Biomedical subjects
Publications and source records attributed to M C Robson.
The use of tissue expanders in reconstructive surgery has become well established, but their use has been associated with multiple complications. Salvage of expanded tissue after traumatic extrusion of the prosthesis has not been previously reported. We have outlined the principles involved in the management of such a case, and reviewed previously reported complications of tissue expansion.
The theoretical alterations of wound healing caused by infection apply to the clinical situation. The level of bacteria is clinically important as are the specific qualities of a given species. This latter consideration has not been as completely studied as have the quantitative aspects. However, as pharmacologic means of overcoming the wound healing alterations are sought, specific bacterial species' idiosyncrasies will have to be examined. This has already been identified for the beta-hemolytic streptococcus. That species has not adhered to the level of greater than 10(5) organisms to produce wound complications. It has been repeatedly shown to cause wound problems at a much lower inoculum. Similar information may become available for other organisms. However, it is clear that because wound healing in the clinical situation occurs in the presence of bacteria, it is important to be aware of potential alterations in the repair process that these bacteria can cause.
Topical antimicrobial agents are essential to optimal burn care. However, exposure of WI-38 human diploid fibroblasts (ATCC CCL 75) and fresh donor human dermal fibroblasts to silver sulfadiazine and mafenide acetate results in a significant reduction in cell proliferation, as determined by hemocytometer cell counts and total matrix protein assays, within 48 hr of exposure. Changes in cellular morphology and progressive deterioration of cytoplasmic organelles and the nucleus are seen with phase-contrast microscopy and transmission electron microscopy. These findings may explain the clinical observation of delayed wound healing after the use of topical antimicrobial agents.
The following report reviews 851 applications of Biobrane on partial skin thickness burn wounds awaiting epithelialization. After the patients had been evaluated and resuscitated as needed, the burn wounds were cleansed and debrided. Those evaluated as shallow were treated with Biobrane application. Joint surfaces were splinted for immobilization. The wound was inspected at 24 and 48 h and if any fluid had accumulated it was aspirated and the wound was redressed. When the Biobrane was adherent, the wound was covered with a light dressing and joint immobilization was discontinued. Treatment with Biobrane dressing provided certain advantages over other topical wound care. As the dressing changes were performed less frequently outpatient care was possible, with a resultant decrease in both the length of hospital stay and the ultimate cost of burn care. Wound desiccation is prevented and pain is decreased. Accurate diagnosis of wound depth is crucial if Biobrane is to be used. Very deep wounds will not allow Biobrane adherence, neither will it occur if the wound has a high bacterial count. If joint surfaces are not splinted, the Biobrane will shear and not adhere to the wound. Convex and concave surfaces can be treated with Biobrane, which may need to be meshed.
The burn patient initially requires many of the same measures as any other trauma patient. Both depth and surface extent of the burn injury should be evaluated. Evaluation for smoke inhalation is important, since this is prevalent and life-threatening among burn victims. A treatment plan begins with a realistic appraisal of the probability of survival. Once goals of management have been established, treatment is aimed at both physiologic and aesthetic rehabilitation.
Minor burns are common but require early and appropriate care to avoid infection and scarring. Damage can be arrested by immersing the burn in cold water as soon as possible. The goals of care are then to remove dead tissue and protect viable tissue during healing. Very superficial burns require only application of an emollient to limit inflammation and pain and prevent desiccation. Partial-thickness burns that are clean and superficial may benefit from use of a biosynthetic bilaminar membrane dressing, which forms a skin substitute while protecting the wound. A patient with an infected wound or one on a primary area (hands, feet, face, or perineum) may have to be hospitalized to ensure proper care.
The increasing incidence of illicit intravenous drug abuse has reached epidemic proportions in western society. Although the accompanying infectious complications such as hepatitis and acquired immunodeficiency syndrome receive the most notoriety, injection injuries are causing an increasing number of problems. A retrospective review of patients requiring admission for acute or chronic drug injection injuries of the upper extremities was made at the Detroit Receiving Hospital from 1980 through 1985. The demographical, historical, physical, microbiological, and follow-up data were analyzed. The majority of the injuries involved subcutaneous injections into the hand with accompanying inflammatory or infectious complications. The bacteriological data revealed unique characteristics and did not reflect patterns expected from inoculation of normal skin flora. A treatment regimen based on the data is proposed.
Burn wound sepsis can be due to exogenous or endogenous bacteria. When rare organisms cause infection, exogenous sources are implicated. This sets into motion hospital infection control team searches, which are both exhausting and harassing to patients and staff. This study examines the skin bacteria present at admission and the frequency of endogenous infection in burn patients. Sixty-two patients with burns up to 92% of the total body surface area underwent unburned skin bacterial surveillance on admission and at weekly intervals using RODAC contact plates. Burn wounds were biopsied for quantitative and qualitative analyses. Morphologically dissimilar colonies were isolated and identified using standard gram-positive and gram-negative identification strips (Analytab Products, Inc. [API]). On admission, the patients harbored Staphylococcus species, many of which were burn wound sepsis were infected with the same organisms cultured from their unburned skin on admission. A subset of patients (14) grew methicillin-resistant Staphylococcus aureus from their wounds or other sites. A comparison with admission isolates showed identical susceptibilities. These data suggest skin is an endogenous source of infection in the burned patient.
The hospital records of all patients presenting to a large urban trauma center emergency department with facial fractures from 1980 through 1984 were reviewed retrospectively. There were 788 patients in the study group, averaging 1.8 fractures per patient for a total of 1,423 facial fractures. The study population had 638 (80.9%) males and 150 (19.1%) females. Racial mix was 71.6% black, 27.8% white, and 0.6% oriental. The most frequent fracture involved the zygoma (23.6%), followed by the orbital floor (21.4%), maxilla, mandible, and nasal bones. The most frequent etiology was assault with a blunt object or fist (70.1%) followed by motor vehicle accidents (13.5%), falls (9.3%), and gunshot wounds (6.1%). Initial diagnostic procedures included a facial X-ray series in 99.9%, tomograms in 43.1%, and CT studies in 8.1%. Surgical intervention was required in 61.2% of cases. Prosthetic materials were used in 8.5% of the cases. At our institution, personal assault was found to be the primary cause of both midface fractures and mandibular fractures.
Six cases of large defects of the scalp, skull, and dura following tumor ablation and radiation are presented. Each was accompanied by chronic infection in the irradiated defect. Efforts to reconstruct the resulting defects with local flaps were not successful. One-stage reconstruction was then accomplished in each case utilizing a latissimus dorsi musculocutaneous or myo-osteocutaneous free flap transferred by microvascular anastomoses. The versatility of the latissimus dorsi musculocutaneous and/or osseous flap allows single-stage reconstruction of these complex defects.
Long-term follow-up of breast development in adolescent female patients with burns of the anterior chest wall is poorly documented. Between 1971 and 1976, 28 female patients with photographic documentation of burns to the anterior chest wall involving the nipple-areolar complex were reviewed. All patients were followed at least until their early teens. The mean age at the time of thermal injury was 5.9 +/- 2.5 years, with a mean follow-up time of 8.9 +/- 2.6 years. Thirteen patients (46 percent) were admitted to the Shriners Burns Institute in Galveston for acute care of their burns. Fifteen patients (54 percent) were referred for long-term follow-up or specific reconstructive procedures following care of the acute burns. In spite of significant thermal injury to the anterior chest wall with involvement of the nipple-areolar complex, no patient failed to develop breasts. Twenty patients (71 percent) required releases of the anterior chest wall to assist breast development. All anterior chest wall releases were accomplished with the use of skin grafts or local skin flaps.
