Effects of transpositional muscle flaps transfected with vascular endothelial growth factor gene in the treatment of experimental osteomyelitis.

BACKGROUND: Based on the angiogenetic and stimulating effects of bone healing and formation of vascular endothelial growth factor (VEGF), the present study was designed to assess the efficacy of VEGF gene application in the management of experimentally induced osteomyelitis. METHODS: Thirty-two male Sprague Dawley rats were divided into 4 groups, and osteomyelitis was induced in the left tibial bones. Group 1 (n=8) was designated as a control group, and, after the induction of osteomyelitis, no treatment was applied for a period of 4 weeks. Group 2 (n=8) received only antibiotic treatment for 4 weeks following induction of osteomyelitis. In Group 3 (n=8), proximally pedicled gastrocnemius muscle flap was transposed over the osteomyelitic region following induction of osteomyelitis and antibiotic treatment applied for a 4-week period. In Group 4 (n=8), VEGF gene-transfected gastrocnemius muscle flap was transposed over the osteomyelitic region following identical antibiotic regimen applied for a 4-week period. For each group, body temperature, white blood cell (WBC) count, and radiological and histological parameters were evaluated. RESULTS: Body temperature and WBC count remained high in the control group, but returned to normal in Groups 2, 3, and 4 after the third week of treatment. Statistical analysis of the total scores of radiological and histological results revealed significant differences between Groups 1 and 3, Groups 1 and 4, Groups 2 and 3, and Groups 2 and 4 (p<0.05). Regarding radiological parameters of abscess and sequester, and histological parameter of abscess, statistically significant differences were found between Group 4 and the other groups (p<0.05). CONCLUSION: The efficacy of the VEGF gene-transfected muscle flap in the management of experimental osteomyelitis was proven by the results of the present study.

Palmar contracture release with arterialized venous instep flap: An anatomical and clinical study.

BACKGROUND: Plantar skin has similar histologic features to the palmar area and appears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomic examination was performed to determine the superficial venous architecture of the instep area, and the use of arterialized venous instep flaps for palmar contracture release was assessed. METHODS: The anatomical study was performed on 12 fresh cadaver feet. The arterialized venous instep flap, including the skin, subcutaneous tissue and superficial venous plexus, was harvested. To determine the venous structure, dissection (n = 6) and injection-corrosion (n = 6) techniques were used. In the clinical study, nine arterialized venous instep flaps were used for palmar contracture release. All flaps were harvested above the deep fascia and included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site of the flap, two or three veins, one of which was used, were dissected for a sufficient length for the arterial anastomosis. The saphenous vein was used for the venous anastomosis. RESULTS: Dissection and injection-corrosion techniques revealed that the flap had 7-12 and 4-6 veins at its plantar and superior edges, respectively, with numerous anastomoses and interconnections between the veins. The flap dimensions were between 3 × 5 cm and 4 × 6 cm. All flaps survived, with two partial flap necrosis that healed with spontaneous epithelization. No debulking procedures were undertaken and all flaps adapted well to the recipient site. CONCLUSIONS: The arterialized venous instep flap is a good alternative to reconstruct palmar contractures by adding similar tissue that is thin and pliable with minimal donor site morbidity.

Effect of VEGF gene therapy and hyaluronic acid film sheath on peripheral nerve regeneration.

