Optimal timing of extracorporeal shock wave treatment to protect ischemic tissue.

Enhancement of flap survival through extracorporeal shock wave treatment (ESWT) is a promising new technique; however, no attempt has been made to define the optimal time point and frequency of ESWT to optimize treatment with ESWT for ischemic indications. Twenty-eight male Wistar rats were randomized into 4 groups and an oversized, random-pattern flap was raised and reattached in place in each animal. ESWT was applied 7 days before (group E7) or immediately after the surgical intervention (group E0). The third group was treated with ESWT 7 days before and additionally immediately after the operation (group E7/0). The fourth group served as a control group and did not receive any ESWT (group C). Seven days after flap harvest the results of flap survival, perfusion, microvessel density, and vascular endothelial growth factor concentrations were assessed. Flap survival was significantly increased in all ESWT groups as compared with the control group. The groups (E7 and E0) that received ESWT pre- or postoperatively showed a significant increase in flap perfusion and microvessel density. Combined pre- and postoperative ESWT application (group E0/E7) did not demonstrate a cumulative effect in any evaluation. In this study, we were be able to prove the effectiveness of ESWT in the protection of ischemic tissue flaps. This study suggests that single postoperative application is the most efficacious protocol for clinical applications of ESWT in the treatment of ischemic tissue.

Extracorporeal shock wave treatment in ischemic tissues: what is the appropriate number of shock wave impulses?

The dose-dependent effect of extracorporeal shock wave technology (ESWT) was evaluated using a murine skin flap model. Thirty-six Sprague-Dawley rats were divided into six groups (ESWT groups 1 through 5 and a control group). After surgery, shock wave impulses doses were administered: 200 (group 1), 500 (group 2), 1500 (group 3), 2500 (group 4), 5000 (group 5), and 0 (control group 6). Flap viability was evaluated on day 7. Overall, significantly smaller percentages of necrotic zones were observed in groups 2, 3, and 4 compared with groups 1, 5, and the control group ( P < 0.05). ESWT treatment with 200 impulses was found to be ineffective. ESWT treatment of 5000 impulses resulted in a significant increase in the percentage of necrosis compared with other ESWT groups ( P < 0.05). However, ESWT treatments between 500 and 2500 impulses at 0.11 mJ/mm (2) enhanced epigastric skin flap survival significantly.

Preoperative shock wave therapy reduces ischemic necrosis in an epigastric skin flap model.

Extracorporeal shock wave therapy (ESWT) has recently been demonstrated to improve skin flap survival. In all these studies EWST was applied immediately after the surgical intervention. Thus, the purpose of this study was to determine the preoperative effect of ESWT as a noninvasive technique to precondition flap tissue in a rat epigastric skin flap model. EWST and control groups each contained 10 animals. ESWT was applied 7 days before the surgical intervention, whereas the control group received no treatment. Follow-up evaluation was performed on postoperative day 5. The mean area of flap necrosis, expressed as a percentage of the total flap area, was calculated. A significant reduction of the average flap necrosis area was observed in the ESWT group (27.2% +/- 9.6%) compared with the control group (46.1% +/- 7.9% (P < 0.05). In summary, this study indicates that preoperative ESWT may enhance skin flap survival in a rodent model.

Shock wave therapy reduces necrotic flap zones and induces VEGF expression in animal epigastric skin flap model.

The effect of extracorporeal shock wave (ESW) therapy on skin flap survival and growth factor expression was investigated in a rat model using epigastric skin flap. Treatment and control groups each contained 20 animals. ESW effectively enhanced epigastric skin flap survival by significant reduction of areas of necrotic zones. At day 7 after the operation, necrotic zones of 4.2% were found in the ESW-treated group compared with 18.3% in the control group ( P < 0.01). Concomitantly, in tissue samples adjacent to the necrosis areas, increased vascular endothelial growth factor expression was observed in the ESW-treated animals (median 84.5%, range 57.4 to 94.5%) compared with the control group (median 46.7%, range 29.1 to 93.1%; P < 0.1). However, for expression of basic fibroblast growth factor, no difference was found between the two groups. The authors conclude that the success of the shock wave treatment may partly be due to modulation of growth factor expression.

Peroneal nerve palsy associated with knee luxation: evaluation by sonography--initial experiences.

