Paulo Tuma Junior

Experience with local negative pressure (vacuum method) in the treatment of complex wounds

CONTEXT AND OBJECTIVE Use of topical negative pressure over difficult-to-heal wounds has been studied. The objective of this study was to analyze the effects from negative pressure in the treatment of complex wounds. DESIGN AND SETTING Case series developed at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. METHODS Twenty-nine patients with complex wounds were treated with the vacuum system and then underwent a surgical procedure to close the wound. RESULTS 85% of the skin grafts took well, and 87.5% of the local flaps were successful, thus demonstrating adequate wound preparation. The wounds were closed within shorter times than observed using other conventional treatments In two cases, the vacuum system was also used to stabilize the skin grafts over the wounds. CONCLUSIONS Use of the vacuum method is safe and efficient for preparing wounds for surgical closure. It allows for an improvement of local wound conditions, and healthy granulation tissue develops with control over local infection.

Atuação da cirurgia plástica no tratamento de feridas complexas

OBJECTIVE: To report the performance of plastic surgery in the treatment of complex wounds in a tertiary hospital, analyzing its characteristics, types of injuries and approaches adopted, with emphasis on surgical treatment. METHODS: We conducted a etrospective analysis of patients with complex wounds treated by plastic surgery in a tertiary hospital in a period of five years (2006 to 2010). Data collection was obtained from visits made, serial assessments and records of the medical charts. RESULTS: There were 1927 patients treated (32 queries / month), mean age 46.3 years, predominantly male (62%). The surgical specialties requested 1076 consultations (56%), and the clinical, 851 (44%). The distribution by type of wound showed predominance of pressure ulcers (635/33%), traumatic wounds (570/30%), complicated surgical wounds (305/16%) and necrotizing wounds (196/10%), with the remainder represented by vasculitis (83 / 4%), venous ulcers (79 / 4%), diabetes (41 / 2%) and post-radiation (18 / 1%). The treatment was surgical in 1382 patients (72%) and non-operative in 545 cases (28%). There were 3029 operations, predominantly debridement (1988/65%) and skin grafting (619/21%) associated or not with negative pressure therapy (vacuum), followed by pedicle flaps (237 / 8 %), digital reimplantation (81 / 3%), microsurgical flaps (66 / 2%) and other (38 / 1%). CONCLUSION: The plastic surgeon played an important role in the treatment of complex wounds by adopting early surgical treatment, contributing to the effective resolution of cases.

Negative pressure therapy (vacuum) for wound bed preparation among diabetic patients: case series

CONTEXT Complications from diabetes mellitus affecting the lower limbs occur in 40 to 70% of such patients. Neuropathy is the main cause of ulceration and may be associated with vascular impairment. The wound evolves with necrosis and infection, and if not properly treated, amputation may be the end result. Surgical treatment is preferred in complex wounds without spontaneous healing. After debridement of the necrotic tissue, the wound bed needs to be prepared to receive a transplant of either a graft or a flap. Dressings can be used to prepare the wound bed, but this usually leads to longer duration of hospitalization. Negative pressure using a vacuum system has been proposed for speeding up the treatment. This paper had the objective of analyzing the effects of this therapy on wound bed preparation among diabetic patients. CASE SERIES Eighty-four diabetic patients with wounds in their lower limbs were studied. A commercially available vacuum system was used for all patients after adequate debridement of necrotic tissues. For 65 patients, skin grafts completed the treatment and for the other 19, skin flaps were used. Wound bed preparation was achieved over an average time of 7.51 days for 65 patients and 10 days for 12 patients, and in only one case was not achieved. CONCLUSIONS This experience suggests that negative pressure therapy may have an important role in wound bed preparation and as part of the treatment for wounds in the lower limbs of diabetic patients.

Influência da imunossupressão na regeneração nervosa com utilização de aloenxertos: Estudo experimental em ratos

PURPOSE: This paper was aimed to study nerve regeneration after allografting using conventional point counting technique. INTRODUCTION:The interest towards nerve allografting has been growing since the recent development of better immunosuppressant drugs. METHODS: Three groups were studied: Group A - Lewis rats receiving nerve grafts from isogenic donors; Group B - Lewis rats receiving nerve grafts from Brown-Norway donor rats and treated with saline solution; Group C - Lewis rats receiving nerve grafts from Brown-Norway donor rats and treated with cyclosporine. Nerve regeneration was evaluated by histological analysis and by histomorphometric studies after 6 and 12 weeks. RESULTS: At 6 weeks, nerve fiber density and the percentage of neural tissue in the immunosupressed allograft group (C) were significantly higher than in group B. Allograft groups (B and C) showed significantly lower nerve fibers density and percentage of neural tissue when compared to the autograft group A at 6 or 12 weeks. CONCLUSIONS: We conclude that the point counting method was simpler to use than the computerized model, and yielded accurate and reproducible results.

Terapia por pressão negativa na ferida traumática complexa do períneo

OBJECTIVE To review the experience (2011 and 2012) of Wound Center of Plastic Surgery Service, Clinics Hospital, Faculty of Medicine, University of São Paulo, with treatment of complex traumatic wounds in the perineal region with the association of negative pressure wound therapy followed by a surgical skin coverage procedure. METHODS This was retrospective analysis of ten patients with complex wound in the perineum resulting from trauma assisted by the Department of Plastic Surgery in HC-USP. Negative pressure was used as an alternative for improving local conditions, seeking definitive treatment with skin grafts or flaps. RESULTS Negative pressure was used to prepare the wound bed. In patients, the mean time of use of negative pressure system was 25.9 days, with dressing changes every 4.6 days. After negative pressure therapy, 11 local flaps were performed in nine patients, with fasciocutaneous anterolateral thigh flap used in four of these. Mean hospital stay was 58.2 days and accompaniment in Plastic Surgery was 40.5 days. CONCLUSION The use of negative pressure therapy led to improvement of local wound conditions faster than traditional dressings, without significant complications, proving to be the current best alternative as an adjunct for the treatment of this type of injury, always followed by surgical reconstruction with grafts and flaps.

