[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Admission cell free DNA as a prognostic factor in burns: quantification by use of a direct rapid fluorometric technique.

BACKGROUND: Despite great advances in the treatment of burn patients, useful prognostic markers are sparse. During the past years there has been increasing interest in circulating plasma cell free DNA as a potential marker for tissue injury. We have developed a rapid direct fluorescent assay for cell free DNA quantification that allows obtaining accurate, fast, and inexpensive measurements. OBJECTIVE: To use this technique for measuring plasma cell free DNA levels in burn patients and to further explore the use of cell free DNA as a potential marker of patient outcome in burns. METHODS: Cell free DNA levels obtained from 14 burn victims within 6 hours of injury and 14 healthy controls were quantified by a direct rapid fluorometric assay. RESULTS: Patient admission cell free DNA levels were significantly elevated compared with that of controls (1797 ± 1523 ng/mL versus 374 ± 245 ng/mL, P = 0.004). There are statistically significant correlations between cell free DNA admission levels and burn degree (Spearman's correlation = 0.78, P = 0.001), total body surface area (Spearman's correlation = 0.61, P = 0.02), and total burn volume (Spearman's correlation = 0.64, P = 0.014). CONCLUSIONS: Admission cell free DNA levels can serve as a prognostic factor in burns and future routine use can be made possible by use of our direct rapid fluorometric assay.

Total lip reconstruction with tendinofasciocutaneous radial forearm flap.

INTRODUCTION: Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. PATIENTS AND METHODS: This procedure was used in 5 patients with 80-100% lip defect resulting from Squamous cell carcinoma. Patients' age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. RESULTS: All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. CONCLUSION: We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.

Polydactyly in the multiethnic 'Negev' population at southern Israel.

The objective of this study was to characterize the prevalence, ethnic mix, and associated malformations of polydactyly in a multiethnic population. A retrospective analysis of 189 polydactyly patients was carried out. The incidence of polydactyly was 0.5/1000 live births and was higher in the Bedouin population. Preaxial polydactyly was 10 times more prevalent in the Jewish population and sporadic, and postaxial polydactyly was more prevalent in the consanguineous Bedouin population and associated with other malformations. We conclude that the pathologies in embryogenesis leading to preaxial and postaxial polydactyly vary, with the former occurring sporadically compared with the latter, which predominates in consanguineous families and syndromes.

Idiopathic distal radioulnar synostosis.

Radioulnar synostosis is rare, and exists in two forms: congenital and post-traumatic. The congenital form presents only in the proximal forearm, and the post-traumatic form may present anywhere along the radius and ulna. The only known aetiology for distal radioulnar synostosis is post-traumatic. We present a rare case of distal radioulnar synostosis with no previous history of trauma.

Efficacy of enzymatic debridement of deeply burned hands.

BACKGROUND: The burned hand is a common and difficult to care-for entity in the field of burns. Due to the anatomy of the hand (important and delicate structures crowded in a small limited space without sub-dermal soft tissue), surgical debridement of the burned tissue is technically difficult and may cause considerable complications and, therefore, should be performed judiciously. Selective enzymatic debridement of the burn wound can preserve the spontaneous epithelialisation potential and reduce the added injury to the traumatised tissue added by a surgical debridement. OBJECTIVE: The aim of the study was to assess the implication of a selective enzymatic compound (Debrase(®) - Ds) in the special field of deep hand burns, by comparing the actual burn area that required surgical coverage after enzymatic debridement to the burn area clinically judged to require skin grafting prior to debridement. MATERIALS AND METHODS: This was a retrospective data collection and analysis from 154 complete files of prospective, open-label study in 275 hospitalised, Ds-treated burn patients. RESULTS: A total of 69 hand burns diagnosed as 'deep' was analysed; 36% of the wounds required surgical intervention after enzymatic debridement; 28.6% of the total burned area estimated initially as deep was covered by skin graft (statistically significant p<0.001). CONCLUSION: Debridement of deep-hand burns with a selective enzymatic agent decreased the perceived full-thickness wound area and skin-graft use.

[The burn array in Israel].

Circa 2700 burn victims require hospitalization in Israel each year. Most of these burns happen as household accidents, caused by hot liquids and involve less than 20% of the total body surface area. Treatment is dictated by the burn severity. Patients with severe burns are referred to one of the five dedicated burn services complying with the ABA & EBA criteria, located at the tertiary trauma centers which are situated in accordance with Israel's geographic, demographic and security needs. In most centers, the joint treatment of the most severe cases, provided by plastic surgeons and intensive care specialists allows the use of advanced techniques and treatment protocols, improving outcome. In order to further improve the quality of care for the burn patients, to allow improved national capability to contend with scenarios of disaster and mass casualty, to provide a sound database for future planning and billing, and also to produce appropriate intervention plans, Israel should have a system similar to the US's National Burn Repository.

Long-term follow-up of high-pressure injection injuries to the hand.