OBJECTIVE: Traumatic knee dislocation needs immediate surgical repair to restore joint function. A concomitant traction injury of the peroneal nerve is reported to exist in up to 25% of cases and is often overlooked initially. In patients with major nerve lesions, immediate surgical nerve repair might be necessary to avoid irreversible loss of neural function. In the present study, we tried to evaluate whether sonography is a valuable tool for identification of nerve pathology that warrants surgical intervention. SUBJECTS AND METHODS: In this prospective study, both peroneal nerves in nine patients with one-sided peroneal nerve palsy after closed knee luxation and the peroneal nerves of 11 healthy volunteers were investigated with sonography. Using statistical analysis, we tried to define the comparability and significance of the findings. RESULTS: The mean cross-sectional area of healthy peroneal nerves in the genicular region was 0.18 cm2 (SD, 0.07 cm2). Impaired nerves were significantly discerned because of their increased cross-sectional area at the level of the injury (mean cross-sectional area, 0.7 cm2; SD, 0.46 cm2; p < 0.05). Identification of caliber changes and depiction of at least one nerve stump were found to be the most specific criteria for the definition of a major neural lesion. The ability of sonography to provide additional information about surrounding soft-tissue impairment (scar tissue and hematoma formation) proved helpful. CONCLUSION: Sonography allows radiologists to visualize neural and extraneural pathology and to define the exact level and extent of lesions. Thus, it may be a valuable adjunct in the decision of whether surgical intervention is necessary.

Gene therapy with adenovirus-mediated VEGF enhances skin flap prefabrication.

We investigated the feasibility in rats of enhancing skin-flap prefabrication with subdermal injections of adenovirus-encoding vascular endothelial growth factor (Ad-VEGF). The left saphenous vascular pedicle was used as a source for vascular induction. A peninsular abdominal flap (8 x 8 cm) was elevated as distally based, keeping the epigastric vessels intact on both sides. After the vascular pedicle was tacked underneath the abdominal flap, 34 rats were randomly divided into three groups according to treatment protocol. The implantation site around the pedicle was injected with Ad-VEGF in group I (n = 10), with adenovirus-encoding green fluorescent protein (Ad-GFP) in control group I (n = 14), and with saline in control group II (n = 10). All injections were given subdermally at four points around the implanted vessel by an individual blinded to the treatment protocol. The peninsular flap was sutured in its place, and 4 weeks later, an abdominal island flap based solely on the implanted vessels was elevated. The prefabricated island flap was sutured back, and flap viability was evaluated on day 7. Skin specimens were stained with hematoxylin and eosin for histological evaluation. In two rats from each group, microangiography was performed to visualize the vascularity of the prefabricated flaps. There was a significant increase in survival of prefabricated flaps in the Ad-VEGF group compared to the control groups: Ad-VEGF, 88.9 +/- 6.1% vs. Ad-GFP, 65.6 +/- 9.4% (P < 0.05) and saline, 56.0 +/- 3.4% (P < 0.05). Sections from four prefabricated flaps treated with Ad-GFP revealed multiple sites of shiny deposits of green fluorescent protein around the area of local administration 1 day and 3 weeks after gene therapy. Histological examination done under high-power magnification (x400) with a light microscope revealed increased vascularity and mild inflammation surrounding the implanted vessel in all groups. However, we were unable to demonstrate any significant quantitative difference with respect to vascularity and inflammatory infiltrates in prefabricated flaps treated with Ad-VEGF compared with controls. Microangiographic studies showed increased vascularity around the implanted pedicle, which was similar in all groups. However, vascularization was distributed in a larger area in the prefabricated flaps treated with Ad-VEGF. In this study, the authors demonstrated that adenovirus-mediated VEGF gene therapy increased the survival of prefabricated flaps, suggesting that it may allow prefabrication of larger flaps and have the potential to reduce the time required for flap maturation.

Comparison of the effectiveness of gene therapy with transforming growth factor-beta or extracorporal shock wave therapy to reduce ischemic necrosis in an epigastric skin flap model in rats.

