Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

Extracellular matrix (ECM) mechanical cues guide healing in tendons. Yet, the molecular mechanisms orchestrating the healing processes remain elusive. Appropriate tissue tension is essential for tendon homeostasis and tissue health. By mapping the attainment of tensional homeostasis, we aim to understand how ECM tension regulates healing. We hypothesize that diseased tendon returns to homeostasis only after the cells reach a mechanically gated exit from wound healing.

We engineered a 3D mechano-culture system to create tendon-like constructs by embedding patient-derived tendon cells into a collagen I hydrogel. Casting the hydrogel between posts anchored in silicone allowed adjusting the post stiffness. Under this static mechanical stimulation, cells remodel the (unorganized) collagen representing wound healing mechanisms. We quantified tissue-level forces using post deflection measurements. Secreted ECM was visualized by metabolic labelling with non-canonical amino acids, click chemistry and confocal microscopy. We blocked cell-mediated actin-myosin contractility using a ROCK inhibitor (Y27632) to explore the involvement of the Rho/ROCK pathway in tension regulation.

Tissue tension forces reached the same homeostatic level at day 21 independent of post compliance (p = 0.9456). While minimal matrix was synthesized in early phases of tissue formation (d3-d5), cell-deposited ECM was present in later stages (d7-d9). More ECM was deposited by tendon constructs cultured on compliant (1Nm) compared to rigid posts (p = 0.0017). Matrix synthesized by constructs cultured on compliant posts was less aligned (greater fiber dispersion, p = 0.0021). ROCK inhibition significantly decreased tissue-level tensional forces (p < 0.0001).

Our results indicate that tendon cells balance matrix remodeling and synthesis during tissue repair to reach an intrinsically defined “mechanostat setpoint” guiding tension-mediated exit from wound healing towards homeostasis. We are identifying specific molecular mechanosensors governing tension-regulated healing in tendon and investigate the Rho/ROCK system as their possible downstream pathway.

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remain a challenge. A novel surgical technique named Tibial Cortex Transverse Transport has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In present study, we aimed to explore the wound healing effects after undergoing this novel technique via multiple ways.

A novel rat model of Tibial Cortex Transverse Transport was established with a designed external fixator and effects on wound healing were investigated. All rats were randomized into 3 groups, with 12 rats per group: sham group (negative control), fixator group (positive control) and Tibial Cortex Transverse Transport group. Laser speckle perfusion imaging, vessel perfusion, histology and immunohistochemistry were used to evaluate the wound healing processes.

Gross and histological examinations showed that Tibial Cortex Transverse Transport technique accelerated wound closure and enhanced the quality of the newly formed skin tissues. In Tibial Cortex Transverse Transport group, HE staining demonstrated a better epidermis and dermis recovery, while immune-histochemical staining showed that Tibial Cortex Transverse Transport technique promoted local collagen deposition. Tibial Cortex Transverse Transport technique also benefited to angiogenesis and immunomodulation. In Tibial Cortex Transverse Transport group, blood flow in the wound area was higher than that ofother groups according to laser speckle imaging with more blood vessels observed. Enhanced neovascularization was seen in the Tibial Cortex Transverse Transport group with double immune-labelling of CD31 and α-SMA. The M2 macrophages at the wound site in the Tibial Cortex Transverse Transport group was also increased.

Tibial cortex transverse transport technique accelerated wound healing through enhanced angiogenesis and immunomodulation.

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Drainage from the knee wound after TKA is an obvious concern for the arthroplasty surgeon. One of the inherent problems with a total knee arthroplasty is there is a focus on obtaining maximum range of motion but at the same time the wound needs to heal in a timely fashion. Consistent knee drainage after a TKA is a source of concern. The quantity and quality of drainage needs to be assessed and there are certain questions that need to be answered including: 1) Is there bloody drainage which suggests fascial dehiscence?; 2) Is the patient too active?; 3) Is the drainage in some way related to DVT prophylaxis?; 4) Is the patient obese and could the drainage be secondary to fat necrosis or seroma? and 5) Is the drainage suggestive of an infection? The work-up can include C-reactive protein and sed rate, and possibly a knee aspiration. In general, C-reactive protein >100mg/L within the first six weeks after surgery suggests the presence of an infection. The sed rate is generally not useful in the early post-operative period. In the first six weeks after surgery if the number of white cells in the aspiration is >10,000 this suggests infection especially if there are 80–90% polymorphonuclear cells.

Each day of prolonged wound drainage is noted to increase the risk of infection by 29%. Morbid obesity has been shown to be an independent risk factor for infection. Some anticoagulants (i.e. low molecular weight heparin) have been associated with increased wound drainage. In a retrospective review of 11,785 total joint arthroplasties, 2.9% of joints developed wound drainage, and of these patients, 28% required further surgery. It was noted that patients that were malnourished had a 35% failure rate with respect to controlling the drainage and preventing infection versus 5% in patients that were healthy.

The International Consensus Conference on Infection concluded that a wound that has been persistently draining for greater than 5–7 days requires surgical intervention. The available literature provides little guidance regarding the specifics of this procedure. In general, if the wound is draining or is red, rest the leg for a day or two. In some instances a bulky Jones dressing can be helpful. If the drainage persists one could consider using a negative pressure dressing (wound vac) but there is little data on efficacy after TKA. If there is persistent drainage or cellulitis, then operative intervention is probably necessary. Evaluation of CRP and a knee joint aspiration can be helpful. The decision to return to the OR should be made within the first 7 days after the surgery. At the time of the procedure one will need to decide to perform either a superficial washout versus a washout and polyethylene exchange.

Drainage from the knee wound after TKA is an obvious concern for the arthroplasty surgeon. One of the inherent problems with a total knee arthroplasty is there is a focus on obtaining maximum range of motion but at the same time the wound needs to heal in a timely fashion. Consistent knee drainage after a TKA is a source of concern. The quantity and quality of drainage needs to be assessed and there are certain questions that need to be answered including: 1) Is there bloody drainage which suggests fascial dehiscence?; 2) Is the patient too active?; 3) Is the drainage in some way related to DVT prophylaxis?; 4) Is the patient obese and could the drainage be secondary to fat necrosis or seroma? and 5) Is the drainage suggestive of an infection? The work up can include C-reactive protein and sed rate, and possibly a knee aspiration. In general, C-reactive protein >100 mg/L within the first six weeks after surgery suggests the presence of an infection. The sed rate is generally not useful in the early post-operative period. In the first six weeks after surgery if the number of white cells in the aspiration is >10,000 this suggests infection especially if there are 80–90% polymorphonuclear cells.

Each day of prolonged wound drainage is noted to increase the risk of infection by 29%. Morbid obesity has been shown to be an independent risk factor for infection. Some anticoagulants (i.e. low molecular weight heparin) have been associated with increased wound drainage. In a retrospective review of 11,785 total joint arthroplasties, 2.9% of joints developed wound drainage, and of these patients, 28% required further surgery. It was noted that patients that were malnourished had a 35% failure rate with respect to controlling the drainage and preventing infection versus 5% in patients that were healthy.

The International Consensus Conference on Infection concluded that a wound that has been persistently draining for greater than 5–7 days requires surgical intervention. The available literature provides little guidance regarding the specifics of this procedure. In general, if the wound is draining or is red, rest the leg for a day or two. In some instances a bulky Jones dressing can be helpful. If there is persistent drainage or cellulitis, then operative intervention is probably necessary. Evaluation of CRP and a knee joint aspiration can be helpful. The decision to return to the OR should be made within the first 7 days after the surgery. At the time of the procedure one will need to decide to perform either a superficial washout versus a washout and polyethylene exchange.

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

1. The incidence of failure of wound healing by primary intention due to infection, haematoma and gaping of wound edges, has been compared in 100 patients with rheumatoid arthritis and in 100 matched controls following a variety of orthopaedic operations.

2. There were thirty-one cases of failure of wound healing in the patients with rheumatoid arthritis and sixteen in the controls (P< ·02). There was no significant difference in the numbers of infected wounds or in those in which a haematoma developed. However, there was a significant excess of wound edge separation in the rheumatoid patients (thirteen) compared with the controls (four) (P< ·05).

3. The problems of wound healing were minor since there was no difference in the mean number of days ±1 standard deviation to wound healing between the patients: l6·6±7·5 days; and the controls: 15·2±7·9 days.

4. There was no correlation between duration or severity of rheumatoid disease and wound healing.

5. There was no difference in wound healing between patients with sero-positive and seronegative disease.

6. Forty-nine patients received corticosteroid therapy in small dosage. This was associated with an increased incidence of wound infection. Treatment for more than three years was associated with a significant increase in the mean number of days to wound healing.

7. The results are discussed in the light of the increased incidence of infection in several sites in patients with rheumatoid arthritis and of the effect of corticosteroid therapy on wound healing in man and experimental animals. It is suggested that more marked abnormalities might have been expected, and that these findings may need to be considered in the future surgical management of such patients.

