Treatment of wounds at different stages of the wound process (general idea of ​​differentiated treatment of wounds). Treatment of granulating wounds Types of granulation

Regardless of the type of wound and the extent of tissue loss, the healing of any wound includes certain phases that overlap in time and cannot be sharply demarcated. The division into phases is based on the main morphological changes during the repair process.

In further presentation we will use a taxonomy that includes three main phases:

1. 
   inflammatory or exudative phase, including stopping bleeding and cleaning the wound;


2. 
   proliferative phase, covering the development of granulation tissue;


3. 
   differentiation phase, including ripening, scar formation and epithelialization.

In practice, the three phases of wound healing are abbreviated as phases of purification, granulation and epithelialization.

Inflammatory (exudative) phase

The inflammatory (exudative) phase begins from the moment of injury and physiological conditions lasts approximately three days. The first vascular and cellular reactions consist of stopping bleeding and blood clotting and end after about 10 minutes.

Due to vasodilation and increased capillary permeability, increased exudation of blood plasma into the intercellular space occurs. As a result, the migration of leukocytes into the wound area is stimulated, primarily neutrophilic granulocytes and macrophages, whose function is to protect against infection and cleanse the wound primarily through phagocytosis. At the same time, they release biologically active mediator substances that stimulate the cells involved in the next phase. In this case, macrophages play a key role. Their presence in sufficient quantities is critical for successful wound healing.

Blood clotting and stopping bleeding

The first task of restoration processes in a wound is to stop bleeding. When injured, vasoactive substances are released from damaged cells, which cause vasoconstriction (vasoconstriction) to prevent large blood loss until platelet aggregation provides initial closure of the damaged vessels.

Blood platelets circulating in the blood plasma adhere to the damaged vessel wall at the site of injury and stimulate the formation of a blood clot.

	A fibrinous clot consisting of platelets, red blood cells and fibrin strands.

During the complex process of platelet aggregation, the blood coagulation system is activated. The gradual coagulation of blood (coagulation cascade), in which more than 30 different factors are involved, leads to the formation of an insoluble fibrin network of fibrinogen. A clot forms that stops bleeding, covers the wound and protects it from further bacterial contamination and fluid loss.

Bleeding is stopped only in the wound area so that the body is not subject to thrombotic complications. Fibrinolytic ability controls the blood coagulation system.

Inflammatory reactions

Inflammatio or inflammation is a complex protective reaction of the body to the influence of a wide variety of damaging factors of mechanical, physical, chemical or bacterial origin. Its goal is to eliminate or inactivate these damaging factors, cleanse the tissue and create the prerequisites for subsequent proliferative processes.

Thus, inflammation processes occur in any wound, including closed ones. They intensify with an open wound, which is always subject to bacterial contamination, and there is a need to eliminate infiltrated microorganisms and detritus, as well as other foreign bodies.

Inflammation is characterized by four symptoms:

Redness (Rubor)

Increase in temperature (Calor)

Tumor

Pain (Dolor)

Arterioles, which after injury to a short time narrowed and expand under the influence of vasoactive substances such as histamine, serotonin and kinin. This leads to increased blood flow in the wound area and to an increase in local metabolism necessary to eliminate damaging factors. Clinically, the process manifests itself in redness and increased temperature around the site of inflammation.

At the same time, due to vasodilation (vasodilation), vascular permeability increases with plasma effusion into the intercellular space. The first peak of exudation occurs approximately 10 minutes after the wound occurs, the second - approximately one to two hours later.

Swelling appears externally as a tumor, in the formation of which slow blood circulation also plays a role, as well as local acidosis (a shift in the acid-base balance to the acidic side) in the wound area. It is currently believed that local acidosis enhances catabolic processes, and an increase in the volume of tissue fluid makes it possible to dilute the toxic products of tissue breakdown and bacterial activity.

Pain in the wound area develops due to exposure of nerve endings and the development of edema, as well as under the influence of certain products of the inflammatory process, such as bradykinin. Consequence severe pain there may be a limitation of function (functionio laesa).

Phagocytosis and protection against infection

Approximately 2-4 hours after injury within inflammatory reactions migration of leukocytes to the wound area begins, which carry out phagocytosis of detritus, foreign material and microorganisms.

In the initial phase of inflammation, neutrophil granulocytes predominate, which release into the wound various substances that promote inflammation, the so-called cytokines (TNF-oc and interleukin), phagocytose bacteria, and also secrete protein-digesting enzymes (proteases) that destroy damaged and dead components of the extracellular matrix. This provides initial cleaning of the wound.

After about 24 hours, monocytes arrive in the wound area during degranulation. They differentiate into macrophages, which carry out the process of phagocytosis, and also have a decisive influence on the process of secretion of cytokines and growth factors.

The migration of leukocytes stops within a time interval of about 3 days, when the wound becomes “clean” and the inflammation phase comes to an end. If infection occurs, leukocyte migration continues and phagocytosis increases. This leads to a slowdown in the inflammatory phase and thereby to an increase in wound healing time.

Detritus-filled phagocytes and destroyed tissue form pus. The destruction of bacterial material inside phagocyte cells can only occur with the help of oxygen; This is why adequate oxygen supply to the wound area is so important to protect against infection.

The dominant role of macrophages

Today it is considered firmly established that wound healing is impossible without the functioning of macrophages. Most macrophages come from hematogenous monocytes, the differentiation and activation of which to macrophages occurs in the wound area.

Attracted by chemical irritants in the form of bacterial toxins, as well as additional activation by neutrophil granulocytes, the cells migrate from the circulating blood into the wound.

As part of their phagocytotic activity, which is associated with the maximum degree of cell activation, macrophages are not limited to only direct attack on microorganisms, they also help in the transfer of antigens to lymphocytes. Antigens captured by macrophages and partially destroyed are transferred to leukocytes in an easily recognizable form.

In addition, macrophages secrete cytokines that promote inflammation (interleukin-1, IL-1 and tumor necrosis factor a, TNF-a)

and various growth factors (EGF = epidermal growth factor, PDGF = platelet-derived growth factor, and TGF-a and -p = transforming growth factor a and p).

These growth factors are polypeptides that influence cells involved in wound healing in a variety of ways: they attract cells and increase their flow into the wound area (chemotaxis), stimulate cells to proliferate, and can also cause cell transformation.

Proliferative phase

During the second phase of wound healing, cell proliferation predominates, aimed at restoring the vascular system and filling the defect with granulation tissue.

This phase begins approximately on the fourth day after the wound occurs, but the prerequisites for this are already created during the inflammatory-exudative phase. Intact fibroblasts from the surrounding tissue can migrate into the fibrin clot and fibrin network formed during blood coagulation and use them as a temporary matrix; the already released cytokines and growth factors stimulate and regulate the migration and proliferation of cells responsible for the formation of new vessels and tissues.

Formation of new vessels and vascularization (angiogenesis)

Without new blood vessels to provide sufficient blood, oxygen and nutrients to the wound area, wound healing cannot progress. The formation of new vessels begins from intact blood vessels at the edge of the wound.

