Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon’s armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound’s “chronicity” on its healing, comparing the mean graft take only in “acute” wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

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643 The Use of Topical Exogenous Nutrient Supplementation to Improve Graft Take on an Avascular Wound Bed

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.263 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S167-S168

Author(s):

Laura Cooper ◽

Phillip Kemp Bohan ◽

Anders H Carlsson ◽

Rodney K Chan ◽

Tyler Everett

Keyword(s):

Graft Survival ◽

Skin Graft ◽

Skin Grafting ◽

Dermal Substitute ◽

Skin Grafts ◽

Pressure Therapy ◽

Nutrient Supplementation ◽

Successful Model ◽

Dermal Substitutes ◽

Graft Take

Abstract Introduction Skin graft survival relies on imbibition, inosculation, and revascularization from the wound bed. When a wound bed is poorly vascularized, as in the case of exposed fascia, tendon or bone, skin grafting may be delayed until the wound bed improves. We propose that topical nutrient supplementation may be able to increase take of skin grafts applied over an avascular wound bed. Methods Twenty full-thickness 5cm-diameter wounds were created on the dorsum of anesthetized swine and a dermal substitute (0.4mm, 0.8mm, 1.2mm, or 1.6mm thick) was placed on each wound. Negative pressure therapy with and without intermittent (3x per day) saline instillation was applied. Wounds were analyzed using a non-contact 3D camera at day 7 and day 14. Results Dermal substitutes of 0.8mm, 1.2mm, and 1.6mm thicknesses inhibited graft take significantly (p< 0.01, p=0.02, p< 0.01, respectively) for all wounds treated with wound vac alone. Addition of the normal saline instill showed a significant improvement in graft take (p=0.03) over wound vac alone for the wounds treated with the 0.8mm dermal substitute. Wounds covered with 1.2mm and 1.6mm dermal substitute continued to show significantly decreased graft take (p=0.03 and p=0.02, respectively). Wounds with 0.4mm dermal substitute showed similar graft take to control for both the wound vac and wound vac + instill treatments. Conclusions Dermal substitutes ≥0.8mm create a successful model of an avascular wound bed. Vac + instill treatment overcame the impedance of an avascular wound bed only for the 0.8mm dermal substitute thickness. This thickness of dermal substitute creates an ideal avascular wound bed model from which to conduct further studies incorporating topical nutrients instilled directly onto skin grafts placed onto avascular wound beds. Applicability of Research to Practice Single-stage skin grafting procedures onto avascular wound beds may become feasible with topical nutrient supplementation providing the environment to maintain graft survival until the wound bed is able to support the skin graft.

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The The Effectiveness of Amniotic Membrane as Skin Graft Fixator and Graft Take Accelerator, a Clinical Research Study

Kurdistan Journal of Applied Research ◽

10.24017/science.2016.1.1.8 ◽

2016 ◽

Vol 1 (1) ◽

pp. 70-75

Author(s):

Dana A Abdilkarim

Keyword(s):

Skin Graft ◽

Amniotic Membrane ◽

Graft Loss ◽

Fetal Membrane ◽

Skin Substitutes ◽

Burned Skin ◽

Graft Take ◽

Innermost Layer ◽

Skin Healing ◽

A Prospective Study

The amnion is a thin semi-transparent tissue forming the innermost layer of the fetal membrane. It has been claimed to be one of the most effective biological skin substitutes used in burn wounds, with efficiency of maintaining low bacteria count.This study was set to evaluate the effectiveness of amniotic membrane as skin graft fixator and graft take accelerator.This work is a prospective study carried out in Burns and Plastic Surgery Hospital in Sulaimani for period from 1st of April to end of August 2015 on convenient sample of 33 burned patients.Mean age of burned patients was 24±19 years, Most (93.9%) of burned patients were treated by covering raw area with meshed SSG and only two patients were treated by covering with sheet SSG. Most (90.9%) of burned patients who had treated with covered SSG had taken in comparison with non-covered SSG with amniotic membrane. Postoperative complications for skin areas treated with covered technique were 3; graft loss due to infection, graft loss due to shearing and graft loss due to hematoma.Amniotic membrane induces the graft take among burned skin and fastening the skin healing with fewer complications.

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Outcome of successful graft take of Integra and split thickness skin graft after the release of post-burn neck contracture.

