Steven E.R. Hovius

A review of topical negative pressure therapy in wound healing: sufficient evidence?

BACKGROUNDnTopical negative pressure (TNP) therapy has become a useful adjunct in the management of various types of wounds. However, the TNP system still has characteristics of a black box with uncertain efficacy for many users. We extensively examined the effectiveness of TNP therapy reported in research studies.nnnDATA SOURCESnA database search was undertaken, and over 400 peer-reviewed articles related to the use of TNP therapy (animal, human, and in vitro studies) were identified.nnnCONCLUSIONSnAlmost all encountered studies were related to the use of the commercial VAC device (KCI Medical, United States). Mechanisms of action that can be attributed to TNP therapy are an increase in blood flow, the promotion of angiogenesis, a reduction of wound surface area in certain types of wounds, a modulation of the inhibitory contents in wound fluid, and the induction of cell proliferation. Edema reduction and bacterial clearance, mechanisms that were attributed to TNP therapy, were not proven in basic research.

The role of topical negative pressure in wound repair: Expression of biochemical markers in wound fluid during wound healing

The clinical effects of topical negative pressure therapy (TNP) on wound healing are well described in numerous articles. While the mechanism(s) of action are not completely understood, it is postulated that reduction of local and interstitial tissue edema, increased perfusion of the (peri‐) wound area, changed bacterial composition, and mechanical stimulation of the woundbed contribute to the clinical success. Our hypothesis is that with the removal of excessive fluid, proteolytic enzymes negatively influencing the healing process are removed. Our aim was to assess whether the concentrations of albumin, matrixmetalloproteinase‐9 (MMP‐9), and tissue inhibitor of metalloproteinase (TIMP‐1) were different between wounds treated with TNP and conventional gauze therapy. We analyzed wound fluid samples of 33 wounds treated with either TNP therapy (n=15) or conventional therapy (n=18) on albumin, pro‐ and activated MMP‐9, TIMP‐1, and the ratio of total MMP‐9/TIMP‐1. Albumin levels were found to increase significantly in acute wounds compared with chronic wounds; however, no difference could be found on comparing TNP with conventional therapy. We did find significantly lower levels of pro‐MMP‐9 and lower total MMP‐9/TIMP‐1 ratio in TNP‐treated wounds during the follow‐up of 10 days. These data strongly suggest that TNP therapy influences the microenvironment of the wound.

Outcome of Hand Trauma: The Hand Injury Severity Scoring System (HISS) and Subsequent Impairment and Disability

This study was designed to evaluate correlations between the hand injury severity scoring system (HISS) and measures of impairment and disability obtained 6 months after a hand injury. A statistically significant positive correlation was found between the severity of the injury (HISS) and residual impairment, as measured with the American Medical Association’s (AMA) “Guides to the evaluation of permanent impairment, 4th edition”. No statistically significant correlation was found between the severity of the injury (HISS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, which measures disability from the patient’s perspective. There was however a statistically significant correlation between AMA total body impairment measured and the results of the DASH questionnaire. The results indicate the potential of the HISS for predicting the final impairment after hand injuries.

Is the pectoralis myocutaneous flap in intraoral and oropharyngeal reconstruction outdated

METHODSnOur experience with 224 immediate pectoralis major myocutaneous flap reconstructions in patients with carcinomas of the oral and oropharyngeal cavities is presented.nnnRESULTSnAlthough flap-related complications developed in 53% of the patients, all flaps survived, and we had no major skin paddle loss. The incidence of reoperation due to flap-related complications was 2%. All other complications were minor and did not affect the length of hospitalization. Analysis showed no significant risk factors for the development of complications. Because of fistula formation, infection, or metal exposure, plate removal was necessary in 10% of the AO fixation plates used in cases of mandibular swing. This occurred in 68% of the anterior and 22% of the lateral mandibular reconstructions performed with a reconstruction plate (P < 0.05).nnnCONCLUSIONSnWe conclude that a reconstruction plate is unsatisfactory for anterior mandibular continuity reconstruction and debatable for lateral mandibular reconstruction. At present, anterior defects are reconstructed with free vascularized osteocutaneous flaps that should probably also be used for lateral mandibular reconstruction. Furthermore, in a large number of series, it is reported that free flaps also have high complication rates and 5-10% flap loss. As all pectoralis major flaps survived in our series, it still remains a good choice in intraoral and oropharyngeal reconstruction when there is no necessity to reconstruct bone.

