The surgical and oncological safety of immediate breast reconstruction.

AIM: The aim of our study was to (1) examine the incidence of surgical complications, (2) determine the incidence of loco-regional recurrences and (3) examine the safety of saving the nipple-areola-complex after immediate breast reconstructions in breast cancer. METHODS: Sixty-six immediate breast reconstructions were performed. Wide local excision (WLE), skin sparing mastectomy and subcutaneous mastectomy (SCM) were performed to 12, 20 and 34 patients, respectively. In all patients with WLE the reconstruction was performed with the latissimus dorsi (LD) miniflap. In other patients reconstructions were done with a free TRAM-flap (n=26) LD-flap (n=27) or with a prosthesis only (n=1). RESULTS: Major flap necrosis developed in four patients. Local recurrence rate was 8.3% in the group where nipple-areola-complex was removed and 7.1% in the group where nipple-areola-complex was saved. Metastases were found in 12.5 and 0%, respectively. CONCLUSION: SCM compared to skin sparing mastectomy may lead to an enhanced risk of immediate surgical complications, but does not threat the oncological safety. Saving the nipple-areola-complex in immediate breast reconstructions is possible in early breast cancer, if the tumour is not in the central part of the breast.

Cemented Lubinus and Furlog total hip endoprosthesis: a 12-year follow-up study of 175 hips comparing the cementing technique.

We analyzed 175 total hip replacements with cemented Lubinus and Furlong arthroplasties in 164 patients with a median age of 65 (32-80) years and followed them for 12 years to evaluate and compare the efficacy of total hip prosthesis designs. Survival analysis was combined with an analysis of radiological findings and a study of functional outcome of the patients. The 12-year survival of Furlong arthroplasty in patients of 60 years of age and older was O.85 (95% CI 1.00-0.52). The survival of Lubinus arthroplasty in patients younger than 60 years of age was 0.70 (0.91-0.48), while the survival in older patients was 0.75 (0.89-0.61). The 12-year survival of well-cemented Lubinus prosthesis was 0.91 (1.00-0.79), indicating the importance of the cementing technique. The survival of the cups was marginally better than that of the stems. In the 12-year follow-up study, the clinical state and function varied from hips ready for revision to hips where a continuously long survival could be predicted. Harris hip score did not differentiate between patients who had intact and loose components. We conclude that cemented arthroplasty affords a notable alternative with satisfactory long-term survival and function. The better survival of cemented cup than the stem may be utilized as a basis for "reverse" hybrid arthroplasty. Adequate long-term follow-up of all arthroplasties as a quality maintenance and to prevent difficult revisions is a major challenge.

Impaction bone grafting in revision hip surgery. A high incidence of complications.

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification. The Mayo hip score improved from a mean of 32 (SD +/- 18) to 62 (SD +/- 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united. The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases. In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications.

A prospective study of teleconferencing for orthopaedic consultations.

We carried out a prospective study of teleconsulting in orthopaedics. A commercial videoconferencing system was connected by three ISDN lines between the Satakunta Central Hospital in Pori and the Orton Orthopaedic Hospital in Helsinki, 240 km away. A document camera was used to transfer radiographic images and paper documents. Twenty-nine patients who needed an orthopaedic consultation were studied over three months. They were examined by a surgeon in Pori with the aid of teleconferencing and again later in a traditional, face-to-face appointment in Helsinki. Patients and doctors completed questionnaires after the consultations. Technically, the videoconferencing system functioned reliably and the quality of the video was judged to be good. Twenty patients (69%) would not have needed to travel for a face-to-face appointment, because the teleconsultation afforded a definite treatment decision. The orthopaedic surgeons considered all the treatment decisions arising from the teleconsultation good, except in one case which was considered satisfactory. The quality of the radiographic images transferred with the document camera was good or very good in 17 cases and satisfactory in three cases. None of the patients had experienced videoconferencing before; 87% of them thought that teleconsultation was a good or very good method and the rest felt that it was satisfactory. All patients wanted to participate in teleconsultations again and most would have recommended it to other patients.

Five-shot questionnaire on heavy drinking.