As a result of stimulation by growth factors of the cells of the epithelial layer lining blood vessels(called endothelium in this case), acquire the ability to destroy its basement membrane, mobilize and migrate into the tissues and fibrin clot surrounding the wound. During further cell divisions / they form a tube-like formation there, which again divides at its end, which looks like a kidney. Individual vascular buds grow towards each other and connect to form capillary vascular loops, which in turn continue to branch until they encounter more large vessel, into which they could fall.

A well-supplied wound is extremely rich in blood vessels. The permeability of newly formed capillaries is also higher than that of other capillaries, due to which increased metabolism in the wound is maintained. However, these new capillaries have low strength under mechanical stress, so the wound area must be protected from injury. With the subsequent maturation of granulation tissue into scar tissue, the vessels disappear.

Granulation tissue

Depending on the time course of vessel formation, approximately on the fourth day after the wound occurs, the defect begins to be filled with new tissue. The so-called granulation tissue develops, in the construction of which fibroblasts play a decisive role.

Firstly, they produce collagen, which forms fibers outside the cells and gives strength to the tissue, and secondly, they also synthesize proteoglycans, which form the jelly-like ground substance of the extracellular space.

Fibroblasts

Spindle fibroblasts originate primarily from local tissues. They are attracted by the mechanism of chemotaxis. The nutrient substrate for them is amino acids, which are formed when a blood clot is destroyed by macrophages. At the same time, fibroblasts use the fibrin network formed during blood clotting as a matrix for the construction of collagen. The close relationship between fibroblasts and the fibrin network has led in the past to the suggestion that fibrin is converted to fibrinogen. In fact, however, as collagen structures grow, the fibrin network is destroyed and the blocked vessels open again. This process, controlled by the enzyme plasmin, is called fibrinolysis.

Thus, fibroblasts migrate to the wound area when amino acids from dissolved blood clots appear there and detritus disappears. If hematomas, necrotic tissue, foreign bodies and bacteria are present in the wound, fibroblast migration is delayed. Thus, the degree of development of granulation is directly related to the volume of blood clots and the intensity of inflammation, including the cleaning of the wound by the body’s own forces using the mechanism of phagocytosis.

Although fibroblasts are generally considered a “uniform cell type,” it is important from a wound healing perspective that they differ in function and response. There are fibroblasts in the wound of various ages, which differ both in their secretory activity and in their response to growth factors. During wound healing, some fibroblasts transform into myofibroblasts, which tighten the wound.

Features of granulation tissue.

Granulation tissue can be considered as a temporary primitive tissue or as an organ that “finally” closes the wound and serves as a “bed” for subsequent epithelization. After performing these functions, it gradually turns into scar tissue

The name “granulation” was introduced in 1865 by Billroth and is due to the fact that as the tissue develops, light red glassy-transparent grains (Latin Granula) are visible on its surface. Each of these grains corresponds to a vascular tree with numerous thin capillary loops that arose during the formation of new vessels. New tissue forms at these loops.

With good granulation, the grains increase in size over time and also increase in number, so that eventually an orange-red, wet, shiny surface appears. This granulation indicates good healing. On the contrary, the fact that the healing processes have become irregular and protracted is evidenced by granulations covered with a gray coating, having a pale and spongy appearance or a bluish color.

Phase of differentiation and restructuring

Approximately between the 6th and 10th days, the maturation of collagen fibers begins. The wound contracts, the granulation tissue becomes increasingly poor in water and blood vessels and turns into scar tissue. After this, epithelialization completes the wound healing process. This process involves the formation of new epidermal cells through mitosis and cell migration primarily from the edges of the wound.

Wound contraction

Contraction of the wound by bringing undamaged tissue areas closer to each other leads to the fact that the area of ​​“incomplete repair” is made as small as possible, and the wound spontaneously closes. This process is more effective, the greater the mobility of the skin relative to the underlying tissues.

In contrast to previous views, according to which wound contraction is caused by wrinkling of collagen fibers, today it is known that this wrinkling plays only a subordinate role. The fibroblasts of the granulation tissue are largely responsible for the contraction, which, after completing their secretory function, are partially transformed into fibrocytes (an inactive form of fibroblasts), and partially into myofibroblasts.

Myofibroblast resembles smooth muscle cells and, like them, contains the muscle contractile protein actomyosin. Myofibroblasts contract, and collagen fibers simultaneously contract. As a result, the scar tissue shrinks and pulls the skin tissue toward the edge of the wound.

Epithelialization

Closed wounds with skin mark the completion of the healing process, and the processes of epithelization are closely related to the granulation of the wound. On the one hand, chemotactic signals emanate from the granulation tissue, directing the migration of the marginal epithelium; on the other hand, epithelial cells require a moist, smooth surface for migration. Re-epithelialization is also a complex process, which is based on increased mitosis in the basal layer of the epidermis and the migration of new epithelial cells from the edge of the wound.

Mitosis and migration

Metabolically active cells of the basal layer, capable of participating in the wound healing process, apparently have an unlimited potential for mitotic division, which under normal conditions is suppressed by tissue-specific inhibitors, the so-called Kaylons, but in case of damage it manifests itself to the full extent of its powers. Thus, if, after damage to the epithelium, the extracellular level of Kaylons drops sharply as a result of the loss of numerous Kaylon-producing cells in the wound area, a correspondingly high mitotic activity of the cells of the basal layer appears and the process of cell proliferation necessary to close the defect is triggered.

Cell migration also has its own characteristics. While during physiological maturation of the epidermis, cells migrate from the basal layer to the surface of the skin, reparative cell replacement occurs by moving cells horizontally towards the opposite edge of the wound. Epithelization, coming from the edge of the wound, begins immediately from the moment the integrity of the epidermis is broken. Epithelial cells separated from each other, due to active amoeboid movements, reminiscent of the movements of single-celled cells, crawl towards each other, trying to close the gap.

However, this is only possible in the case of superficial wounds. In all other skin wounds, the migration of the epithelium of the wound edge is associated with the filling of the tissue defect with granulation tissue, since the epithelial cells do not show any tendency to descend into the depression or wound crater - they can crawl only along a smooth, flat surface.

The migration of cells located at the edge does not occur uniformly, but in stages, probably related to the state of granulation in the wound. The initial growth of the marginal epithelium is followed by a phase of thickening of the original single-layer epithelium due to the pushing of cells on top of each other. From this point on, the rapidly multilayered epithelial coatings become stronger and denser.

Features of reepithelialization

According to the scheme physiological regeneration Only superficial skin abrasions heal, and the regenerate is completely complete and no different from the original tissue. With other skin wounds, as mentioned above, the resulting tissue loss is replaced by the migration of cells from the edge of the wound and from the remaining skin remnants. The result of such re-epithelialization is not a full-fledged skin replacement; it is a thin, vascular-poor replacement tissue that lacks essential components of the skin, such as glands and pigment cells, and lacks some important properties skin, for example, a sufficient wealth of nerve endings

Granulation of wounds is an intermediate stage natural process healing of damaged tissues. With its help, epithelial cells are formed, which subsequently cover the surface of the wound. Many cells take part in the complex process, which prevent pathogenic microorganisms from entering the body.

Granulation is one of the stages of skin regeneration, resulting in the formation of temporary tissue that protects the boundaries of the wound. During complete healing, granulation regresses, after which the wound is covered with scar tissue.

