Light and TEM study of nonregenerated and experimentally regenerated scales of Lepisosteus oculatus (Holostei) with particular attention to ganoine formation.
Sire J Y
The Anatomical record
BACKGROUND:The structure of nonregenerated and experimentally regenerated scales of the holostean fish Lepisosteus oculatus and the events taking place before and during ganoine deposition on the scale surface were studied. The aim of this study was to answer the question of the origin of the ganoine in lepisosteids, the scales of which are devoid of dentine, and to compare them to ganoine formation in polypterid scales and to enamel formation in teeth. METHODS:Two adult specimens were used and the scale structure was studied using light and transmission electron microscopy. Regeneration was used as an alternative to the lack of developmental stages and to induce ganoine deposition on the scale surface. RESULTS:Nonregenerated scales are composed of a thick, avascular bony plate capped by ganoine that is covered either by the epidermis or by dermal elements. The ganoine surface is separated from the covering soft tissues by an unmineralized layer, the ganoine membrane. During the first 2 months of regeneration, the bony plate forms. It differs from the bony plate of nonregenerated scales only by its large, woven-fibered central region and by the presence of numerous vascular canals. Shortly before ganoine deposition, the osteoblasts cease their activity and an epithelial sheet comes to contact them and spreads on the bony surface. This epithelial sheet is connected to the epidermis by a short epithelial bridge only and is composed of two layers: the inner ganoine epithelium (IGE), in contact with the bone surface and composed of juxtaposed columnar cells that synthesize the ganoine matrix, preganoine; the outer ganoine epithelium (OGE), composed of elongated cells, the surface of which is separated from the overlying dermal space by a basal lamina. Isolated patches of preganoine are deposited by the IGE cells in the upper part of the osteoid matrix of the scale. The interpenetrated preganoine and osteoid matrices constitute an anchorage zone between ganoine and bone. Preganoine patches fuse and a continuous layer of preganoine is progressively synthesized by the IGE cells. Preganoine progressively mineralizes to become ganoine. CONCLUSIONS:The processes of ganoine formation are similar to those known for the ganoine in the polypterid scales and to those described for enamel deposition in teeth. Ganoine is enamel.
10.1002/ar.1092400206
The histological structure of glyptosaurine osteoderms (Squamata: Anguidae), and the problem of osteoderm development in squamates.
Buffrénil Vivian de,Sire Jean-Yves,Rage Jean-Claude
Journal of morphology
Glyptosaurinae, a fossil clade of anguid lizards, possess robust osteoderms, with granular ornamentation. In this study, the structural and histological features of these osteoderms were described in order to reconstruct their developmental pattern and further document the degree of homology that could exist between vertebrate integumentary skeletons. Glyptosaurine osteoderms have a diploe architecture and display an unusually complex structure that includes four tissue types: a core of woven-fibered bone intensely remodeled; a peripheral formation of the same tissue containing dense bundles of long Sharpey fibers; a thick basal layer of lamellar bone; and a superficial layer of a non-osseous material that belongs to the category of hypermineralized tissues such as ganoine, or enameloid and enamel tissues. The growth pattern of glyptosaurine osteoderms involved appositional processes due to osteoblast activity. In early growth stages, osseous metaplasia might have also been involved, but this possibility is not substantiated by histological observations. The superficial layer of the osteoderms must have resulted from epidermal contribution, a conclusion that would support previous hypotheses on the role of epidermal-dermal interactions in the formation of squamate osteoderms.
10.1002/jmor.10829
Multiscale modelling of desquamation in the interfollicular epidermis.