Introduction

Wound condition after primary total knee arthroplasty (TKA) is important for prevention of periprosthetic infection. Any delay in wound healing will cause deep infection, which leads to the arthroplasty failure. Prevention of soft tissue problems is thus essential to achieve excellent clinical results. However, it is unknown as to the important surgical factors affecting the wound healing using detailed wound score after primary TKA so far.

It was hypothesized that operative technique would affect wound healing in primary TKA. The purpose of the present study was to investigate and to clarify the important surgical factors affecting wound score after primary TKA.

Aim of the study: Due to the fact, that there is no publication in Medline available concerning the influence of external compression of the wound area after total hip arthroplasty we started a prospective, randomised study to evaluate this effect.

Materials and Methods: In a prospective randomised study including primary total hip replacements we compared 2 different prefabricated compression bandages, maintaining different levels of pressure on the wound area(Group A, B), a group with circular semi elastic bandages (group C) and a group without any bandage (group D). The sample calculated for each group was 130 Patients (level of significance 0.05, power 90%). Parameters concerning postoperative blood loss (haematocrit, need of blood units, blood in drainage) and wound heeling (bleeding of wound area, secretion, haematoma, additional need of antibiotics) were measured. For statistical evaluations Chi²-Test and T-Test were used.

Results: The group using semi elastic, circular bandages (C ) had to be stopped after 13 patients due to non-compliance of more than 50% of the patients because of discomfort and skin lesions. Without compression bandage the frequency of re-operations due to early septic complications was statistically significant higher than in groups using external compression. In the groups B and D the rates of wound secretion have been significantly higher than in group A using high pressure bandages. Duration and quantity of secretion, need of additional antibiotics as well as subcutaneous haematoma were increasing by decreasing external compression. The amounts of blood in Redon drainage were significantly reduced by external compression. In regard to the need of blood units no statistical differences could be detected.

Conclusion: Sufficient compression bandages are able to significantly reduce the frequency of re-operations due to septic complications and support wound healing after total hip arthroplasty. A remarkable number of insufficient products are sold on the market.

Purpose of the study: is to evaluate the wound healing problems following. Open reduction and internal fixation (ORIF) of calcaneal fractures. Introduction: Calcaneal fracture is challenging to all orthopaedic surgeons. It can be disabling injury with economical consequences, particularly it usually happen in men workers. ORIF is often needed to improve the final outcome of these difficult injuries. However, without careful selection of patients, time of surgery and using meticulous surgical technique, wound breakdown (the most frequent complication) can be disastrous. Material and Method: We reviewed 45 consecutive series calcaneal fractures treated by O.R.I.F. between 1996 and 2001.

The mean age was 36 years (range 18 to 57) All but one fracture resulted from a fall from height. Cases were analyzed to ascertain the mechanism of injury, associated injuries, presence of medical problems e.g. Diabetes or peripheral vascular disease, smoking. Number of days elapsed before surgery, method of wound closure, and the use of drain and Saunders grade. Results: All patients were Saunders grade two& three in our study. Fourteen were smokers. No one with peripheral vascular compromise, Body mass Index was within normal limit in all of them. Average time elapsed before surgery was 8 days. All operations were done by one surgeon, who closed all wounds in layers and regularly used a drain. We had four (11%) delayed healing (more than 2 weeks). No serious wound problems needing free flaps or amputation. Conclusion: ORIF for certain calcaneal fractures greatly improve the outcome of these unpleasant injuries. Appropriate patient selection and adherence to meticulous surgical technique significantly reduces wound healing problems.

CAR (CARSKNKDC) is a systemically administered wound-homing peptide that specifically recognizes angiogenic blood vessels and extravasates into sites of injury. CAR peptide requires heparan sulfate proteoglycans (HSPGs) for its cell penetrating activity. Syndecan-4 (SDC4) is a HSPG and binding to it triggers the wound re-epithelialization process. We have discovered that CAR peptide has the inherent ability to promote wound healing; wounds close and re-epithelialize significantly faster in CAR treated mice than in control groups (PBS and mutant peptide, i.e. mCAR injections). To delineate the molecular mechanism by which CAR accelerates wound healing, we focused on the requirement of HSPG binding for CAR peptide function. We demonstrate that CAR peptide endocytosis and its stimulation of keratinocyte cell migration are both dependent on SDC4. Finally, we show that the systemic administration of CAR peptide stimulates wound re-epithelialization only in WT mice, but not in SDC4 knockout (KO) mice. As SDC4 has very restricted expression in skin wounds, we propose that CAR peptide activates SDC4 function to promote re-epithelialization. CAR peptide may provide an entirely new way of enhancing wound healing, and perhaps tissue regeneration in general. This therapeutic approach is systemic, yet target organ- and cell- specific, and dependent on the naturally occurring SDC4 dependent migratory pathway that is crucial for tissue regeneration.

