Indication-Specific Effect of a Phytotherapeutic Remedy on Human Fetal Osteoblastic Cells: An in vitro Analysis.

BACKGROUND: Impaired fracture healing is a recurring interdisciplinary medical challenge. Alternative treatment concepts, apart from conventional medicine, are popular, but scientific evidence on their effects is still lacking. Plant-derived substances are widely assumed to support bone homeostasis. To clarify the effects on bone healing mechanisms, a commercially available, homeopathic-spagyric remedy, containing inter alia two herbal substances with assumed osteogenic potential, equisetum arvense and bellis perennis, was analyzed. METHODS: Human fetal osteoblastic (hFOB) 1.19 cells were incubated with the test substance in serial dilutions from 10 to 0.00001%. Cell viability has been evaluated through ATP level (CTG assay) and MTT tetrazolium reduction. Cell proliferation was analyzed by BrdU incorporation and cell migration by wound healing assay (WHA) via image analysis. Additionally, determination of the expression of key genes via real-time PCR and proteins via proteome array for inflammation, cell proliferation, and angiogenesis were performed. RESULTS: An incubation of hFOB 1.19 cells with the test substance for 24/72 h showed no reduction in cell number, viability, or proliferation. Cell migration was unimpaired. The test substance induced inflammatory genes and growth factors along with genes of osseous regeneration (ALP, Col1, IL-1α, IL-6, IL-8, IL-10, Osteocalcin, Osteonectin, RUMX2, TGF, VEGFA). Increased protein expression was found in multiple cytokines, chemokines, and acute phase proteins. CONCLUSION: The test substance did not impair cell vitality parameters (MTT, CTG, BrdU, and WHA). A tendency to activate growth factors, bone regeneration genes, and proteins was shown for osteoblasts, indicating a possible positive effect on osteogenic processes.Störungen des komplexen Prozesses der Knochenheilung stellen auch heutzutage noch eine interdisziplinäre Herausforderung dar. Es existieren zahlreiche alternative Therapiekonzepte, deren Evidenz jedoch häufig nicht belegt ist. Es wird davon ausgegangen, dass pflanzliche Substanzen die Knochenheilung unterstützen können. Wir analysierten die Wirkung eines kommerziellen, homeopathisch-spagyrischen Heilmittels, welches unter anderen zwei Pflanzenstoffe enthält, denen ein osteogenes Potential zugeschrieben wird (Equisetum arvense und Bellis perennis).Es erfolgte eine Inkubation humaner fetaler Osteoblastenzellen (hFOB 1.19) mit der Testsubstanz in absteigender Verdünnung von 10 bis 0.00001%. Die Zellvitalität wurde anhand der Zellzahlbestimmung durch ATP-abhängige metabolische Aktivität mittels CellTiter-Glo® (CTG) Test sowie durch Tetrazolium Reduktion (MTT) evaluiert. Die Zellproliferation wurde durch Inkorporation von Bromdesoxyuridin (BrdU) in die DNA aktiver Zellen analysiert. Der Wound Healing Assay (WHA) diente der Quantifizierung der Zellmigration. Zusätzlich wurde die Expression bestimmter Schlüsselgene mittels real-time PCR und die Proteinexpression via proteom array für Inflammation, Zellproliferation und Angiogenese erhoben.Die Inkubation von hFOB 1.19 mit der Testsubstanz für 24/72 Stunden führte zu keiner Reduktion von Zellzahl, -vitalität oder -proliferation. Auch die Zellmigration war unbeeinträchtigt. Es zeigte sich eine Induktion inflammatorischer Gene, Wachstumsfaktoren sowie Genen der knöchernen Regeneration (ALP, Col1, IL-1α, IL-6, IL-8, IL-10, Osteocalcin, Osteonectin, RUMX2, TGF, VEGFA). Verschiedene Zytokine, Chemokine und Akute Phase Proteine wurden vermehrt exprimiert.Die Testsubstanz hatte keine negativen Auswirkungen auf die gemessenen Zellvitalitätsparameter (MTT, CTG, BrdU and WHA). Es zeigte sich eine Aktivierungstendenz für Wachstumsfaktoren, Gene und Proteine der Knochenregeneration, die auf einen möglichen positiven Effekt der Substanz auf den Prozess des Knochenheilung hinweisen.

