Initial Experience with the PONTiS Tendon Repair System in Traumatic Upper Extremity Injuries.

BACKGROUND: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. The authors review their initial experience with the PONTiS flexor tendon repair system, a knotless, multifilament, stainless steel crimp system. METHODS: Consecutive patients undergoing repair by plastic and orthopedic surgeons with the PONTiS system were reviewed for the period from 2015 to 2017. Multivariate risk and Kaplan-Meier survival analyses were performed to assess risk factors associated with complications. RESULTS: Eighty-one patients, with a mean follow-up of 75 days (range, 0 to 33 months), were identified. The most common demographics showed patients were right-handed (82.9 percent), male (71.4 percent), and laborers (35.7 percent) and sustained laceration injuries (77.1 percent) at zone 2 (27.2 percent). There were, on average, 3.7 tendon injuries per patient. Associated injuries included fractures (21.4 percent), arterial injuries (24.3 percent), and nerve injuries (61.4 percent). Thirteen patients (16.0 percent) developed complications, including adhesions/contracture ( n = 4), rupture ( n = 2), flap ischemia ( n = 2), arterial thrombosis ( n = 1), wound dehiscence ( n = 1), tendon lag ( n = 1), and erosion of the PONTiS system through soft-tissue grafts ( n = 2). Multivariate analysis identified poor soft-tissue coverage (OR, 9.990; p = 0.043) and zone 2 involvement (OR, 7.936; p = 0.016) as risk factors, while epitendinous repairs (OR, 0.096; p = 0.010) were protective against complications. CONCLUSIONS: The PONTiS flexor tendon repair system is rapid, simple to deploy, and advantageous, especially in multiple traumatic tendon injuries. In comparison to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. The authors advise using it with caution in cases with poor soft-tissue coverage to minimize risks of extrusion, and they strongly recommend the use of epitendinous sutures concurrently to limit complications.

Indocyanine Green Angiography: A Helpful Tool for Intraoperative Assessment of Upper Extremity Perfusion.

Assessment of tissue perfusion can be a challenge for the hand surgeon. Indocyanine green (ICG) angiography has been shown to be a valuable adjunct to physical examination and clinical judgment when there is a concern for tissue perfusion. The use of this technology has risen sharply in recent years in reconstructive surgery. Applications of ICG angiography have been developed throughout the field of surgery, including breast surgery, free tissue transfer, bowel surgery, neurosurgery, and lymphatic reconstruction. In this study, we discuss the novel applications of ICG angiography within the field of upper extremity surgery, and provide specific case examples of its successful use.

Adipose Tissue Drives Response to Ischemia-Reperfusion Injury in a Murine Pressure Sore Model.

BACKGROUND: Ischemia-reperfusion injury contributes significantly to the pathogenesis of chronic wounds such as pressure sores and diabetic foot ulcers. The authors' laboratory has previously developed a cyclical murine ischemia-reperfusion injury model. The authors here use this model to determine factors underlying tissue response to ischemia-reperfusion injury. METHODS: C57BL/6 mice were subjected to cycles of ischemia-reperfusion that varied in number (one to four cycles) and duration of ischemia (1 to 2 hours). For each ischemia-reperfusion condition, the following variables were analyzed: (1) digital photographs for area of necrosis; (2) hematoxylin and eosin staining and immunohistochemistry for inflammatory infiltrate; and (3) expression of inflammatory markers by quantitative polymerase chain reaction. In addition, human adipocytes and fibroblasts were cultured in vitro under conditions of hypoxia and reoxygenation, and expression of inflammatory markers was analyzed by quantitative polymerase chain reaction. RESULTS: Increases in both ischemia-reperfusion cycle number and ischemia duration correlated with increased areas of epithelial necrosis both grossly and histologically, and with an increase in cellularity and neutrophil density. This increased inflammatory infiltrate and a significant increase in the expression of proinflammatory markers (Hmox1, interleukin-6, interleukin-1, and monocyte chemoattractant protein-1) was observed in adipose tissue subjected to ischemia-reperfusion injury, but not in dermis. These results were mirrored in human adipose tissue. CONCLUSIONS: The authors further characterize a novel, reproducible murine model of ischemia-reperfusion injury. The results of their study indicate that adipose tissue is less tolerant of ischemia-reperfusion than dermal tissue. Rather than being an "innocent bystander," adipose tissue plays an active role in driving the inflammatory response to ischemia-reperfusion injury.

Excisional wound healing is delayed in a murine model of chronic kidney disease.

BACKGROUND: Approximately 15% of the United States population suffers from chronic kidney disease (CKD), often demonstrating an associated impairment in wound healing. This study outlines the development of a surgical murine model of CKD in order to investigate the mechanisms underlying this impairment. METHODS: CKD was induced in mice by partial cauterization of one kidney cortex and contralateral nephrectomy, modifying a previously published technique. After a minimum of 6-weeks, splinted, dorsal excisional wounds were created to permit assessment of wound healing parameters. Wounds were harvested on postoperative days (POD) 0, 3, 7, and 14 for histological, immunofluorescent, and quantitative PCR (qPCR). RESULTS: CKD mice exhibited deranged blood chemistry and hematology profiles, including profound uremia and anemia. Significant decreases in re-epithelialization and granulation tissue deposition rates were found in uremic mice wounds relative to controls. On immunofluorescent analysis, uremic mice demonstrated significant reductions in cellular proliferation (BrdU) and angiogenesis (CD31), with a concurrent increase in inflammation (CD45) as compared to controls. CKD mice also displayed differential expression of wound healing-related genes (VEGF, IL-1ß, eNOS, iNOS) on qPCR. CONCLUSIONS: These findings represent the first reported investigation of cutaneous healing in a CKD animal model. Ongoing studies of this significantly delayed wound healing phenotype include the establishment of renal failure model in diabetic strains to study the combined effects of CKD and diabetes.