Aims: The aims of this study were to 1) determine if vacuum assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, 2) if it helps debride wounds and 3) if it prevents the need for further surgery

Materials and Methods: 15 patients were reviewed, average age 49.3yrs at an average of 6.3 months (1–18months). Ten patients had diabetes (8 IDDM) with 5 patients having grade 3 ulcers (Wagner-Meggitt). All wounds were surgically debrided prior to the application of the VAC therapy. The VAC therapy was applied according to the manufacturers instrucrtions. The main outcome measures were 1) time to satisfactory wound closure 2) change in the wound surface area and 3) need for further surgery

Results: Satisfactory healing was achieved in 11 patients (73.3%). 10 were diabetic, 5 patients had peripheral vascular disease and 5 patients had both. The time to satisfactory healing was 2.5 months, average 1–6 months. The average size of the wound ulcer was 7.41cm2 (2–10cm2) prior to treatment and 1.58cm2 (0–2cm2) following treatment in an average of 2.5 months. VAC therapy helped debride all non healing wounds following surgical debridement. In 10 patients, the need for further radical surgery, namely amputation, was avoided.

Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound /ulcers in patients with diabetes with or without periphearl vascular disease. Its use in foot and ankle surgery leads to a quick wound closure and in some cases avoids the need for further surgery with a potential for limb salvage.

A prospective study was undertaken of wound healing in HIV positive patients undergoing orthopaedic implant surgery. 175 implant operations were assessed. 40 operations (23%) were in HIV positive individuals. Wounds were scored using the Asepsis scoring system.

Closed fractures in HIV positive patients had 1 (3. 5%) major infection. No correlation was seen between CD4 count and risk of wound infection.

With regards to early wound sepsis, implant surgery can be undertaken safely in HIV positive individuals with closed injuries regardless of CD4 count. The risk of wound sepsis rises dramatically in implant surgery for HIV positive patients with open fractures.

Skin necrosis after total knee arthroplasty can rapidly lead to infection of the prosthetic components. Risk factors for the development of skin necrosis include rheumatoid arthritis, steroid use, immunosuppression, malnutrition, peripheral vascular disease, and multiple prior scars.

Vascularity of the skin over the knee will affect the rate of healing postoperatively and risk of necrosis. Johnson measured transcutaneous skin oxygen tension and found that the oxygen tension decreases for the first two to three days after surgery and then increases. In addition, the lateral skin edge is more hypoxic than the medial edge. This suggests that when multiple prior scars are present, the most vertical lateral incision should be used to minimise skin hypoxia.

Constant passive motion further decreases skin oxygen tension. Particularly for patients with multiple risk factors for developing wound complications, avoidance or delayed used of early range of motion exercises may be beneficial in reducing the development of skin necrosis.

If skin necrosis does occur after total knee arthroplasty, early recognition of the problem and treatment will minimise the risk of deep infection of the prosthetic components. Necrosis of the proximal wound including the area over the patella may be treated by local wound care and skin grafting. However, necrosis over the tibial tubercle or patellar tendon requires muscle flap coverage to prevent infection involving the patellar tendon. If the patellar tendon is not viable and the extensor mechanism disrupted, the medial gastrocnemius flap can also be used to augment the extensor mechanism. The tendon of the gastrocnemius is repaired to the quadriceps tendon maintaining continuity between the tibia and extensor mechanism.

Introduction: Systemic sclerosis of the hand is an uncommon form of arthritis that can cause significant functional loss in the hand. Because of decreased microcirculation, wound-healing problems are feared and surgical interventions avoided. We report the results after operations performed on the hand and forearm of patients with systemic sclerosis with special reference to wound healing problems.

Material and methods: This retrospective study evaluates the results of 41 consecutive operations performed in 19 patients between 1985 and 2000 at our unit. The mean age was 50 years (14 – 84 years). Sixteen patients were female and 3 male. Twelve patients were operated twice or more. Operations were elective in 27 cases, with excision of calcinosis in 8 patients, excision of calcinosis plus skin transplant in 2 patients, neurolysis of median, radial or ulnar nerve in 7 patients, wrist procedures (fusion or implant) in 3 patients and other procedures (e. g. finger joint fusion, removal of osteosynthetis material, finger osteotomy) in 7 patients.

In 14 cases the operations were indicated in reason of spontaneous skin necrosis or defects. These operations were: amputation with or without flap in 3 cases, wound revision in 6 cases, wound revision and flap in 5 cases (including skin transplantation in 3 of these patients).