The Professional Medical Journal ◽

10.29309/tpmj/2021.28.01.4668 ◽

2021 ◽

Vol 28 (01) ◽

pp. 106-112

Author(s):

Abdul Malik Mujahid ◽

Fraz Ahmed Tarar ◽

Farrukh Aslam Khalid ◽

Yawar Sajjad ◽

Usman Ishaque ◽

...

Keyword(s):

Skin Graft ◽

Reconstructive Surgery ◽

Case Series ◽

Scar Tissue ◽

Split Thickness Skin Graft ◽

Skin Staples ◽

Graft Take ◽

Thickness Skin ◽

Insignificant Difference ◽

The Mean

Objective: To determine the frequency of the successful graft take of Integra™ and split thickness skin graft after the release of post-burn neck contracture. Study Design: Descriptive Case Series. Setting: Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Lahore. Period: 1st October, 2017 to 30th September, 2018. Material & Methods: A total of 70 cases, those who full filled the inclusion criteria were included in the study through non-probability consecutive sampling. Informed consent was obtained from all the patient. Integra was applied in all the patients after the release of contracture and excision of scar tissue and was inspected every 3-5 days. After 3 weeks, the outer layer of silicone sheet was removed and replaced by thin split-thickness skin graft. The graft was secured with skin staples, absorbent gauze and the crepe bandage. All the patients were followed up regularly and the final outcome was assessed at 6 weeks. Results: The mean age of the patients was observed as 34.51 ± 14.19 years with age range of 11to 59 years. Among these 70 patients 61.4% were male and 38.6% were females. The mean body mass index was observed to be 22.59 + 3.68 kg/m2. Out of these 70 patients, the outcome in terms of successful graft take with Integra treatment was achieved in 60 (85.7%) patients. On stratification, statistically insignificant difference was observed for the effect modifiers like age, gender and BMI. Conclusion: In our study we found that Integra and STSG can be considered as one of emerging and promising modality in burn management and reconstructive surgery with the significantly high success rate in terms of complete re vascularization and skin graft take.

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Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review

Journal of Neurosurgery ◽

10.3171/2019.5.jns19227 ◽

2020 ◽

Vol 133 (3) ◽

pp. 830-838 ◽

Cited By ~ 1

Author(s):

Andrea Franzini ◽

Giuseppe Messina ◽

Vincenzo Levi ◽

Antonio D’Ammando ◽

Roberto Cordella ◽

...

Keyword(s):

Neuropathic Pain ◽

Lower Limb ◽

Internal Capsule ◽

Posterior Limb ◽

Vas Score ◽

The Mean ◽

Deep Brain ◽

Stimulation Of

OBJECTIVECentral poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.METHODSClinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.RESULTSFour patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8–10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0–6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3–8). The mean percentage of long-term pain reduction was 38.13%.CONCLUSIONSThis series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.

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Digital volumetric measurements based on 3D scans of the lower limb: A valid and reproducible method for evaluation in lymphedema therapy. (Preprint)

10.2196/preprints.16923 ◽

2019 ◽

Author(s):

Daniel Schiltz ◽

Natalie Kiermeier ◽

Dominik Eibl ◽

Christoph Koch ◽

Karolina Müller ◽

...

Keyword(s):

Lower Limb ◽

Lower Leg ◽

T Test ◽

Volume Changes ◽

Quick Method ◽

Reproducible Method ◽

The Mean ◽

3D Scans ◽

Paired T Test ◽

Volumetric Measurements

BACKGROUND Exact quantification of volumetric changes of the extremities is difficult. There are several direct and indirect methods to assess extremity volume. As water displacement volumetry is rarely viable in a clinical setting and circumference measurements are prone to errors due to poor reproducibility and high inter- and intra-observer variability, an objective and easily reproducible method is indispensable. OBJECTIVE The aim of this study was to establish a standardized method based on 3D scans with defined caudal and cranial landmarks of the lower leg which allows for measurements of exactly the same body area. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema. METHODS 3D-scans of the lower limb were performed with a mobile 3D-scanner. Volumetric calculation was done digitally. “Repeatability“ and “Inter-observer reliability” of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema. ANOVA (analyses of variance) was conducted to compare the digital volumetric measurements. To assess the sensitivity to changes in digital volumetry, the mean volume of 31 patients before and 3 months after therapy were compared by a paired t-Test. RESULTS Calculations of repeatability of the volume based on 20 3D-scans of the same lower leg showed a mean volume of 2,488 ± 0,011 liters (range: 2,470 – 2,510). The mean volume of the 7 measurements of the 3 examiners did not differ significantly (F(2,18) = 1,579, p = .233). The paired t-Test showed a significant mean volume decrease of 375ml (95% CI = 245/505ml) between pre and post treatment (t (30) =5,892, p < .001). CONCLUSIONS 3D-Volumetry is a noninvasive, easy and quick method to assess volume changes of the lower leg. Other than the costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