The free fillet flap after traumatic amputation: a review of literature and case report.

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.

Double lateral band transfer for treatment of traumatic hyperextension instability of the proximal interphalangeal joint: a report of two cases.

Post-traumatic hyperextension instability of the proximal interphalangeal joint may lead to pain, difficulty with initiating finger flexion, and a swan-neck deformity. Most techniques to correct a traumatic hyperextension deformity of the proximal interphalangeal joint require a window in the flexor retinaculum, retraction of the flexor tendons, and manipulation of the joint capsule with a conceivable potential for joint stiffness, tendon adhesions, and tendon bowstringing. We describe an extra-articular lateral band transfer technique that utilizes strips of both lateral bands and preserves the functional integrity of the flexor tendon sheath.

Limitations of the db/db mouse in translational wound healing research: Is the NONcNZO10 polygenic mouse model superior?

Murine models have provided valuable insights into the pathogenesis of both diabetes and chronic wounds. However, only a few published reports to date have investigated wound healing differences among the differing diabetic mouse models. The goal of the present study was to further define the wound healing deficiency phenotypes of streptozotocin-induced (STZ-induced), Akita, and db/db diabetic mice in comparison with a promising new polygenic strain of Type 2 diabetes (NONcNZO10) by using three specific wound models that targeted different critical processes in the pathogenesis of chronic wounds. Incisional, excisional, and ischemia/reperfusion wound models were established on mice of each strain. Wound healing parameters including tensile strength, epithelial gap, and wound necrosis were evaluated. In contrast to the other diabetic mice, the NONcNZO10 strain was found to have significant wound healing impairments in all wound healing models. Not only do the NONcNZO10 mice appear to better model human Type 2 diabetes, these provocative findings suggest that the mice may show more clinically relevant wound healing deficiencies than previous diabetic mouse models.

Abdominoplasty flap elevation in a more superficial plane: decreasing the need for drains.

BACKGROUND: Abdominoplasty has continued to become more frequently performed in the post-bariatric surgery and aesthetic patient populations. With the increase in these procedures, there is a need to decrease the length of drains for patient comfort and postoperative recovery. The authors' hypothesis was that a more superficial plane of abdominal flap elevation during abdominoplasty would decrease the postoperative need for drains. METHODS: The authors reviewed 202 consecutive abdominoplasties with 99 procedures performed using a standard suprafascial dissection (group I) and 103 procedures using a modified plane of flap elevation that preserves the thin areolar tissue along the abdominal wall (group II). Patient demographics, perioperative complications, and drain data were recorded. RESULTS: Patient characteristics did not differ significantly, with the mean age of group I and group II (44 +/- 8.9 years and 44 +/- 9.6 years, respectively) and body mass index of group I and group II (24 +/- 3.8 and 24 +/- 3.8, respectively) being similar. Perioperative complications included seven seromas in group I and two seromas in group II. There were two minor hematomas in group I and two minor hematomas in group II. The drains for patients in group II met criteria for removal 3 days earlier than those for group I (p < 0.0001). On average, patients in group II had drains removed at postoperative days 4 to 5. CONCLUSIONS: Flap elevation in a plane superficial to the standard suprafascial approach during abdominoplasty may decrease the length of time required for drains in the postoperative period in the abdominoplasty patient. Decreasing the length of time for postoperative drains may improve patient comfort and expedite recovery.

Adjunctive therapies in the treatment of osteomyelitis.

The current management for chronic osteomyelitis centers on adequate antibiotic coverage and surgical debridement of nonviable tissue. The eradication of osteomyelitis, however, often involves a prolonged and frustrating course of management. Nonsurgical adjunctive modalities have not been widely used, mostly due to a lack of perceived efficacy, and have remained in a state of infancy. In this article, we will outline the rationale, current status, and evidence for several potential adjuncts to osteomyelitis management.

Animal models of wound healing: utility in transgenic mice.

Transgenic and knockout mouse technology represents a powerful tool for exploring the molecular pathways behind the wound healing process. The design and utilization of mouse wound healing models must be approached mindful of limitations of both the transgenic technology and the models themselves in order to continue generating useful information from studies with transgenic mice. A battery of standard and impaired wound healing models, when used in a systematic and combinatorial fashion, should yield significant contributions to wound healing research.

A review of becaplermin gel in the treatment of diabetic neuropathic foot ulcers.

Diabetic neuropathic foot ulcers represent a serious health care burden to patients and to society. While the management of chronic diabetic foot ulcers has improved in recent years, it remains a frustrating problem for a variety of clinicians. This review examines the scientific underpinnings supporting the use of becaplermin (Regranex((R)); Ortho-McNeil Pharmaceutical, Raritan, NJ), or recombinant human platelet-derived growth factor (rhPDGF-BB), in diabetic forefoot wounds. An emphasis is placed upon proper medical and surgical care of diabetic foot wounds, as multiple studies have demonstrated that the success of this growth factor in accelerating healing is ultimately dependent on proper ulcer care. A focus on the cost-effectiveness of this form of therapy in the treatment of diabetic foot ulcers is also outlined.