Results: One wound healing problem occurred in the 27 elective operations. The patient operated with an arthrodesis of the small finger PIP-joint had to have both the cerclage wire and K-wire removed to obtain complete wound healing.

Seven of 14 patients in the group with spontaneous skin necrosis healed uneventfully after operation. Two patients had consecutive wound infections that caused a longer healing period of 5 months; another patient also had a longer healing period but his wounds healed shortly after he quit smoking. Four patients had necrosis/infections, which required additional surgery.

Conclusion: In systemic sclerosis, surgery performed in elective operations does not seem to have an increased rate of infections or other wound healing problems. Even larger operations like wrist arthrodesis or wrist prosthesis can be performed. In non-elective cases with spontaneous skin necrosis, in critically ischaemic fingers, the wound healing is not always easy and several operations can be necessary, however a good end result, without need for amputations, can be achieved.

Introduction

Nowadays, autologous platelet-rich plasma is used commonly in wound treatment. However, platelet gel, which was derived from allogeneic platelet-rich plasma (PRP) [1,2], has never been studied about efficacy in vivo or animal models. We aimed to determine efficacy of allogeneic platelet-gel on wound healing in rats by comparing with untreated, antibiotic-gel (Mupirocin 2%) treated and gel (sodium carboxymethylcellulose(NaCMC))-treated control.

Our previous study has revealed that silver nanoparticles (AgNPs) have potential to promote wound healing by accelerated re-epithelization and enhanced differentiation of fibroblasts. However, the effect of AgNPs on the functionality of repaired skin is unknown. The aim of this study was to explore the tensile properties of healed skin after treatment with AgNPs. Immunohistochemical staining, quantitative assay and scanning electron microscopy (SEM) were used to detect and compare collagen deposition, and the morphology and distribution of collagen fibers. Our results showed that AgNPs improved tensile properties and led to better fibril alignments in repaired skin, with a close resemblance to normal skin.

Based on our findings, we concluded that AgNPs were predominantly responsible for regulating deposition of collagen and their use resulted in excellent alignment in the wound healing process. The exact signaling pathway by which AgNPs affect collagen regeneration is yet to be investigated.

The Cincinnati incision is widely utilized in clubfoot surgery and allows excellent access to the medial, lateral and posterior structures involved. Closure of the skin at the end of the procedure without undue tension may be difficult. Wound necrosis and excessive scarring may occur and may lead to inadequate correction. One alternative is to splint the foot in an initial equines position post-operatively with repeat cast changes to achieve optimal position once soft tissue swelling has decreased. A further method is to leave the wound open and allow it to granulate.

The healing and final cosmetic appearance of wounds allowed to heal by granulation following the Cincinnati incision were reviewed.

We reviewed 14 feet in 10 patients who had undergone partial closure of the Cincinnati incision following peritalar release. The majority of the children were male and the average age at surgery was 28 weeks. All corrections were performed as primary procedures on patients with idiopathic CTEV. At the end of the procedure an above-knee plaster was applied. The plaster was changed weekly in the outpatients department until the wound had healed. Patients were maintained in plaster for 12 weeks.

All final wounds were cosmetically acceptable both to the surgeon and the parents. The widest scar was 3 mm and the average time to heal four weeks. No infection had occurred although two wounds were treated for overgranulation.

Partial wound closure of the Cincinnati incision avoids undue tissue tension and allows a fully corrected position of the foot to be maintained at the end of the initial procedure. A second anaesthetic to obtain further correction is therefore avoided. Partial wound closure leaves cosmetically acceptable scarring with minimal complications. Parents should be warned about the initial appearance of the wound but may be reassured regarding final outcome.

Aim: We have carried out a prospective study to compare duplex ultrasonography and transcutaneous oxygen tension as predictors of wound healing after knee arthroplasty.

Methods and Materials: 53 patients were included in the study. All underwent pre-operative duplex scans of their lower limbs. In addition, transcutaneous oxygen tension measurements were made adjacent to the proposed incision pre-operatively and on days 1, 3 and 7 post knee arthroplasty. Wound healing was assessed using the ASEPSIS wound score.

Results: 4 wounds had evidence of delayed wound healing. Duplex ultrasonography was a poor predictor of such problems; however there was a significant correlation between pre-operative transcutaneous oxygen tension and post-operative wound scores.

Conclusion: Pre-operative transcutaneous oxygen tension measurement is a better predictor of wound healing after knee replacement surgery than duplex ultrasonograph, and may be a useful adjunct to the investigation of patients at risk of wound problems post knee arthroplasty.