Optimized approach to surgical treatment of wound surfaces

Treatment of traumatic defects and chronic venous ulcers is one of the persistent problems of medical science. Objective. To improve outcomes of patients with wounds, traumatic, functional and aesthetic defects by developing a comprehensive program of surgery to restore form and functions of the body. Materials and methods. We have operated on 179 patients with wound defects of various etiology in the clinic. Depending on the cause of wound defect, the patients were divided into groups: trophic ulcers of vascular etiology – 75 patients, post-traumatic (mechanical) wound defects – 42 patients, postishemic wound defects (compartment syndrome) – 12 patients, neurotrophic ulcers – 15 patients, consequences of purulent – infl ammatory diseases – 35 patients. We consider the ultrasound duplex scanning with color mapping as the primary diagnostic criterion in choosing patients’ treatment tactics. Results. In the patients’ group with trophic ulcers of vascular etiology the fi rst stage of treatment was sanation of trophic defect with the mandatory appointment of specifi c antibacterial therapy, in 58 patients autodermoplasty with the split, perforated fl ap was performed, in 4 patients it was carried out with single-step alofi broblasts’ transplantation, 17 patients were performed transplantation of full layer skin grafts. In patients with wounds after injury cellulocutaneous and musculocutaneous fl aps on the vascular pedicle, plasty with local tissues and split seed grafting autodermoplasty were used. In compartment syndrome secondary sutures were imposed and autodermoplasty with split seed grafting was performed. In neurotrophic ulcers of vertebral localization and in the geater tochanters’ area plasty with one or two V – like musculocutaneous rotation fl aps, cellulocutaneous double lobe pedicle fl ap was used. In patients with consequences of purulent – infl ammatory complications autodermoplasty with split seed grafting and rotation cellulocutaneous fl aps on the axial blood supply were performed. Conclusion. The choice of surgical treatment in patients with wound defects of trunk and extremities is determined by anatomic functional and hemodynamic features of the damaged area and the results of surgical correction of wound surfaces depend on a technically perfect surgery and adequate antibacterial therapy. Zaporozhye medical journal 2016; No6 (99): 93–96

Mechanical damage of skin integuments with the formation of large wound defects in severe trauma is often accompanied by signifi cant blood loss, shock, followed by the possibility of skin fl aps' necrosis, development of wound infection. In the process mortality from injuries has grown by 32.7 % for the last 10 years [3].
The main factors of trophic ulcers is a disturbance of venous outfl ow in the lower limbs due to the growing progressively worse of chronic venous or chronic lymph-venous insuffi ciency. Less commonly, ulcers of other genesis occur against the background of arterial disease, vasculitis, hypertensive (Martorell syndrome), diabetic, neurotrophic (including decubital) ones [4].
Thus, despite the numerous means of conservative therapy and surgical treatment methods that have been broadly dealt with in many prominent publications, the problem of treatment wound defects with different etiology still remains. However, the recent success of developments in the medical-biological sciences give every reason to the formation of new approaches concerning the treatment of many diseases, including wound defects and trophic ulcers.
Objective To improve patients' outcomes with wounds, traumatic, functional and aesthetic defects by developing a comprehensive program of surgery to restore the form and functions of body parts.

Materials and methods
We have operated on 179 patients with wound defects of various etiology in the clinic. Of them there were 88 men (49.2 %), 91women (50.8 %). The patients' age ranged from 17 to 72 years.
Depending on the cause of wound defect, the patients were divided into groups: 1. All the patients were examined either in the outpatient procedure or in the hospital on the protocols developed according to the nosology of the disease. To the standard methods of diagnosis were attributed the following ones: general clinical investigation, angiologic, neurologic study, clinicallaboratory diagnostics, microbiological monitoring, histological studies electroneuromyography, ultrasound scanning and Dopplerography, angiography, grade scales, photographic documentation.
We consider ultrasonic duplex scanning with color mapping as the leading diagnostic criterion in choosing the therapeutic approach of patients with chronic venous insuffi ciency of the lower limbs [5]. The study was performed on the apparatus "Vivid 3 Exspert" fi rm "General Electric" (USA), using the linear sensor with a frequency range of 3.5-5 MHz (for the study of patients with overweight and with considerable edema of the lower limbs). The research objectives included the confi rmation of the venous patency for the whole length, identifying functional insuffi ciency of venous valves, getting the characteristics of vessel lumen and its wall, determining pathological vein -venous refl uxes.
In addition, the method of ultrasonic duplex scanning is used by us for the study of regional hemodynamics in the area of wound defect and in the donor area of the future complex vascular pedicle fl ap on, namely marking musculocutaneous fl ap. Under the sensor control the length and the width of the pedicle and the fl ap and its direction is determined. Also the characteristics of the artery -its inner diameter, linear blood fl ow velocity, the presence of collateral branches, anastomoses and perforants is evaluated, which is especially important for the transplanting of complex grafts using sophisticated microsurgical techniques.
In patients with concomitant diabetes mellitus for the study of peripheral arterial blood fl ow dopplerography research and reovasography were used.
The development of aesthetic medicine and experience of literature allowed to use the technique of mesotherapy and redermalization in modern surgery too that is in the treatment of long-term existing trophic ulcers. Our clinic has developed and patented the original technique of using unstructured hyaluronic acid for the treatment of trophic ulcers in the lower extremity with vascular etiology.
Currently histological and cytometric studies are conducted that will scientifi cally substantiate the choice of surgery method, depending on the functional possibilities of damaged area, "aging" of tissue and regional hemodynamics.