The induction of neoangiogenesis by exogenous growth factors in failing skin flaps has recently yielded promising results. Gene transfer with virus vectors has been introduced as a highly capable route of administration for growth factors, such as vascular endothelial growth factor or fibroblast growth factor. Extracorporal shock waves (ESW) deliver energy by means of high amplitudes of sound to the target tissue and have been shown to induce angiogenesis. We compared the effectiveness of gene therapy with adenovirus-mediated transforming growth factor-beta (TGF-beta) and ESW therapy to treat ischemically challenged epigastric skin flaps in a rat model. Thirty male Sprague-Dawley rats were divided into three groups of 10 each with an 8 x 8 cm epigastric skin flap. Rats received either subdermal injections of adenovirus (Ad) encoding TGF-beta (10(8) pfu) or ESW treatment with 750 impulses at 0.15 mJ/mm2. The third group received no treatment and served as a control group. Flap viability was evaluated after 7 days and digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area calculated. Histologic evaluation and increased angiogenesis were confirmed by CD31 immunohistochemistry. Overall, there was a significant increase in mean percent surviving area in the Ad-TGF-beta group and the ESW group compared to the control group (ESW group: 97.7 +/- 1.8% vs. Ad-TGF-beta: 90.3 +/- 4.0% and control group: 82.6 +/- 4.3%; p < 0.05). Furthermore, in the ESW group mean percent surviving areas were significantly larger than in the Ad-TGF-beta group (ESW group: 97.7 +/- 1.8% vs. Ad-TGF-beta: 90.3 +/- 4.0%; p < 0.05). Flap vascularization was increased by Ad-TGF-beta and ESW with numerous vessels, however, there was no significant difference between the two treatment groups. We conclude that treatment with ESW enhances epigastric skin flap survival significantly more than Ad-TGF-beta treatment and thus represents a modality that is feasible, cost-effective, and less invasive compared to gene therapy with growth factors to improve blood supply to ischemic tissue.

Sciatic nerve enlargement in the Klippel-Trenaunay-Weber syndrome.

The case of a 35-year-old woman with Klippel-Trenaunay-Weber syndrome (KTWS) showing clinical symptoms of a peroneal nerve lesion is presented. An immense nerve enlargement along most of the sciatic, peroneal and tibial nerve was found to be due to a lipoma arising from the epi- and perineurium. Treatment consisted of extensive microsurgical neurolysis and excision of the tumor resulting in decompression of the affected nerves. Although rare, a perineural lipoma should be kept in mind in patients with KTWS showing neurological abnormalities.

Adenovirus-mediated transforming growth factor-beta ameliorates ischemic necrosis of epigastric skin flaps in a rat model.

BACKGROUND: Gene therapy has been recently introduced as a novel approach to treat ischemic tissues by using the angiogenic potential of certain growth factors. We investigated the effect of adenovirus-mediated gene therapy with transforming growth factor-beta (TGF-beta) delivered into the subdermal space to treat ischemically challenged epigastric skin flaps in a rat model. MATERIAL AND METHODS: A pilot study was conducted in a group of 5 animals pretreated with Ad-GFP and expression of green fluorescent protein in the skin flap sections was demonstrated under fluorescence microscopy at 2, 4, and 7 days after the treatment, indicating a successful transfection of the skin flaps following subdermal gene therapy. Next, 30 male Sprague Dawley rats were divided into 3 groups of 10 rats each. An epigastric skin flap model, based solely on the right inferior epigastric vessels, was used as the model in this study. Rats received subdermal injections of adenovirus encoding TGF-beta (Ad-TGF-beta) or green fluorescent protein (Ad-GFP) as treatment control. The third group (n = 10) received saline and served as a control group. A flap measuring 8 x 8 cm was outlined on the abdominal skin extending from the xiphoid process proximally and the pubic region distally, to the anterior axillary lines bilaterally. Just prior to flap elevation, the injections were given subdermally in the left upper corner of the flap. The flap was then sutured back to its bed. Flap viability was evaluated seven days after the initial operation. Digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area were measured and expressed as percentages by using a software program. RESULTS: There was a significant increase in mean percent surviving area between the Ad-TGF-beta group and the two other control groups (P < 0.05). (Ad-TGF-beta: 90.3 +/- 4.0% versus Ad-GFP: 82.2 +/- 8.7% and saline group: 82.6 +/- 4.3%.) CONCLUSIONS: In this study, the authors were able to demonstrate that adenovirus-mediated gene therapy using TGF-beta ameliorated ischemic necrosis in an epigastric skin flap model, as confirmed by significant reduction in the necrotic zones of the flap. The results of this study raise the possibility of using adenovirus-mediated TGF-beta gene therapy to promote perfusion in random portion of skin flaps, especially in high-risk patients.