The active process of granulation develops on days 5-6, and its duration depends entirely on the degree of tissue damage and the individual characteristics of the body.

The following types of cells take part in the granulation process:

1. Leukocytes - eliminate pathogenic microorganisms in contact with the wound surface.
2. Plasmocytes - activate the production of substances and blood clotting factors, with the help of which it is possible to accelerate the process of formation of a blood clot.
3. Mast cells – help accelerate the regeneration process of damaged cells.
4. Fibroblasts - control the synthesis and transportation of collagen cells, with the help of which the process of regeneration of damaged tissues is carried out.

Externally, granulation looks like a thin film enveloping the surface of the wound. It has a soft pink color with a characteristic mirror gloss. Within a month, granulation is completed, after which the thin film comes off, and dense scar tissue forms underneath it.

Phases of regeneration of damaged tissues

During the healing process, a wound goes through several stages:

1. Inflammation - after damage to epithelial cells in the body, a natural mechanism is launched, with the help of which the maximum short time bleeding is eliminated. The formed blood clots clog the damaged vessels, eliminating extensive bleeding. A large number of leukocytes are sent to the site of injury, which have a bactericidal effect.
2. Granulation - 5-6 days after injury, the granulation mechanism is launched, with the help of which new epithelial cells are formed. The process lasts at least a month, after which the wound is covered with scar tissue.
3. Epithelization - granulation tissue gradually dies, and new epithelial cells form under it.

Granulation occurs in stages and consists of six processes passing into each other:

1. Superficial leukocyte-necrotic layer - consists of light gray or greenish neoplasms that are located within the wound surface.
2. The surface layer of vascular loops - with its help, new capillaries are formed, which will subsequently fill the site of damage.
3. The layer of vertical vessels ensures the restoration of metabolic processes in damaged areas of tissue.
4. The maturing layer of the epithelium has a soft pink color with a characteristic gloss.
5. A layer of fibroblasts located horizontally provides maximum protection of the wound surface from pathogenic microorganisms, as well as additional trauma.
6. The fibrous layer is the densest and precedes the formation of a scar.

The granulation period lasts individually for each person. For some, the process of complete healing takes no more than 3 weeks, while others observe a picture of regeneration for about a year.

Treatment of injured areas in the granulation phase

Granulation tissue in the early stages of formation is very thin and delicate, easily susceptible to injury. This requires compliance with certain rules, with the help of which you can achieve rapid healing of the wound and preserve granulation tissue for as long as possible.

1. Wipe the wound, removing the top layer, using cotton pads - the wound is treated exclusively with warm disinfectant solutions with minimal contact to the wound surface. Cotton particles can get into the wound, which will intensify the inflammation process and slow down the regeneration of damaged cells.
2. Tearing off bandages that have dried to the wound - the granulation layer is torn off along with the bandage, so the regeneration of damaged areas slows down tenfold. Before replacing the bandage, soak it in disinfectant solutions, which will make it easier to remove from the wound.
3. Comb and independently tear off the crusts formed on the surface of the wound.

There are three methods of treating wounds during the period of granulation: medication, physiotherapy and folk medicine. All of them are selected individually, taking into account the specifics of the wounds.

Drug treatment

The use of local wound healing agents promotes faster scar formation. Such drugs have bactericidal properties, reducing the risk of pathogenic microorganisms entering the blood through the wound.

The most effective drugs when granulating wounds are:

1. Bepanten-Plus (Panthenol, Dexpanthenol) – in addition to active process regeneration, the drug has a bactericidal effect due to the content of chlorhexidine. It has a dense texture that protects the surface of the wound from the penetration of pathogenic microorganisms. Can be applied either under a bandage or openly.
2. Methyluracil ointment - normalizes the exchange of nucleic acids in cells, which accelerates the regeneration process by increasing the metabolic rate. The active components act locally without penetrating into the blood. Suitable for the treatment of weeping and long-term non-healing wounds.
3. Solcoseryl - improves local blood circulation, which helps accelerate the process of formation of new cells. The gel texture allows you to apply the drug in a thin layer, which is quite enough to prevent the development of the inflammatory process.

Methyluracil ointment is one of the drugs that is used for ranulation of wounds

Ointments, creams and gels are applied only to a previously cleaned wound surface. For preliminary disinfection, hydrogen peroxide, furacillin solution, and iodicirin are used. Before applying the cream, the wound should be dried using blotting movements of a sterile bandage.

The wound is treated at least 3 times a day. If a bandage is used, it is pre-soaked and then removed along with the scab. It is recommended to allow the wound to dry for some time before applying ointments and creams.

In cases where the wound is very painful, painkillers can be used:

1. Non-steroidal anti-inflammatory drugs - have antipyretic, anti-edematous and anti-inflammatory effects. Has an analgesic effect for up to 5 hours. Used for shallow wounds.
2. Complex analgesics – eliminate pain and also relieve additional unpleasant symptoms.
3. Opioid analgesics - used when the wounds are large and deep. Block pain formation centers in the brain.

An integrated approach to treatment produces the best results. It is strictly forbidden to use medications without a doctor’s prescription, as some of them have adverse reactions and can provoke the development of allergies.

Physiotherapeutic procedures

With their help, it is possible to accelerate the processes of regeneration of damaged cells, as well as reduce the likelihood of penetration of pathogenic microflora. The most effective of them are:

1. UHF - exposure to ultraviolet radiation has a beneficial effect on the condition of the wound. The rays destroy germs and also help skin cells grow faster.
2. Magnetotherapy - exposure to magnetic radiation can accelerate the formation of granulation tissue, as well as make the scar more even, smooth and durable.

Physiotherapeutic procedures are indicated when the wound does not heal well, a purulent scab forms for a long time, and its edges become inflamed. In most cases, minor wounds can be treated without the use of physical therapy. This method of treatment is indicated for extensive lesions, the presence of immunodeficiencies, as well as pathologically reduced local immunity.

Traditional methods of treatment

Self-medication using alternative methods of medicine is indicated only when the wound is shallow and small in area, has smooth edges, and there is no contamination. In this case, you can resort to the following methods of treating wounds:

1. Compress from medicinal herbs– for a glass of boiling water take 1 teaspoon of oak bark, sage and nettle, 1 tablespoon of eucalyptus. Steam in a thermos for 3-4 hours, then filter. Add 1 teaspoon to the decoction sea ​​salt, after which compresses are placed on the wound surface for 2-3 hours.
2. Irrigation of the wound with a disinfectant solution - for 1 liter of water, take 1 teaspoon of sage, coltsfoot, uterus, 2 teaspoons of nettle leaves, 3 drops of tea tree essential oil. The herbs are boiled in a water bath for 10 minutes, allowed to cool, then filtered and tea tree essential oil is added. The resulting broth is drawn into a syringe and irrigated the wound 5-8 times a day.
3. Ointment based on lamb fat - take 25 g of internal fat and melt it in a water bath until liquid, then add 6 drops of lavender oil, 3 drops of eucalyptus oil, 2 drops of tea tree oil. Mix well and place in a jar, allowing to cool at room temperature. Apply a thin layer to the wound, touching the edges.

