Traumatic wound difficult to heal: use of negative pressure therapy: case report

The skin is one of the largest organs of the anatomy. It is the barrier between the exterior and the first line of defense against aggression. A wound is a loss of continuity of the soft parts of the organism generating an interruption in the structure of the tissue, as a consequence of this loss of continuity, there is a loss of sterility existing inside and infection can occur. Another consequence of discontinuity are possible lesions in adjacent tissues or organs. Trauma results in complex wounds that are difficult to manage due to large skin loss or avulsion of large areas of tissue. Among the factors that can prevent proper healing can be systemic (malnutrition, chemotherapy, steroids) or local (infection, prosthetic material, bone exposure). Among the therapeutic options for complex wounds is negative pressure therapy which generates wound contraction, stabilization of the environment, reduction of edema, removal of exudate and micro-deformations of the surface, increase of angiogenesis, granulation tissue formation and decreased bacterial count. We described a clinical case of traumatic injury at the level of the right pelvic limb in a 70-years-old woman with diabetes and hypertension, in which surgical washing was performed, debridement and use of negative pressure therapy with adequate evolution in a second level public hospital.

Comparison of the characteristics and outcomes of traumatic wound dehiscence after penetrating or Lamellar Keratoplasty for Keratoconus

Purpose: To examine the incidence, causes, characteristics, and the visual outcome of traumatic wound dehiscence (TWD) after penetrating keratoplasty (PK) compared to lamellar keratoplasty (LKP) for keratoconus. Methods: The medical records of all keratoconus patients undergoing TWD repair after PK or LKP over a 7-year period at the King Khaled Eye Specialist Hospital (KKESH), Riyadh were reviewed. Data were collected on patient demographics, interval between keratoplasty and trauma, and characteristics and visual outcomes of TWD. Results: During January 2006 to December 2012, 2863 eyes in KKESH underwent PK. Another 1716 eyes underwent LKP. Of these, 55 (1.9%) and 30 (1.7%) sustained TWD, respectively ( p = 0.675). Approximately two-thirds of patients with traumatic wound dehiscence (TWD) were males in both groups (63.6% and 70.0%, respectively). The mean age at trauma was 24.6 ± 6.7 years (range 12–41 years) in the PK group compared with 22.6 ± 6.0 years (range 13–34 years) in the LKP group ( p = 0.166). The median interval between keratoplasty and trauma was 6.2 (the interquartile range (IQR), 10.9) months for the PK group and 4.6 (IQR, 7.4) months for the LKP group ( p = 0.116). At the last follow-up after wound repair, visual acuity was similar between the PK and LKP groups ( p = 0.595). Conclusion: In our study, the incidence of TWD after PK and LKP in patients with keratoconus was within the previously reported range of values. All patients undergoing these procedures, especially males, should receive adequate information regarding this lifelong risk, and the need for protective eye-wear and seeking early medical advice when complications occur.

1269. Infection, Clinical Syndromes and Antimicrobial Resistance by Aeromonas species: 13-Year Experience with an Emerging Pathogen at a Tertiary Care Center

Background Aeromonas spp. are emerging pathogens that cause a wide breadth of clinical syndromes, ranging from acute gastroenteritis to skin and soft tissue infections, sepsis, and “flesh-eating” necrotizing fasciitis. Aeromonads have been associated with natural disasters and have predominance in estuarine ecosystems, generating a negative impact on the fishing industry and aquaculture, as well as morbidity and mortality in human populations at risk. Antimicrobial resistance patterns differ by geographic locations worldwide, and studies to guide the therapy in the era of multidrug resistance are lacking in the US. Methods A retrospective case series was designed to chart review all adult subjects who had culture proven Aeromonas spp. infections during the period 2008-2020. Demographic data, water exposure, clinical syndromes on presentation, origin (community-acquired vs. nosocomial) and severity of infection, antibiograms, empirical antibiotics, time-to-appropriate therapy, and treatment outcomes were collected. Results Eighty-two subjects were included in the analysis. Demographic and clinical data is summarized in Table 1. Near 20% individuals had water exposure, including 53% of those with traumatic wound infections. Skin and soft tissue infection (including traumatic and surgical wound infections) was the most frequent clinical syndrome (51.2%). Sepsis was present on admission in 33% inpatients. Appropriate antibiotics were instituted in a median of 2 days (IQR=1-5), and the most prescribed empiric agents were piperacillin-tazobactam (48%) and meropenem (13.3%). Most isolates were susceptible to cefepime (70/71, 98.6%), levofloxacin (72/78, 92.3%) and TMP-SMX (69/78, 88.5%). Resistance to meropenem was reported in 18/31 isolates (58.1%) after 2015. Treatment failure was identified in 32.3% cases. Most cases (55%) were encountered during the months of spring and summer, which have warmer temperatures and seasonal heavy rains. Tropical storms caused significant flooding in the Galveston Bay area and Southeast Texas during the summer of 2015, which interestingly coincides with the high number of cases. However, following Hurricane Ike in 2008 or Hurricane Harvey in 2017, the number of cases did not significantly increase. Conclusion Aeromonads are emerging pathogens that cause mainly intraabdominal and skin and soft tissue infections. Their incidence is seasonal (55% cases in spring and summer) and it is associated with water exposure in more than half of those with traumatic wound infections. In subjects with specific risk factors, the use of carbapenem-sparing strategies, such as 3rd or 4th generation cephalosporins, fluoroquinolones or TMP-SMX, may improve outcomes. Disclosures All Authors: No reported disclosures

1574 Does Use of Intra-Operative PPE Affect Post-Operative Infection Rates in Hip Fracture Patients?

Aim COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Method Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (<30-days post-op) from 18/03/20 to 27/04/20 with respective period in 2019. COVID-19 was considered endemic in Northern Ireland from 18/03/20. Patients were identified from the Fracture Outcomes Research Department database and relevant inpatient episode reviewed via Electronic Care Record. Results 464 patients were included– 261(2020) and 203(2019). In 2019, 4 patients (1.5%) returned to theatre within 30-days, however only one was due to wound dehiscence. In 2020, 1 patient (0.5%) returned to theatre for traumatic wound dehiscence, however they had no documented infection. Conclusions There was no difference in post-operative complication rate requiring return to theatre within 30 days between cohorts. Whilst PPE can be considered important for protection of patients and staff against COVID-19, it may not have significant effect on post-operative infection rates.

Preprocedural intravenous Ibuprofen for post-repair pain relief after traumatic wound management: A randomized Clinical Trial

Introduction: Wound repair may cause extra pain and inflammation leading to post-repair discomfort. Previous studies showed that Pre-operative use of NSAIDs may reduce pain after surgery but data on traumatic wound repair are lacking. Methods: This is a double-blind randomized controlled trial. Based on inclusion and exclusion criteria, 194 participants were randomly assigned to either intervention or control groups. In the intervention group Ibuprofen 800 mg in 100 cc normal saline infused before wound repair while the control group received 100 cc normal saline. Numeric pain scores were recorded at the beginning of wound repair and 30 minutes after that. Patients’ satisfaction with analgesia was also recorded 15 minutes after drug infusion, during wound repair, and 6 hours after wound repair. Results: Mean pain scores during wound repair, before local anesthesia with lidocaine, were similar in both groups mean pain score 30 minutes after the repair was significantly lower in patients who received Ibuprofen, 3.86±1.93 vs 4.46±1.89 (p=0.043). Patients’ satisfaction with pain management 6 hours after wound repair was higher in the intervention group (p=0.000). Conclusion: use of IV Ibuprofen before wound repair can reduce pain score after repair and is accompanied by improved patients’ satisfaction.

