Recent advances in the reconstruction of complex Achilles tendon defects.

Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.

COX-2 up-regulation in idiopathic carpal tunnel syndrome.

The objective of this study was to determine whether cyclooxygenase-2 (COX-2) is up-regulated in the synovium of patients with carpal tunnel syndrome. Twenty patients were enrolled: 16 consecutive patients with carpal tunnel syndrome and four control patients (exploration for non-carpal tunnel syndrome-related wrist or forearm pathology). Clinical data (demographics, pertinent history, symptomatology) were obtained preoperatively. Flexor tenosynovial tissue was isolated from all patients and clinically graded as thin, intermediate, or thick. Histologic evaluation was conducted to rule out the presence of inflammatory cells. Immunohistochemical staining for COX-2 was performed. The immunohistochemical data were confirmed by reverse transcriptase-polymerase chain reaction analysis of COX-2 mRNA. Results showed that the majority of carpal tunnel syndrome specimens (88 percent) showed synovial hypertrophy compared with 0 percent of the controls (p < 0.05). Also, 69 percent of carpal tunnel syndrome specimens (11 of 16) versus 0 percent of controls (zero of four) stained positively for COX-2 (p < 0.05). Of the carpal tunnel syndrome patients, 91 percent of thick specimens versus 33 percent of intermediate specimens versus 0 percent of thin specimens showed COX-2 staining. The authors conclude that synovial hypertrophy is a prominent finding in carpal tunnel syndrome. COX-2 is up-regulated in the tenosynovium of patients with carpal tunnel syndrome, and this upregulation may correlate with the clinical grade of the tenosynovium. The role of COX-2 in carpal tunnel syndrome may be to mediate remodeling of pathologic tissue. To this end, it may be a potential therapeutic target for specific inhibition.

Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction.

The use of highly active antiretroviral therapy (HAART) with protease inhibitors can result in a syndrome of peripheral wasting, facial fat atrophy, and central adiposity in as many as 64% of patients infected with human immunodeficiency virus (HIV) who are treated with this regimen for 1 year. In this study the authors evaluated 9 consecutive patients who presented with this disease to define further its anatomic features and to explore techniques for surgical correction. Three of these patients presented with severe facial atrophy, and underwent surgical exploration and reconstruction with submalar silicone implants. Two patients required additional soft-tissue augmentation with synthetic fillers and/or autologous fat. Outcomes were determined through clinical impressions of the patient and surgeons, and comparison of pre- and postoperative photographs. No extrusion or infection was encountered, although 1 patient required repositioning on one side. Both surgeons and patients were satisfied with the results at the long-term follow-up. Detailed anatomic evaluation revealed the presence of a fat pad of Bichat in all patients. Facial atrophy in HIV-related fat redistribution syndrome (HARS) is secondary to atrophy of the subcutaneous fat, but not of the deeper fat pads, as has been described. Durable surgical reconstruction is achieved with a combination of submalar silicone implantation and augmentation of the nasolabial fold. HARS causes noticeable disfigurement that stigmatizes the HIV-infected patient. Given the overall benefit of decreased morbidity and prolonged survival associated with HAART therapy, it is beneficial to attempt surgical correction of these debilitating sequelae before discontinuation of these drugs.

Expression of cyclooxygenase-2 in the periprosthetic capsule surrounding a silicone shell implant in the rat.

Prosthetic breast implants are used frequently for both aesthetic and reconstructive purposes. Histologically, the normal tissue response to silicone implants typically involves an inflammatory infiltrate that consists initially of macrophages, and later consists of fibroblasts, myofibroblasts, and lymphocytes. To characterize further the nature of the inflammatory response to silicone breast implants, the authors evaluated the expression of the enzyme cyclooxygenase-2 (COX-2) by the tissues and cells of the breast capsule after silicone augmentation in an animal model. COX-2 is an inducible enzyme that is expressed primarily in response to inflammatory stimuli and mediates the production of prostaglandins that support the inflammatory process. Fifty-nine animals at five time points were evaluated. Specifically, on days 4, 7, 14, 28, and 80 the authors identified cytoplasmic COX-2 expression in each of the three cell types of interest, including endothelial cells, macrophages, and fibroblasts. Selective COX-2 inhibiting agents may be an appropriate pharmacological intervention for modulating the formation of periprosthetic capsules.