Poststernotomy aspergillosis: successful treatment with voriconazole, surgical debridement and vacuum-assisted closure therapy

Aspergillus spp. are ubiquitous in the environment, including the air, soil and decomposing material (1). Human invasive aspergillosis arises from the inhalation and contiguous spread of Aspergillus to adjacent sites (e.g., petrous bone, the sinuses, the palate). Occasionally, human invasive aspergillosis can be the result of the direct extension or hematogenous spread from pulmonary foci or of intravenous drug abuse (1). Invasive aspergillosis typically occurs in immunocompromised patients. Interestingly, some cases of surgical wound infection have been reported in immunocompetent individuals (1). The occurrence of post-operative aspergillosis can be associated with the dissemination of spores in the operating room through the ventilation system, which can lead to the contamination of exposed tissue, the surgical materials, the prosthesis or the wound dressing (1). Deep bone wound infection is a severe complication of coronary artery bypass graft (CABG) surgery. Chronic osteomyelitis is unusual, reported in 1 to 4% of patients, and is most frequently caused by staphylococci (2,3). Aspergillus spp. are rare but recently recognized causes of nosocomial chronic sternal infections, including especially difficult-to-treat cases of osteomyelitis/costochondritis of the sternum (1). The optimal treatment for invasive bone aspergillosis is a combination of surgical treatment and appropriate antifungal therapy. Currently, voriconazole is being advocated for the treatment of invasive aspergillosis (4,5). Herein, we report an unusual and very interesting case of chronic osteomyelitis and costochondritis caused by aspergillosis of the chest wall following cardiac surgery in an immunocompetent patient who was successfully treated with vacuum-assisted closure therapy following surgical debridement and voriconazole therapy.

Avaliação da sensibilidade cutânea em pacientes com síndrome do túnel do carpo relacionada à hemodiálise

OBJECTIVE: Describe the use of the PSSD (Pressure specified sensory Device) for the diagnosis of carpal tunnel syndrome. METHODS: The PSSD is a tool that incorporates a pressure transducer with two prongs, linked to a computer capable of measuring the cutaneous pressure thresholds. The patients were divided in two groups: Group 1- patients neither with superior limb neuropathy nor renal insufficiency. Group 2- patients with carpal tunnel syndrome related to hemodialysis. Group 2 - patients with carpal tunnel syndrome but no renal insufficiency. RESULTS: The results showed, for two of the four parameters measured, that the group 2 had more benefits for the diagnosis of carpal tunnel syndrome than group 3. CONCLUSION: The PSSD is useful as a diagnostic tool in hemodialysis-related carpal tunnel syndrome Level of Evidence: Level II, development of diagnostic.

Subtotal calcanectomy for the treatment of calcaneal pressure sores with associated osteomyelitis: a report of 2 cases

Introduction: Feet wounds are very common and require multidisciplinary approach for prevention, treatment and rehabilitation. When involving the calcaneus, they offer even greater difficulty and may complicate with osteomyelitis. Debridement of devitalized tissue and antibiotics are important steps for treatment. For the reconstruction, local or free flaps are needed. However, not all patients, due to systemic conditions or local blood supply, are not candidates for this type of reconstruction and some times are submitted to amputations. Cases Report: The authors report two cases in which subtotals calcanectomies were used for the treatment of wounds in the calcaneus. In both cases, amputations were avoided.

Prospective study on tactile sensitivity in the hands of a brazilian population using the pressure-specified sensory device

Objective: To evaluate the pressure perception thresholds on the pulp of two fingers (index and little fingers), among a Brazilian population with no nerve injury or neuropathy. Methods: We used the Pressure-Specified Sensory Device (a computerized device) to derive static and dynamic normal pressure perception thresholds and two-point discrimination distances. Results: We tested finger sensitivity on 30 volunteers. Significance analyses were performed using the Student t test. The mean values (g/mm2) for static one and two-point pressure thresholds (s1PD, s2PD) and dynamic one and two-point discrimination (m1PD, m2PD) in the dominant index finger were: s1PD = 0.4, m1PD = 0.4, s2PD = 0.48, m2PD = 0.51. Conclusion: There was no significant difference in sensitivity between the dominant and nondominant hands.

Estudo prospectivo da sensibilidade tátil em mãos de uma população brasileira usando pressure-specified sensory device

OBJETIVO: Avaliar os limiares de percepcao da pressao em polpas de dois dedos (indicador e minimo), em uma populacao brasileira, sem lesao nervosa ou neuropatia. METODOS: Usamos Pressure-Specified Sensory Device, um equipamento computadorizado para obter limiares de percepcao da pressao normal, tanto estaticos quanto dinâmicos, e discriminacao de dois pontos. RESULTADOS: Testamos a sensibilidade nos dedos, em 30 voluntarios. Os testes de significância foram realizados utilizando o teste t de Student. Os valores medios (g/mm2) para os limiares de pressao estatica de um e dois pontos (s1PD, s2PD) e discriminacao dinâmica de um e dois pontos (m1PD, m2PD) no dedo indicador dominante foram: s1PD = 0,4, m1PD = 0,4, s2PD = 0,48, m2PD = 0,51. CONCLUSAO: Nao ha diferenca significativa na sensibilidade entre as maos dominante e nao dominante.