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Dynamic Asymmetries Do Not Match Spatiotemporal Step Asymmetries during Split-Belt Walking

Symmetry ◽

10.3390/sym13061089 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1089

Author(s):

Stefano Scarano ◽

Luigi Tesio ◽

Viviana Rota ◽

Valeria Cerina ◽

Luigi Catino ◽

...

Keyword(s):

Lower Limb ◽

Step Length ◽

Centre Of Mass ◽

Mean Velocity ◽

Rehabilitation Research ◽

Joint Dynamics ◽

Stance Time ◽

After Effect ◽

The Mean ◽

Step Parameters

While walking on split-belt treadmills (two belts running at different speeds), the slower limb shows longer anterior steps than the limb dragged by the faster belt. After returning to basal conditions, the step length asymmetry is transiently reversed (after-effect). The lower limb joint dynamics, however, were not thoroughly investigated. In this study, 12 healthy adults walked on a force-sensorised split-belt treadmill for 15 min. Belts rotated at 0.4 m s−1 on both sides, or 0.4 and 1.2 m s−1 under the non-dominant and dominant legs, respectively. Spatiotemporal step parameters, ankle power and work, and the actual mean velocity of the body’s centre of mass (CoM) were computed. On the faster side, ankle power and work increased, while step length and stance time decreased. The mean velocity of the CoM slightly decreased. As an after-effect, modest converse asymmetries developed, fading within 2–5 min. These results may help to decide which belt should be assigned to the paretic and the unaffected lower limb when split-belt walking is applied for rehabilitation research in hemiparesis.

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A SIMPLE BOLSTERING METHOD FOR OPTIMIZING SKIN GRAFT TAKE ON THE SHAFT OF THE PENIS

Plastic & Reconstructive Surgery ◽

10.1097/01.prs.0000188843.64055.a4 ◽

2005 ◽

Vol 116 (6) ◽

pp. 1835-1836 ◽

Cited By ~ 2

Author(s):

Robert E. H. Ferguson ◽

Cameron S. Schaeffer

Keyword(s):

Skin Graft ◽

Graft Take

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Word Associations and Meaningfulness Values for Grade-School-Aged Children

Psychological Reports ◽

10.2466/pr0.1964.15.2.447 ◽

1964 ◽

Vol 15 (2) ◽

pp. 447-455 ◽

Cited By ~ 4

Author(s):

Sydelle Stone Shapiro

Keyword(s):

Word Association ◽

Rank Order ◽

Group Analysis ◽

The Other ◽

Grade School ◽

Word Associations ◽

Significant Agreement ◽

School Aged Children ◽

The Mean ◽

Group Sex

Multiple word associations to 65 words, 52 of which were CVCs, were obtained from 100 boys and 100 girls in Grades 4, 6, and 8, aged respectively, 9 and 10, 11 and 12, 13 and 14. Conventional word-association norms were developed for each of these grade-sex groups for first, second, and third responses, separately and pooled. Meaningfulness values for each word, defined as the mean number of associations, were also determined for each group. Analysis of the primaries disclosed that approximately half the set of words had primaries which were the same across all groups and that such primaries were on the average of much higher frequencies than primaries which differed among groups. Primaries which differed among groups very often occurred as secondaries or tertiaries of the other groups. Frequency of primaries did not vary between sexes or across grade-age levels. While m values for the set of words increased with grade and age, the rank ordering of these values was essentially the same within each grade-age-sex group. Sex was not related to m values. Values of m when compared with Noble's m′ showed significant agreement both for rank-order comparisons and values dichotomized into high and low categories.

