Abstracts Preview: ISPeW Oral Abstracts, Continued

Repair and Reconstruction of Complex Wounds in Children: Strategies

Santecchia L, Zama M Rome, Italy 
Abstract
  The strategies of reconstructive surgery consist of the general types of procedures performed by reconstructive surgeons. These procedures in turn reflect the underlying problems (or elements) the surgeon seeks to address.

  There are 2 general types of procedures undertaken in reconstructive surgery: ablative surgery and restorative surgery. Even though this distinction may seem very simple and self-evident, problem analysis in reconstructive surgery must clearly be based on the recognized differences between these 2 types of procedures and the specific types of problems they should solve.

  In ablative surgery, the activities of reconstructive surgeon overlap with those of many other surgical specialists. The goal of ablative surgery is to eliminate the underlying disease or injury that constitutes the etiologic element of the surgical problem. A successful ablation must be accomplished before restoration procedures can be undertaken.

  Ablative surgery follows the principles of treatment associated with specific etiologies. In the treatment of cancer, the ablative procedure is done according to established standards of adequate resection, management of nodal involvement and metastases, and utilization of adjunctive therapies. In trauma cases, the ablative elements include control of hemorrhage, debridement of devitalized tissue, and removal of foreign body debris.

  In established chronic wounds such as osteomyelitis and pressure sores, ablation includes removal of chronic, scarred tissue involved infected bone, and such contributing factors as disrupted hip joints leading to synovial fistulae and pressure sores. The reconstructive surgeon may perform the ablative procedures or may work in conjunction with other surgeons. In any case, the reconstructive surgeon brings an important dimension to ablation by having the potential to proceed with restoration. In cancer resections, ablation can sometimes be more aggressive with a reliable prospect of reconstruction as part of the plan.

  Traumatic injuries can sometimes be diverted from amputation to salvage through acute and secondary restorative procedures. Some lesions, such as osteoradionecrosis or arteriovenous malformation, can be spared prolonged and uncertain piecemeal treatment and go on to definitive resection supported by the prospect of reliable surgical restoration.   Incomplete or confused ablative procedures doom restorate procedures to be compromised or lost in the underlying disorder. Such misadventures are based on misunderstanding of the etiologic element or ineffective treatment of it. Flaps or grafts placed on incompletely treated or overlooked cancers or infection will break down while the disease progresses.

  Closure attempts will fail because of incompletely debrided traumatic wounds. Flaps for a pressure sore reconstruction overlying a neglected synovial fistula from a chronically dislocated hip joint will become part of a recurrent wound.

  The reconstructive surgeon can extend the limits of ablation, decreasing the chances of residual disease, as well as coordinate the timing of restorative surgery to optimize the course and outcome of surgical sequences.

  The strategies of restoration distinguish the reconstructive surgeon as the physician most capable of providing an optimum possible outcome to patients with diseases and injuries that damage and destroy body parts.

  The strategies that the reconstructive surgeon can bring to such situations are increasingly sophisticated but such procedures must be based on a clear definition of the restorative problem elements remaining after thorough ablation. These restorative problem elements fall into the categories of wounds, defects, and deformity.

  A wound is a disruption of parts. The restoration of a wound is achieved by specific repair of the disrupted parts. A defect is a loss of parts. The restoration of a defect requires bringing new parts to the problem site. A deformity is a distortion of parts. Deformities are restored by identifying and mobilizing the disarrayed parts and proceeding to a repair that brings the parts into proper positions and relationships. The strategies applicable to these categories of problems overlap but also have some specific distinctions. In repairing a wound, a surgeon must be able to identify all-important components and use specific surgical techniques applicable to bone, tendon, nerve, vessels, skin, and special structural units such as lips, eyelids, and ears.

  Defects require that the surgeon replace lost parts, and such replacements can consist of grafts of skin, bone, nerve, and vessels, flaps and alloplastic materials. The reconstruction of a defect should be based on a thorough analysis of the missing parts and as compatible a replacement of critical parts as is technically and biologically possible. Correction of deformity requires that the surgeon be able to mobilize the distorted parts and reassemble them in some approximation of their normal positional and functional relationships as in cleft lip and palate. This is to say that this kind of correction is not just “to close a gap or filling up in a hole.”

  Microsurgery has changed the categories of many postablative elements, with consequently improved application of expanded restoration strategies. For example, a thumb amputation may be considered as a defect within the perspective of conventional restorative procedures.

  The restorative strategies may consist of conservative stump closure and possible secondary multistaged reconstruction with bone grafts and pedicled flaps.

  Microsurgery transforms the problern of thumb amputation in several ways. A sharply amputated thumb may be considered as a wound requiring repair of parts, including microsurgical repair of vessels and nerves.

  An amputated thumb with a significant zone of injury may be a defect that can be isolated into specific components that can be replaced by microsurgical techniques or vessel grafting and nerve grafting, thereby permitting functional salvage of the amputated part.