Functional nerve regeneration after reconstructive nerve surgery remains unsatisfying. In this study, vascular endothelial growth factor (VEGF) gene therapy combined with a hyaluronic acid (HA)-enriched microenvironment in nerve regeneration was investigated. Sciatic nerve was transected, and end-to-end neurorrhaphy was performed on 32 male Sprague-Dawley rats, which were randomly divided into four groups (n = 8 per group): nerve coaptation without treatment (group I); nerve coaptation covered with HA film sheath (group II); nerve coaptation with intramuscular VEGF gene in plasmid injection (group III); and nerve coaptation combined with HA film sheath and intramuscular VEGF gene in plasmid injection (group IV). Contralateral sciatic nerves were used as control. VEGF expression was verified from gluteal muscle biopsies surrounding the sciatic nerve by reverse transcriptase-PCR. Electrophysiological, histopathological, and electron microscopic evaluations were performed after 4 weeks. Mean peak amplitude of groups I-IV and nonoperated sciatic nerve were 4.5 ± 0.6 mV, 6.4 ± 0.4 mV, 6.7 ± 0.5 mV, 8.5 ± 0.4 mV, and 9.8 ± 0.5 mV, respectively. Mean myelinated axonal counts of groups I-IV and nonoperated sciatic nerve were 105 ± 24, 165 ± 19, 181 ± 22, 271 ± 23, and 344 ± 17, respectively. Treatment with HA film sheath coverage combined with intramuscular VEGF gene in plasmid injection yielded statistically significant higher peak amplitudes and myelinated axonal counts (P < 0.001). In addition, significantly less scar formation with HA administration (groups II and IV; P < 0.001) was found. Thus, it was found that VEGF might crucially regulate nerve regeneration processes and that HA can reduce the scar formation. This study showed that the combination of HA film sheath and VEGF gene may synergistically promote peripheral nerve regeneration.

Calvarial reshaping using bifocal bidirectional transport distraction osteogenesis.

PURPOSE: The aim of this study is to assess 3-dimensional reconstruction of cranial defects by use of bifocal bidirectional transport distraction osteogenesis (BBTDO). MATERIALS AND METHODS: This study was performed on 8 sheep, divided into a control group (n = 3) and treatment group (n = 5). Full-thickness cranial defects (50 x 40 mm) were created on calvaria. In the control group only the skin was closed. In the treatment group BBTDO was performed. Distraction was performed with a custom-made distraction device with a transport segment of 40 x 20 mm. After a 5-day period of latency, distraction was applied to the transport segment. During the first 20 days of distraction, the transport segment was distracted 1 mm in the forward direction and 0.5 mm in the upward direction. After the next 20 days of distraction, the transport segment was distracted 1 mm forward and 0.5 downward. After a total of 40 days' distraction, a 30-day consolidation period was applied. Macroscopic, radiologic (computed tomography with volume measurements), and histologic evaluations were done. RESULTS: No major complications were seen during the whole study period. In the control group the bone defects remained unhealed at the end of the study period. The same-sized defects in the treatment group healed with a convexity like the calvaria. Preoperative and postoperative cranial volume measurements of the treatment group animals showed an increase in cranial volume (P < .05). Histologic evaluation showed inductive bone regeneration and mature bone structure development within the distraction zone. CONCLUSION: The BBTDO is an effective and safe technique for 3-dimensional closure of cranial defects.

Comparison of the effects of inhalation, epidural, spinal, and combined anesthesia techniques on rat cremaster muscle flap microcirculation.

BACKGROUND: This experimental study was designed to investigate and compare the effects of different anesthesia techniques on rat cremaster muscle flap microcirculation. METHODS: Fifty male Sprague-Dawley rats (130-150 g body weight) were divided into five experimental groups containing ten animals each. Group I, group II, and group III were designated as inhalation, epidural, and spinal anesthesia groups, respectively. Group IV was designated as a combination group for inhalation and epidural anesthesia. Group V was a combination group of inhalation and spinal anesthesia. RESULTS: Group III and group V showed significant increases in the number of rolling and sticking leucocytes and in RBC volume (peripheral stasis) when compared with group I. Blood flow and velocity significantly increased without peripheral stasis in groups II and IV when compared with group I. Although there was no statistically significant difference in the numbers of rolling, sticking, and transmigrating leucocytes or in functional capillary perfusion, group IV had better flow hemodynamics in the peripheral microcirculation when compared with group I. CONCLUSIONS: The inhalation and epidural anesthesia combination was determined to be the ideal anesthesia technique for improved peripheral microcirculation. Spinal anesthesia, either separately or in combination with inhalation anesthesia, has adverse effects on microcirculation.

Closure of the defect resulting from caudal regression syndrome with duplicated rectum.

