The development of reporting guidelines over the past 20 years represents a major advance in scholarly publishing with recent evidence showing positive impacts. Whilst over 350 reporting guidelines exist, there are few that are specific to surgery. Here we describe the development of the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery). We published our protocol apriori. Current guidelines for case series (PROCESS), cohort studies (STROBE) and randomised controlled trials (CONSORT) were analysed to compile a list of items which were used as baseline material for developing a suitable checklist for surgical cohort guidelines. These were then put forward in a Delphi consensus exercise to an expert panel of 74 surgeons and academics via Google Forms. The Delphi exercise was completed by 62% (46/74) of the participants. All the items were passed in a single round to create a STROCSS guideline consisting of 17 items. We present the STROCSS guideline for surgical cohort, cross-sectional and case-control studies consisting of a 17-item checklist. We hope its use will increase the transparency and reporting quality of such studies. This guideline is also suitable for cross-sectional and case control studies. We encourage authors, reviewers, journal editors and publishers to adopt these guidelines.

The mechanism of action of the Vacuum Assisted Closure Therapy (VAC; KCI, San Antonio, Texas), a recent novel innovation in the care of wounds, remains unknown. In vitro studies have revealed that cells allowed to stretch tend to divide and proliferate in the presence of soluble mitogens, whereas retracted cells remain quiescent. The authors hypothesize that application of micromechanical forces to wounds in vivo can promote wound healing through this cell shape–dependent, mechanical control mechanism. The authors created a computer model (finite element) of a wound and simulated VAC application. Finite element modeling is commonly used to engineer complex systems by breaking them down into simple discrete elements. In this model, the authors altered the pressure, pore diameter, and pore volume fraction to study the effects of vacuum-induced material deformations. The authors compared the morphology of deformation of this wound model with histologic sections of wounds treated with the VAC. The finite element model showed that most elements stretched by VAC application experienced deformations of 5 to 20 percent strain, which are similar to in vitro strain levels shown to promote cellular proliferation. Importantly, the deformation predicted by the model also was similar in morphology to the surface undulations observed in histologic cross-sections of the wounds. The authors hypothesize that this tissue deformation stretches individual cells, thereby promoting proliferation in the wound microenvironment. The application of micromechanical forces may be a useful method with which to stimulate wound healing through promotion of cell division, angiogenesis, and local elaboration of growth factors. Finite element modeling of the VAC device is consistent with this mechanism of action.

The vacuum-assisted closure device is widely used clinically, yet its mechanisms of action are incompletely understood. In this study, the authors designed a partially splinted full-thickness murine vacuum-assisted closure model to better understand the mechanism of action of the vacuum-assisted closure device. Full-thickness wounds (n = 10 per group) were excised in diabetic mice and treated with the vacuum-assisted closure device or its isolated components: an occlusive dressing, subatmospheric pressure at 125 mmHg (suction), and a polyurethane foam without and with downward compression. Results were quantified with a two-dimensional immunohistochemical staging system based on blood vessel density (CD31) and cell proliferation (Ki67) 7 days after wounding. Microscopic strain was measured by fixing in situ all dressing modalities. Wounds exposed to polyurethane foam in compressed and uncompressed dressings or to the vacuum-assisted closure device showed a 2-fold increase in vascularity compared with the occlusive dressing group (p < 0.05). The vacuum-assisted closure device in addition stimulated cell proliferation, with up to 82 percent Ki67-positive nuclei, compared with the other groups. Direct measurements of wound surface deformations showed significant microstrains in the vacuum-assisted closure and foam in compressed dressing groups (60 percent and 16 percent, respectively) compared with all other groups. These data provide profound insights into the mechanism of action of the vacuum-assisted closure device, providing an explanation for the increases in wound bed vascularity and cell proliferation based on its components. Results suggest that the vascular response is related to the polyurethane foam, whereas tissue strains induced by the vacuum-assisted closure device stimulated cell proliferation.

Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors' institution for these injuries. Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology.