Petrenko O. Surgical management of purulent necrotic wounds of the lower extremities

In contrast, in biopsies obtained from chronic wounds of patients with diabetes, on the 7th postoperative day, the activity of both gelatinases remained at a high level and was not statistically different from this value determined on the 4th day (p<0.05). Increased gelatinase activity in diabetic wounds reflects the course of the chronic inflammatory process and is proposed for the use as a prognostic indicator of the course of healing. Based on the obtained results, it was first proposed to conduct a comprehensive microbiological study and enzyme diagnosis of chronic wounds in patients with diabetes in order to improve the effectiveness of treatment and monitoring of the wound process. In the present thesis, it has been established for the first time that the normalization of proteolytic processes due to the evacuation of excess collagenolytic activity from purulent-necrotic ulcers of the soft tissues of patients with diabetes mellitus by vacuum-assisted closure (VAC-therapy) correlates with the positive dynamics of chronic wound healing and can be considered as one of the key mechanisms for the realization of its healing effects. The application of VAC-therapy for chronic purulent ulcers in patients with diabetes resulted in a decrease in MMP activity in tissue biopsy of wounds by 68 and 45% at the 5th and 10th days after treatment compared with this indicator before treatment (p <0.05). In contrast, gelatinase activity in wound exudates after application of wound evacuation increased by 68 and 85%, respectively, compared to this value before treatment (p <0.05). In patients undergoing traditional therapy, the activity of MMPs in the tissues of the wound surface remained consistently high. The study of bacterial film in acute and chronic wounds of the lower extremities was carried out. It was established that biofilms are formed within 24 hours in vitro. It was proved that biofilms in acute purulent wounds are formed at the 3rd day. In 65% of cases, biofilm is formed by gram-negative microorganisms. In diabetic foot syndrome, 68% of wounds are biofilm-containing. A direct correlation between the ability of microorganisms to form a bacterial film and the duration of the disease was found (Pearson linear correlation coefficient rp = 0.67, p <0.05). In contrast, the correlation of this feature with the regression timing of clinical manifestations of SIRS was less significant and had the opposite direction (rp = - 0.42). The correlation between the ability of pathogens to produce films with a granulation term was weak (rp = 0.27, p <0.05). Based on the obtained results, a positive paracrine effect of the application of cultured allogeneic multipotent mesenchymal stromal cells derived from adipose tissue (MSSC-VT) and fibrin hydrogel, which changes the cytomorphological state of the wound swab, allowing thereby accelerating the development of regenerative processes in wounds by 2 times, has been shown for the first time. The use of MSC applications for skin grafts in combination with dosed vacuum therapy allows them to achieve complete engraftment during autodermoplasty. Improved methods of expanded skin defects closing with vascularized flaps have been developed and put into practice. The expediency of using of these methods of plastics depending on the localization of the defect and the pathogenesis of wounds has been proved. Thus, it has been verified that the use of innovative technologies in the treatment of purulent-necrotic lower extremity wounds and the introduction of new techniques based on additional knowledge on their pathogenesis, allows to achieve complete wound healing regardless of the etiology of the disease