Ointment based on lamb fat - a folk way to speed up the granulation of wounds

• the wound constantly bleeds and hurts a lot;
• the edges around the wound are inflamed, painful and itchy;
• the wound does not heal for a long time;
• appears purulent plug and an unpleasant odor.

Any wounds that do not heal in more than 5 days should be examined by a specialist. For various reasons, the regeneration process becomes difficult, which is extremely dangerous for the entire body.

When the granulation process is delayed, the wound can rot, which threatens the health of the entire body. This requires a surgical operation during which the affected and necrotic areas of the skin are excised. Further treatment requires the use of antibiotics to help eliminate pathogenic microorganisms.

Complications

If granulation is complicated by other processes, the wound does not heal for a long time, which requires additional measures. The most dangerous complications are:

1. Sepsis is a blood infection that develops due to the entry into the body of a large amount of pathogenic microflora, which is activated when the body’s defenses are low.
2. Suppuration of the wound and the need for necroectomy, during which the affected areas of the wound are excised.

Granulation becomes more complicated due to non-compliance with hygiene rules, as well as improper treatment of wounds. Special ointments and creams will help speed up the regeneration process, with the help of which the wound will be covered with scar tissue as quickly as possible.

In response to injury to body tissue, a complex mechanism is launched to restore the previous functioning and integrity of organ systems. This process is called tissue regeneration. There are three stages in the development of this mechanism. Their duration is individual for each person and directly depends on his age and the state of the immune system.

The prognosis for the healing time of a particular injury is also made based on observations of the nature of the injury and depends on the degree of its severity. All types of wounds are divided into two types according to the depth of damage:

• Simple - the integrity of the skin, adipose tissue, and the structure of adjacent muscles is compromised.
• Complex wounds are characterized by damage internal organs, large veins and arteries, bone fractures.

The stages of regeneration are the same for any damage, regardless of its origin and type.

Shulepin Ivan Vladimirovich, traumatologist-orthopedist, highest qualification category

Total work experience over 25 years. In 1994 he graduated from the Moscow Institute of Medical and Social Rehabilitation, in 1997 he completed a residency in the specialty “Traumatology and Orthopedics” at the Central Research Institute of Traumatology and Orthopedics named after. N.N. Prifova.

All human organ systems have the ability to restore structure. However, their regeneration rates vary. In case of damage, the skin is restored especially quickly. Reparative changes in other systems take much longer.

Interesting fact! Until recently, scientists were sure that nerve endings did not have the ability to recover. But modern research proved that the central nervous system forms new neurons, albeit extremely slowly.

The following phases of reparative regeneration of damaged tissues are distinguished:

• Inflammatory stage;
• Granulation stage;
• Stage of scar formation;

Each of these phases has pronounced external manifestations, gradually replacing each other as the wound heals.

Features of the inflammation stage

Immediately after tissue integrity is damaged, a complex enzymatic mechanism is launched, leading to blood clotting and stopping bleeding. There are two stages to this process:

1. Primary hemostasis characterized by a sharp narrowing of blood vessels in the damaged area and mechanical clogging of the torn capillary walls by platelet aggregates, which form a kind of plug. The average time for this phase is 3 minutes.
2. Secondary hemostasis occurs with the participation of the fibrin protein, which forms blood clots and thickens the blood. As a result of its formation, the blood will change its consistency, becoming cheesy and losing its fluidity. The process of formation of a fibrin clot takes 10-12 minutes.

Depending on the depth of the damage and the nature of the bleeding, I put stitches on the wound or use a bandage. If the injured area has not been infected with pathogenic microflora, after the bleeding stops, gradual tissue regeneration begins.

External manifestations of the inflammation stage:

• Swelling. It occurs due to increased release of plasma from destroyed cells into the intercellular space.
• Local temperature increase. Tissue injury leads to a sharp disruption of blood circulation, which leads to a change in temperature balance.
• Redness of the damaged area. This phenomenon is also explained by changes in microcirculation and increased permeability of capillary walls.

Typically, the inflammation phase lasts for 5-7 days.

All applied sutures are removed after its completion, if there is no purulent discharge and obvious signs healing of the injured area. Gradually, the formation of new tissues begins, and the restoration process flows into the granulation stage.

Characteristics of the granulation stage

The inflammatory reaction characteristic of the damaged area is replaced by processes of wound cleansing and exfoliation of dead cells. At the same time, granulation tissue is formed. Its formation begins at the periphery of the wound, and only then the neoplasm reaches the center of the injured area.

In young tissue, restoration processes are actively underway, primarily the growth of new capillaries. They reach the wound surface and then, forming loops, return deep into the tissue. The damaged surface becomes granular and bright red. Due to its appearance, the tissue is called granulation tissue.

The appearance of the granulation tissue may vary depending on the location of the injury. On the skin and mucous membranes, it looks like a soft-grained, red area, the surface of which is often covered with plaque. In the thickness of the internal organs, granulation tissue is easily recognizable by its rich color and larger structure.

The newly formed tissue is very delicate; if touched carelessly, it can easily cause bleeding due to the large number of capillaries being formed.

Interesting! There are no nerve endings in the thickness of the granulation formation, so touching it does not cause pain.

The granulation tissue lining the wound consists of six distinct layers:

1. Leukocyte-necrotic layer. Formed from exfoliated cells. Covers the wound for a long time until the scar is completely formed.
2. Layer of vessels and capillaries. If wound healing is delayed, thick collagen fibers are formed in this layer, which are parallel to the surface of the damaged area.
3. Layer of vertical vessels. The capillaries of this layer are surrounded by amorphous tissue. It actively synthesizes fibroblasts - cells that form connective tissue fibers.
4. Maturation layer. Cells that form the basis of the surface layers develop in it. Here the fibroblasts formed in the deep layers take their final form.
5. The layer of horizontal fibroblasts increases as the wound heals. Consists of young fibroblasts and a large number of collagen fibers.
6. The fibrous layer is a barrier that protects the internal environment of the body from external factors. It has pronounced bactericidal properties and blocks the effects of pathogenic microorganisms.

The main role in the formation of granulation formation belongs to fibroblasts - cells involved in the synthesis of collagen. With sufficient accumulation of it, the granulation stage moves into a new phase - scar formation.

Stages of wound healing. A visual picture. Daily photo report for two weeks

Stage of scar formation

The longest phase of the wound healing process.

It takes about a year for a dense scar to form.

Initially it retains a deep red color, but then takes on the color of the skin. This is explained by a decrease in the number of blood vessels in the connective tissue after the wound granulation stage is completed.

Interesting! The density of scar tissue is very high. It makes up more than 80% of the density of healthy skin.

However, the newly formed tissue does not have the ability to stretch. Once formed on the skin in the joint area, it can interfere with the normal flexion of the limbs, leading to limited mobility of the individual.

The timing of each healing phase depends on many factors. The age of the patient has the greatest influence. Observations have shown that the stage of formation of the scar phase passes much faster in pre-pubertal children.

Infection of the wound leads to an increase in healing time. Weak immunity and disease in patients also have a negative impact on the regeneration process.