  If the amputated thumb is mangled beyond the possibilities of salvage, then a defect does result. Microsurgical reconstruction options change the definition of the defect and the goals of restoration. With conventional bone grafts and pedicled flaps, the amputated thumb is defined as a sensate post and the success of the restorative procedure is assessed accordingly.

  With a microsurgical restoration using a transplanted toe, the defect can be considered as an aesthetic unit containing functional parts including tendon, a joint, and sensory nerves. The outcome of the reconstruction is then assessed by these refined deflnitions of the defect.

  Microsurgical replantation techniques allow for the transformation of many amputations from defects to wounds. Amputations of extremities, genitalia, and facial parts may then be repaired primarily, avoiding disabling or grotesque defects that are either endured or restored to various degrees by rnultistaged procedures.

  ln other circumstances, microsurgery can allow an element to be reconstructed as a defect rather than as a wound. This change can lead to radically different restoralive strategies and outcomes. Direct wound closure after mastectomy and significant facial cancer ablation can have notoriouslyunsatisfactory functional and social consequences.

  Microsurgical flap reconstruction of these problems redefined as defects can offer specially detailed restorations, and can frequently be performed at the time of ablation.

  In cases of trauma and chronic wounds, thorough debridement can lead to a decared state of irreparable wound. This categorization can indicate an amputation.

  Microsurgical procedures, including soft tissue and bone flaps, and vessel and nerve grafting, can be used to reconsider such problems as defects with replaceable parts.

  The reconstructive surgeon, as well as the oncologic surgeon and the trauma surgeon, can profit from reconsidering and reanalyzing accepted analyses of problerns.

  The reconstructive surgeon may have had training and practice based on the concept that a nerve gap is a wound that can be closed by mobilization, transposition, and direct approximation of the proximal and distal nerves.

  The oncologic surgeon may be similarly committed to the concept that the result of a maxillectomy is a wound closure problem, while the trauma surgeon may consider a complex open tibial fracture with associated soft tissue and nerve injuries as a wound that can only be treated by amputation.

  Familiarity with microsurgical techniques of nerve grafting and soft tissue and bone flaps allows reconsideration of these problems with possible improved alternative outcomes.

  Strategy disputes between ablative surgeons and reconstructive surgeons can often be based on implicit or explicit differences in problem analysis, and discussion of such differences may lead to a better, mutually understood plan of treatment.

  The usefulness of the reconstructive ladder, namely simplicity and sequence, should not be forgotten, and the metaphor will remain a working image.

  Remembering, however, that a metaphor is a form of "improper naming" the reconstructive surgeon should have ready resort to analyses of elements and strategies to provide treatment plans that truly address the details of the problem and solutions of dynamic reconstructive surgery.

  Microsurgery has transformed the components of this analysis remarkably, and will continue to do so.

Disability and Palliative Wound Care

From Geriatric to Paediatric Patients: To Care and to Love the Two Extreme of the Life

Meaume S Paris, France
Abstract
  The most common non-healing wounds are: pressure ulcers, diabetic foot ulcers, venous and arterial leg ulcers and malignant wounds. Many of these wounds develop among the elderly, becoming non-healing to the extent that the patient may live with them all of his life, or even die because of them. Not enough attention is done to the underlying, contributing problems specific to the elderly patient. Those factors are physiologic (aging skin, immune state, atherosclerosis) and/or pathologic situations (diabetes, ischemia, undernutrition, cognitive disorders, chronic inflammation, incontinence). Therefore, a geriatric approach is complete and multidisciplinary. Those including: precise diagnose and management of patient’s comorbidities, functional status (measured by appropriate scales), nutritional status (evaluation and appropriate management), social support, ethical beliefs and quality of life and not only the wound itself. Each caregiver (nurse, physician, pain specialist, dietitian, social worker, occupational and physiotherapist) has its own task in preventing and treating such wounds. The ultimate goal therefore has been altered from healing of the wounds to symptom control, prevention of complications and to contribute to the patient’s and family’s overall wellbeing, like with pediatric patients. This lecture review all those items in a geriatric point of view, and explain how to deal with this different type wounds including malignant ones or ischemic, sometimes in a palliative way. A parallel with pediatrics management of wound will be evocated.

Palliative Wound Care in Children and Adolescents

Ciprandi G Palidoro, Italy
Abstract
  During the last 5 years, more than 400 children were wound-cared and 35% of them had a neurological primary system dysfunction with a subsequent moderate to severe disability. These children were treated also because of pulmonary (55%) gastrointestinal (38%) and cardiovascular (28%) conditions.

  Palliative medicine is appropriate for children in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life.

  Palliative care/cure utilizes a multidisciplinary approach to child treatment, relying on input from physicians, nurses, psychologist in formulating a plan of care to relieve suffering from neonatal age to adolescence. The optimal result is work as a team and not as a “one man show”: alleviation of symptoms or curing the collateral diseases associated to the main condition is as difficult as a major operation.

  Palliative wound care promote wound healing, controlling pain, managing infection, odor, bleeding, exudate and maintaining a good quality of life for the child and caregiver.