Multicenter consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in Hand Surgery.

OBJECTIVE: The purpose of this agreement was to establish consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in hand surgery. METHODS: Based on Delphi consensus methodology, a preliminary list of questions on the use of LIPUS in hand surgery was developed by an interdisciplinary team of hand and plastic surgeons as well as psychologists and experts from communications science. Based on these, questionnaires were invented and a total of three Delphi rounds have been conducted. Delphi panelists consisted of 11 German hand surgeons with a mean experience in hand surgery of 15 years (7-23 years). Questions and statements were revised during this process, resulting in a consensus at the end of round three. RESULTS: After three Delphi rounds, the following recommendations could be derived. LIPUS can be applied for impaired fracture healing of the digits, metacarpals, carpal bones as well as a prophylactic procedure in order to avoid further revision surgery. LIPUS therapy can be useful in addition to revision surgery for delayed union and non-unions. In the case of certain risk factors (replantation, revascularization, osteoporosis, smoking), it can be applied directly postoperatively in order to prevent impaired fracture healing. It should be applied for 90-120 days. CONCLUSION: There is a consensus among German hand surgeons, when and how LIPUS can be applied for improving fracture healing of the hand. Randomized controlled trials with direct comparison of fracture treatment with and without LIPUS are needed to support these statements with objective data.

Perfusion of the proximal scaphoid pole: correlation between preoperative ge-MRI and intraoperative findings.

BACKGROUND: Gadolinium enhanced MRI (ge-MRI) is considered as gold standard for perfusion evaluation in case of scaphoid nonunion (SNU). However, its clinical value and specificity is still not clearly evaluated. This study compares preoperative ge-MRI-based perfusion assessment and intraoperative proximal pole (PP) perfusion after scaphoid reconstruction by vascularized bone grafts. In addition, the postoperative osseous consolidation (OC) was correlated to intraoperative perfusion findings. METHODS: Between 08/2010 and 01/2020, 60 of 271 patients with scaphoid nonunion received a vascularized radius bone graft for reconstruction. Medical reports were checked for intra-op perfusion findings. Consolidation rate was assessed at mean follow-up of 3 months by CT evaluation. In 50 cases (83.2%), complete medical and radiological history could be obtained. Preoperative ge-MRI was reevaluated by a blinded radiologist for advanced analysis of sensitivity and specificity. RESULTS: Preoperative ge-MRI (initial finding, IF) showed 23 avascular, 20 malperfused, and seven vital PP. Blinded radiological follow-up (second finding, SF) revealed 14 avascular, 28 malperfused, and 8 vital PP, with a concordance of 65.3% (n = 35). After correlation with the intra-op findings, a specificity of preoperative ge-MRI of 76.5% (IF) and 88.2 (SF), respectively, was revealed for exclusion of avitality. For detection of malperfusion, there was a sensitivity of 92.7% (IF) and 85.4% (SF), respectively. Complete OC was seen 12 weeks postoperatively in 37 (73.5%), partial OC in 9 (18.3%), and nonunion in 4 cases (8.2%) on CT-scans. Of the 41 malperfused/avascular PP, 31 (75.6%) progressed to complete and 6 (14.6%) to partial (at least 2 adjacent CT-layers of 2 mm) OC, with 4 nonunions. CONCLUSION: The sensitivity and specificity of ge-MRI for detection/ exclusion of malperfusion/avitality of the PP was lower than expected. Therewith, the intraoperative assessment of PP perfusion regains a high value in decision-making for the appropriate graft. We recommend preservation of the dorsal radial vascular plexus initially until the vascularity of the proximal pole has been estimated. Patient education for all contingencies and retraction options should be obtained.

Digital avulsion injuries: epidemiology and factors influencing finger preservation.