The importance of the granulation phase for tissue repair

The granulation stage of the formation of new tissue is a complex process in which several groups of cells take part. It includes:

• Plasmocytes are cells that synthesize antibodies, which, in turn, are responsible for the body’s immune response.
• Histiocytes. Execute protective function, inactivating foreign objects that enter the newly formed layer of tissue.
• Fibroblasts responsible for secreting the precursor protein collagen.
• Leukocytes - protect the body from any pathogenic agents.
• Mast cells are one of the components of formed connective tissue.

The entire maturation cycle of granulation tissue takes 20-30 days.

It should be remembered that this is a temporary formation that will be replaced by dense scar tissue. Most of it consists of newly formed capillaries. Over time, the thin walls of the vessels are covered with new cells, which continue to divide, forming a dense layer that covers the site of damage.

Treatment of injured areas in the granulation phase

Granulation tissue has a delicate, loose structure. It can be easily damaged by carelessly touching it or carelessly changing the bandage. When treating a wound, you should be as careful as possible.

It is not allowed to wipe the surface of the damaged area with cotton pads or swabs.

It is only permissible to irrigate the wound with warm bactericidal solutions. There are several types of treatment for injured tissue:

• Physiotherapeutic;
• Medication;
• Treatment at home;

When choosing a treatment method, it is necessary to take into account the nature of the wound, as well as the characteristics of its healing.

Physiotherapeutic method of treatment

Among the specific methods of accelerating regeneration, the following method should be highlighted: ultraviolet irradiation. When used, the surface of the damaged area is cleansed of pathogenic microflora, and regeneration processes are significantly accelerated. This method will be especially relevant for slowly forming, flaccid granulating tissue. Indications for the use of irradiation:

• Wound infection;
• Copious purulent discharge;
• Weakened immunity and, as a result, disruption of repair mechanisms;

However, other treatment methods are also used to speed up the healing of the damage. Most often they resort to medicinal methods treatment of the wound surface.

Use of drugs at the granulation stage

A properly selected medication promotes faster epithelization of the wound. As a rule, for hypergranulation, doctors recommend using gel forms of drugs. Whereas if the surface of the damaged area dries too quickly, ointments are used.

The main drugs used at the granulation stage:

One of the most popular drugs prescribed at this stage is Solcoseryl. Granulation of sutures, healing of damaged areas after burns and other injuries to the skin are accompanied by the appearance of unaesthetic scars. Solcoseryl promotes the formation of more uniform connective tissue, which looks much more natural.

Home treatment of wounds in the granulation phase

TO folk methods Treatment of injuries should only be used for minor injuries to the skin (minor cuts on the fingers, first-degree burns, mild frostbite).

The most well-known remedy for promoting cell regeneration has long been St. John's wort oil.

To prepare the oil, mix 300 ml of sunflower oil with 30-50 grams of dried St. John's wort herb. The resulting mixture is boiled in a water bath for no more than 30 minutes.

Soak in chilled St. John's wort oil gauze bandages and apply them to the damaged area.

Options for further development of the granulation stage

If the first and second stages of wound healing have passed without complications, then gradually the damaged area is completely covered with dense scar tissue and the regeneration process is successfully completed.

However, sometimes tissue repair mechanisms fail. For example, necrosis occurs in areas adjacent to the wound.

This condition is extremely dangerous for the patient and requires immediate surgical intervention.

A necroectomy is performed - an operation to remove dead tissue.

If the wound is infected with pathogenic microflora, the healing process may take a long time. Antibiotics are used to restore normal tissue regeneration.

The granulation stage of healing of the damaged area is a complex adaptation mechanism aimed at rapid separation internal environment body from adverse external influences. It ensures the formation of new layers of tissue to replace damaged ones. Thanks to the granulation stage, the trophism of the injured area is restored and the protection of other, deeper tissues is ensured.

Our body's wound healing system. The most important stage of granulation.

Wound granulation - what is it? The process consists of several stages of restoration of damaged tissue areas. Depending on the severity of injuries, there are minor and complex wounds. It is their character that makes it possible to formulate forecasts for the success of treatment and the rate of tissue renewal.

Phases of tissue repair after damage

There are several phases:

• inflammation;
• epithelium formation.

Further in the material we will consider these stages of tissue regeneration in detail. Let's find out which therapeutic methods help to activate the processes of tissue granulation, speedy restoration of damaged areas and renewal of healthy epithelium.

Inflammatory stage

The presented process of wound granulation occurs within a week from the moment of formation of the injury. The primary reaction here is the body’s production of substances that promote increased blood clotting. Excessive granulation in wounds leads to blockage of blood vessels. Thus, bleeding completely stops at the site of tissue damage.

After a few days, tissue inflammation begins at the wound site, the development of which is caused by excessive cell division. Thanks to this, new tissue gradually grows.

The inflammatory stage of wound granulation, as a rule, requires suturing the existing damage. The reason for this is the fairly strong tension of the tissues, the edges of which can repeatedly diverge during the healing process due to the production of rather fragile granulation material.

Granulation phase

Wound granulation - what is it? is activated approximately on the 7th day after the onset of damage. At this stage, the wounds continue to fill with granulation material. Over the course of a month, new healthy cells, sprouting blood vessels, and strong connective tissue are formed in its structure.

How does wound granulation complete at this stage? The photos presented in the material allow you to see how healthy epithelial cells are deposited on the lining of newly formed tissues. Previously damaged tissues are connected to each other by young scars, which have a bright red tint.

Tissue epithelization phase

This stage of tissue healing is also known as the period of scar formation or reorganization of scar structures. At this stage, there is no loose matter that can be released from the wound. The superficial areas at the site of damage become dry.

Epithelization is most pronounced closer to the edges of the wound. Here, so-called islands of healthy tissue formation are formed, which differ in their somewhat textured surface. Wherein central part The wound may remain at the stage of inflammation for some time. Therefore, at this stage, differentiated treatment is most often resorted to. It promotes active cell renewal closer to the edges of the wound and prevents its suppuration in the central part.

Depending on the complexity of the wound, final epithelialization may take up to one year. During this time, the damage is completely filled with new tissue and covered with skin. The initial number of vessels in the scar material also decreases. Therefore, the scar changes its bright red color to its usual flesh tone.

Cells that take part in wound granulation processes

What causes healing and its acceleration? Granulation of the wound is carried out due to the activation of leukocytes, plasmacytes, mast cells, fibroblasts and histiocytes.

As the inflammatory phase progresses, tissue cleansing occurs. Restriction of access of pathogenic microorganisms to the deep layers of damage occurs due to their conservation by fibroblasts and fibrocytes. Then platelets come into action, binding active substances and enhancing catabolic reactions.

Subsequently, the body actively produces T-lymphocytes, which penetrate the wound and bind potentially dangerous bacteria. The development of this process is necessarily accompanied copious discharge pus. If the wound is severely festering, this indicates the presence in the tissues of an abundant amount of microorganisms that are “devoured” by T-lymphocytes.

At the granulation stage, fibroblasts play a major role. Cells of this type insert collagen along the edges of the wound. The process slows down with the development of tumors, inflammation, and the formation of copious amounts of dead tissue. Accordingly, insufficient transport of collagen to damaged tissues leads to longer healing.