BACKGROUND: High-pressure injection injury is an injury caused by accidental injection of substances by industrial equipment. This injury may have devastating sequelae. The goal of this study was to assess the long-term outcome of high-pressure injection injury to the hand. METHODS: In this historical prospective study, patients who had previously sustained high-pressure injection injury were examined. Assessment included measurement of grip and pinch strength, range of motion, two-point discrimination, and use of a questionnaire regarding present complaints and return to the work force. RESULTS: Twenty-three patients were examined. Follow-up length was on average 8.5 years. The injured hand was most often (43 percent) the right dominant hand, the index in 65 percent, the thumb in 25 percent, and other locations in 10 percent. Only 43 percent of patients returned to their previous employment. Patient complaints were, in descending frequency, cold intolerance, hypersensitivity, paresthesias, constant pain, and impairment of activities of daily living. Metacarpophalangeal range of motion was decreased on average by 8.1 percent (p = 0.019), proximal interphalangeal joint range of motion was decreased by 23.9 percent (p = 0.001), and distal interphalangeal range of motion was decreased by 29.7 percent (p= 0.018). Maximum grip was decreased compared with the expected grip by 12 percent (p = 0.023). Pinch was decreased by 35 percent (p < 0.001). Two-point discrimination was increased by 49 percent (p < 0.007). CONCLUSION: This study confirms the fact that high-pressure injection injury to the hand is a significant problem. Virtually all patients suffer sequelae of this injury. The injury has significant repercussions for future function and reintegration into the work force.

Escharotomy using an enzymatic debridement agent for treating experimental burn-induced compartment syndrome in an animal model.

BACKGROUND: In patients with deep circumferential burns, adequate resolution of burn-induced compartment syndrome (BICS) is achieved by surgical escharotomy. Surgical escharotomy is traumatic, may cause considerable blood loss, does nothing toward debridement of the burn wound, and entails possible morbidity and complications. Debridase is a Bromelain derived enzymatic preparation capable of lysing the burn eschar within 4 hours, obviating the need for surgical debridement. It has an affinity to burned necrotic tissue and does not damage healthy skin. In our clinical assessment of the Debridase efficacy, we found in several cases of deep burns of the limbs that the measured IC pressure subsided after 2-4 hours of Debridase application and none of the enzymatic escharotomy treated patients suffering from circumferential burns developed BICS. To confirm these observations we conducted this controlled study. AIM: to assess the efficacy of Debridase for treating BICS in an animal model. MATERIALS AND METHODS: A model for BICS was developed by making circumferential burns to pig legs and monitoring the anterior compartment the legs. BICS was induced in the legs of 5 pigs, 20 legs. 10 legs were treated with Debridase and 10 served as nontreated controls, treated by surgical escharotomy at the conclusion of the experiment. RESULTS: Debridase reduced BICS within 30 minutes from application. Debridase was as effective as a standard surgical escharotomy. CONCLUSION: Escharectomy using an effective enzymatic debriding agent is potentially an adequate, simple, fast and effective procedure to treat BICS, it has the added benefit of burn debridement without surgical escharotomy.

Three-square-flip-flap reconstruction for post burn syndactyly.

INTRODUCTION: Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly. METHOD: Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen. RESULTS: The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications. CONCLUSION: The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.

Safety and efficacy of a proteolytic enzyme for enzymatic burn debridement: a preliminary report.

A prospective, non-comparative study design was used to describe our experience with a bromelain-derived debriding agent, Debridase, in 130 patients with 332 deep second degree and third degree burns treated between 1984 and 1999. Debridase was applied after saturating the burns with a moist dressing for 2-24h. Debridase was applied for a period of 4h under an occlusive dressing. Mean patient age was 18.6 +/- 19.3, 42 (32.3%) were female, and 63 (48.5%) were children under age 18. Most burns were small. Debridase was applied once in 241 (72.6%) of the 332 wounds, twice in 67 (20.18%) cases, three times in 12 (3.61%) cases, and four times in 2 (0.6%) cases. The percentage debridement by number of applications was 89 +/- 21% for a single application, 77 +/- 27% for two, and 62 +/- 27% for three Debridase applications, respectively. There were no significant adverse events. The availability of a fast acting, reliable and complication-free enzymatic debriding agent may open new horizons and provide a new treatment modality for burns.

Transdermal scopolamine use for post-rhytidectomy sialocele.

BACKGROUND: Post-rhytidectomy sialocele is a rare complication. The usual treatment uses prolonged drainage. The use of antisialogogues has been described previously, but has potential side effects. Transdermal scopolamine SCOPODERM TTS is indicated for the prevention of motion sickness and also has antisialogugue action. METHODS: An interventional case report is presented. RESULTS: The application of transdermal scopolamine SCOPODERM TTS resulted in resolution of a post-rhytidectomy sialocele within 6 days. CONCLUSION: Transdermal scopolamine delivery should be considered as an option for the treatment of post-rhytidectomy parotid fistulas.