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Experience with the negative pressure closure system of chronic wounds in pediatric patients
Experiencia con el sistema de cierre de presión negativa en heridas crónicas en pacientes pediátricos: experiencia de 8 casos
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"apellidos" => "Saleme-Cruz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Garavito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Ortopedia Pediátrica, Hospital Shriners para Niños México, Ciudad de México, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Ortopedia y Traumatología, Cruz Roja Mexicana, Ciudad de México, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cirugía Plástica y Reconstructiva, Hospital Shriners para Niños México, Ciudad de México, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Experiencia con el sistema de cierre de presión negativa en heridas crónicas en pacientes pediátricos: experiencia de 8 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 408 "Ancho" => 1800 "Tamanyo" => 155970 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient with sequelae after <span class="elsevierStyleItalic">Loxosceles laeta</span> spider bite. A) Initial condition of the wound. B) After debridement. C) With application of VAC<span class="elsevierStyleSup">®</span> system. D) Condition of the wound after 3 applications. E) Final result: wound with skin graft.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Deep infections in pediatric patients represent a major complication, especially in spine surgery and neuromuscular disorders, with an infection rate up to 20%, involving high morbidity and costs, increasing pain and hospital stay, as well as a challenge for orthopedic surgeons. The use of the vacuum-assisted closure system (VAC<span class="elsevierStyleSup">®</span>) (KCI Inc., San Antonio, TX, USA) for the treatment of soft tissue defects in traumatic wounds<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and deep infections in pediatric orthopedics has increased considerably in the last decade. There are a number of works on the VAC<span class="elsevierStyleSup">®</span> system, which generally report favorable results.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The VAC<span class="elsevierStyleSup">®</span> system includes a polyurethane or polyvinyl alcohol sponge, placed in the wound and connected by a discharge tube to a negative pressure device. This is sealed in order to create a vacuum and can then be used for days or weeks, changing the sponge every 48–72<span class="elsevierStyleHsp" style=""></span>h. This technique can be used to cover the exposed bone or soft tissue defects, reducing chronic edema and increasing local blood supply. The controlled application of sub-atmospheric pressure, continuously or intermittently, aids the formation of granulation tissue, acts as a sterile barrier decreasing bacterial colonization and infection by up to 82%,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> drains fluids through the pores of the polyurethane sponge, approximates the edges of the wound and accelerates the healing process compared to traditional methods.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The benefit of the application of VAC<span class="elsevierStyleSup">®</span> for control of infections has been demonstrated. It creates a hypoxic environment which modulates the growth of gram-negative bacteria and, in turn, stimulates angiogenesis and the growth of fibroblasts and epidermal cells.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to describe the results in pediatric patients with chronic wounds treated with VAC<span class="elsevierStyleSup">®</span> to control infections and demonstrate the decreased length of stay after its application.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a retrospective analysis of patients undergoing the use of VAC<span class="elsevierStyleSup">®</span> at Shriners Hospital for Children in Mexico between January 2008 and December 2012. We collected data from medical records and found 8 patients treated with this method who were included in the study regardless of the reason for the application of the VAC<span class="elsevierStyleSup">®</span> system.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We evaluated the reason for the use of the system, the results of wound culture, the number of days of hospital stay, the frequency of application, the system change interval and the number of days until discharge after application, as well as the final treatment for the wounds.