During wound healing, not only the active production of appropriate cells is important, but also ensuring sufficient oxygen access to the damaged area. Promotes the rapid restoration of tissue structures and saturates the body with vitamin C, zinc, and iron.

Wound care during the early stages of healing

The optimal solution for speedy restoration of damaged tissue is the regular use of dressings. Disinfection here is also carried out with hydrogen peroxide. These substances are applied warm to a gauze swab. Next, the wound is carefully soaked, which avoids touching the wound with your hands - this can lead to the development of infections.

In the initial stages, it is strictly forbidden to forcibly separate dead tissue. You can only remove flake-like elements, which can easily be torn off with slight exposure with sterile tweezers. To quickly form a dead scab in other areas, they are treated with a 5% iodine solution.

Physiotherapy treatment

Among the physiotherapeutic methods, ultraviolet irradiation may be prescribed at the stage when wound granulation is actively occurring. What it is? First of all, UV irradiation involves a moderate thermal effect on the damaged area. This type of therapy is especially useful if the victim experiences stagnation of granulations that have a sluggish structure. Also, gentle exposure to ultraviolet rays on the wound is recommended in cases where natural discharge of purulent plaque does not occur for a long time.

Wound granulation - treatment with traditional methods

If there is a simple injury, in which only the superficial outer layers of the epithelium are affected, you can resort to traditional methods of treatment for recovery. Good decision This looks like an overlay of oil-soaked St. John's wort. The presented method promotes the speedy completion of the granulation phase and active tissue renewal.

To prepare the above remedy, it is enough to take about 300 ml of refined vegetable oil and about 30-40 grams of dried St. John's wort. After mixing the ingredients, the composition should be boiled over low heat for about an hour. The cooled mass must be filtered through gauze. It can then be used to apply bandages.

Wounds at the granulation stage can also be healed using pine resin. The latter is taken in its pure form, rinsed with water and, if necessary, softened with low heat. After such preparation, the substance is applied to the damaged area of ​​​​tissue and fixed with a bandage.

Treatment with drugs

Often, wound granulation turns out to be a rather lengthy process. The speed of healing depends on the condition of the body, the area of ​​damage, and its nature. Therefore, when choosing medication To treat a wound, it is necessary to analyze what stage of healing it is currently at.

Among the most effective medicines It is worth highlighting the following:

• ointment "Acerbin" - is universal remedy, which can be used at any stage of the wound process;
• ointment "Solcoseryl" - promotes rapid granulation of damage, avoids tissue erosion and the appearance of ulcerative tumors;
• Hemoderivative of the blood of dairy calves - available in the form of a gel and ointment, is universal highly effective drug for wound healing.

Sometimes regression occurs during wound healing with the use of ointments. In such cases, it is necessary to stop using the drug for a while or contact more effective means, for example, medications in the form of gels. The result of this approach to treatment should be rapid wound cleansing, as well as the appearance of new granulations.

Surgical intervention

When granulation processes are delayed, deep wound tracts may form, in which there is an accumulation of purulent leaks. In such cases, it is difficult to clean the wound due to the use of ointments and gels. Elimination of unpleasant complications most often occurs through surgery. In this case, the specialist makes an incision, removes purulent accumulations, disinfects the wound, and then applies counter-apertures.

Finally

So we figured it out, wound granulation - what is it? As practice shows, one of the determining conditions for accelerating the healing process is differentiated treatment. It also matters correct selection medications. All this contributes to the rapid granulation of the damaged area and the formation of new, healthy tissue.

Healing of wounds of various areas and organs, similar in general characteristics, proceeds according to general patterns, but their morphological characteristics vary depending on the nature of the damage, the size of the defect, the presence of infection, etc.

According to long ago rooted According to the ideas, wound healing is carried out in two ways: by the type of primary and by the type of secondary intention. Both of them lead to the replacement of the defect with young connective tissue, which later acquires the character of scar tissue, and nevertheless, both of these processes are not only quantitatively, but also qualitatively different from each other (I.V. Davydovsky, 1959). Each of them is preceded by a different tissue condition, especially with regard to the nature of inflammation, which always accompanies the wound process; they have different lengths in time, and the young connective tissue that appears during this period has functional and structural differences. Not all young connective tissue is granulation tissue; the latter characterizes only secondary intention and is not typical for primary intention of wounds.

This classification is more complete and is now widely used by everyone. Usually the hole is on the outside outside. There is slight damage to the soft parts. Especially characterized among athletes and military personnel. Most often the tibial segment. It involves unusual, intense and repetitive restrictions. In this case, bone scintigraphy, which is very sensitive, shows localized hyperfixation. Fracture stage or actual fatigue fracture, when acute optional pressure pain occurs, inability to continue sports activities.

Primary tension is is the process of organizing (that is, replacing with connective tissue) the contents of the wound canal (blood clots, partly necrotic masses that have not undergone decay - I. E. Esipova, 1964).

Condition of tissues pre-primary intention, can be characterized as serous inflammation or traumatic swelling, accompanying to one degree or another every injury. Swelling of the walls of the wound canal or defect leads to their convergence and partly to the displacement of foreign bodies, that is, to mechanical cleansing of the wound. Nevertheless, the latter always contains free masses of coagulated blood, and therefore fibrin, which represents a nutrient medium for the development of cellular elements of the mesenchyme. The proliferation of the latter begins at the very beginning of the wound process, that is, it coincides in time with the development of wound inflammation.

In this case X-rays show the fracture line associated or not with images of the bone structure. The treatment combines sports recreation, orthopedic treatment at the pre-fracture stage. Surgical treatment is indicated in cases of delayed union, recurrence, or in the specific case of an isolated anterior cortical tibial fracture, which has a poor reputation for nonrecovery.

The importance of the meniscus in articular and general physiology. Total menisectomy involves the onset of well-known joint degenerative phenomena. Currently, most observations of syringe in the meniscal are as follows. While contraindications are presented.

Wound inflammation is represents the first stage of the wound process. Its morphological manifestations include expansion vascular network in the circumference of the wound, the phenomenon of exudation and swelling of the edges of the wound defect, leukocyte infiltration. Active expansion of arterioles occurs very quickly, almost instantly, and the closer to the edge of the wound, the more pronounced it is. Venules also expand in the early period. Capillaries react somewhat later (F. Marchand, 1901).

Vascular disorders of systemic metabolic diseases that affect the synthesis of collagen congenital disorders of renal collagen syndrome in the post-lateral area of ​​the lateral meniscus. But not all meniscal injuries need to be repaired; spontaneous healing has been reported. The meniscal suture material and must follow some warnings. The sutures should not be wide so as not to throttle the synovium and, therefore, limit the blood supply to the meniscus. Other proposed methods to speed up and facilitate the healing process of the meniscus are to invert the synovial all internal leaflets of the lesion before the suture, in interrupting the fibrin clot, possibly by connecting it to the fascial flap in complex meniscal lesions.

Following hyperemia, it begins exudation of serous fluid, which saturates the edges of the defect and penetrates the wound. On the wound surface, the exudate mixes with blood and lymph that flows during the wound, and with rejected tissue particles. It soon collapses. This is how a scab is formed.