The single-fascicle method of nerve grafting.

In this study a single-fascicle technique for neural deficits repair was evaluated using a rat sciatic nerve model. Twenty-four Lewis rats were divided into 4 groups: group 1, 1.5-cm deficit without repair; group 2, conventional autograft; group 3, large-fascicle autograft; and group 4, small-fascicle autograft. Nerve regeneration was evaluated by pin-prick and toe-spread tests. Nerve samples were estimated by histomorphometry. Group 1 presented no recovery. Groups 3 and 4 demonstrated significantly better pin-prick results compared with those from conventional repair. Histology revealed a significantly higher number of axons and myelin thickness in the small-fascicle (2.8 +/- 0.4 x 10(3) axons, 4.22 +/- 0.41 microm) and large-fascicle (5.1 +/- 1.7 x 10(3) axons, 4.62 +/- 0.28 microm) groups compared with the conventional autograft group (2.1 +/- 0.3 x 10(3) axons, 2.93 +/- 0.20 microm). The small-fascicle group had a significantly greater mean axon area (58.59 +/- 15.81 microm2) than the large-fascicle group (29.66 +/- 12.67 microm2) and the conventional group (25.35 +/- 7.52 microm2). In this study, peripheral nerve repair using a single-fascicle graft resulted in faster functional recovery and better morphometric outcome compared with conventional nerve repair.

Gracilis muscle split into two free flaps.

A case is presented in which the gracilis muscle was transversely split into two free flaps for coverage of two separate defects in a patient with a multi-segment fracture of the metatarsal bones and the ankle joint.

Morphology and topography of intraosseous ganglion cysts in the carpus: an anatomic, histopathologic, and magnetic resonance imaging correlation study.

PURPOSE: To assess the morphology, topography, frequency, and etiology of intraosseous carpal ganglions. METHOD: Two hundred and eighty formalin fixed cadaveric wrists (mean age 80.3 +/- 9.7 years, range 40 to 101 years) were radiographed. Fifty specimens suspicious for cyst-like bone lesions underwent magnetic resonance imaging (T1w and proton density-fat-saturated images, 1.5T). Dissection, articular surface assessment, and histological examination were performed. Cystic lesions with adjacent destruction of the hyaline cartilage were classified as degenerative and were excluded. RESULTS: In 27 of the 50 specimens, 48 ganglion cysts (GC) were found. Prevalence of GC was 9.6%. Of 48 intraosseous carpal GC, 41 (85%) were in a peripheral location; 27/48 (56%) were located at the palmar carpus. GC had a macroscopic and microscopic relationship to the insertion of degenerated ligaments. They developed near longitudinally orientated bone surfaces, which serve as insertion for ligaments and are exposed to tension loading. CONCLUSIONS: Unlike degenerative cysts, ganglion cysts do not erode the hyaline articular cartilage and almost always have a continuity with the capsular ligaments. Intraosseous carpal ganglion cysts are probably the result of mucoid degeneration of adjacent ligaments.

Breast deformity in adolescence as a result of pneumothorax drainage during neonatal intensive care.

OBJECTIVE: During intensive care of newborns, a number of invasive techniques may be necessary for resuscitation. The margin of safety between effective treatment and iatrogenic damage is narrow. The objective of this study was to identify and discuss iatrogenic damage in females resulting from treatment of pneumothorax and to give neonatologists anatomically based advice for prevention. PATIENTS AND METHODS: We report 2 female patients (aged 13 and 16 years) born prematurely in whom breast deformity occurred caused by drainage of multiple pneumothoraces during intensive care. In an additional anatomic study, both hemithoraces of 5 newborn female cadavers (n = 10) were dissected to measure the extension of the breast tissue. RESULTS: The anatomic investigations in newborns demonstrate that breast tissue extends vertically from the second or third rib to the sixth rib and from close to the sternal edge medially, almost to the anterior axillary line laterally. CONCLUSION: Psychological distress and corrective surgery because of deformed breasts in adolescent girls who have undergone drainage of pneumothoraces as newborns can be avoided by placing the skin incision in the anterior axillary line, maintaining a distance of 4 to 5 cm inferior to the nipple, and by inserting the chest drain through the fifth or sixth intercostal space during neonatal treatment.

A novel technique for peripheral nerve repair.