Caudal regression syndrome covers a range of congenital malformations that range from simple anal atresia to absence of sacral, lumbar, and possibly lower thoracic, vertebrae. To the best of our knowledge, this is the first case of caudal regression syndrome combined with rectal duplication. We present a case and describe our technique of reconstruction.

The crooked nose: the use of medial iliac crest bone graft as a supporting framework.

The crooked nose is one that the vertical axis of the nose inclines from the midline. As a rule, a major septal deformity almost always accompanies to impairing breathing and aesthetic appearance. To achieve total straightening of the crooked nose, the septum must become the target of the treatment. To prevent redeviation, we used rigid bone grafts instead of flexible and relatively weak cartilage to maintain the support of the corrected deformity. Between February 2005 and July 2007, 9 patients (all male) with crooked noses underwent corrective surgery. The mean age of the patients was 21 years (range, 19-23 years). The source of the bone graft was medial side of iliac crest in all patients. The mean follow-up was 18 months, ranging from 10 to 26 months. All patients had both functional and cosmetic problems. Mean operation time was 4 hours. Airway patency was improved in all cases. The grafts did not shift in any case and did not develop unsightly irregularities over time. Absorption of the grafts was not seen in the follow-up. There were no cases of extrusion or infection. No donor site complication occurred. None of the patient required secondary surgery. A residual deviation can be obvious despite all attempts, which has no deleterious effect on patient satisfaction. This article introduces a novel technique for the correction of the crooked nose.

Aesthetic and functional restoration using dorsal saddle shaped Medpor implant in secondary rhinoplasty.

Functional disorders due to alar valve collapse and cosmetic unsatisfactory results can be seen after rhinoplasty operation in some patients. Because of overresection of the upper and lower lateral cartilages, nasal lateral walls may collapse during inspiration pressing against the septum and obstructing airway. On the other hand, overresection may result in several cosmetic deformities. Fourteen patients presenting with nasal deformation and functional insufficiency, were treated using thin sheet porous polyethylene (Medpor). Cottle sign was positive in all patients. On examination, collapse during inspiration, depression at the supratip area, and asymmetry were common findings. Saddle shaped implants, 1.2 x 40 mm in dimension, were introduced into pouches prepared via bilateral rim incision. After suturing incisions, bandage and cast were applied. In the mean 14-month follow-up period, 1 implant malposition was seen in a patient because of larger planning the pocket that was corrected by a subsequent shaving of the implant. Asymmetries of the noses were totally corrected. No exposition was found. Alar collapse and respiration impairment had disappeared in all patients. Although, autologous tissue is known as the best material, Medpor can be used safely regarding its low complication rate because of its porotic architecture and low morbidity in donors. Medpor implant provides functional improvement by its strength body. Its smooth surface helps to correct the asymmetry by filling the defects. Using a saddle shape enabled us to treat different components of the postrhinoplasty deformity with a single implant.

Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction osteogenesis technique.

Transport distraction technique is a good treatment modality for unilateral temporomandibular joint ankylosis. However, with a unidirectional distraction, it is not possible to correct facial asymmetry that results from mandibular hypoplasia associated with early-onset unilateral temporomandibular joint ankylosis. For this purpose, gap arthroplasty and simultaneous bidirectional transport distraction was used to correct these deformities. Although vertical distraction corrects vertical deficiency of the ramus and creates a neocondyle, the simultaneous anteroposterior distraction of the transport segment corrects facial asymmetry resulting from horizontal shortness of mandible. Three patients, whose mean mouth opening was 8.6 mm, were successfully treated with this technique. Mean advancements in vertical and anteroposterior direction were 14.7 and 7.7 mm, respectively. Mean maximal mouth opening was 29.7 mm postoperatively. The average follow-up period was 13 months (range, 12-15 mo). During this period, reankylosis was not observed, and the interincisal distance did not decrease. Gap arthroplasty and bidirectional transport distraction of the mandibular ramus is a good and effective therapeutic option in treatment.

Imaging of porous polyethylene implant by using multidetector spiral computed tomography.