Percutaneous Aponeurotomy and Lipofilling (PALF): A Regenerative Approach to Dupuytren Contracture

Dupuytren disease is a progressive fibroproliferative disorder, which leads to flexion contractures of the digits. A minimally invasive technique consisting of an extensive percutaneous aponeurotomy of the cord with a needle combined with lipofilling is presented. The selective cutting of the cords under continuous tension disintegrates the cords while sparing the looser neurovascular bundles. Subsequently, lipoaspirate is injected subcutaneously. The authors prospective results show a significantly shorter recovery time and less overall complications in this technique when compared with open surgery, while no significant difference was observed in the extent of immediate contracture correction and in the recurrence rate at 1xa0year follow-up.

Relationships among manual body functions, manual capacity, and bimanual performance using the prosthetic upper extremity functional index in children with congenital hand differences

Background Most surgical techniques intervene at the level of body functions of the upper limb, aiming to improve manual capacity and activity performance. However, the nature of the relationships among these levels of functioning and evidence for hand function variables predicting performance have scarcely been investigated. Objective The primary aim of this study was to assess aspects of hand function and manual capacity that influence bimanual performance in children with congenital hand differences (CHDs), ranging from surgically corrected polydactyly or syndactyly to radial dysplasia. A secondary aim was to assess whether the number of items on the Prosthetic Upper Extremity Functional Index (PUFI) can be reduced without losing information on bimanual performance in this population. Design A cross-sectional design was used. Methods One hundred six 10- to 14-year-old children with CHD participated in the study, which was conducted in a university hospitals outpatient clinic. Bimanual performance was evaluated with child self-reports on an adapted version of the PUFI, calculating ease of performance and actual use of the affected hand. Additionally, hand function and manual capacity were assessed. Results The median score on ease of performance was high, and, on average, the children used their affected hand actively in 97% of all activities. Manual capacity of the nondominant hand and lateral pinch strength of the dominant hand predicted attainment of maximum PUFI scores. Nonmaximum PUFI scores were predicted by opposition strength of the nondominant hand and lateral pinch strength of the dominant hand. In addition, in this patient group, only 6 items of the PUFI explained all variance in PUFI scores. Limitations The generalizability of the results is limited by the carefully selected age range. Second, the cross-sectional design of the study limits statements on causality on the relationships found. Conclusion Children with a CHD generally have good bimanual performance and, on average, perform activities with active use of the affected hand. Therapy directed toward increasing manual capacity and finger muscle strength might assist in improving bimanual performance in children with CHD. Furthermore, the number of items on the PUFI could be reduced from 38 to 6 items in children with CHD.

Identification of Associated Genes and Diseases in Patients With Congenital Upper-Limb Anomalies: A Novel Application of the OMT Classification

PURPOSEnCongenital upper-limb anomalies (CULA) can present as a part of a syndrome or association. There is a wide spectrum of CULA, each of which might be related to different diseases. The structure provided by the Oberg, Manske, and Tonkin (OMT) classification could aid in differential diagnosis formulation in patients with CULA. The aims of this study were to review the Human Phenotype Ontology (HPO) project database for diseases and causative genes related to the CULA described in the OMT classification and to develop a methodology for differential diagnosis formulation based on the observed congenital anomalies, CulaPhen.nnnMETHODSnWe reviewed the HPO database for all diseases, including causative genes related to CULA. All CULA were classified according to the OMT classification; associated non-hand phenotypes were classified into 12 anatomical groups. We analyzed the contribution of each anatomical group to a given disease and developed a tool for differential diagnosis formulation based on these contributions. We compared our results with cases from the literature and with a current HPO tool, Phenomizer.nnnRESULTSnIn total, 514 hand phenotypes were obtained, 384 of which could be classified in the OMT classification. A total of 1,403 diseases could be related to those CULA. A comparison with 10 recently published cases with CULA revealed that the presented phenotype matched the descriptions in our dataset. The differential diagnosis produced using our methodology was more accurate than Phenomizer in 4 of 5 examples.nnnCONCLUSIONSnThe OMT classification can be used to describe hand anomalies that may present in over 1,400 diseases. CulaPhen was developed to provide a (hand) phenotype-based differential diagnosis. Differential diagnosis formulation based on the proposed system outperforms the system in current use.nnnCLINICAL RELEVANCEnThis study illustrates that the OMT diagnoses, either individually or combined, can be cross-referenced with different diseases and syndromes. Therefore, use of the OMT classification can aid differential diagnosis formulation for CULA patients.