INTRODUCTION: The surgical treatment of ring avulsion injuries is still challenging. This study provides data concerning epidemiology and factors influencing finger survival rate. We wanted to answer the question whether microsurgical advancement and a high level of surgical expertise nowadays may improve the outcome. PATIENTS AND METHODS: Between 11/2007 and 06/2016 95 ring avulsions were treated (classified according to Kay). Complete documentation was available from 87 patients (25 female). The mean age was 34 (4-82) years. Intact perfusion (Kay I) was preoperatively seen in 20 fingers while 67 were avascular (Kay II-IV). RESULTS: In 89%, the ring finger was injured during mainly private accidents. Primary amputation was performed in 38 Kay II-IV injuries. Revascularization was applied to 29 fingers while 8 of them (28%) primarily failed. After initially successful revascularization/replantation of 21 fingers, 6 had to be amputated secondarily (success rate: 52%). There was no significant correlation between affected finger and rate of finger preservation. Climbing over a fence as trauma mechanism significantly correlated with lower finger preservation rates and higher incidence of Kay IV injuries. CONCLUSION: Despite microsurgical advances and high levels of surgical expertise the finger survival rate after ring avulsion injuries still seems to be mostly influenced by the extend of intrinsic damage.

Vascularized Medial Femoral Condyle Autografts for Osteochondral Lesions of the Talus: A Preliminary Prospective Randomized Controlled Trial.

Talar osteochondral lesions (OCLs) lead to progressive stages of talar destruction. Core decompression with cancellous bone grafting (CBG) is a common treatment for Berndt and Harty stages II and III. However, in a subset of patients, talar revascularization may fail. Surgical angiogenesis using vascularized medial femoral condyle (MFC) autografts may improve on these outcomes. These 2 treatment strategies were directly compared via a prospective preliminary randomized trial including 20 participants with talar core decompression followed by either cancellous (CBG group, n = 10) or vascularized MFC (MFC group, n = 10) bone grafting. Outcome analysis was performed with visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Lower Extremity Functional Scale (LEFS), and contrast-enhanced magnetic resonance imaging (MRI) scans. At 12 months of follow-up, the mean VAS score was reduced from 6.6 ± 2.5 preoperatively to 4 ± 1.9 in the CBG group and from 5.2 ± 2.9 preoperatively to 1 ± 1.1 in the MFC group (p < .001). The LEFS improved from 53.4 ± 13.1 to 62.6 ± 16.2 CBG and from 53 ± 9.3 to 72.4 ± 7.4 MFC (p = .114). AOFAS improved from 71 ± 12.1 to 84.1 ± 12.5 in CBG and from 70.5 ± 7.4 to 95.1 ± 4.8 in MFC (p = .019). The MRI scans in the CBG group demonstrated 9 partial malperfusions and 1 hypervascularized bone graft, whereas the MFC group had 8 well-vascularized grafts incorporated into the talus and 1 partial malperfusion. Vascularized MFC autografts provide superior pain relief along with improvement of physical function in patients with talar OCL stage II and III compared with CBG. To confirm these promising results, further multicenter randomized controlled trials are required.

Donor site morbidity of vascularized bone grafts from the medial femoral condyle for osseous revascularization.