  Improving mobility in otherwise immobile children is a tremendous effort: however, improving or relieving pain permit a more comfortable assistance and if the child cooperate a double good result is achieved: 1. to make him responsible of his movements: even if he is not able to move the absence of pain facilitate the turnover of different not dangerous positions of the body, relieving undue pressure and the child is therefore active in this process; 2. No pain means healing and the child classifies this caring time as useful for future improvements of its condition.

  There’s an enormous relationship between wound healing and psychosocial factors.

  And that’s why most relevant to the medical setting are the extended-family members in the caregiving role. The definition of family caregiver varies: this role include the informal and unpaid care provided by devoted figures that goes beyond usual and normative social support provided in social relationship. Counseling the family and caregivers is an integral part of treating the chronic wound. Supporting the dressing changes with a solid and warm (not only technical) medical action improves the wound care.

  The best palliation for a wound that impairs quality of life is to provide to the “Triad Complex.”

  Any information necessary to understand how and why the wound is getting better: a daily diary stress both the healing process and the active consequences produced by this palliative action: a painless wound, infection-free, without a foul smell and a good tissue repair and regeneration limits the parental distress, makes more accepted the child by other patients, he can start again to play with them and the mother should mark on the Diary when his sun become to walk again for the first time after a long time.

Multiple Pressure Ulcers and Spastic Quadriplegia: A Multidisciplinary Approach

Ottonello M, Ferraro S, Massone A Savona, Italy

Abstract
  The authors describe their experience about 387 patients joints to our observation in our Spinal Cord Unit after spinal cord injury, for pressure ulcers in period 1999-2010, 276 of these introduced 2 or more ulcerative lesions (until to a max of 6 ulcers contemporary) for a total of 512 lesions.

  In our casistic we consider 15 patients with the age from 10 to 15, with quadriplegia complicated by pressure ulcers. The complexity of the clinicians pictures needs of a careful therapeutic programming to the aim to obtain turns out to you satisfactory, reunited to one acceptable duration of the hospitalization with reduction of complications. Our strategy is based above all on the preparation in team of the surgical program, the preparation and post-operative management to the return to home of the patient.

  Materials and Methods. All the patients that we reach our observation for the treatment of the pressure ulcers have the same protocol that we describe, in particular when draft of multiple lesions, we plan the surgical treatment to the aim to reduce most possible the times of the hospitalization. We consider in our presentation 10 patients males and 5 females of medium age of 12 years (range10-15 years) affections from multiple pressure ulcers (from 2 to 6), for a total of 31 lesions and for which analogous to how much we carry out for the simple lesions, it comes established, 7-10 days before the intervention, one adapted to nutrition for I.V. way with caloric contribution from 1830 to 2550 kcal to second of the necessities of the patient in considerations of controls of the weekly estimated nutritional parameters, continuing the infusion for all the post-operative period. It comes carried out a colturale biopsy of every wounded and begun one specific antibiotic therapy aimed 2 days before the participation maintaining it in order at least 15 days, moreover the patient and subordinate to prevention of deep the venous thromboses with eparine to low molecular weight from the day of the participation. The surgical treatment (10 intervention), when possible, it has been carried out using miocutaneus flaps that give one cover of adapted thickness and carrying out closings at least two ulcers contemporary. The post-operative passed one has happened on a fluidized bed, and subsequently a period of weaning on bed to air. To obtained our goal the patients have begun a training in wheel chair for increase times them with recovery of the ADL to the aim to guarantee one good resumption of the autonomies, and one postural study with computerized control of the sitting to the aim to reduce the recurrence that they are monitored in the follow up (2-4-6-12-18-24 months).

  Results. All the patients have obtained the complete clinical resolution and the resumption of the ADL in wheel chair with medium hospitalization of 90 days (ranges from 45 to 180 days). In four lesions the surgical review of the wounds has been necessary, for marginal necroses of the edges of the wound with successive clinical resolution. The follow up of the patients it is in average of 60 months (range from 12to 120 months) has put in evidence one recurrence.

  Conclusion. Ours turn out suggest to you that the happened one in the treatment of these complex clinical situations happens thanks to the careful programming of equipe and the possibility to manage in suitable atmospheres, which are the Spinal Cord Units, the necessities of these particular patients, remembering that the pressure ulcers represents the spy of the bad clinical conditions of the worse patient or of the failure of its rehabilitative program.

Palliative Wound Care for Onocological Patients

Fromantin I Paris, France
Abstract
  In pediatric oncology, wounds may be minor or major. All children involved in these two situations seem to share same priorities: no pain during dressing, no more adhesive bandage, no odour, and no discomfort. The malignant wounds are the more unbearable type of wound for the family, doctors and nurses.

  In a palliative context, this wound requires more specific care depending of the imminence of the end of life, including a perfect technical skill and interdisciplinary think.

  When wound care in a curative aim is no more possible, treatment must attempt to improve quality of life, and health care team must adopt an appropriate approach to manage the daily wound care, controlling pain, malodour, infection and bleeding. In this aim, it is necessary to know, to use, and to adapt all the products and technologies to each situation, and to take into account the child wishes, when possible.

  Quality of palliative wound care need to be human, with exact technique