Leukocyte infiltration begins 2-3 hours after injury. First, leukocytes located near the walls are observed in small vessels and capillaries. They then actively penetrate the capillary wall. Polymorphonuclear neutrophil leukocytes emigrate earlier than others and in greater numbers. Simultaneously with the emigration of polynuclear cells, monocytes, polyblasts, and lymphoid elements of tissue origin accumulate at the edges of the wound; further, the cellular elements differentiate towards macrophages, which absorb decay products, and fibroblasts.

You can use absorbable or non-absorbable wires for suturing. According to Miller, there are no significant differences in the type of seam. Meniscal cartilage requires healing over a longer period of time than other tissues; however, you don't know exactly how long complete healing will take. Arnocki and Warren showed that scarring is completed between 8 and 12 weeks with disorganized fibrocartilaginous tissue that is mechanical and less valid than the original structure.

The seam can be made with horizontal or vertical points. The latter are mechanically more efficient. The points of suture material should be evenly distributed above and below the meniscus so that the lesions are completely repaired and in contact. According to Lindelfeld, it is preferable to place the suture points on the surface of the tibia since there is no movement between the meniscus and the tibial plate. According to Pouget, the points can protrude evenly on the two surfaces of the outer meniscus because they are concave; In the inner meniscus there is only the femoral and concave surface, so it is preferable that dots be applied to it.

During 1-2 days among fibrin fibers that glue the wound together, strands of fibroblasts and cracks appear due to the drying of fibrin, which are subsequently lined with endothelium proliferating from cut, injured vessels (I.K. Esipova, 1964). The formation of such vessels, as well as the process of germination by fibroblasts itself, has much in common with recanalization and the organization of blood clots.

The inside-out technique, developed by Henning and used by many authors, allows suture points to be placed under direct arthroscopic control. Use straight needles or a different bend radius, single or double cannula. This method can be dangerous for adjacent noble structures, since the exit point of the needle cannot be perfectly controlled. To avoid such complications, it is recommended to make a small incision in the skin at the exit point of the needle, knocking out the main tissue until the capsule and following some technical devices, recalling that the structures at risk are: in the middle part of the nerve and saphenous vein, in which side is the common peroneal nerve, posterolaterally the popliteal artery, some authors use a femoral distractor to increase. joint space, which improves endocytic vision, lightens suture tissue and reduces the risk of cartilage damage.

As it germinates fibrinous masses by fibroblasts, fixing the edges of the wound instead of fibrinous gluing, the latter (fibroblasts) are gradually replaced by collagen and argyrophilic fibers, which are much more numerous than cellular elements, already in the early period of wound healing. This is what distinguishes the contents of a wound that heals by primary intention from granulations, which are characterized by a long-term predominance of cells over the paraplastic substance.

The external technique was proposed by Warren and was less used than the previous one. Small incision 10 mm. practiced after medially when affected. The capsule is cut through a skin incision and then a special cannula needle is pulled into the capsule so that under arthroscopic control it penetrates the joint at the posterior end of the lesion and then crosses the flap to the desired point. The suture wire is inserted into the extra-articular end of the needle and slid until it appears at the intra-arterial junction.

The second needle is first inserted with the same technique so that it crosses the lesion to 6-7 mm. from this. A special spindle with a “metal end” is inserted inside. The wire passes through a metal bend, which is retracted outward from the joint, carrying along with the thread itself. The two ends of the thread, like extracapsular, are then pulled and tied.

By the end of 5-7 days phagocytosis and resorption of dead tissue elements ends, the wound gap is filled with young connective tissue. At the same time, regeneration begins nerve fibers. Epithelization of the wound occurs quickly, since wounds glued with fibrin and fibroblasts reduce the defect, the conditions for epithelization are favorable.

The operation is repeated several times until the seam is completed. When using the all-in-one method, the risks of damage to the neurovascular side are eliminated, since the suture is completely intracapsulated. The method uses an appropriate device consisting of curved needles that pass through the meniscal lesion without exceeding the capsule and instruments that allow “Knotting All” to expand the hinge wires. This method is suitable for the most central meniscal lesions.

Postoperative treatment of meniscal sutures, as can be seen from the literature in this regard, is very diverse. Avoid exercise above 90° for 3 months. Scott immobilizes the knee at 30° of flexion with load-bearing tension for two months to reverse the shear forces acting on the meniscus. After the third month and allowed to use the bike, race after 5-6 months, sports recovery after 9-12 months.

During wound healing primary intention and healing under the scab, which fundamentally differs little from healing by primary intention, all processes of reparative regeneration occur in the depths of the wound, that is, below the level of its edges, which also distinguishes primary intention from healing by secondary intention.

One of the phases of healing of damaged tissue is wound granulation. A wound means a violation of the integrity of the skin, muscles, bones or internal organs. The type of wound complexity varies depending on the degree of damage. On this basis, the doctor makes a prognosis and prescribes treatment. Granulation tissue, which forms during wound healing, plays a huge role in the healing process. How is it formed, what does it represent? Let's look at it in more detail.

Knee removal after 8 weeks. Partial loading at 4 weeks, total loading at 6 weeks, muscle improvement at 8 weeks, stallion at 9 weeks, squat at 4 months, race at 5 months, sport at 6 months. Jacob turns white at 30° within 5-6 weeks. with partial load. Morgan is immobilized for 4 weeks at full extension because in this position he has best treatment damage and gives immediate stress.

Partial weight bearing for 6 weeks with a knee extension. In case of unstable injuries, such as bucket handles, rehabilitation protocol and more carefully: decrease from 20° to 70°C for 1 month without load, car racing straight for 4-5 months, winding and jumping up to 7-8 months. Sommerlath's 7-year review of arthrotocomic sutures ends with a recommendation for early functional rehabilitation to avoid deficits in flexible expansion.

What does granulation tissue look like?

Granulation tissue is young connective tissue. It develops during the healing of a wound, ulcer, or during encapsulation of a foreign body.

Healthy, normal granulation tissue has a pink-red color, granular structure and dense consistency. A cloudy grayish-white purulent exudate is separated from it in small quantities.

This patient was again operated on with a meniscal suture and then immobilized for 6 weeks, thereby allowing healing. Partial weight bearing for 5 weeks with a knee extension. For unstable injuries such as dental knobs, the most reassuring and cautious protocol is bending between 10° and 80° for 1 month without weight-bearing, followed by partial weight-bearing for another 30 days. Full motion capture in the first 3 months.

We did not use orthopedic surgeons except special occasions. We advise you to resume racing in a straight line no earlier than 3 months and exercise no earlier than 6 months later. The results of meniscal sutures described in the literature are not uniform in type of lesion, associated lesions, surgical technique, postoperative treatment and remote assessment. Results of arthrotomy sutures menstrual cycle superimposed on the results of arthroscopic sutures. Failures are more likely to occur in unstable knees.

Such tissue appears at the borders between dead and living, after injury on the 3-4th day. Granulation tissue consists of many granules that are closely pressed together. They include: amphora substances, loop-shaped vascular capillaries, histiocytes, fibroblasts, polyblasts, lymphocytes, multinucleated vagal cells, argyrophilic fibers and segmented leukocytes, collagen fibers.