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Bioelectrical Impedance Analysis of Water Reduction in Lower-Limb Lymphedema by Lymphaticovenular Anastomosis

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1675368 ◽

2018 ◽

Vol 35 (04) ◽

pp. 306-314 ◽

Cited By ~ 3

Author(s):

Yoshichika Yasunaga ◽

Daisuke Yanagisawa ◽

Erika Ohata ◽

Kiyoshi Matsuo ◽

Shunsuke Yuzuriha

Keyword(s):

Lower Limb ◽

Bioelectrical Impedance Analysis ◽

Linear Regression Analysis ◽

Reduction Rate ◽

Bioelectrical Impedance ◽

Impedance Analysis ◽

Body Water ◽

Volume Reduction ◽

Water Volume ◽

The Mean

Background Although lymphedema is fundamentally abnormal accumulation of excess water in the extracellular space, previous studies have evaluated the efficacy of physiological bypass surgery (lymphaticovenular anastomosis [LVA]) for lymphedema without measuring water volume. This study clarified the water reductive effect of LVA using bioelectrical impedance analysis (BIA). Methods The efficacy of LVA for unilateral lower-limb lymphedema was evaluated using BIA in a retrospective cohort. The water volume of affected and unaffected legs was measured using multifrequency BIA before and after LVA. Preoperative measurements were undertaken after compression therapy for at least 3 months. The follow-up period after LVA was a minimum of 6 months. Results Thirty consecutive patients with unilateral lower-limb lymphedema were enrolled. The mean water volume reduction of the affected leg by LVA (ΔLBW) was 0.86 L (standard deviation [SD]: 0.86, median: 0.65) with a mean number of 3.3 anastomoses (SD: 1.7). The mean reduction rate of edema was 45.1% (SD: 36.3). Multiple linear regression analysis revealed water volume difference between the affected and unaffected legs before LVA (excess LBW) as the strongest predictor of ΔLBW (R 2 = 0.759, p < 0.01; β = 0.500, p < 0.01). Conclusion The LVA reduces the volume of accumulated body water in lower-limb lymphedema. As excess LBW most strongly predicted the amount of water volume reduction by LVA, body water volume measurement by BIA before LVA might identify patients with low excess LBW not expected to benefit from LVA, regardless of apparent differences in limb circumference.

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Efficacy of intrathecal midazolam on enhancing analgesic effect of fentanyl in patients undergoing lower limb surgery

Biomedical Research and Therapy ◽

10.15419/bmrat.v5i10.487 ◽

2018 ◽

Vol 5 (10) ◽

pp. 2726-2732

Author(s):

Masoum Khoshfetrat ◽

Sima Davarpanah ◽

Aliakbar Keykha

Keyword(s):

Nerve Block ◽

Lower Limb ◽

Analgesic Effect ◽

Synergistic Effects ◽

Sensory Nerve ◽

Study Groups ◽

The Third ◽

Significant Difference ◽

Lower Limb Surgery ◽

The Mean

Background: Co-administration of drugs with synergistic effects is considered as one of the methods to increase the effectiveness of intrathecal anesthesia and to reduce the need for injectable analgesics. The purpose of this study was to investigate the efficacy of intrathecal midazolam on enhancing the analgesic effect of fentanyl in patients undergoing lower limb surgery. Materials: The present double-blinded clinical trial was conducted on 90 candidate patients undergoing lower limb orthopedic surgery in 2017 at Khatam-Al-Anbiya Hospital in the city of Zahedan, Iran. To this end, the patients were selected via convenience sampling method and then randomly divided into three groups. Afterwards, 3 cc of 0.5% hyperbaric Marcaine was injected intrathecally in the first group, 3 cc of Marcaine + 25 ug of fentanyl was administered to the second group, and 3 cc of Marcaine + 25 ug of fentanyl + 1 mg of midazolam was administered to the third group (the final volume of all three syringes was brought up to 3.7 cc with normal saline). The duration of sensory nerve block and those of motor block and analgesia, as well as changes in vital signs, were then measured in these groups. Moreover, the data were analyzed using SPSS Statistics (Version 22.0) through Chi-square test and one-way analysis of variance (ANOVA). Results: The mean age and gender distribution of the patients in the three study groups did not differ significantly. The mean duration of sensory nerve block was equal to 98.6+/-11.1 min in the first group, 142.2+/-12.4 min in the second group, and 174.3+/-10.9 min in the third group; all showed a statistically significant difference (P=0.0001, P=0.001, P=0.000).The mean duration of analgesia was also reported to be 204.43+/-0.3 min in the first group, 323.62+/-7.4 min in the second group, and 526.22+/-0.9 min in the third group, indicating a statistically significant difference between the three study groups (P=0.0001, P=0.000, P=000). Conclusion: The results of this study demonstrated that adding midazolam to intrathecal fentanyl could significantly increase the duration of sensory nerve block and that of post-operative analgesia.

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