The porous polyethylene implant (Medpor; Porex Surgical, Inc., Newnan, GA) is one of the most usable implants in clinical practice. Because it is radiolucent on both direct radiography and conventional computed tomography, visualization of the implant becomes an important issue. In this clinical study, availability of multidetector spiral computed tomography for visualization of the implant was evaluated. The technique was used in 15 patients who had Medpor reconstructions on their faces, including frontal (seven), malar (five), and mandibular (five) regions. A 16-channel multislice computed tomography scanner was used in spiral scanning mode. Sagittal, coronal, and transverse multiplanar reformation and volume-rendered images were reformatted using a PC-based three-dimensional reconstruction program (Extended Brilliance Workspace, Release 1.0.1.1, Philips Medical Systems, Amsterdam, The Netherlands). The three-dimensional images along the course of the implant were additionally reformatted. Window width and level were adjusted for viewing the bone as respective values of 1100 HU and 450 HU in contrast to the values of 800 HU and 200 HU, respectively, for the implant. The detailed contour of the implants could be easily traced on the multidetector computed tomographic images, including either the concave or convex areas. The calcifications and cystic formations around the implants and the spatial relationship between the defects and the implants were also shown. We believe that the present multidetector computed tomographic technique offers direct visualization of the Medpor implant in the body. It has many advantages over the current magnetic resonance imaging techniques that need tissue in growth for visualization.

Investigation of epidermal growth factor containing liposome formulation effects on burn wound healing.

It was aimed to develop liposome formulations containing epidermal growth factor (EGF) and to investigate the healing effects of these formulations on second-degree burn wounds in rats. Multilamellar type liposomes containing EGF were prepared by film formation method. In vitro releases of EGF from liposome formulations were determined using spectrofluorometer. Second-degree standard burn wounds were formed on rats and liposome formulations containing 10 microg/mL EGF (ELP group), EGF solution (ES group), liposome without containing EGF (LP group), and Silverdine ointment (SIL group) were applied daily. Untreated control groups [unburned (S) and untreated (Y) rats] were also evaluated. Biopsies were taken at the 3rd, 7th, and 14th day of the treatment from the wounds and histological observations were performed under transmission electron microscope. Bromodeoxyuridine (BrdU) staining technique was used for immunohistochemical analysis. After trichrome stainings, the thicknesses of the epidermis and the areas of the fibroblast nucleus were measured using a light microscope and Vision Screening Analysis Program. It was observed that the healing in the ELP group was the fastest among all groups (p < 0.05) at the 14th day of therapy. The healing effect in order from highest to lowest efficacy was found to be ELP>SIL>ES groups, respectively, at the 14th day. All results indicated that the EGF-liposome formulation is effective and can be used for the treatment of burn wounds.

Thalidomide decreases the plasma levels of IL-1 and TNF following burn injury: is it a new drug for modulation of systemic inflammatory response.

TNF and IL-1, which are produced from phagocytic cells, can produce a significant systemic inflammatory response independently by inducing systemic leukocyte and endothelial cell activation. These cytokines play a pivotal role in development of systemic inflammatory response after severe burn. Thalidomide has been shown to decrease the secretion of TNF from phagocytic cells, therefore suppression of TNF and IL-1 production from activated phagocytic cells might be a successful treatment modality for prevention of systemic inflammatory response following severe burn. To address this issue, we aimed to show whether thalidomide treatment decreased or suppressed plasma levels of TNF and IL-1 following burn in rats. Following the injury, 36 rats were randomly separated into two experimental groups at the third and seventh days. Rats in the experimental group had oral thalidomide (10mg/kg day) treatment for three and seven consecutive days whereas animals in control groups had no treatment. Thalidomide treatment decreased TNF and IL-1 significantly in both experimental groups at both the points (P<0.05). Although in this study we just showed inhibitory effect of thalidomide on plasma the level of TNF and IL-1, we speculate that thalidomide may have modulatory effect on the systemic inflammatory response after burn by decreasing plasma levels of TNF and IL-1.