OBJECTIVE: To evaluate a novel technique for the repair of neural deficits using a single fascicle to bridge an injury in the rat sciatic nerve. STUDY DESIGN: Twenty-four male Lewis rats were divided into four groups as follows: group 1 (control group), 1.5-cm deficit without repair; group 2, conventional epineural repair with autografts (100% diameter); group 3, nerve repair with large single autograft fascicle (50% diameter); and group 4, nerve repair with small single autograft fascicle (25% diameter). METHODS: Nerve regeneration was evaluated at 3, 6, and 12 weeks by somatosensory evoked potential (SSEP) evaluation and standardized pin-prick and toe-spread tests. Nerve samples were harvested at 12 weeks and stained with toluidine blue to assess the total number of myelinated axons, axon area, and myelin sheath thickness. RESULTS: In group I, the pin-prick and toe-spread tests showed no response at 3, 6, and 12 weeks. Rats in groups 3 and 4 demonstrated significantly better pin-prick test results and a trend toward better toe-spread test responses compared with conventional-repair animals. The SSEP evaluations displayed nondiagnostic waves in rats in group 1 rats. There was no evidence that the other surgery groups differed significantly in median SSEP latencies. Histological evaluation revealed fibrosis in rats in group 1 rats and a significantly higher median number of axons and myelin thickness in the small single fascicle (1296 axons and 4.22 microm, respectively) and large fascicle (2682 axons and 4.62 microm, respectively) groups compared with the conventional autograft group (630 axons and 2.93 microm, respectively). The small fascicle group had a significantly greater mean axon area (58.59 micro m2) than the large fascicle (29.66 micro m2) and conventional autograft (25.35 micro m2) groups. CONCLUSIONS: Peripheral nerve repair using a single fascicle graft resulted in better functional recovery and morphometric outcome without a significant difference in electrophysiological status compared with conventional nerve repair. This technique may provide expanded sources of nerve autografts and alleviate the morbidity of harvesting peripheral nerves from multiple sites for individuals with extensive peripheral nerve injuries.

Microsurgical management of the diabetic foot.

Allthough there has been dramatic progress in limb salvage in recent decades, management of nonhealing wounds in diabetic patients continues to present a dilemma for the reconstructive surgeon. However, the acceptance of free-flap resurfacing of diabetic foot ulcers has increased in recent years. This study reviews 10 microvascular free muscle flaps in nine patients over a mean follow-up period of 44 months. Five patients had evidence of peripheral vascular disease. There was one flap loss, and nine flaps were transferred successfully. No perioperative mortality was encountered. The operations required a long, costly hospitalization (average hospital stay was 40 days). Seven of eight patients whose flaps survived had complications related to the free-flap recipient site. These seven patients underwent 20 secondary surgical procedures due to arterial and venous thrombosis, partial necrosis of the skin grafts, minor local infections, and gangrene or necrosis of the remaining toes. In three patients, progressive ischemic necrosis of the remaining toes, with total survival of the flap, was attributed to a microvascular steal phenomenon. However, all eight patients whose flaps survived subsequently ambulated on their flaps. The study demonstrates that microvascular surgery may result in functional lower-extremity salvage in diabetic patients with foot wounds that are not treatable by local flaps or skin grafts, and are destined for amputation.

Ultrasonographic appearance of supinator syndrome.

OBJECTIVE: To describe ultrasonographic findings in 4 patients with supinator syndrome (i.e., deep branch of the radial nerve). METHODS: Four patients with weakness and pain in their forearm underwent ultrasonographic examination with subsequent electroneurographic testing and surgical nerve inspection. Normal measurements of the deep branch of the radial nerve in 10 healthy volunteers served as comparison for measurements in the patients. RESULTS: An enlarged deep branch of the radial nerve was found in all 4 patients at the affected side. Electroneurographic testing and surgical inspection confirmed the ultrasonographic findings. The mean transverse diameter was 4.2 mm (range, 3.8-4.5 mm), and the anteroposterior diameter was 3.3 mm (range, 2.5-3.8 mm). In volunteers, the mean transverse diameter was 2.13 mm (range, 1.7-2.6 mm), and the mean anteroposterior diameter was 1.3 mm (range, 1.0-1.5 mm). CONCLUSIONS: The deep branch of the radial nerve appears enlarged in patients with supinator syndrome.