Increased risk of periprosthetic joint infection after acute, traumatic wound dehiscence following primary total knee arthroplasty

Aims To describe the risk of periprosthetic joint infection (PJI) and reoperation in patients who have an acute, traumatic wound dehiscence following total knee arthroplasty (TKA). Methods From January 2002 to December 2018, 16,134 primary TKAs were performed at a single institution. A total of 26 patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68 years (44 to 87), 38% (n = 10) were female, and mean BMI was 34 kg/m2 (23 to 48). Median time to dehiscence was 13 days (interquartile range (IQR) 4 to 15). The dehiscence resulted from a fall in 22 patients and sudden flexion after staple removal in four. The arthrotomy was also disrupted in 58% (n = 15), including a complete extensor mechanism disruption in four knees. An irrigation and debridement with component retention (IDCR) was performed within 48 hours in 19 of 26 knees and two-thirds were discharged on antibiotic therapy. The mean follow-up was six years (2 to 15). The association of wound dehiscence and the risk of developing a PJI was analyzed. Results Patients who sustained a traumatic wound dehiscence had a 6.5-fold increase in the risk of PJI (95% confidence interval (CI) 1.6 to 26.2; p = 0.008). With the small number of PJIs, no variables were found to be significant risk factors. However, there were no PJIs in any of the patients who were treated with IDCR and a course of antibiotics. Three knees required reoperation including one two-stage exchange for PJI, one repeat IDCR for PJI, and one revision for aseptic loosening of the tibial component. Conclusion Despite having a traumatic wound dehiscence, the risk of PJI was low, but much higher than experienced in all other TKAs during the same period. We recommend urgent IDCR and a course of postoperative antibiotics to decrease the risk of PJI. A traumatic wound dehiscence increases risk of PJI by 6.5-fold. Cite this article: Bone Joint J 2021;103-B(6 Supple A):191–195.

SUTURE MATERIALS AND SUTURE TECHNIQUES IN AYURVEDA – A REVIEW ARTICLE

Seevan Karma (suturing) is the closing method of surgical or traumatic wound and also last step of every operative procedure. Among these Seevan Karma of prime importance as appropriate suturing with specified thread and nee- dle leads to fast wound healing and minimized scar formation after surgery. Acharya Sushruta described the basic tents of experimental operative surgery for surgical training. The great need of such a training and describes the methods of experimental surgery using artificial objects (Non-living things) for learning the operative procedure like suturing2. In suturing or Seevan Karma using appropriate principals and instrument also describing the indica- tion, contraindication and method (Poorva Karma – preoperative procedure, Pradhan Karma- main procedure, Paschat Karma- post suturing procedure). Keywords: Seevan Karma, Sutra, Needle, Kartari

Cork cells in cork oak periderms undergo programmed cell death and proanthocyanidin deposition

Vascular plants with secondary growth develop a periderm mostly composed of dead suberized cork cells to face environmental hostile conditions. Cork oak has a highly active and long-living phellogen forming a remarkably thick periderm that is periodically debarked for industrial purposes. This wounding originates the quick formation of a new traumatic periderm, making cork oak an exceptional model to study the first periderm differentiation during normal development in young sprigs and traumatic (wound) periderm formation after debarking. Here, we studied the poorly known first periderm differentiation steps that involve cell wall suberization, polyphenolic accumulation and programmed cell death (PCD) by combining transmission electron microscopy, histochemical and molecular methods in periderms from young sprigs. These processes were further compared with traumatic periderms formed after wounding using molecular and histochemical techniques, such as the polyphenolic accumulation. In the first periderms from young sprigs, four distinct differentiation stages were defined according to the presence of PCD morphological features. First young and traumatic periderms showed an upregulation of genes related to suberin biosynthesis, proanthocyanidins biosynthesis and transport, autophagy, and PCD. Traumatic periderms revealed an overall upregulation of these genes, likely resulting from ontogeny differences and distinct phellogen origin associated with a faster metabolism, highlighting the impact of wounding on phellogen activity after debarking. First periderms from young sprigs showed gradual accumulation of proanthocyanidins in the vacuoles throughout PCD stages until total filled lumens, whereas in traumatic periderms, these compounds were found cell wall linked in already empty cells. This work enabled a comprehensive overview of the cork cells differentiation processes contributing to deepening the knowledge of the fundamental ontogenic program of this protective tissue, which is also a unique forest product, constituting the basis of a sustainable and profitable industry.