A new composite flap: rectus abdominis muscle flap harvested with pubic bone segment--anatomic considerations.

The aim of this study was to incorporate a segment of pubic bone to rectus abdominis muscle (RAM). Eight RAM flaps from four fresh cadavers were used. During surgical dissection, utmost care was paid to enclose the areolar tissue between the main deep inferior epigastric (DIE) vessels and the pubic bone. A bone segment, 1.5 x 5 cm in dimension with an intact periosteum, was included with the RAM. Surgical dissections revealed two major vascular branches. The first branch arising from the DIE artery (DIEA) at a distance of 5.2 +/- 1.4 cm from the origin gave rise to two consistent subbranches. The second major branch originated from the DIEA at a distance of 8.4 +/- 1.8 cm from the origin. The first branch gave off two subbranches. The second subbranch coursed anteromedially and nourished the periosteum of the pubic bone. Microangiography showed a similar branching pattern of the vessels that create two significant networks. The X-rays confirmed a rich vascular network around the periosteum of the pubic bone. This wealthy nourishment of the pubic periosteum comes mainly from the perpendicular descending branches. In conclusion, a vascularized part of pubic bone can be incorporated to the RAM flap by preserving the delicate vascular network between the DIE vessels and the pubic periosteum.

Contour restoration of the secondary deformities of zygomaticoorbital fractures with porous polyethylene implant.

Inappropriate treatment or untreated fractures of the zygomaticoorbital area results in secondary deformities such as loss of malar projection, enophthalmos, and dystopia. Secondary deformities can be corrected with osteotomies, contour restoration, or a combination of both. Contour restoration can be performed with using onlay grafting with autogenous material or alloplastic implants. In this study, mild to moderate secondary deformities of zygomaticoorbital fractures were corrected with porous a polyethylene implant, which is a highly biocompatible, durable, and stable material. The number of patients who have no surgical treatment at the time of their initial injury was 15, whereas the number of patients who have an initial treatment that resulted in secondary deformities was seven. Twelve of 15 patients had only loss of cheek projection and three of the 15 patients had dystopia and loss of cheek projection. The remaining seven patients had secondary deformities resulting from skeletal surface contour abnormality as a result of comminuted fractures. In 17 of the patients, we used a subciliary approach while using the old incision scar for access in the remainder. In 22 patients, 24 implants were used. Porous polyethylene implant was carved outside in according to the existing contour deficit and was placed in the subperiosteal plane and fixed with titanium screws. The mean follow-up period was 13 months (range, 6-24 months). In this follow-up period, there was no implant extrusion, exposition, infection, or any complication resulting from subciliary incision. Patients were satisfied with the results. The best result can be achieved with porous polyethylene implant in contour restoration of mild to moderate secondary deformities of zygomaticoorbital fractures. The use of this implant in the zygomaticoorbital area is safe and has minimal morbidity.

Assessment of distraction regenerate using quantitative bone scintigraphy.

In this study, we examined whether quantitative bone scintigraphy can be used to assess new bone formation following distraction osteogenesis (DO). A vertical osteotomy was performed on the right hemimandible of male Sprague-Dawley rats, and a custom-made distraction device was applied. Following the gradual distraction, rats were divided into 2 subgroups, the second and fourth week. Cephalograms were taken and scintigraphic and histomorphometric analysis was performed at the second and fourth week. Scintigraphic findings showed good correlation with histomorphometric results. Results were compared with sham-operated (skin and muscle incision and placement of pin but no osteotomy) and acute distraction (5-mm acute distraction) groups. Scintigraphic mean uptake ratios were significantly higher in the gradual distraction group compared with the sham-operated and acute distraction groups. Quantitative bone scintigraphy is a promising method for the assessment of DO and consolidation. It could offer objective qualitative and quantitative data for the noninvasive evaluation of bony regenerate.

Effects of topical glutathione treatment in rat ischemic wound model.

