Chronic Knee and Ankle Pain Treatment through Selective Microsurgical Approaches: A Minimally Invasive Option in the Treatment Algorithm for Refractory Lower Limb Pain

 Injury or compression of a sensory nerve is an under-reported source of disabling pain in the lower limb. It is known that peripheral nerve microsurgeons can reconstruct and rewire injured nerves to relieve chronic pain but this option remains not completely understood and ignored by most orthopaedic surgeons, neurologists, and pain therapists. In this paper, we describe our experience with knee and ankle peripheral nerve surgery to improve the condition of patients suffering from chronic, posttraumatic lower limb pain

Noninfectious Wound Complications in Clean Surgery: Epidemiology, Risk Factors, and Association with Antibiotic Use

Background: Noninfectious wound complications are frequent and often are confused with and treated as infection. Methods: We assessed the epidemiology, impact, risk factors, and associations with antibiotic use of noninfectious wound complications in clean orthopedic and trauma surgery. We report a single-center, prospective, observational study in an orthopedic department. Results: Among 1,073 adult patients, 630 (59%) revealed clinically relevant postoperative noninfectious wound complications, leading to a significant prolongation of hospital stay (14 vs. 12days; Wilcoxon rank-sum test; p<0.02) compared with patients without complications. The most frequent and severe complications were discharge with dehiscence (n=437; 41%) and hematoma (n=379; 35%). Forty-seven patients (47/630; 7%) underwent reoperation for dehiscence (n=39) or hematoma (n=8). These patients made up 4.3% of the entire study population (47/1,073). In multivariate analysis, an ASA score ≥2 points, age≥60years, surgery duration for ≥90min, implant-related surgery, and poor compliance toward nurses' recommendations were pronounced risk factors for these complications, whereas antibiotic-related parameters had no influence. Staple use was significantly associated with wound discharge but not with hematoma. Conclusions: Wound complications, such as dehiscence with discharge or hematoma after clean orthopedic and trauma surgery, are frequent with an overall incidence of 60%. Although they lead to few surgical reinterventions, they prolong hospital stay by 2days. Few clinical parameters show association with wound complications. Among them, improvements of patient compliance and avoidance of staples use for skin closure are the most promising actions to decrease complication ris

Use of the parabiotic model in studies of cutaneous wound healing to define the participation of circulating cells

Previous experimental studies to assess the contribution of blood-borne circulating (BBC) cells to cutaneous wound healing have relied on discontinuous pulsing of labeled BBC elements or bone marrow transplant protocols. Such approaches do not allow the examination of stable BBC cells that have matured in a physiologically normal host. We have used a parabiotic murine model for cutaneous wound healing to evaluate the relative contribution of stable populations of peripheral blood cells expressing the green fluorescent protein (GFP) transgene in otherwise normal animals. Circulating cells (mature and immature) expressing the GFP transgene were easily detected and quantified in wounds of GFP− parabiotic twins during all evaluated stages of the healing response. Using multiple antibody probes, the relative contribution of various subsets of BBC cells could be comparatively assessed. In early wounds, some cells expressing mesenchymal epitopes were documented to be of hematopoietic origin, indicating the utility of this model in assessing cell plasticity in the context of tissue regeneration and repair. Application of this approach enables further investigation into the contribution of peripheral blood in normal and abnormal healing responses.National Institutes of Health (U.S.) (NIH 5 T32 HL007627- 22 Physician-Scientist Training Grant)National Institutes of Health (U.S.) (NIH/NIDDK (5 P30 DK36836-20))Brigham and Women’s Hospital (Program in Dermatopathology core grant (SDRC))National Institutes of Health. (U.S.). Department of Health and Human Services (Brigham and Women’s Hospital’s Program in Dermatopathology core grant (SPORE)

Nouvelles strategies pour traiter les plaies complexes : le mécanisme d'action du "Vacuum Assisted Closure Device" et les forces mécaniques

Les plaies chroniques, caractérisées par des défects tissulaires au processus de cicatrisation inefficace, sont en constante augmentation en raison du vieillissement de la population et de la prévalence accrue de maladies chroniques comme le diabète ou l'obésité. Leur traitement est un réel challenge tant pour le patient que pour le système de santé. Ainsi, de nouvelles stratégies thérapeutiques innovantes sont grandement nécesssaires. Le Vaccum Assisted Closure Device (VAC), un appareil non-pharmacologique récent pour le traitement des plaies, apporte des résultats prometteurs. Pourtant les mécanismes d'action ne sont pas parfaitement connus. Dans l'étude présentée ici, nous avons pu démontrer, à l'aide d'un modèle expérimental de plaie de souris, que le VAC transmettait des forces mécaniques causant des microdéformations du lit de la plaie. Ces déformations sont associées, au niveau cellulaire, à une stimulation de la prolifération cellulaire. Dans un modèle d'extension cutanée, nous avons observé que l'application de forces mécaniques induisait une réponse biologique prolongée. Cet effet était plus important après application cyclique que continue. Extrapolé au VAC, l'effet d'une application plus courte mais cyclique a aussi été plus efficace que celui d'une application continue. Ces resultats nous permettent une meilleure compréhension du mode d'action du VAC et ouvrent de nouvelles perspectives dans la thérapie des plaies, qui devraient avoir un impact significatif sur la qualité de vie des patients. En conclusion, les forces mécaniques représentent une nouvelle approche thérapeutique prometteuse dans le traitement des plaies complexes

Minimally invasive nerve and artery sparing surgical approach for temporal migraines

Summary: Background: Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Methods: Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Results: Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Conclusion: Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations

The use of the vac in complex wounds - does it work and how?