Mesh expansion as the cause of bulging after abdominal wall hernia repair

Highlights • Swelling of the abdominal wall after abdominal wall reconstruction can be caused by a recurrence or bulging of the mesh.• CT-scan can be useful to distinguish between a true recurrence or bulging of the mesh.• Bulging of a mesh can be caused by pore enlargement and expansion of the mesh.• The distinction between a recurrence and bulging of the mesh is therapeutically irrelevant in symptomatic patients.• Mesh characteristics should be considered when choosing a feasible and suitable mesh for abdominal wall reconstruction.

Controversies in Poland Syndrome: Alternative Diagnoses in Patients With Congenital Pectoral Muscle Deficiency

PURPOSEnPoland syndrome was first described as a deficiency of the pectoral muscle with ipsilateral symbrachydactyly. Currently, numerous case reports describe variations of Poland syndrome in which pectoral muscle deficiency is often used as the only defining criterion. However, more syndromes can present with pectoral muscle deficiency. The aim of this review is to illustrate the diversity of the phenotypic spectrum of Poland syndrome and to create more awareness for alternative diagnoses in pectoral muscle deficiency.nnnMETHODSnA systematic literature search was performed. Articles containing phenotypical descriptions of Poland syndrome were included. Data extraction included number of patients, sex, familial occurrence, and the definition of Poland syndrome used. In addition, hand deformities, thoracic deformities, and other deformities in each patient were recorded. Alternative syndrome diagnoses were identified in patients with a combination of hand, thorax, and other deformities.nnnRESULTSnOne hundred-and-thirty-six articles were included, describing 627 patients. Ten different definitions of Poland syndrome were utilized. In 58% of the cases, an upper extremity deformity was found and 43% of the cases had an associated deformity. Classic Poland syndrome was seen in 29%. Fifty-seven percent of the patients with a pectoral malformation, a hand malformation, and another deformity had at least 1feature that matched an alternative syndrome.nnnCONCLUSIONSnPectoral muscle hypoplasia is not distinctive for Poland syndrome alone but is also present in syndromes with other associated anomalies with a recognized genetic cause. Therefore, in patients with an atypical phenotype, we recommend considering other diagnoses and/or syndromes before diagnosing a patient with Poland syndrome. This can prevent diagnostic and prognostic errors.nnnCLINICAL RELEVANCEnDifferentiating Poland syndrome from the alternative diagnoses has serious consequences for the patient and their family in terms of inheritance and possible related anomalies.

Documenting Combined Congenital Upper Limb Anomalies Using the Oberg, Manske, and Tonkin Classification: Implications for Epidemiological Research and Outcome Comparisons

PURPOSEnCongenital upper limb anomalies (CULAs) exhibit a wide spectrum of phenotypic manifestations. To help the clinician evaluating this variety of CULAs, the Oberg, Manske, and Tonkin (OMT) classification was recently introduced. The OMT classification allows for documentation ofxa0combined hand anomalies. However, subsequent epidemiological and validation studies using the OMT scheme commonly registered only the main anomaly per arm. This study illustrates both the deficits of single diagnosis documentation as well as the merits of registering every anomaly for epidemiological research, outcome comparison, and overall applicability of the classification.nnnMETHODSnWe retrospectively reviewed patients visiting the Erasmus MC - Sophia Childrens Hospital between 2012 and 2014. All congenital anomalies of both limbs were classified according to the OMT scheme. The frequency of combined diagnoses as well as recurrent combinations were analyzed. The relation to the coregistered syndromes was studied.nnnRESULTSnWe included 746 patients, 79.5% of whom could be documented with a single OMT diagnosis. In 20.5%, a combination of OMT diagnoses was documented. We documented 149 different combinations: 102 were documented once, 47 were documented repeatedly (nxa0= 196); for example, in patients with Greig syndrome. The prevalence of this syndrome was significantly higher in patients with a combination of radial polydactyly, ulnar polydactyly, and/or syndactyly (2.9% vs 33.3% and 60% in patients with 1 vs 2 and 3 diagnoses).nnnCONCLUSIONSnDocumentation of combined OMT diagnoses is required in a fifth of the patients. Not doing so will cause loss of phenotypic information and can hamper outcome comparison and epidemiological research. Documentation of combined OMT diagnoses can help to identify subgroups within a population, for example, patients with an underlying syndrome. Last, combined documentation of diagnoses improves flexibility of the classification and thereby better allows universal application.nnnCLINICAL RELEVANCEnConsensus on the application of the OMT classification is critical to achieving the universal adoption of the system by hand surgeons and other medical professionals.