To achieve optimal hand function, wound closure becomes the most important ingredient in hand burns. This study documents the use of a biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. The glove allowed rapid active motion and minimized the pain of open wounds. Forty-two Biobrane glove applications were evaluated with 50 per cent applied over superficial hand burns and 50 per cent over deep partial thickness or full thickness injuries. In the superficial hand burns, the patients were discharged home after a mean time of 2.8 days. With the deep burns the dressing provided a closed wound after early excision of eschar without the use of an autograft or biological dressing. Based on these studies, we conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.
Wound healing disturbances can be systemic or local. Systemic disturbances at this point can be diagnosed but not necessarily treated. In the future, these disturbances may be reversed with a specific drug. More importantly, local factors responsible for most of the disturbances in wound healing seen in the emergency department are often under the control of the physician. These can be diagnosed and, frequently, corrected.
We have devised an algorithm employing the exclusive use of biosynthetic dressing (Biobrane) to treat the less extensive burn wounds of patients under DRG 460. This protocol has allowed us to decrease the hospital stay of these patients by 46 percent and turn this patient group from a deficit for the hospital to a substantial profit.
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Sepsis in the burned individual can arise from multiple causes. However, the unique source is the burn wound itself. It is clear that health is association with maintenance of a bacterial equilibrium in the wound and that infection is a result of an imbalance in favor of the bacteria. The primary host defense mechanism, an intact epithelial barrier, has been lost at the time of burning. A portal of entry has been created, and the bactericidal defenses have been neutralized. All of the host defense mechanisms associated with inflammation are evoked but may be limited by the avascular isolation of much of the wound. In addition to alteration in vascular response associated with the burns, there are adverse changes in the neutrophils themselves. The alterations in nutrition that may follow burn injury further reduce systemic host resistance. Associated diseases, such as diabetes, may present a further hazard. All of the local factors influencing host resistance are adversely affected in the burn wound. There is necrotic tissue, decreased local tissue perfusion, and loss of the mechanical barrier. Quantitative techniques have demonstrated that bacteria are present in the depths of the wound from the time of injury. Infection and burn wound sepsis are clearly represented by the quantitative increase in bacteria to numbers exceeding 10(5) per gram of tissue. In no other instance has the importance of the "amphibiont" organisms been more clearly demonstrated than in the burn wound. Today's nonpathogen has all too often become tomorrow's killer. As therapeutic control becomes effective against the current organism, the ecologic void is filled by another, which, by definition, is resistant to the treatment being employed.
As experience with digital replantation increases, preoperative factors affecting outcome are being identified. Injury type, injury cause, ischemia time, and zone of injury have previously been reported. In addition, this report analyzes the effect of injury pattern and surgical group upon outcome. This data implies a multi-factor effect on the viability of replanted/revascularized parts. The lack of thorough reporting of the factors may account for the variability seen in success rates of various centers. An injury-injury type-injury level-ischemia time classification scheme has been proposed to standardize the reporting and the discussing of amputation/devascularization injuries. In clear cut situations, injury pattern may simply reflect type of injury (e.g. avulsion); however, in those situations where the mechanism is unclear, injury patterns may provide prognostic variables valuable in predicting replant viability. Further, a multi-group, multi-surgeon service functioning within a hospital may have results comparable to those of a single surgeon or single group practice.
There has been experimental information suggesting that iatrogenic anemia may improve the survival of pedicled free flaps. This has been attributed to a decrease in blood viscosity secondary to hemodilution. The hemoglobin (Hb) and hematocrit (Hct) levels of 14 successful and 6 failed free flaps at the time of operation, during hospitalization, and at discharge are reviewed. There was no difference in Hb or Hct levels between successful and failed flaps. Reconstruction of traumatic defects showed an increased risk of failure. If flaps survived longer than 10-14 days, they were unlikely to fail subsequently. In conclusion, Hb and Hct levels in clinically acceptable ranges have no effect on free flap survival.