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The 8 patients in the sample analyzed in this study required the application of the VAC<span class="elsevierStyleSup">®</span> system due to defects in wound closure. A wound culture was taken prior to the application and colonization by pathogenic microorganisms was found in all cases. <span class="elsevierStyleItalic">Staphylococcus aureus</span> was the most prevalent organism in these patient samples, followed by <span class="elsevierStyleItalic">Enterococcus faecalis</span>, in 4 and 3 patients, respectively. In 6 cases, the infection was monobacterial. The results of the variables analyzed are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The mean application interval was 3 days, at an intermittent pressure of 125<span class="elsevierStyleHsp" style=""></span>mmHg. We observed that the mean discharge time after applying the VAC<span class="elsevierStyleSup">®</span> system was 14.7 days. Of all the patients who were administered the system, only 1 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) required a transtibial amputation due to the chronicity of the process and bone involvement. In the remaining cases there was no recurrence of the infectious process or new wound dehiscence, with complete healing by the final closure method selected by the surgeon after a monitoring period of 2 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Chronic wounds represent a challenge for any surgeon, especially in orthopedic surgery, in which implants act as a reservoir for infectious microorganisms. In recent years, the use of the VAC<span class="elsevierStyleSup">®</span> system has revolutionized the way in which these injuries are treated, as it reduces swelling, so local perfusion is increased up to 4 times more than normal,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> stimulating the formation of large amounts of granulation tissue. In the study by Barnaby et al. there was a 50% decrease in the need for free or pedicled flaps for the coverage of defects in open fractures in children, with this method being reported as safer and more effective.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The study by Suissa et al. observed a significant reduction in wound size compared with traditional methods,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> thereby decreasing hospitalization time. Regarding costs, no increase has been observed, despite the fact that the materials employed in the care of wounds with the VAC<span class="elsevierStyleSup">®</span> system are more costly than with traditional treatment methods. This balance in costs is explained by a decrease in the need for staff to change wound dressings many times per day.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding infection control, we have not observed a decrease in the bacterial load within the wounds, although we have observed a decrease of non-fermenting Gram-negative microorganisms caused by the hypoxic environment. Establishing a hypoxic environment stimulates angiogenesis, fibroblasts and epidermal growth factors. We have also observed that continuous aspiration of excess fluid leads to decompression of small caliber blood vessels, increasing local blood flow. All these factors favor wound healing.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In this study we examined the time elapsed for wound closure after application of the VAC<span class="elsevierStyleSup">®</span> system and found that the mean time until discharge of patients after initiation of VAC<span class="elsevierStyleSup">®</span> treatment was 37% of the total hospitalization time. This datum enabled us to verify the usefulness of adjuvant therapy for the control of infections, as well as the improvement in granulation tissue, which created the ideal conditions within the wounds for the application of skin grafts or local rotation flaps.</p><p id="par0065" class="elsevierStylePara elsevierViewall">As noted in the study, we should emphasize that the wound closure treatment with negative pressure alone is not a substitute for lavage and surgical debridement. When considering this type of treatment we must bear in mind the natural progression of the injuries, as well as the need for appropriate antibiotic coverage according to microorganism susceptibility and the final treatment of injuries, which often require the application of skin grafts or local rotation flaps from healthy tissue (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The cases presented in this study showed a decrease in length of stay after application of VAC<span class="elsevierStyleSup">®</span> treatment compared to the total time of stay; with a mean time until discharge of 14 days after VAC<span class="elsevierStyleSup">®</span> application. This was due to an increase in granulation tissue and the lack of clinical evidence of infection, which generated favorable conditions for the application of the final treatment with local flaps or skin grafts. Only 1 case required a radical treatment due to bone involvement which prevented a feasible limb.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There are few studies on the use of the VAC<span class="elsevierStyleSup">®</span> system in pediatric patients with orthopedic conditions, especially of neuromuscular origin. The results recorded in this study showed the efficacy of the treatment in this population. Thus, we recommend its use, in conjunction with adequately selected antibiotic treatment according to the susceptibility of the pathogen, for the treatment of chronic wounds in pediatric patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of people and animals</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres273597" "titulo" => array:6 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Discussion" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec255600" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres273596" "titulo" => array:6 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Discusión" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec255599" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-30" "fechaAceptado" => "2013-04-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec255600" "palabras" => array:3 [ 0 => "VAC" 1 => "Chronic wounds" 2 => "Pediatrics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec255599" "palabras" => array:3 [ 0 => "VAC" 1 => "Heridas crónicas" 2 => "Pediatría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To show the results and advantages of using the negative pressure closure system in a pediatric population with infections and wound closure defects.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis was conducted on pediatric patients in whom the VAC<span class="elsevierStyleSup">®</span> negative pressure wound closure system was used in the Shriners Hospital for Children, Mexico, from January 2008 to December 2012. We were able to include 8 patients treated with this system. We evaluated the cause for use, wound colonizing microorganism, number of days of stay at the hospital, number of times applied, interval of application, and number of days in the hospital until discharge after VAC<span class="elsevierStyleSup">®</span> application, and final treatment.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The average days after VAC application till discharge was 13.7 days. The final treatment in 7 of the 8 patients was direct closure or application of skin grafts for closure of the wounds.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Through this study we were able to observe that, after the application of this treatment, there was an increase in the granulation tissue at the wounds, as well as resolution of the infection.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We were able to confirm the efficiency of this treatment in controlling the infection and decreasing skin defects, allowing an easier and earlier wound closure.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se exponen los resultados y ventajas del uso del sistema de presión negativa (VAC<span class="elsevierStyleSup">®</span>) en los pacientes pediátricos con defectos cutáneos y/o infecciosos.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Análisis retrospectivo de los pacientes sometidos al uso del VAC<span class="elsevierStyleSup">®</span> en el Hospital Shriners para Niños México, desde enero de 2008 a diciembre de 2012. Se incluyeron 8 pacientes tratados con el VAC<span class="elsevierStyleSup">®</span>. Se evaluó el motivo de colocación, microorganismo colonizante de la herida, número de días de estancia, número de ocasiones aplicadas, intervalo de aplicación, número de días al alta posterior a la aplicación, y el tratamiento final.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se observó que el promedio de días desde la colocación al alta fue de 13,7. El tratamiento final en 7 de los 8 pacientes fue cierre directo de la herida o aplicación de injerto cutáneo.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Discusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mediante este estudio se pudo observar que después de la aplicación de este tratamiento hay una mejoría importante en la capacidad de granulación de las heridas, así como erradicación de las infecciones.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se ha podido constatar la eficacia de este tratamiento en el control de la infección, y la disminución de los defectos cutáneos haciendo más sencillo y rápido el cierre de las heridas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dabaghi-Richerand A, Gómez-Chavarría J, González-Sánchez M, Saleme-Cruz J, Garavito E. Experiencia con el sistema de cierre de presión negativa en heridas crónicas en pacientes pediátricos: experiencia de 8 casos. Rev Esp Cir Ortop Traumatol. 2013;<span class="elsevierStyleBold">57</span>:282–5.