PLoS computational biology
Maintenance of epidermal thickness is critical to the barrier function of the skin. Decreased tissue thickness, specifically in the stratum corneum (the outermost layer of the tissue), causes discomfort and inflammation, and is related to several severe diseases of the tissue. In order to maintain both stratum corneum thickness and overall tissue thickness it is necessary for the system to balance cell proliferation and cell loss. Cell proliferation in the epidermis occurs in the basal layer and causes constant upwards movement in the tissue. Cell loss occurs when dead cells at the top of the tissue are lost to the environment through a process called desquamation. Desquamation is thought to occur through a gradual reduction in adhesion between cells, due to the cleaving of adhesion proteins by enzymes, in the stratum corneum. In this paper we will investigate combining a (mass action) subcellular model of desquamation with a three dimensional (cell centre based) multicellular model of the interfollicular epidermis to better understand maintenance of epidermal thickness. Specifically, our aim is to determine if a hypothesised biological model for the degradation of cell-cell adhesion, from the literature, is sufficient to maintain a steady state tissue thickness. These investigations show the model is able to provide a consistent rate of cell loss in the multicellular model. This loss balances proliferation, and hence maintains a homeostatic tissue thickness. Moreover, we find that multiple proliferative cell populations in the basal layer can be represented by a single proliferative cell population, simplifying investigations with this model. The model is used to investigate a disorder (Netherton Syndrome) which disrupts desquamation. The model shows how biochemical changes can cause disruptions to the tissue, resulting in a reduced tissue thickness and consequently diminishing the protective role of the tissue. A hypothetical treatment result is also investigated: we compare the cases of a partially effective homogeneous treatment (where all cells partially recover) and a totally effective heterogeneous treatment (in which a proportion of the cells totally recover) with the aim to determine the difference in the response of the tissue to these different scenarios. Results show an increased benefit to corneum thickness from the heterogeneous treatment over the homogeneous treatment.
10.1371/journal.pcbi.1010368
Increased epidermal thickness and abnormal epidermal differentiation in keloid scars.
Limandjaja G C,van den Broek L J,Waaijman T,van Veen H A,Everts V,Monstrey S,Scheper R J,Niessen F B,Gibbs S
The British journal of dermatology
BACKGROUND:The pathogenesis underlying keloid formation is still poorly understood. Research has focused mostly on dermal abnormalities, while the epidermis has not yet been studied. OBJECTIVES:To identify differences within the epidermis of mature keloid scars compared with normal skin and mature normotrophic and hypertrophic scars. METHODS:Rete ridge formation and epidermal thickness were evaluated in tissue sections. Epidermal proliferation was assessed using immunohistochemistry (Ki67, keratins 6, 16 and 17) and with an in vitro proliferation assay. Epidermal differentiation was evaluated using immunohistochemistry (keratin 10, involucrin, loricrin, filaggrin, SPRR2, SKALP), reverse-transcriptase polymerase chain reaction (involucrin) and transmission electron microscopy (stratum corneum). RESULTS:All scars showed flattening of the epidermis. A trend of increasing epidermal thickness correlating to increasing scar abnormality was observed when comparing normal skin, normotrophic scars, hypertrophic scars and keloids. No difference in epidermal proliferation was observed. Only the early differentiation marker involucrin showed abnormal expression in scars. Involucrin was restricted to the granular layer in healthy skin, but showed panepidermal expression in keloids. Normotrophic scars expressed involucrin in the granular and upper spinous layers, while hypertrophic scars resembled normotrophic scars or keloids. Abnormal differentiation was associated with ultrastructural disorganization of the stratum corneum in keloids compared with normal skin. CONCLUSIONS:Keloids showed increased epidermal thickness compared with normal skin and normotrophic and hypertrophic scars. This was not due to hyperproliferation, but possibly caused by abnormal early terminal differentiation, which affects stratum corneum formation. Our findings indicate that the epidermis is associated with keloid pathogenesis and identify involucrin as a potential diagnostic marker for abnormal scarring.
10.1111/bjd.14844
Study of melanocyte density and epidermal thickness in vulvar lichen sclerosus lesions.
