Post Traumatic Reconstruction of the Pediatric Heel and Achilles Tendon: A Review of Pedicle Flap Options in 31 Motorcycle Spoke Trauma Patients.

Severe motorcycle spoke injuries of the heel lead to Achilles tendon defects, calcaneal tubercle exposure or loss, and overlying soft tissue defects, which are challenging to treat. Given the special physiological and developmental characteristics of children, severe spoke injuries of the heel in children are especially troublesome.We report details of 31 cases of severe motorcycle spoke injuries of the heel in children. The reconstruction timing depended on the time since injury, systematic conditions, and concurrent injuries. Eighteen cases were reconstructed at the time of emergency surgery, and 13 cases underwent delayed reconstruction. Appropriate flap transfer and Achilles tendon repair were conducted based on the defect size of the Achilles tendon, the main location of the soft tissue defect, and the distal residues of the Achilles tendon.Of the 31 cases, 16 cases were reconstructed with sliding gastrocnemius musculocutaneous flaps, 7 cases had saphenous neurocutaneous flaps, 4 cases had posterior tibial perforator flaps, 3 cases had sural neurocutaneous flaps, and 1 case was repaired with a peroneal artery perforator flap. All flaps healed uneventfully except for 3 cases of flap partial necrosis and 1 case of local infection of the Achilles tendon. During 6 months to 4 years of follow-up, dorsiflexion of the ankle was obviously limited at first but gradually recovered and enabled normal walking. However, due to the possibilities of calcaneal defects, epiphyseal injuries, and Achilles tendon problems, long-term follow-up is indicated.

TLR4 Activation Promotes Bone Marrow MSC Proliferation and Osteogenic Differentiation via Wnt3a and Wnt5a Signaling.

Mesenchymal stem cells (MSCs) from adult bone marrow maintain their self-renewal ability and the ability to differentiate into osteoblast. Thus, adult bone marrow MSCs play a key role in the regeneration of bone tissue. Previous studies indicated that TLR4 is expressed in MSCs and is critical in regulating the fate decision of MSCs. However, the exact functional role and underlying mechanisms of how TLR4 regulate bone marrow MSC proliferation and differentiation are unclear. Here, we found that activated TLR4 by its ligand LPS promoted the proliferation and osteogenic differentiation of MSCs in vitro. TLR4 activation by LPS also increased cytokine IL-6 and IL-1ß production in MSCs. In addition, LPS treatment has no effect on inducing cell death of MSCs. Deletion of TLR4 expression in MSCs completely eliminated the effects of LPS on MSC proliferation, osteogenic differentiation and cytokine production. We also found that the mRNA and protein expression of Wnt3a and Wnt5a, two important factors in regulating MSC fate decision, was upregulated in a TLR4-dependent manner. Silencing Wnt3a with specific siRNA remarkably inhibited TLR4-induced MSC proliferation, while Wnt5a specific siRNA treatment significantly antagonized TLR4-induced MSC osteogenic differentiation. These results together suggested that TLR4 regulates bone marrow MSC proliferation and osteogenic differentiation through Wnt3a and Wnt5a signaling. These finding provide new data to understand the role and the molecular mechanisms of TLR4 in regulating bone marrow MSC functions. These data also provide new insight in developing new therapy in bone regeneration using MSCs by modulating TLR4 and Wnt signaling activity.

The Role of the Distal Runoff Vessel of the Descending Branch of the Lateral Circumflex Femoral System in Anterolateral Thigh Flap Surgery: A Case Series and Literature Review.

BACKGROUND: As a distal portion of the descending branch of the lateral circumflex femoral system (LCFS), the role of the distal runoff vessel in anterolateral thigh (ALT) flap surgery has long been overlooked. Recently, however, the distal runoff vessel has been increasingly used in many aspects of ALT flap surgery, and it has exhibited superior properties in solving some difficult problems. METHODS: Fourteen ALT flaps using the distal runoff vessel of the descending branch of the LCFS for extremity defects were retrospectively reviewed, and recent reports on using the distal runoff vessel were reviewed to determine the role of this vessel in ALT flap surgery. RESULTS: In our series, the distal runoff vessel was used as a flow-through pattern in 10 cases, as a recombined chimeric flap in 2 cases, and as a backup vessel for flap salvage in 2 cases. All of the ALT flaps completely survived. None of the donor sites presented with additional morbidity as a result of harvesting the distal runoff vessel. In the literature review, the following are 5 other options for using the distal runoff vessel: in interposition artery and vein grafts, as the pedicle of the reverse-flow ALT flap, as the recipient vessel, to avoid twisting, and as a monitoring method. CONCLUSIONS: The distal runoff vessel of the descending branch of the LCFS could be used for many aspects of the ALT flap surgery, and this vessel plays an irreplaceable role in some difficult reconstruction surgeries.