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 485 "Ancho" => 1500 "Tamanyo" => 113993 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patient with neuromuscular scoliosis with surgical wound dehiscence treated by application of the VAC<span class="elsevierStyleSup">®</span> system. Sequence of wound treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 408 "Ancho" => 1800 "Tamanyo" => 155970 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient with sequelae after <span class="elsevierStyleItalic">Loxosceles laeta</span> spider bite. A) Initial condition of the wound. B) After debridement. C) With application of VAC<span class="elsevierStyleSup">®</span> system. D) Condition of the wound after 3 applications. E) Final result: wound with skin graft.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">MTT: metatarsal; PMR: posteromedial release; PO: postoperative.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reason for application \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Final treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Days of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Post VAC<span class="elsevierStyleSup">®</span> discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number of applications \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent MTT ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Myelomeningocele + left ischiatic ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PO astragalectomy wound dehiscence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left hemithorax wound dehiscence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PO PMR skin necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Myocutaneous graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin necrosis in the thorax and neck, secondary or due to a bite from <span class="elsevierStyleItalic">Loxosceles laeta</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recurrent plantar ulcer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transtibial amputation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spinal surgical wound dehiscence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Skin graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab392941.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Demographic data.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subatmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type iii open tibial shaft fractures in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 1 | 5 |
| 2024 October | 6 | 4 | 10 |
| 2024 September | 11 | 8 | 19 |
| 2024 August | 13 | 3 | 16 |
| 2024 July | 15 | 2 | 17 |
| 2024 June | 9 | 5 | 14 |
| 2024 May | 12 | 4 | 16 |
| 2024 April | 20 | 1 | 21 |
| 2024 March | 13 | 0 | 13 |
| 2024 February | 28 | 9 | 37 |
| 2024 January | 20 | 7 | 27 |
| 2023 December | 24 | 12 | 36 |
| 2023 November | 22 | 2 | 24 |
| 2023 October | 40 | 12 | 52 |
| 2023 September | 25 | 3 | 28 |
| 2023 August | 20 | 8 | 28 |
| 2023 July | 13 | 6 | 19 |
| 2023 June | 19 | 4 | 23 |
| 2023 May | 23 | 2 | 25 |
| 2023 April | 19 | 7 | 26 |
| 2023 March | 19 | 1 | 20 |
| 2023 February | 23 | 2 | 25 |
| 2023 January | 24 | 12 | 36 |
| 2022 December | 28 | 3 | 31 |
| 2022 November | 29 | 4 | 33 |
| 2022 October | 10 | 5 | 15 |
| 2022 September | 23 | 7 | 30 |
| 2022 August | 17 | 12 | 29 |
| 2022 July | 21 | 11 | 32 |
| 2022 June | 8 | 8 | 16 |
| 2022 May | 11 | 6 | 17 |
| 2022 April | 10 | 10 | 20 |
| 2022 March | 19 | 11 | 30 |
| 2022 February | 20 | 4 | 24 |
| 2022 January | 27 | 4 | 31 |
| 2021 December | 31 | 8 | 39 |
| 2021 November | 25 | 7 | 32 |
| 2021 October | 17 | 10 | 27 |
| 2021 September | 9 | 11 | 20 |
| 2021 August | 11 | 7 | 18 |
| 2021 July | 13 | 5 | 18 |
| 2021 June | 13 | 4 | 17 |
| 2021 May | 25 | 6 | 31 |
| 2021 April | 22 | 16 | 38 |
| 2021 March | 26 | 11 | 37 |
| 2021 February | 21 | 11 | 32 |
| 2021 January | 8 | 6 | 14 |
| 2018 February | 13 | 0 | 13 |
| 2018 January | 8 | 0 | 8 |
| 2017 December | 8 | 0 | 8 |
| 2017 November | 10 | 1 | 11 |
| 2017 October | 17 | 2 | 19 |
| 2017 September | 25 | 5 | 30 |
| 2017 August | 15 | 10 | 25 |
| 2017 July | 18 | 9 | 27 |
| 2017 June | 28 | 12 | 40 |
| 2017 May | 20 | 1 | 21 |
| 2017 April | 18 | 2 | 20 |
| 2017 March | 25 | 32 | 57 |
| 2017 February | 76 | 1 | 77 |
| 2017 January | 23 | 0 | 23 |
| 2016 December | 18 | 5 | 23 |
| 2016 November | 28 | 6 | 34 |
| 2016 October | 52 | 4 | 56 |
| 2016 September | 112 | 5 | 117 |
| 2016 August | 32 | 1 | 33 |
| 2016 July | 12 | 1 | 13 |
| 2016 June | 21 | 3 | 24 |
| 2016 May | 18 | 10 | 28 |
| 2016 April | 31 | 8 | 39 |
| 2016 March | 17 | 4 | 21 |
| 2016 February | 10 | 11 | 21 |
| 2016 January | 3 | 1 | 4 |
| 2015 December | 7 | 4 | 11 |
| 2015 November | 12 | 6 | 18 |
| 2015 October | 15 | 2 | 17 |
| 2015 September | 8 | 5 | 13 |
| 2015 August | 11 | 10 | 21 |
| 2015 July | 8 | 0 | 8 |
| 2015 June | 0 | 1 | 1 |
| 2015 April | 0 | 1 | 1 |
| 2014 September | 1 | 0 | 1 |
| 2014 August | 1 | 0 | 1 |
| 2014 July | 4 | 3 | 7 |
| 2014 June | 6 | 0 | 6 |
| 2014 May | 4 | 0 | 4 |
| 2013 September | 1 | 0 | 1 |
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