Results
In the group of patients with trophic ulcers of vascular etiology the fi rst stage of treatment was sanation of trophic defect with the mandatory appointment of specifi c antibiotic therapy. In patients (69 patients) with decompensated forms of chronic venous or lymph-venous insuffi ciency of the lower limbs corrective surgery was performed on the superfi cial venous system with the appointment of phlebolymphotonics and elastic compression hosiery. In chronic arterial circulatory insuffi ciency of the lower limbs III-IV degree (3 patients) restorative surgery was performed (if peripheral blood fl ow was present) or intervention aimed to improve the collateral circulation. Three patients with diabetic foot mixed form were prescribed the standard course of angioprotective therapy in conjunction with the methodology of redermalization. Simultaneously with the second phase all the patients were performed ulcer closure with skin fl aps. Depending on the size of the trophic defect and the status of blood fl ow in 58 patients autodermoplasty with the split, perforated fl ap with single-step alofi broblasts' transplantation was carried out in 4 patients, 17 patients were performed transplantation of skin grafts. In 4 cases trophic ulcer relapse was marked in the period from 1.5 to 9 months, the repeated surgical intervention was performed.
In mechanical trauma (42 patients) the choice of surgical policy depended on the anatomic functional and hemodynamic features of damaged areas. Thus, in 3 cases in the presence of a wound defect on the heel cellulo-cutaneous fl ap was used in the axial blood supply. In 1 case of traumatic amputation of the upper limb at the level of shoulder joint, to form functional prosthetic stump musculocutaneous fl ap of a broad back muscle on the vascular pedicle was used. Patients were discharged on 10-14 days with a positive result. In 11 patients plasty with local tissues also with a satisfactory result was used. 27 patients with minor surface wound defects and active granulation were performed autodermoplasty with a split seed grafting.
In all the cases of compartment syndrome (12 cases) patients with post ichemic wound defects were presented, in whom the method of facsiotomy had not been used correctly. The fi rst stage was wound defect debridement and necrectomy of deadened areas was performed, then the second stage in 4 cases was mobilizaton of wound edges and the secondary sutures imposing, in 8 cases autodermoplasty was performed with a split seed grafting. In all cases positive results were achieved.
In neurotrophic ulcers (3 patients) with damage to peripheral nerve trunks electroneuromyographic studies were compulsory conducted and neurosurgeon's examination with the appointment of a special treatment. In 2 cases, in trophic ulcers of the lower limbs autodermoplasty was performed with a split seed grafting, in 1 case of wound defect on the forearm plasty was performed with a rotation cellulo-cutaneous fl ap in the axial blood supply. In 12 patients decubital trophic defects III-IV degree were diagnosed in the area of the vertebra (8 cases) and the area of greater trochanter of the femur (7 cases). In 3 patients 2 localizations occurred simultaneously, 2 patients -3 localizations. In vertebral localization of neurotrophic ulcers in 2 cases plasty with one or two V-like musculocutaneous rotation fl aps was used and in 8 cases -plasty with cellulocutaneous double lobe pedicle fl ap (Esser, 1918;Zimany, 1953) in 5 patients with neurotrophic ulcers in the area of greater trochanter plasty with rotation cellulocutaneous double lobe pedicle fl ap was performed. The surgical intervention was necessarily preceded by preparation. It included a rational antibacterial therapy in consideration of inoculated fl ora sensitivity, restoring of electrolyte, water and protein balance. In all the cases primary healing of wound defects was observed. No cases of rejection, marginal fl aps' necrosis were found. In 3 cases, it was noticed the emergence of small size subfl ap seroma, which was successfully eliminated. In the long-term period neurotrophic ulcer recurrence is not observed.
Of the 35 cases of the consequences of purulent-infl ammatory complications there were 19 patients with wound defects after phlegmonous forms of erysipelas, 7 patients with wound defects after abscesses and 8 patients after soft tissue of trunk and extremities' phlegmons. Most of the patients were hospitalized into in-patient specialized hospital with granulating wound defects. In 31 cases autodermoplasty was performed with a split seed grafting, at large scale defects -with a perforated one. In 4 cases rotation cellulocutaneous fl ap in axial blood supply was used. In one case in the early postoperative period fl ap necrosis occured, followed by necrectomy and re-plasty with a split seed grafting. Conclusions 1. The choice of surgical treatment in patients with wound defects of trunk and extremities is determined by anatomic functional and hemodynamic features of the damaged area.
2. We consider ultrasonic duplex scanning as the most effective method of diagnosis, which allows not only differential approach to the choice of surgical correction, as well as to explore the donor's area of the future complex fl ap on the vascular pedicle.
3. The results of surgical correction of wound surfaces depend on a technically perfect surgery and adequate antibacterial therapy.