Fu Yu,Bao Yingqiu,Li Ziyuan,Gao Xiaoman,Chang Jianmin
International journal of dermatology
OBJECTIVE:This study aimed to analyze changes in melanocyte density and epidermal thickness in vulvar lichen sclerosus (VLS). METHODS:Vulvar skin tissues were collected from 15 VLS female patients in Beijing Hospital, classified into early (n = 7) and late VLS (n = 8) groups according to pathological manifestations. Melanocyte density and full epidermal and cell-layer (from the bottom of the stratum corneum to that of the basal layer) thickness were calculated using an image analysis software. The control group was normal vulvar skin tissues from 15 females after plastic surgery. RESULTS:The early VLS (0.170 ± 0.071 µm) and late VLS (0.110 ± 0.035 µm) groups had significantly lower densities of epidermal melanocytes than the control group (0.275 ± 0.036) (F = 36.426, P < 0.001). The cell-layer thickness did not differ between the early VLS (154.603 ± 121.984 µm) and control (176.974 ± 80.296 µm) groups (P = 0.899) but significantly decreased in the late VLS group (83.455 ± 37.129 µm) compared to the control group (P = 0.003). CONCLUSIONS:Melanocyte density decreased in early and late VLS. The full epidermal and cell-layer thickness did not significantly change in early VLS, but the cell-layer thickness decreased in late VLS.
10.1111/ijd.15555
The effect of subcutaneous fat and skin-to-lamina distance on complications and functional outcomes of minimally invasive lumbar decompression.
International orthopaedics
PURPOSE:Minimally invasive lumbar decompression (MIS) in obese pzatients is technically challenging due to the use of longer tube retractors. The purpose of this study was to evaluate the impact of the thickness of the soft tissue and subcutaneous fat on complications, revisions, and patient-reported functional outcomes after MIS. METHODS:This is a retrospective analysis of 148 consecutive patients who underwent minimally invasive lumbar decompression at our institute between 2013 and 2017 and had at least one year of follow-up. Analysis was performed five times, each time the study group was defined by another measure of adiposity: BMI > 30, skin to lamina distance at the site of surgery and at L4 > 6 cm, and subcutaneous fat thickness at the site of surgery and at L4 > 3 cm. Outcomes included intraoperative complications (durotomy or neurological deficit), possibly inadequate decompression (residual disc, reoperation), length of stay, return to the emergency room or readmission, postoperative medical complications, and functional outcomes: visual analog scores for back and leg pain, and Oswestry Disability Index (ODI). RESULTS:Patients with a thicker layer soft tissue had a significantly higher burden of comorbidities than controls, including higher prevalence of cardiovascular disease (p = 0.002), diabetes (p < 0.001), hypertension (p < 0.001) and higher ASA scores (p = 0.002). Nevertheless, there was no significant difference between the patient groups in surgical and medical complications, functional outcomes, and other assessed outcomes. CONCLUSION:Our results indicate that minimally invasive lumbar decompression is safe and effective for patients with a thick layer of soft tissue and subcutaneous fat.
10.1007/s00264-023-05852-4
The PINS Trial: a prospective randomized clinical trial comparing a traditional versus an emollient skincare regimen for the care of pin-sites in patients with circular frames.
Ferguson David,Harwood Paul,Allgar Victoria,Roy Anu,Foster Patrick,Taylor Martin,Moulder Elizabeth,Sharma Hemant
The bone & joint journal
AIMS:Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame. METHODS:Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system. RESULTS:Out of 116 patients who were enrolled in the study, 23 patients (40%) in the CHX group and 26 (44%) in the DML group had at least one bad or ugly pin-site infection. This difference was not statistically significant (p = 0.71). There was no significant relationship between pH or hydration of the skin and pin-site infection. The epidermal thickness was found to be significantly greater in patients who had a pin-site infection compared with those who did not (p = 0.01). Skin irritation requiring a change of treatment occurred in four patients (7%) using CHX, and none using DML. CONCLUSION:We found no significant difference in the incidence of pin-site infection between the CHX and DML treatment groups. Dermol appeared to offer a small but significant advantage in terms of tolerability. We did not find a significant association between patient or treatment related factors and pin-site infection. It is therefore difficult to make specific recommendations based upon these results. The use of either cleaning agent appears to be appropriate. Cite this article: 2021;103-B(2):279-285.
10.1302/0301-620X.103B2.BJJ-2020-0680.R1
Distal radius fractures in the superelderly: an observational study of 8486 cases from the Swedish fracture register.
