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Wound Healing
Natasha Holder MD, MSc, FRCSCOrthopaedic Oncology Fellow
For Dr. Joel Werier
Objectives
• Describe the pathophysiology of wound healing• Describe the complications of wound healing• Describe how to treat and prevent wound complications• Describe scar formation and clinical treatments for
abnormal scars
What is a wound?
• A wound is a disruption of the normal structure and function of the skin and underlying soft tissue
Wound Classification
• Acute:– normal, healthy individuals heal through an orderly
sequence of physiological events that include hemostasis, inflammation, epithelialization, fibroplasia, and maturation
– Easily identifiable mechanism e.g. trauma• Chronic:
– Physiologic process is altered or stalled– more likely to occur in patients with underlying
disorders such as peripheral artery disease, diabetes, venous insufficiency, nutritional deficiencies, and other disease states
Phases of Wound Healing
• Mediated by the activation of – Keratinocytes– Fibroblasts– Endothelial cells– Macrophages– Platelets
• Organized cell migration and recruitment of endothelial cells for angiogenesis
• Many growth factors and cytokines are also released
Phases of Wound Healing
Phases of Wound Healing
1. Inflammatory2. Proliferative3. Maturation
Phases of Wound Healing
Phases of Wound Healing
Phases of Wound Healing
Impaired Wound Healing
• Occurs due to disruption of the phases of healing– Local tissue ischemia– Neuropathy– Tissue necrosis– Infection– Wound edema
Risk Factors for Non-healing Wounds
• Peripheral Artery Disease
• Diabetes• Chronic venous
insufficiency• Aging• Immunosuppressive
therapy• Sickle cell disease
• Cancer Therapy• Radiation therapy• Spinal cord disease
and immobilization• Malnutrition• Infection• Smoking
Wound Management
1. Primary Closure (Primary Intention)2. Secondary Closure (Secondary Intention)3. Delayed Primary Closure (Tertiary Intention)
Primary Closure
Skin & Subcutaneous
Secondary Wound Closure
Secondary Wound Healing
Granulation: Capillary proliferation, leukocytes, bacteria
Hemostasis
Platelets and Fibrin – Clot, Cytokines
Inflammation
PMN’s and macrophages
Fibroplasia
Macrophages attract fibroblasts New connective tissue matrix
Maturation
Inflammatory cells decrease, angiogenesis stops, Equalization of collagen synthesis & degradation
Contraction
Powerful mechanical forces in the body Ancient peoples: Skin wounds heal & contract
if kept clean & protected with a dressing Skin margins move together to produce a healed wound Contraction can yield a devastating result
in some injuries ie. burns
Severe Contracture
Excision & Full Thickness Skin Grafting
Delayed Primary Closure
Wound is left open due to gross contamination
Delayed Primary Closure
Open Fracture Wounds Open Fracture Wounds
Delayed Primary or Secondary ClosureDelayed Primary or Secondary Closure But Never Primary ClosureBut Never Primary Closure
Wound Complications
Early• Seroma/Hematoma• Dehiscence• Infection• Hernia• Hypertrophic and
Keloid Scars
Late• Hypertrophic scar• Keloid formation• Necrosis• Abscess
Seroma and Hematoma
Seroma• Collection of serous
fluid• Fluctuation, swelling,
redness, tenderness
TREATMENT:• Sterile punture and
compression• Suction drain
Hematoma• Collection of blood –
Bleeding, anticoagulant
• Risk of infection• Swelling, fluctuation,
pain, redness
TREATMENT• Sterile puncture• Surgical exploration
Wound Dehiscence
• Complete breakdown of the wound closure• Systemic Risk Factors:
– Diabetes, Malnutrition, obesity, COPD, steroids, cytotoxic drugs
• Local Risk factors:– Technical error, infection, hematoma, ischemia,
radiation
VAC Assisted therapy
Skin does not grow over exposed dead bone
Gastrocnemius Rotation Flap
Patella
Right: Lateral View
• 70 yr. old male
• 3B Prox. tibia
• Prop injury
Superficial (Cortical) Osteo
Patella
Patella
Left Tibia
• Typically, medial aspect proximal tibia• Medial gastrocnemius is “workhorse”
Gastrocnemius Muscle:Vascular Supply
Branches of popliteal artery
Medial sural artery
Lateral sural artery
Gastrocnemius Rotation Flap
• Medial goes farther
• Midline defect
• Femoral condyles
• Key is to take a slip
of distal tendon Medial Lateral
Antibiotic-Loaded Acrylic Cement Spacer Block
Right Knee-Calf: Medial View
Right Knee Lateral View
Ankle
8 Weeks Later – IV Antibiotics
Type of Healing Here?
Right Knee
Flap Options
Infection
• Superficial versus deep?• Superficial wound infection:
– Treatment: Antibiotics• Deep wound infection:
– Treatment: • identify organism with cultures• surgical exploration (irrigation and debridement)• IV antibiotics based on cultures and ID
consultation
Wound Debridement
• Gentle handling of tissues minimizes bleeding• Control residual bleeding with compression, ligation or
cautery• Dead or devitalized muscle is dark in color, soft, easily
damaged and does not contract when pinched.• During debridement, excise only a very thin margin of
skin from the wound edge
Wound Debridement
• Debride the wound meticulously to remove any loose foreign material such as dirt, grass, wood, glass or clothing.
• With a scalpel or dissecting scissors, remove all adherent foreign material along with a thin margin of underlying tissue and then irrigate the wound again.
Hypertrophic and Keloid Scars
• Excessive tissue response to dermal injury characterized by local fibroblast proliferation and overproduction of collagen
• Overexpression of growth factors, such as transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF), and connective tissue growth factor (CTGF)
Hypertrophic Scars
• Sites of surgical wounds, lacerations, burns, or inflammatory or infectious skin conditions (eg, acne, folliculitis, chicken pox, and vaccinations).
• They are raised, may be erythematous, and typically do not exceed the margins of the original wound
Keloid Scars
• Raised dermal lesions that extend beyond the boundaries of the original wound and invade the surrounding healthy skin
• Sites of minor injuries to the skin, such as earlobe piercings, or may develop in the absence of an obvious inciting stimulus
Treatment of Hypertrophic and Keloid Scars
• Intralesional Cortisone injection
• Silicone gel sheets
• Pressure therapy• Cyrotherapy• Surgical Excision
Thank You