BACKGROUND: Vascularized bone grafts from the medial femoral condyle (MFC) are used to gain surgical revascularization of osseous defects. To date objective data regarding the donor site morbidity are limited. This study aims to evaluate the donor site associated outcome after MFC flap harvest. PATIENTS AND METHODS: From 2008 to 2016, 22 patients who underwent MFC bone flap harvest for osseous revascularization of 9 talus, 8 scaphoids, 2 metacarpals, 1 phalanx, 1 pilon tibiale, and 1 distal femur were included. Outcome analysis was performed for the whole cohort as well as for two subgroups (recipient site upper [group A] and lower extremity [group B]) by the lower extremity functional scale (LEFS), the OAK-score of the Swiss Orthopedic Society and the visual analog scale (VAS). Additionally, a 3D gait analysis was performed for four patients. RESULTS: The mean flap size was 1 × 1 × 3 cm. No flap loss was observed. One minor surgical revision was performed due to donor site hematoma. Mean follow-up was 35.8 (12-98) months. Mean LEFS-score was 74.9 ± 9.5 (A: 74.3 ± 7.9; B: 75.6 ± 11.2, p > .05) and OAK-score was 92.8 ± 9.4 (A: 93.2 ± 5.8; B: 92.4 ± 12.3, p > .05). At follow-up examination, pain at rest was stated with 0.1 ± 0.2 (A: 0.1 ± 0.3; B 0 ± 0, p > .05) and with activity 0.6 ± 1.4 (A: 1.2 ± 1.8; B: 0 ± 0, p > .05) on VAS. The 3-D gait analysis showed normative walking patterns. CONCLUSION: After MFC flap harvest knee function and gait pattern were almost unimpaired. Donor site morbidity can be considered as being of minor concern in the decision-making for this microvascular procedure.

Validation of the Ludwigshafen German Version of the Burn Specific Health Scale-Brief.

The Burn Specific Health Scale-Brief (BSHS-B) is one of the most commonly used instruments to measure quality of life after burns. Our aim was to establish and to provide a German version of the BSHS-B for all German-speaking burn facilities. Translation and cross-cultural adaptation of the original English version into the German language was conducted. In a pilot study, 20 burn patients qualitatively validated the translated version concerning comprehensibility and content validity. The final version was then quantitatively validated by 364 patients who were treated in our burn center between 2011 and 2015. Internal consistency and test-retest reliability were assessed. Criterion validity was determined by correlating the subscales with relevant instruments (Short-Form Health Survey 36, Hospital Anxiety and Depression Scale, and Disabilities of the Arm, Shoulder and Hand Outcome Measure). The structure of the German version was investigated by principal component analysis. Confirmatory factor analysis was used to compare the structure with the original 9-factor structure and the second-order 3-factor structure. Qualitative testing revealed adequate comprehension and content validity. Cronbach's alphas ranged from α = 0.80 to α = 0.92. The test-retest reliability ranged from r = 0.72 to r = 0.97. The subscales correlated significantly with the measures of criterion validity (r = 0.30 to r = -0.77). The principal component analysis results showed a satisfactory overlap with the original data structure, except for the Affect and Sexuality domains, which were merged into 1 factor. The confirmatory factor analyses revealed the best model fit for the second-order 3-factor structure, excluding the Work domain. The Ludwigshafen German version of the BSHS-B shows good psychometric properties. It is well suited for clinical use, further research, and international comparison.

Reconstruction of Extended Bone Defects Using Massive Allografts Combined with Surgical Angiogenesis: A Case Report.

CASE: A 20-year-old patient presented with an extended composite knee defect with destruction of the medial femoral condyle, including the medial collateral ligament. Treatment included using an anterolateral thigh flap for soft-tissue reconstruction, tensor fasciae latae muscle for ligament repair, and a massive allogenic bone graft of the medial femoral condyle that was revascularized with an osteocutaneous composite free flap from the contralateral femur. At 17 months postoperatively, the outcome was evaluated with scores on several established scales and radiographic assessment. CONCLUSION: The combination of vascularized soft-tissue reconstruction and osseous reconstruction using allogenic bone along with surgical angiogenesis proved to be effective. Complex extremity reconstruction should be discussed with interdisciplinary specialists.

Surgical Revascularization-An Innovative Approach to the Treatment of Talar Osteonecrosis Dissecans Stages II and III.