Open achilles tendon defects: a 12-year study on the injury mechanisms, reconstructions, and late complications.

BACKGROUND: Open injuries of the Achilles tendon, which can be complicated by skin and bone injuries, continue to be a great challenge for surgeons. This study aims to report our experience with treatment of open Achilles tendon defects, focusing on the injury mechanisms, soft tissue coverage and late complications. METHODS: A retrospective review was performed on 31 patients with open Achilles tendon defects between 1999 and 2011. The analyzed factors were injury mechanisms, surgeries, and long follow-up complications. The defect lengths of the Achilles tendons in the study ranged from 1 to 11 cm and the soft tissue defects ranged from 3 × 3 to 12 × 10 cm. Nine types of flaps were used for the coverage of concomitant skin defects. RESULTS: Motorcycle spoke injuries were the most common cause of injury. There was no complete flap loss or rerupture of the reconstructed Achilles tendon. At the latest follow-up, all limbs were preserved and all the patients had regained full walking abilities. The algorithm of one-stage reconstruction was established, according to the defect length of the Achilles tendon and the defect size of skin. Late complications included maximum dorsiflexion loss and failure of heel raising ability on the single reconstructed foot. CONCLUSION: Open Achilles tendon defects are characteristic of concurrent skin and bone injuries and the reconstruction protocols of the different tissues should not be separated.

[Characteristics and treatment of grade III spoke heel injuries in children].

OBJECTIVE: To evaluate the characteristics, treatment, and effectiveness of grade III spoke heel injury in children. METHODS: Between January 2007 and June 2013, 31 children with grade III spoke heel injuries were treated. There were 19 boys and 12 girls, aged from 3 to 12 years (mean, 5.2 years). The time from trauma to operation was 2 hours to 26 days (mean, 4.4 days). The soft tissue defects of the heels ranged from 3.5 cm x 2.5 cm to 8.0 cm x 4.5 cm, which all complicated with Achilles tendon and calcaneus tuberosity defects. In 16 cases of large Achilles tendon defects which can not be stretched straightly to calcaneus tuberosities, repair with sliding gastrocnemius musculocutaneous flaps (16 cm x 5 cm to 21 cm x 10 cm) and insertion reconstruction of the tendon were performed. In 15 cases of Achilles tendon defects which can be stretched straightly to calcaneus tuberosities, repair with reversed pedicled flap (4.0 cm x 2.5 cm to 8.0 cm x 4.5 cm) and insertion reconstruction of the tendon were given. Nerve anastomosis was not performed. The donor site was covered with split-thickness skin graft. RESULTS: All children were followed up 6 months to 4 years (mean, 13 months). The other flaps survived except 3 cases having partial necrosis. The color and appearance of the flaps were satisfactory, with no impact on wearing shoes and walking. The flaps recovered sensory function. As more follow-up time, the angle of dorsal flexion was gradually improved. Heel raising on one leg was restored. The bone amount of calcaneus tuberosity increased slowly based on X-ray films. CONCLUSION: Grade III spoke heel injury in children possesses peculiar features, surgical methods should be based on defects of Achilles tendon and soft tissue. Dorsal flexion of the ankle is obviously limited; as follow-up time goes on, the ankle function is progressively improved. However, long-term follow-up is needed.

Motorcycle spoke injuries of the heel.

INTRODUCTION: The spoke injuries of the lower extremity seems never stop haunting the surgeons since its first report 62 years ago. A prospective study of motorcycle spoke injuries in the heel was undertaken to study the injury mechanism, the treatment protocols, and the outcomes. PATIENTS AND METHODS: From 2001 to 2010, 89 cases of motorcycle spoke injuries of the heel were examined. The various injury mechanisms were analysed. Flaps and other reconstruction surgeries were used to manage the involved extremity. RESULTS: The mechanisms of the motorcycle spoke injuries of the heel had some unique features. A grading system was developed for the injuries according to the tissues involved. The surgery protocols primarily consisted of flap transfers, Achilles tendon reconstruction, and calcaneus management. CONCLUSIONS: The eradication of the motorcycle spoke injuries is a difficult task, but the treatment outcomes have been greatly improved due to the advancement of surgical techniques.