Their incidence and 13% according to Ryu. The importance of the knee menu is known to everyone and does not require any confirmation. Likewise, it is a known fact that meniscal suture, when possible, is preferable to meninctomy, albeit partial. Some authors have shown that there is no difference in response. Mechanical stresses between a healthy and sutured meniscus The good results of meniscus sutures persist for a long time, this is confirmed by the low percentage of articular degenerative phenomena, as stated by the stone, which brings in 75% of cases, in the absence of signs of Fairbanks distances four years after the meniscus sutures.

Granulation tissue formation

After just two days, in areas free of blood clots and necrotic tissue, you can notice pink-red nodules - the size of millet granules. On the third day, the number of granules increases significantly and already on the 4-5th day the surface of the wound is covered with young granulation tissue. This process is clearly noticeable on an incised wound.

In terms of results, there are no differences between arthrosomal and arthroscopic sutures; however, postoperative and minor pain symptoms in arthroscopic sutures, as well as minor ones, are problems associated with wound healing. This results in the patient being able to recover faster and faster, with fewer impairments. The arthroscopic technique we prefer allows for more accurate diagnosis of the lesion and the ability to repair these central lesions without suture with arthrotomy.

Healthy, strong granulations are pinkish-red in color, they do not bleed, have a uniform granular appearance, a very dense consistency, and secrete a small amount of purulent, cloudy exudate. It contains a large number of dead cellular elements of local tissue, purulent bodies, admixtures of erythrocytes, segmented leukocytes, one or another microflora with the products of its own vital activity. Cells of the reticuloendothelial system, white blood cells emigrate into this exudate, and vascular capillaries and fibroblasts grow here.

This may be associated with endoscopic reconstruction of the anterior cruciate ligament without the need to practice arthrotomy. Ultimately and by far the most aesthetic benefit. On the one hand, it has undoubted advantages, it does not avoid neurovascular complications, but it is easy to avoid with some technical details. In dorsal horn swords, a small skin incision must be made to reach the capsule to prevent such complications. On the lateral side, it is preferable to identify and protect the peripheral nerve.

Due to the fact that in a gaping wound it is impossible for newly formed capillaries to connect with the capillaries of the opposite side of the wound, they bend and form loops. Each of these loops is a framework for the above cells. Each new granule is formed from them. Every day the wound is filled with more and more granules, so the entire cavity is completely contracted.

The most difficult period for a purse-string suture of the meniscus is understood to be in the first weeks after interventions in the early stages of rehabilitation until complete healing is achieved. Best results have vertical lesions. All authors agree that ligamentous location, especially the frontal pectineal ligament, is a fundamental requirement for the success of mandiscal sutures. Rosenberg reports a complete healing rate of 96% for stable knee sutures versus 33% for unstable knees. The Crusader must be reconstructed with intra-articular plastic.

Layers

The layers of granulation tissue are divided:

• to superficial leukocyte-necrotic;
• the layer of granulation tissue itself;
• fibrous deep layer.

Over time, the growth of capillaries and cells decreases, and the number of fibers increases. Granulation tissue begins to turn first into fibrous tissue, and then into scar tissue.

The main role of granulation tissue is barrier function; it prevents microbes, toxins, and decay products from entering the wound. It inhibits the vital activity of microbes, dilutes toxins, binds them, and helps to reject necrotic tissue. Granulations fill the defect cavity, wounds, and a tissue scar is created.

Wound healing

Granulations always form at the boundaries between living and dead tissue. They form faster when in damaged tissue good blood circulation. There are cases when granulations form in different terms, develop unevenly. This depends on the amount of dead cells in the tissue and the timing of their rejection. The faster granulation occurs, the faster the wounds heal. After cleansing the wound of dead tissue and inflammatory exudate, the granulation layer becomes clearly visible. Sometimes in medical practice removal of granulation tissue is required; this is most often used in dentistry during gingivotomy (gum incision).

If there are no reasons preventing healing, the entire wound cavity is filled with granulation tissue. When granulations reach the skin level, they begin to decrease in volume, become a little paler, then become covered with skin epithelium, which grows from the periphery to the center of the damage.

Healing by primary and secondary intention

Wound healing can occur by primary or secondary intention, depending on its nature.

Primary intention is characterized by a reduction in the edges of the wound due to the connective tissue organization of granulation. It firmly connects the edges of the wound. After initial tension, the scar remains almost invisible and smooth. Such tension can tighten the edges of the wound slightly if the opposite sides are at a distance of no more than one centimeter.

Secondary intention is characteristic of the healing of large wounds, where there is a lot of non-viable tissue. Significant defects or all purulent wounds undergo healing by secondary intention. Differing from the primary type, secondary intention has a cavity, which is filled by granulation tissue. The scar after secondary intention has a pale red color and protrudes slightly beyond the surface of the skin. As the vessels in it gradually thicken, fibrous and scar tissue develops, keratinization of the skin epithelium occurs, the scar begins to turn pale, becomes denser and narrower. Sometimes scar hypertrophy develops - this is when an excess amount of scar tissue forms.

Healing under the scab

The third type of wound healing is the simplest - the wound heals under a scab. This is typical for minor wounds and damage to the skin (abrasions, scratches, abrasions, 1st and 2nd degree burns). A scab (crust) on the surface of the wound is formed from blood that has coagulated there and lymph. The role of the scab is a protective barrier that protects the wound from the penetration of infections; skin regeneration occurs under this shield. If the process goes well, no infection has occurred, and after healing the crust comes off without a trace. There are no signs left on the skin that there was once a wound there.

Pathologies of granulation

If the wound process is disrupted, pathological granulations may form. Insufficient or excessive growth of granulation tissue, disintegration of granulations, and premature sclerosis are possible. In all these cases, and also if the granulation tissue bleeds, special treatment will be required.

The development of granulations and epithelization processes fade away if there are such unfavorable factors as deterioration of blood supply, decompensation of any systems and organs, oxygenation, repeated purulent process. In these cases, granulation pathologies develop.

The clinical picture is as follows: there is no contraction of the wound, the appearance of the granulation tissue changes. The wound looks pale, dull, loses turgor, becomes cyanotic, and becomes covered with a coating of pus and fibrin.

Tuberous granulations are also considered pathological when they protrude beyond the edges of the wound - hypergranulations (hypertrophic). Hanging over the edges of the wound, they interfere with the process of epithelization. In these cases, they are cauterized with concentrated solutions of potassium permanganate or silver nitrate. The wound continues to be treated by stimulating epithelization.

The importance of granulation tissue

So, to summarize, let’s highlight the main roles played by granulation tissue:

• Replacement of wound defects. Granulation is a plastic material that fills the wound.
• Protecting the wound from foreign bodies, organisms, and toxins. This is achieved thanks to a large number of leukocytes, macrophages, as well as a dense structure.
• Rejection and sequestration of necrotic tissue. The process is facilitated by the presence of macrophages, leukocytes, as well as proteolytic enzymes that secrete cellular elements.
• During the normal course of healing, epithelialization begins simultaneously with granulation. Granulation tissue is transformed into coarse fibrous tissue, and then a scar is formed.