Talar osteonecrosis dissecans is caused by osseous malperfusion, leading to destruction of the talar bone. The current reference standard for advanced stages lacking arthrosis is core decompression, followed by autologous cancellous bone grafting. However, talar revascularization has not been observed in a subset of patients after this procedure. Microsurgical vascularized bone grafting can improve outcomes by the induction of angiogenesis. We present the 1-year follow-up data from 3 patients with talar osteonecrosis dissecans, who had undergone free vascularized medial femoral condyle autotransplantation. The patients were evaluated preoperatively and 3, 6, and 12 months postoperatively. The active range of motion, pain (visual analog scale [VAS]), and American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and lower extremity functional scale were used. Osteonecrosis dissecans stage II was seen in patient 1 (aged 27 years) and stage III in patients 2 (aged 18 years) and 3 (aged 41 years). Preoperative pain of the ankle was recorded as VAS score of 3 by patients 1 and 2 and VAS score of 6 by patient 3. At 12 months postoperatively, patients 1 and 2 recorded a VAS score of 2 and patient 3, a VAS score of 0. All patients showed improvement in the lower extremity functional scale and American Orthopaedic Foot and Ankle Society scale scores. After 6 and 12 months, magnetic resonance imaging showed a well-vascularized femoral condyle incorporated into the talus in all the patients. Autotransplantation of vascularized bone grafts from the medial femoral condyle is a promising technique for surgical revascularization of talar osteonecrosis dissecans stage II and III.

The free fasciocutaneous infragluteal (FCI) flap: Outcome and patient satisfaction after 142 breast reconstructions.

BACKGROUND: The free fasciocutaneous infragluteal flap (FCI) is relatively rarely used for autologous breast reconstruction; however, it is a good option for thin patients. The outcome of 142 FCI flaps for breast reconstruction is presented here. MATERIALS AND METHODS: Between January 2008 and December 2013, 142 patients underwent unilateral breast reconstruction with the FCI flap. Outcome analysis, scar quality, postoperative pain, and patient satisfaction were evaluated by questionnaires and established scores. The tactile sensitivity of the breast was measured by the Semmes-Weinstein monofilament test. RESULTS: The mean age was 45.4 ± 9.17 (23-69) years, the mean follow-up was 40.2 (12-58) months, and the rate of flap loss was 0.7% (n = 1). Postoperative pain was stated with 4.2 ± 2.5 points on the visual analog scale (VAS). The quality of breast reconstruction was rated "very good" (n = 43) or "good" (n = 33) by 71% of patients, and 89% (n = 96) of patients would recommend this procedure to others. As expected, postoperative mobility was achieved in 80% (n = 86) of patients and some obtained this even earlier. Forty-seven patients presented for follow-up examination (44%). Scars on the reconstructed breasts were rated with 1 (n = 16) or 2 (n = 22) points in 81% and scars at the infragluteal donor site with 2 (n = 17) or 3 (n = 25) points on the Vancouver scar scale (VSS) in 89%. Patients subjectively stated having better sensitivity of the reconstructed breast than measured objectively by monofilaments. CONCLUSION: The FCI flap is a safe method for breast reconstruction due to a low percentage of flap loss and complications. Good patient satisfaction along with fast postoperative mobilization can be achieved. The FCI flap should be considered a suitable alternative for autologous breast reconstruction.

Free and pedicled flaps for reconstruction of the weightbearing sole of the foot: a comparative analysis of functional results.

Reconstruction of the weightbearing sole of the foot is complex and requires soft tissue that is resistant to weight, pressure, and shear stress. Despite a variety of flap types and techniques, it is still challenging to meet these demands. The present retrospective study included 21 patients after reconstruction of plantar tissue defects from 2001 to 2011. The outcome was evaluated using the lower extremity functional scale, Weber score, pedobarography, assessment of shifting, and sensory recovery. The patients' quality of life was documented using the SF-36 questionnaire. Plantar reconstruction was performed using 12 free and 9 pedicled flaps. No differences in functional results were observed between the flap types, despite a better sense of temperature in the adipocutaneous flaps. The extent of flap shifting was independent of the flap type and did not correlate with the functional results. Pedobarography showed a tendency for increased peak pressure and prolonged contact time in the reconstructed weightbearing plantar areas compared with the sound feet and a control group. The present study found no relevant differences in the functional results between different flap types and free or pedicled techniques. Flap selection should be based on the individual requirements and availability of donor sites.