[Treatment of chronic osteomyelitis of rabbit with liposomal gentamicin-impregnated allogeneic cortical bone].

OBJECTIVE: It is difficult to treat chronic osteomyelitis due to the formation of the Staphylococcus aureus biofilms. Liposomal gentamicin-impregnated allogeneic cortical bone can inhibit the formation of the Staphylococcus aureus biofilms. To explore the treatment of chronic osteomyelitis of rabbit by liposomal gentamicin-impregnated allogeneic cortical bone. METHODS: The liposomal gentamicin, liposomal gentamicin-impregnated allogeneic cortical bone and gentamicin-impregnated allogeneic cortical bone were produced. Then the chronic Staphylococcus aureus osteomyelitis models of rabbit were made in left lower limbs of 40 6-month-old rabbits and the right lower limbs were used as controls. After 2 weeks, the observations of gross and X-ray were done. Four rabbits died within 10 days after the models were made and other 36 rabbits were divided into 6 groups: group A (no antibiotics), group B (intravenous injection of gentamicin), group C (intravenous injection of liposomal gentamicin), group D (implantation of gentamicin-impregnated allogeneic cortical bone), group E (implantation of liposomal gentamicin-impregnated allogeneic cortical bone), and group F (implantation of allogeneic cortical bone). After 2 weeks of treatment, the bacterial culture, X-ray and HE staining were done. RESULTS: The chronic Staphylococcus aureus osteomyelitis model of rabbit was made successfully. The X-ray showed dissolution of bone and periosteal reaction in groups A, B, C, and F, and no obvious dissolution of bone and periosteal reaction in groups D and E. The Norden scores were (2.5 +/- 0.3), (2.1 +/- 0.2), (1.5 +/- 0.3), (1.5 +/- 0.2), (0.9 +/- 0.3), and (2.7 +/- 0.3) points in groups A-F, respectively; showing significant differences between group A and groups B-E (P < 0.05), between groups B, E, F and other groups (P < 0.05). The results of blood and marrow cultures for Staphylococcus aureus were positive in groups A and F, and negative in other 4 groups; the results of bone marrow culture for Staphylococcus aureus were positive in 6 rabbits of group B, 4 rabbits of group C and 3 rabbits of group D; and the results were negative in group E. HE staining showed: in groups A and F, abscess and dead bone formed, and no new bone formation were observed; in groups B and C, different degrees of neutrophil accumulation was seen; in group D, some neutrophil accumulation occurred, and osteoprogenitor cells and osteoclasts were seen around implanted bone; and in group E, no neutrophil accumulation was observed, a lot of granulation tissues formed, and osteoprogenitor cells and osteoclasts were seen around implanted bone. CONCLUSION: Implantation of liposomal gentamicin-impregnated allogeneic cortical bone has remarkably better effect in treating chronic osteomyelitis than intravenous injection of liposomal gentamicin and implantation of gentamicin-impregnated allogeneic cortical bone.

[Application of skin flaps with supra-carpal cutaneous branch of the ulnar artery and dorsal carpal branch of the anterior interosseous artery in reconstruction of complicated amputaled palm].

OBJECTIVE: To investigate the clinical efficacy of carpal branch of ulnar artery skin flap and dorsal carpal branch of anterior interosseous artery skin flap in replantation of complicated severed hand. METHODS: From August 1999 to October 2005, 18 patients with complicated severed hands were treated in our department. According to the skin defect of severed hand, the palm of the hand was restored with upper carpal branch of ulnar artery skin flap (2-4 cm x 3-6 cm), followed by restoration of the back of the hand with dorsal carpal branch of anterior interosseous artery skin flap (4-6 cm x 5-8 cm) and replantation of the hand was performed simultaneously. RESULTS: All the replanted hands and the skip flaps survived after the surgery with satisfactory shape and function. The surgery achieved an over 70% recovery of the hand function in all cases. CONCLUSIONS: For complicated severed hands, upper carpal branch of the ulnar artery skin flap and dorsal carpal branch of the anterior interosseous artery skin flap are effective to repair the skin defect, and this procedure provides a good option for reconstructing shape and function of the severed hands.