To develop an effective, but short, questionnaire to detect heavy drinking, we combined two questions from AUDIT and three from CAGE. We have tested earlier this new Five-Shot questionnaire among male alcoholics who all had a total score of at least 4/7. The purpose of the present study was to find out the effectiveness of the Five-Shot questionnaire among middle-aged men. In the present study, the Five-Shot questionnaire was distributed to all (n = 853) 40-year-old men attending health screening in a Finnish town. The participation percentage in the screening was 70.3%. Self-reported alcohol consumption was used as a gold standard; 557 of these men gave a self-report that they consumed less absolute alcohol than 140 g/week (moderate drinkers), and 70 reported consuming > or = 280 g/week (heavy drinkers). None of the individual Five-Shot questions was superior to any other in detecting heavy drinkers. The cut-off point > or = 3 for Five-Shot gave a 77% sensitivity in detecting heavy drinkers, with a specificity of 83% and an overall accuracy of 83%. The corresponding figures with > or = 2.5 cut-off were 96%, 76%, and 78%. The commonly used cut-off for CAGE, > or = 2, gave a result of 47%, 87%, and 83%, respectively. The area under the receiver operating characteristic curve for the CAGE was clearly worse, compared with that of the Five-Shot. The new Five-Shot questionnaire seems to be efficient in differentiating between moderate and heavy drinkers. It is also easy and fast for physicians to use in different health-care settings. Thus, it can serve as a good aid in early detection of heavy drinking.

Selective modulation of collagen gene expression by different isoforms of platelet-derived growth factor in experimental wound healing.

Subcutaneous sponges in rat were used as a wound model to study the changes in collagen gene expression induced by different isoforms of platelet-derived growth factor (PDGF). The steady state levels of proalpha1(I) and proalpha1(III) collagens rose markedly in response to PDGF-AB treatment. In marked contrast to PDGF-AB, PDGF-BB exerted a down-regulatory effect on the expression of type I and III procollagen mRNA levels. In situ hybridisation signal for proalpha1(I) collagen mRNA was most prominent in the periphery of the sponges in response to PDGF-AB. In PDGF-AA and PDGF-BB treated sponges, however, the hybridisation signal for proalpha1(I) collagen mRNA was evenly distributed. Immunolabellings demonstrated the presence of type I and III collagen epitopes and thus revealed the deposition of these proteins into developing granulation tissue. The volume of ingrown granulation tissue was estimated by measuring the cross-sectional area of the samples. PDGF-AB and PDGF-BB were both effective resulting in a significant increase in the amount of granulation tissue. However, only a limited enhancement of granulation tissue ingrowth was observed in response to PDGF-AA treatment. To conclude, PDGF-AB and PDGF-BB induced significantly the ingrowth of repair tissue in wounds. PDGF-AB distinctively upregulated collagen gene expression, while PDGF-BB primarily seemed to be mitogenic.

Experimental telemedicine in orthopaedics.

There have so far been few telemedical applications in orthopaedics. This experiment involved clinicians in three different locations, two in Helsinki and the third in Tampere, consulting one another simultaneously. We used an ATM network to transfer X-ray pictures, digitized by a 12-bit CCD scanner and archived in a central image server. The consultations between the clinicians and the examination of the patient were transmitted by a videoconferencing system using the ISDN. We found that telemedicine offers new possibilities in orthopaedics, for clinical work, for training and for research.

Low field MRI and scaphoid fracture.

18 consecutive patients suspected of and treated for an acute scaphoid fracture were examined by lowfield MRI. This showed 11 fractures while seven scaphoids were considered normal. T1 weighted images showed a fracture as an area of decreased signal intensity. Two radiologically obvious fractures produced normal MR images. These fractures proved to be the result of old trauma. A wide spectrum of additional traumatic lesions in the wrists, not detected by routine X-ray analysis, were also demonstrated. These included seven fragmented triangular fibrocartilages (TFC), torn scapho-lunate ligaments in four cases and one torn triquetro-lunate ligament. Bone bruises of other carpal bones and seven other carpal fractures were also detected. Low field MRI can be used to show scaphoid fractures and allows diagnosis of additional or simulating lesions.

Platelet-derived growth factor isoforms PDGF-AA, -AB and -BB exert specific effects on collagen gene expression and mitotic activity of cultured human wound fibroblasts.

This study was designed to clarify the action of three different isoforms of PDGF (PDGF-AA, PDGF-AB and PDGF-BB) on the proliferation rate and collagen synthesis of fibroblasts cultured from normal human wounds. PDGF-AA and PDGF-BB down-regulated both the steady-state levels of pro alpha 1 (I) and pro alpha 1 (III) collagen chain mRNAs and the production of collagen, both in a dose-dependent manner. Interestingly, low concentrations (1 ng/ml) of PDGF-AB up-regulated the expression of type I and III procollagen mRNAs by cultured wound fibroblasts, while under high concentrations (30 ng/ml) of PDGF-AB this effect changed to the opposite. The proliferation rate of wound fibroblasts was stimulated by PDGF-BB which elicited a dose-dependent (1-30 ng/ml) stimulation of cell proliferation, whereas PDGF-AB and -AA were less effective in this respect.