Sagerfors Marcus,Jakobsson Hugo,Thórdardóttir Ásgerdur,Wretenberg Per,Möller Michael
BMC geriatrics
BACKGROUND:The distal radius fracture (DRF) is the most common fracture in adults. With an ageing population, the number of wrist fractures in the superelderly (≥ 80 years) is expected to rise. Optimal treatment for displaced DRFs remains controversial, especially in the superelderly group. In addition, basic knowledge of the outcome after a DRF in this heterogenic group is lacking. The aim of this study was to study injury characteristics, treatment and outcome of DRFs in superelderly patients using data from a large national register. METHODS:We used prospectively collected data from the Swedish Fracture Register. All distal radius fractures registered between April 2012 and December 2018 in patients ≥ 80 years of age were included. Data on epidemiology, fracture type, trauma mechanism and treatment are registered by the physician treating the patient. Patients are also sent a subjective outcome questionnaire including EQ-5D, EQ-VAS and Short Musculoskeletal Function Assessment questionnaire (SMFA-score) at the time of injury and after 12 months. The 12-month questionnaire was sent to those who had completed the questionnaire at the time of injury. A Mann-Whitney U-test was used to assess differences between treatment methods. RESULTS:Mean age for this population was 86 years (80-105 years), a majority of the patients were female (86.7%). The dominating injury mechanism was a simple fall (74.6%) in the patient's residence. The majority of fractures were AO type A (70%) followed by AO type C (20.9%) and type B (8.6%). The incidence of open fractures was significantly higher in females (2.6%) compared to males (1.5%). A majority of the fractures were treated with a cast (87.5%) with volar locking plate as the second most common treatment method (6.6%). Patient-reported outcome measures (PROMs) EQ-5D, EQ-VAS and the Arm Hand Function Index of the SMFA-score deteriorated somewhat one year after injury compared to pre-injury. PROMs did not correlate to treatment with cast or a volar plate. CONCLUSIONS:This nationwide register study provides detailed data on DRFs in the superelderly regarding epidemiology, treatment and self-reported outcome. A good self-reported outcome is possible, but many patients do not recover completely. PROMs did not correlate to type of treatment. The frequency of open fractures was significantly higher in females. The reason for this is unclear but different skin thickness in older males versus females may be one explanation.
10.1186/s12877-022-02825-x
Increased Surgical Site Subcutaneous Fat Thickness Is Associated with Infection after Posterior Cervical Fusion.
Surgical infections
Previous literature has associated increased body mass index (BMI) with risk of surgical site infection (SSI) after posterior cervical fusion (PCF) surgery. However, few studies have examined the association between local adiposity and risk of SSI, re-admission, and re-operation after PCF. Local adiposity is easily measured on pre-operative magnetic resonance imaging (MRI) and may act as a more accurate predictor compared with BMI. Subjects undergoing PCF from 2013-2018 at a single institution were identified retrospectively. Posterior cervical subcutaneous fat thickness, paraspinal muscle thickness, and lamina-to-skin distance measurements were obtained from computed tomography (CT) or MRI scans. Subjects with active infection, malignancy, or revision procedures were excluded. Two hundred five patients were included with 20 developing SSIs. Subjects with SSIs had a longer fusion construct (4.90 vs. 3.71 levels; p = 0.001), higher Elixhauser comorbidity index (ECI; 2.05 vs. 1.34; p = 0.045), had a history of diabetes mellitus (30% vs. 10.8%; p = 0.026), higher subcutaneous fat thickness (30.5 vs. 23.6 mm; p = 0.013), and higher lamina-to-skin distance (66.4 vs. 57.9 mm; p = 0.027). Subcutaneous fat thickness (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10]; p = 0.026) and lamina-to-skin distance (OR, 1.05; 95% CI, 1.01-1.09]; p = 0.014) were associated with SSI in multivariable analysis. A subcutaneous fat thickness cutoff value of 23.2 mm had 90% sensitivity and 54.1% specificity for prediction of SSI. There was no association need for re-admission or re-operation. Increased posterior cervical fat may increase the risk of SSI after PCF. Pre-operative advanced imaging may be a valuable tool for assisting with patient counseling, optimization, and risk stratification.
10.1089/sur.2021.271
Skeletal measurements using a flying spot digital imaging device.