Oxidative stress secondary to ischemia can cause physiopathologic changes that adversely affect wound healing. In this experimental study, we hypothesized that the topical use of esterified glutathione, a well-known antioxidant, can minimize the effects of oxidative stress by an increase in intracellular glutathione and accelerate wound healing by increasing the contraction capacity of fibroblasts and preventing keratinocytes from apoptosis in a rat ischemic wound model. Experimental models were divided into 3 groups as treatment, control, and healthy. Bipedicled flaps were elevated from the dorsum of the rats, and 6-mm punch wounds were created at the end of the first day when the ischemia is most apparent. Wounds were followed histopathologically and immunohistochemically, and matrix metalloproteinase (MMP)-1 and tissue inhibitors of metalloproteinase (TIMP-1) levels were measured by ELISA. Samples were collected at 0, 5, 8, 10, and 12 days. Histopathologic evaluation revealed significant extracellular matrix deposition and reepithelization every fifth day in treatment and healthy groups when compared with control group. Immunohistochemical evaluation revealed increased apoptosis in basal keratinocytes in the control group when compared with the other groups. The evaluation of the samples collected at 5 and 8 days revealed increased MMP-1 levels in treatment and control groups, but the increase in TIMP-1 levels was more significant than MMP-1 levels in treatment group. MMP-1/TIMP-1 ratio was significantly low in the treatment group.Our results showed that topical GSH treatment can reduce oxidative stress, and the reestablishment of the MMP-1/TIMP-1 ratio gives way to adequate and regular extracellular matrix production and reepithelization. It is concluded that esterified GSH, which is experimentally shown to be effective in ischemic wound healing, can be used clinically in ischemic wounds.

Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap.

In the management of a debilitated burned hand due to contractures, thumb reconstruction constitutes the most crucial part for a beneficial functional outcome. Among the limited local flap alternatives for the thumb, the first dorsal metacarpal artery flap, harvested from the dorsal aspect of the index finger can provide elastic, durable and sensate coverage for soft tissue defects after contracture release. In a 3-year period, neurovascular island first dorsal metacarpal artery flap was used in 14 patients suffering thumb deformities. The time elapsed after the underlying injury until reconstruction ranged from 5 months to 17 years. Follow-up revealed that all deformities were successfully treated with satisfactory functional recovery and cosmetic results. Donor site morbidity was minimal with an acceptable scar on the dorsum of the index finger and adequate tendon gliding without producing extension deficit. Our experience with management of deformities involving the thumb and/or adjacent thenar area revealed that the first dorsal metacarpal artery flap is a reliable local neurovascular island flap option, offering acceptable functional and cosmetic outcomes in respect to sensation, elasticity, durability and skin-match.

Congenital double lip: review of 5 cases.

Congenital double lip is rare and usually involves the upper lip. Apart from a deformity that interferes with speech and mastication, operation may be indicated for cosmetic reasons. We have operated on five patients with double lip deformities for cosmetic reasons. Although a midline constriction band between two mucosal bulges is thought to be a constant feature, four of our five cases did not have a midline constriction. We used an elliptical excision of the mucosal excess in the four patients. The one with central constriction had an elliptical excision on each side, combined with a vertical midline Z-plasty to release the central constriction. Satisfactory aesthetic results were achieved in all patients.

A retrospective analysis of 101 zygomatico-orbital fractures.

A 5-year review of 101 cases of zygomatico-orbital fractures is presented. The epidemiology, fracture patterns, treatment modalities, and complications were evaluated in this retrospective study. A majority of fractures were sustained by males and resulted from trauma inflicted during altercations and traffic accidents. The most common fracture pattern was tripod fracture and the most common associated facial fractures were mandibular fractures. Open reduction and rigid fixation was the most frequently employed treatment modality. Depending on the stability of reduced zygoma, one, two and three-point fixations were applied. Orbital floor exploration was performed in 41 cases. Ten out of 16 orbital floor bone defects required reconstruction. In these cases orbital floor was reconstructed with 1.5-mm porous polyethylene implant. Although we encountered a few complications related to the incisions for open reduction, the rate of complication in which correction was difficult (e.g. facial asymmetry) was lower with this approach when compared with the literature.