Stimulation of wound healing by the immunomodulator LS-2616 (Linomide).

LS-2616 (Linomide), a quinoline-3-carboxamide, is an immunomodulator that has been suggested to act on macrophage-like cells. Based on a hypothesis that LS-2616 would stimulate macrophages in the wound and affect the healing process, the effects of LS-2616 on developing granulation tissue were evaluated using a wound model in rats. Subcutaneously implanted cylindrical cellulose sponges were used as an inductive matrix for the ingrowth of granulation tissue. LS-2616 was continuously present at a concentration of 1.2 mg/ml in the drinking water either for 7 days before implantation or starting at the implantation of sponges. Seven days after implantation LS-2616 treatment increased the mean amounts of nitrogen and collagen hydroxyproline over the control level [+20% (p < 0.05) and +59% (p < 0.05), respectively]. The effect was less pronounced in the rats receiving LS-2616 in advance [+7% (NS) and +38% (p < 0.05), respectively]. The mean amounts of nucleic acids and proteoglycans tended to decrease in the rats receiving LS-2616 in advance compared to the control rats [-12% to 13% (NS) and -25% (p < 0.05), respectively]. It was concluded that continuous oral administration of LS-2616 enhanced wound repair in the rat. This immunoenhancement of wound healing results in increased accumulation of collagen.

Effects of heterodimeric isoform of platelet-derived growth factor PDGF-AB on wound healing in the rat.

Earlier we reported a positive effect of platelet-derived growth factor (PDGF-BB) on rat wound healing while corresponding doses of PDGF-AA were not as effective. The present work was undertaken to study the effects of the heterodimeric form of PDGF (PDGF-AB) on wound healing in rats. Subcutaneously implanted hollow cylindrical cellulose sponges served as an inductive matrix for the granulation tissue. Fifty microliters of solutions containing 0, 5, 50 or 500 ng of PDGF-AB heterodimer were injected daily into the sponges. The analyses of the granulation tissue in the sponge cylinders were carried out 7 days after implantation. Injections of 500 ng of PDGF-AB stimulated significantly the accumulation of collagen and proteins, indicated by the elevated hydroxyproline and nitrogen content of the sponge (+51%, p < 0.01 and +48%, p < 0.001, respectively). Similarly, the amounts of DNA, RNA, hexosamines and uronic acids were significantly higher, reflecting a PDGF-AB-induced increase in the cellularity and glycosaminoglycans. Analyses of wound fluid showed a marked decrease in the number of polymorphonuclear leukocytes in response to PDGF-AB treatment. Injections of a lower dose, 50 ng, of PDGF-AB increased significantly the mean amounts of nitrogen, RNA and uronic acids but no significant changes were observed in other parameters. The lowest dose of PDGF-AB, 5 ng daily, induced no essential effect. In vitro PDGF-AB increased the number of rat granulation tissue-derived fibroblasts and collagen accumulation per culture dish at concentrations of 10 and 30 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of homodimeric isoforms of platelet-derived growth factor (PDGF-AA and PDGF-BB) on wound healing in rat.

Platelet-derived growth factor (PDGF) has been suggested to have a significant role in wound healing. The present work was aimed at studying the effects of PDGF-AA and PDGF-BB homodimers on developing granulation tissue in rats. Subcutaneously implanted hollow cylindrical cellulose sponges were used as an inductive matrix for the ingrowth of granulation tissue. Fifty microliters of solutions containing 0, 5, 50, or 500 ng of PDGF-AA or PDGF-BB homodimers was injected daily into the sponges; 7 days after implantation the granulation tissue in the sponge cylinders was analyzed. Five hundred nanograms of PDGF-BB stimulated significantly the accumulation of collagen, indicated by the elevated hydroxyproline content of the sponge (+34%, P < 0.001). Similarly, the amounts of RNA-ribose, nitrogen, hexosamines, and uronic acids were significantly higher, reflecting a PDGF-BB-induced increase in the accumulation of RNA, protein, and glycosaminoglycans. Analyses of wound fluid showed no essential changes in the composition of different cell types after PDGF-BB-treatment. The PDGF-AA-treatment increased significantly the mean amount of RNA but there were no significant changes in other parameters. In vitro both PDGF-AA and PDGF-BB increased significantly the number of rat granulation tissue derived fibroblasts in culture at concentrations of 10 and 30 ng/ml. This proliferative effect resulted in a lowered level of protein synthesis per cell. To conclude, PDGF-BB accelerates granulation tissue formation both in vitro and in vivo, whereas PDGF-AA is effective in vitro but it is clearly less effective in vivo.