Wilson A J,Ramsby G R
AJR. American journal of roentgenology
A flying spot digital imaging unit was devised to measure skeletal length and angles. This device uses a spinning chopper wheel and fixed slit collimator in front of a conventional X-ray tube to produce a scanning pencil beam that passes through the patient and onto an electronic detector. The beam scans the patient transversely and the device moves longitudinally, creating a digital image with a skin dose of less than 2 mrad (0.02 mGy). Patients can be imaged both when upright and when recumbent. A large field of view makes it possible for the entire length of the spine or lower extremities to be included in a single image. Built-in computer algorithms are used to make measurements of skeletal lengths and angles. The accuracy of the digital device was tested by making measurements of known angles and lengths using protractors and rulers. Skeletal measurements were then made on a number of patients. Interobserver error was tested using both patient and nonpatient images. The following patient measurements were made: Cobb angle in 166 patients with scoliosis; knee joint angles in 120 patients undergoing knee surgery; lower extremity lengths in 78 patients with length inequalities; bony fragment angulation and displacement in 30 patients with healing fractures. These studies have shown the device to be accurate with low interobserver error, while delivering much lower patient dose than more conventional methods. The ability to manipulate window levels and widths enables visualization of thick and thin body parts on the same image. Our experience both in the laboratory and with patients has been encouraging, and the method appears to have several advantages over more conventional techniques.
10.2214/ajr.149.2.339
TNF signaling contributes to the development of nociceptive sensitization in a tibia fracture model of complex regional pain syndrome type I.
Sabsovich Ilya,Guo Tian-Zhi,Wei Tzuping,Zhao Rong,Li Xiangqi,Clark David J,Geis Christian,Sommer Claudia,Kingery Wade S
Pain
Tibia fracture in rats initiates a cascade of nociceptive, vascular, and bone changes resembling complex regional pain syndrome type I (CRPS I). Previous studies suggest that the pathogenesis of these changes is attributable to an exaggerated regional inflammatory response to injury. We postulated that the pro-inflammatory cytokine tumor necrosis factor alpha (TNF) might mediate the development of CRPS-like changes after fracture. RT-PCR and EIA assays were used to evaluate changes in TNF expression and content in skin, nerve, and bone after fracture. Bilateral hindpaw thickness, temperature, and nociceptive thresholds were determined, and bone microarchitecture was measured using microcomputed tomography. Lumbar spinal cord Fos immunostaining was performed for quantification of Fos positive neurons. After baseline testing, the distal tibia was fractured and the hindlimb casted for 4 weeks. The rats were subcutaneously injected either with a soluble TNF receptor type 1 (sTNF-R1, 5mg/kg/d) or saline every 3 days over 28 days and then were retested at 4 weeks post-fracture. Tibia fracture chronically upregulated TNF expression and protein levels in the hindpaw skin and sciatic nerve. After fracture the rats developed hindpaw mechanical allodynia and unweighting, which were reversed by sTNF-R1 treatment. Consistent with the behavioral data, spinal Fos increased after fracture and this effect was inhibited by sTNF-R1 treatment. Collectively, these data suggest that facilitated TNF signaling in the hindlimb is an important mediator of chronic regional nociceptive sensitization after fracture, but does not contribute to the hindlimb warmth, edema, and bone loss observed in this CRPS I model.
10.1016/j.pain.2007.10.013
The effects of patient related factors on hidden and total blood loss in single-level open transforaminal lumbar interbody fusion surgery.
