Injection of hyaluronic acid into the artery can cause obstruction of distal arterioles and microcirculation disorder, which might be the main cause of skin tissue necrosis.

A Case of Intestinal Obstruction Caused by Strangulated Femoral Hernia Accompanying Soft Tissue Necrosis / 대한소화기학회지

Intestinal obstruction involves a partial or complete blockage of the bowel which results in the failure of intestinal contents to pass through. The mechanical causes of obstruction may include the followings: hernias, postoperative adhesions or scar tissue, impacted feces, gallstones, tumors, granulomatous processes, intussusception, volvulus, foreign bodies, and etc. Hernias are the third leading cause of intestinal obstruction by 10% approximately. However, most hernias are the cases with abdominal wall, inguinal or internal hernia. Femoral, obturator, lumbar, or sciatic hernia as the cause of obsturction is rare. Furthermore, the cases accompanying soft tissue necrosis are seldomly reported. Herein, we report a case of intestinal obstruction caused by strangulated femoral hernia accompanying soft tissue necrosis in a 78-years-old female patient.

Role of Staphylococcal Superantigen in Atopic Dermatitis: Influence on Keratinocytes

Staphylococcus aureus may perform an crucial function in atopic dermatitis (AD), via the secretion of superantigens, including staphylococcal enterotoxins (SE) A or B, and toxic shock syndrome toxin-1 (TSST-1). Dysregulated cytokine production by keratinocytes (KCs) upon exposure to staphylococcal superantigens (SsAgs) may be principally involved in the pathophysiology of AD. We hypothesized that lesional KCs from AD may react differently to SsAgs compared to nonlesional skin or normal skin from nonatopics. We conducted a comparison of HLA-DR or CD1a expression in lesional skin as opposed to that in nonlesional or normal skin by immunohistochemistry (IHC). We also compared, using ELISA, the levels of IL-1alpha, IL-1beta, and TNF-alpha secreted by cultured KCs from lesional, nonlesional, and normal skin, after the addition of SEA, SEB and TSST-1. IHC revealed that both HLA-DR and CD1a expression increased significantly in the epidermis of lesional skin versus nonlesional or normal skin in quite a similar manner. IL-1alpha, IL-1beta, and TNF-alpha secretion was also significantly elevated in the cultured KCs from lesional skin after the addition of SsAgs. Our results indicated that KCs from lesional skin appear to react differently to SsAgs and increased proinflammatory cytokine production in response to SsAgs may contribute to the pathogenesis of AD.

Extremity Amputation following Radial Artery Cannulation in Two Patients with Craniotomy / 대한마취과학회지

Percutaneous radial artery cannulation is a very useful method of invasive monitoring in critically ill patients. Although the method is generally safe and simple, it can infrequently lead to tissue necrosis. Recently we experienced this complication in two patients. The first patient was a 52-year-old male who received a craniotomy for removal of a subdural hematoma. Right radial artery cannulation was carried out after a modified Allen's test appeared to be positive. After removal of the cannula on the 9th hour after operation because it was obstructed, his right hand was cool and cyanotic. Despite stellate ganglion block and other supportive therapy, the ischemic changes increasingly worsened. On the 10th day after removal of the cannula, the necrotic change was extended in all fingers of the right hand and he underwent disarticulation of the right wrist. The second patient was a 63-year-old female who received a craniotomy for clipping of a cerebral aneurysm. Left radial artery cannulation was performed without a modified Allen's test. On the 2nd hour after operation, the cannula was removed because the left hand was cyanotic. On Doppler examination, the radial and ulnar arteries were not identified with blood flow. On angiographic finding, the radial artery was occluded almost totally and the ulnar artery was not visualized below the antecubital fossa. After the left stellate ganglion block, thrombectomy and anticoagulant therapy, the ischemia in the left hand was transiently improved, but then became more aggravated and eventually the level of tissue necrosis advanced to the left elbow, therefore amputation above the left elbow joint was performed. Presumptive causes of these tissue necroses were peripheral embolization in the first patient, and inadequate collateral circuation of the ulnar arterial malformation in the second case.