Background: Complex wounds pose a major challenge in reconstructive and trauma surgery. Several approaches to increase the healing process have been proposed in the last decades. In this study we study the mechanism of action of the Vacuum Assisted Closure device in diabetic wounds. Methods: Full-thickness wounds were excised in diabetic mice and treated with the VAC device or its isolated components: an occlusive dressing (OD) alone, subathmospheric pressure at 125 mm Hg (Suction), and a polyurethane foam without (Foam) and with (Foamc) downward compression of approximately 125 mm Hg. The last goups were treated with either the complete VAC device (VAC) or with a silicne interface that alows fluid removel (Mepithel-VAC). The effects of the treatment modes on the wound surface were quantified by a two-dimensional immunohistochemical staging system based on vasculature, as defined by blood vessel density (CD31) and cell proliferation (defined by ki67 positivity), 7 days post wounding. Finite element modelling was used to predict wound surface deformation under dressing modes and cross sections of in situ fixed tissues were used to measure actual microstrain. Results: The foam-wound interface of the Vacuum Assisted Closure device causes significant wound stains (60%) causing a deformation of the single cell level leading to a profound upregulation of cell proliferation (4-fold) and angiogenisis (2.2-fold) compared to OD treated wounds. Polyurethane foam exposure itself causes a frather unspecific angiogenic response (Foamc, 2 - fold, Foam, 2.2 - fold) without changes of the cell proliferation rate of the wound bed. Suction alone without a specific interface does not have an effect on meassured parameters, showing similar results to untreated wounds. A perforated silicone interface caused a significant lower microdeforamtion of the wound bed correlating to changes of the wound tissues. Conclusion: The Vacuum Assisted Closure device induce significanttissue growth in diabetic wounds. The wound foam interface under suction causes profound macrodeformation that stimulates tissue growth by angiogenesis and cell proliferation. It needs to be taken in consideration that in the clinical setting different wound types may profit from different elements of this suction device

Minimally invasive scar release by autologous adipose tissue transfer for post-traumatic neuropathic pain

Introduction: Addressing post traumatic lower limb neuropathic pain is challenging across medical specialties. To address this potentially devastating condition, several invasive and non-invasive approaches have been proposed with inconsistent results. Adipose fat transfer (AFT), also known as fat grafting, is a regenerative medicine technique in which a patient's own fat is harvested from one area of the body (usually through liposuction) and then injected into another area for various purposes, such as aesthetic contour enhancement or reconstruction and regeneration of scarred tissues. Methods: We analyze the effects of fat grafting for neuropathic pain combined with neuroma excision (hybrid technique, hAFT) or alone (AFT). A retrospective review was conducted on 22 patients with neuropathic lower limb pain, after trauma or orthopedic surgery treated with hAFT (n = 9) or AFT (n = 13). Results: Reduction in VAS scale more than 50 % was observed in 6 patients (66 %) treated with hybrid technique and in eleven patients (85 %) treated with AFT alone. Among these, complete pain reduction (>91 %) was achieved in 33.3 % of hAFT and 54 % of AFT technique. A 3.2 points reduction in VAS was found in the hAFT group versus 5.8 points in the AFT group (p = 0.035). Conclusion: This pioneering use of AFT emerges as a minimally invasive breakthrough, promising significant improvement in reconstructing scarred subcutaneous tissue and managing neuropathic pain

Combination of stromal cell-derived factor-1 and collagen-glycosaminoglycan scaffold delays contraction and accelerates reepithelialization of dermal wounds in wild-type mice

While dermal substitutes can mitigate scarring and wound contraction, a significant drawback of current dermal replacement technologies is the apparent delay in vascular ingrowth compared with conventional skin grafts. Herein, we examined the effect of the chemokine stromal cell-derived factor-1 (SDF-1) on the performance of a porous collagen–glycosaminoglycan dermal analog in excisional wounds in mice. C57BL/6 mice with 1 cm × 1 cm dorsal full-thickness wounds were covered with a collagen–glycosaminoglycan scaffold, followed by four daily topical applications of 1 μg SDF-1 or phosphate-buffered saline vehicle. Some animals were also pretreated with five daily doses of 300 mg/kg granulocyte colony-stimulating factor. Animals treated with SDF-1 and no granulocyte colony-stimulating factor reepithelialized 36% faster than vehicle controls (16 vs. 25 days), and exhibited less wound contraction on postwounding day 18 (∼35% greater wound area) plus three-fold longer neoepidermis formed than controls. Conversely, granulocyte colony-stimulating factor promoted contraction and no epidermal regeneration. Early (postwounding Day 3) inflammatory cell infiltration in the SDF-1-treated group was 86% less, while the fraction of proliferating cells (positive Ki67 staining) was 32% more, when compared with controls. These results suggest that SDF-1 simultaneously delays contraction and promotes reepithelialization and may improve the wound-healing performance of skin substitutes