Acta orthopaedica et traumatologica turcica
OBJECTIVE:The aim of this retrospective study was to identify the amount of TBL and HBL and analyse the risk factors using multivariate linear regression analysis during single-level OTLIF surgery. METHODS:In this study 62 patients (32 male, 30 female, mean age 49.22 ± 13.26) who underwent single-level interbody fusion proce dures by a single surgeon between 2015 and 2021 were included. Retrospectively, relevant statistics regarding body mass index (BMI), American Society of Anesthesiologist Score (ASA), preoperative mean arterial pressure (MAP), and age were gathered. Preoperative MR images were used to assess and measure radiological parameters such as skin-disc distance (SDA), canal area (CA), paravertebral muscle area (PVMA),lumbosacral maximum subcutaneous fat thickness (LSMSF), operation level subcutaneous fat thickness (OPSF) and spi nous process length (SPL).Total blood loss (TBL) was calculated according to Nadler's formula. Hidden blood loss (HBL) was measured by deducting the measured (visible) blood loss from TBL. TBL, HBL and their relationship with preoperative parameters were assessed. RESULTS:HBL was determined to be significantly higher in older patients (P = 0.012). MAP was seen to have a statistically significant cor relation with operating time (P = 0.002), operative bleeding (P = 0.002), TBL (P = 0.006), and HBL (P = 0.001), and an inverse correlation with postoperative drainage (P = 0.007). The ASA scores were observed to be statistically significantly correlated with TBL (P = 0.001), and HBL (P = 0.001). LSMSF showed a significant correlation with TBL (P = 0.005) and HBL (P = 0.002). OPSF was determined to be correlated with TBL (P = 0.011), HBL (P = 0.009) and length of stay in hospital (P =0.034). SDD was correlated with TBL (P =0.043), and SPL with HBL (P = 0.013). It was shown that age (P =0.012), MAP (P =0.001), ASA (P =0.001), LSMFS (P = 0.002), OPSF (P = 0.009), SPL (P = 0.013) were risk factors for HBL. According to multivariate logistic regression analysis; two anatomical factors LSMSF and SPL were independent risk factors for HBL (P < 0.05). CONCLUSION:This results of this study have revealed that most patient-related parameters have a significant effect on HBL and TBL.The study has also demonstrated that LSMSF and SPL are independent risk factors for HBL. LEVEL OF EVIDENCE:Level IV, Therapeutic Study.
10.5152/j.aott.2022.21380
Thickness of subcutaneous fat as a risk factor for infection in cervical spine fusion surgery.
Mehta Ankit I,Babu Ranjith,Sharma Richa,Karikari Isaac O,Grunch Betsy H,Owens Timothy R,Agarwal Vijay J,Sampson John H,Lad Shivanand P,Friedman Allan H,Kuchibhatla Maragatha,Bagley Carlos A,Gottfried Oren N
The Journal of bone and joint surgery. American volume
BACKGROUND:Surgical site infections increase the incidence of morbidity and mortality as well as health-care expenses. The cost of care increases threefold to fourfold as a consequence of surgical site infection after spinal surgery. The aim of the present study was to determine the role of subcutaneous fat thickness in the development of surgical site infection following cervical spine fusion surgery. METHODS:We performed a retrospective review of a consecutive cohort of 213 adult patients who underwent posterior cervical spine fusion between 2006 and 2008 at Duke University Medical Center. The horizontal distance from the lamina to the skin surface at the C5 level and the thickness of subcutaneous fat were measured, and the ratio of the fat thickness to the total distance at the surgical site was determined. Previously identified risk factors for the development of surgical site infection were also recorded. RESULTS:Twenty-two of the 213 patients developed a postoperative infection. Obesity (body mass index ≥ 30 kg/m2) was not a significant risk factor for surgical site infection; the body mass index (and 95% confidence interval) was 29.4 ± 1.2 kg/m2 in the patients who developed a surgical site infection compared with 28.9 ± 0.94 kg/m2 in the patients without an infection. However, the thickness of subcutaneous fat and the ratio of the fat thickness to the lamina-to-skin distance were both significant risk factors for infection. The thickness of subcutaneous fat was 27.0 ± 2.5 mm in the patients who developed a surgical site infection group compared with 21.4 ± 0.88 mm in the patients without an infection (p = 0.042). The ratio of fat thickness to total thickness was 0.42 ± 0.019 in the patients who developed a surgical site infection compared with 0.35 ± 0.01 in the patients without an infection (p = 0.020). Multivariate analysis revealed this ratio to be an independent risk factor for developing a postoperative infection (odds ratio, 3.18; 95% confidence interval, 1.02 to 9.97). CONCLUSIONS:The study demonstrated that the thickness of subcutaneous fat at the surgical site is a factor in the development of surgical site infection following cervical spine fusion and deserves assessment in the preoperative evaluation.
10.2106/JBJS.L.00225
Split-thickness skin excision in severe open fractures.
Ziv I,Zeligowski A,Mosheiff R,Lowe J,Wexler M R,Segal D
The Journal of bone and joint surgery. British volume
Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.
10.1302/0301-620X.70B1.3339053
Evaluation of osteoporosis using skin thickness measurements.
Patel Rajesh,Blake Glen M,Fogelman Ignac
Calcified tissue international
Measurement of skin thickness has been proposed as a method of predicting low bone mineral density (BMD) and the consequent risk of osteoporotic fracture in postmenopausal women. The Episcan I-100 device is a new type of ultrasound device that uses high-frequency (20 MHz) ultrasound to measure skin thickness using a small probe placed on the skin. The aims of this study were to investigate whether there is any correlation between skin thickness as measured by ultrasound and BMD as measured by dual-energy X-ray absorptiometry, to establish whether patients with osteoporotic fractures have reduced skin thickness, and to investigate the relationship between skin thickness and clinical risk factors for osteoporosis. Short-term precision based on duplicate measurements on 132 patients gave a coefficient of variation of 3.2%. Small but statistically significant correlations between skin thickness measurements and BMD measurements at axial and peripheral sites were observed (r = 0.21-0.29, P < 0.0001). An odds ratio of 1.42 was found for identifying patients with a prevalent fracture at any skeletal site, suggesting that skin thickness measurements can discriminate patients with fractures. ROC analyses also demonstrated the ability of skin thickness measurements to discriminate fracture patients from controls. When measured by the decrease in Z-score, clinical risk factors for low BMD were found to affect skin thickness measurements to a similar extent as spine and hip BMD measurements. Skin thickness measurements have limited utility in identifying patients with low bone mass.
10.1007/s00223-007-9081-6
Deep skin slough following skin traction for hip fractures.
Shabat S,Gepstein R,Mann G,Kish B,Fredman B,Nyska M
Journal of tissue viability
INTRODUCTION:Elderly patients who fracture their hips are susceptible to complications associated with bed rest before surgery. In some institutions a skin traction device is used in order to relieve pain before surgery. The authors followed ten patients who developed severe (deep) skin slough and evaluated the relationship to the skin traction device. The need for use of a skin traction device is debated and the need for multidisciplinary treatment if this complication develops is emphasised. PATIENTS AND METHODS:All patients who had serious skin slough between January and December 2000 were evaluated. A serious skin slough was defined as any new and abrupt case of a full-thickness skin loss involving damage or necrosis of subcutaneous tissue, but not through the underlying fascia and not extending to underlying bone, tendon or joint capsule. Preoperative assessment including background illness and medications, the application of a skin traction device, the type of surgery that was performed, and complications were noted. RESULTS:Ten patients (nine females and one male) aged 76-90 years met the criteria of serious skin slough. The leading chronic illness was cardiovascular. Among these patients there were intertrochanteric fractures (n = 5), subcapital fractures (n = 4) and a subtrochanteric fracture (n = 1). In all patients a skin traction device was used. In seven out of the ten patients the skin slough occurred during or immediately after surgery. Other postoperative complications included uncontrolled glucose levels (> 130 mg/dl during fasting) (two cases) and urinary tract infections (two cases). The skin slough was treated with a daily wound care regimen by a trained nurse and included daily changing of wet dressings and application of Vaseline gauze. All patients were allowed immediate ambulation after the surgery and were discharged 9-15 days after the surgery. Although improvement of the slough was noted in all patients, none of them had fully recovered, and they had to continue treatment in outpatient clinics. DISCUSSION:The main goal of treatment in elderly patients who fractured their hips is to return them to their previous activities of daily living. A skin traction device, although useful for many of the patients, has the disadvantage of causing serious skin slough. This complication can interfere with the normal curve of rehabilitation and cause prolonged hospital stay. Whenever this complication is expected, the application of the skin traction device should be avoided. Moreover, careful handling of the patients by physicians, physiotherapists and nurses is mandatory. If this complication develops, vigorous multidisciplinary care is recommended.
10.1016/s0965-206x(02)80033-x
Mutations That Alter the Carboxy-Terminal-Propeptide Cleavage Site of the Chains of Type I Procollagen Are Associated With a Unique Osteogenesis Imperfecta Phenotype.
Cundy Tim,Dray Michael,Delahunt John,Hald Jannie Dahl,Langdahl Bente,Li Chumei,Szybowska Marta,Mohammed Shehla,Duncan Emma L,McInerney-Leo Aideen M,Wheeler Patricia G,Roschger Paul,Klaushofer Klaus,Rai Jyoti,Weis MaryAnn,Eyre David,Schwarze Ulrike,Byers Peter H
Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research
Osteogenesis imperfecta (OI) is a genetic bone disorder characterized by fractures, low bone mass, and skeletal fragility. It most commonly arises from dominantly inherited mutations in the genes COL1A1 and COL1A2 that encode the chains of type I collagen. A number of recent reports have suggested that mutations affecting the carboxyl-terminal propeptide cleavage site in the products of either COL1A1 or COL1A2 give rise to a form of OI characterized by unusually dense bones. We have assembled clinical, biochemical, and molecular data from 29 individuals from 8 families with 7 different mutations affecting the C-propeptide cleavage site. The phenotype was generally mild: The median height was ∼33th centile. Eighty percent of subjects had their first fracture by the age of 10 years, and one-third had a femoral or tibial fracture by the age of 25 years. Fractures continued into adulthood, though rates varied considerably. Healing was normal and rarely resulted in long bone deformity. One-third of subjects older than 15 years had scoliosis. The teeth and hearing were normal in most, and blue sclerae were not observed. Other features noted included fibro-osseous dysplasia of the mandible and Achilles tendon calcification. The mean spinal bone mineral density Z-score was +2.9 (SD 2.1) compared with -2.2 (0.7) in subjects with COL1A1 haploinsufficiency mutations. Bone mineral density distribution, assessed by quantitative backscattered electron imaging in bone showed higher levels of mineralization than found in any other disorder. Bone histology showed high trabecular volume and increased cortical thickness, with hyperosteoidosis and delayed mineralization. In vitro studies with cultured skin fibroblasts suggested that these mutations interfere with processing of the chain in which the sequence alteration occurs, but the C-propeptide is eventually cleaved (and detectable in blood), suggesting there are alternative sites of cleavage. The precise mechanism of the bony pathology is not yet clear. © 2018 American Society for Bone and Mineral Research.
10.1002/jbmr.3424
The Efficacy of Hyaluronidase in Early Surgery of Nasal Bone Fracture.
Kim Joo-Hak,Yang Heesang,Oh Sang-Ha,Song Seung Han,Kyung Hyunwoo
The Journal of craniofacial surgery
A nasal bone fracture is one of the most common facial injuries and is often treated by closed reduction. Typically, 2 to 3 weeks are needed for patients to return to daily life because the operation is performed after swelling around the fracture site is reduced. This study aimed to investigate that hyaluronidase injection could reduce swelling, perform early operation and return to daily life accelerated.From January 2017 to December 2017, 181 patients with nasal bone fracture were analyzed. 60 patients underwent hyaluronidase injection and massage to reduce edema, then performed surgery within 2 to 4 days. The remaining patients were treated conservatively (massage alone); they then underwent surgery. Ultrasonography was used to measure changes in skin thickness, and the treatment duration, outcome, and patient satisfaction were compared.The duration from injury to surgery was short in the early operation group, and the period of recovery and return to ordinary life was significantly shorter than in the conventional group. The difference in skin thickness after hyaluronidase injection and massage was 0.8 mm in the early operation group; there was no significant difference in the conventional group. There was no statistically significant difference in satisfaction between the 2 groups, but the mean satisfaction was higher in the early operation group.In patients with nasal bone fracture after facial trauma, hyaluronidase injection, and massage led to reduced edema. This might improve patient satisfaction by allowing earlier operation and earlier return to daily life.
10.1097/SCS.0000000000005646