[Free anterolateral femoral muscle flap and perforator flap transplantation for repair of the huge wound after periorbital tumor resection and orbital enucleation].

Objective: To observe the clinical effect of free anterolateral femoral muscle flap and perforator flap transplantation for repair of the huge wound and after periorbital tumor resection and orbital enucleation. Methods: It was a retrospective case series study. Twelve patients with orbital tumors admitted to the Department of Burn and Plastic Surgery of the Affiliated Hospital of Zunyi Medical University from February 2017 to April 2021 were included. There were 4 males and 8 females, aged 48 to 87 years. Nine patients had cutaneous squamous cell carcinoma, and 3 had basal cell carcinoma. All patients underwent extended resection of the tumor, resection of orbital contents and wound repair.All patients had the lesion completely removed, chimeric anterolateral thigh flap of the anterolateral femoral flap and perforator flap were transplanted to repair the wound. The donor area of the flaps was closed with tension sutures. The size of intraoperative resection lesion,intraoperative resection flap and muscle flap and the depth of the wound cavity were summarized. The postoperative flap survival, wound healing, surgical area appearance, flap color, thickness and texture, scarring and sensation in the surgical area, and tumor recurrence were observed. Results: The surgical procedures were successfully completed in all the 12 patients. The intraoperative resection lesion ranged from 7.0 cm × 5.0 cm to 15.0 cm × 8.0 cm. The depth of the wound cavity was 4.0 to 5.0 cm. The intraoperative resection flap range was 7.0 cm × 5.0 cm to 19.0 cm × 8.0 cm. The muscle flap size ranged from 4.0 cm × 3.0 cm to 5.0 cm × 4.0 cm. All flaps completely survived after surgery, and the wounds healed. The sutures at the recipient area were removed at 5 to 7 days after surgery, while the sutures at the donor area were removed at 12 to 14 days. All of the patients were followed up for 3 to 30 months. The scar at the periorbital area was concealed, and the color, thickness and texture of the flaps were similar to those of the surrounding normal skin. The scarring in the flap supply area was not hypertrophic, with localized decreased skin sensation around it. None of the patients had any tumor recurrence during the follow-up period. Conclusion: The anterolateral femoral muscle flap and perforator flap transplantation could efficiently repair the huge wound after orbital content removal, achieving satisfactory therapeutic effects.

Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures.

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Endoscopic Muscle Repair of Right Internal Carotid Artery Rupture Following Endovascular Procedure.

Carotid artery blowout syndrome (CBS) is a deadly complication usually linked to head and neck cancer therapy. We present a different etiology of endoscopic CBS, a complication of endovascular coiling of an intracranial aneurysm, treated with sternocleidomastoid (SCM) muscle graft packing. Case Presentation: An otherwise healthy 55-year-old female presented to the emergency room with right-sided painless vision loss of 23 days. Computed tomography angiography demonstrated a right ophthalmic ICA aneurysm eroding into the right sphenoid sinus with optic nerve compression. Attempted endovascular repair of the aneurysm was complicated by ICA rupture into the sphenoid. An endovascular balloon was inflated proximal to the aneurysm to reduce hemorrhage as ENT performed an endoscopic sphenoidotomy. A hematoma was seen overlying the aneurysm in the superior lateral sphenoid sinus. Layers of SCM muscle were morselized and packed serially. Post-repair angiography showed no further extravasation. Aggressive antiplatelet therapy was initiated. Packing was removed after 14 days. Twenty days postoperatively, the patient had profuse left-sided epistaxis requiring a left sphenopalatine artery ligation. The patient's vision recovered. Discussion: Whereas CBS is often managed by endovascular coil embolism, in our case CBS was caused by this very treatment itself. This case shows the use of SCM muscle graft as an effective repair modality of ICA rupture due to endovascular coiling. Laryngoscope, 131:E764-E766, 2021.

Platelet-rich plasma enhances the repair capacity of muscle-derived mesenchymal stem cells to large humeral bone defect in rabbits.

Mesenchymal stem cell-based therapy is a highly attractive strategy that promotes bone tissue regeneration. The aim of the present study was to evaluate the combination effect of muscle-derived mesenchymal stem cells (M-MSCs) and platelet-rich plasma (PRP) on bone repair capacity in rabbits with large humeral bone defect. Precise cylindrical bone defects of 10 mm diameter and 5 mm depth were established in rabbit humeral bones, which were unable to be repaired under natural conditions. The rabbits received treatment with M-MSCs/PRP gel, M-MSCs gel, or PRP gel, or no treatment. The bone tissue regeneration was evaluated at day 0-90 after surgery by HE morphological staining, Lane-Sandhu histopathological scoring, tetracycline detection, Gomori staining and micro-computed tomography. Beyond that, Transwell assay, CCK8 assay, Western blot analysis and ALP activity detection were performed in M-MSCs in vitro with or without PRP application to detect the molecular effects of PRP on M-MSCs. We found that the repair effect of M-MSCs group or PRP group was limited and the bone defects were not completely closed at post-operation 90 d. In contrast, M-MSCs/PRP group received obvious filling in the bone defects with a Lane-Sandhu evaluation score of 9. Tetracycline-labeled new bone area in M-MSCs/PRP group and new mineralized bone area were significantly larger than that in other groups. Micro-computed tomography result of M-MSCs/PRP group displayed complete recovery of humeral bone at post-operation 90 d. Further in vitro experiment revealed that PRP significantly induced migration, enhanced the growth, and promoted the expression of Cbfa-1 and Coll I in M-MSCs. In conclusion, PRP application significantly enhanced the regeneration capacity of M-MSCs in large bone defect via promoting the migration and proliferation of M-MSCs, and also inducing the osteogenic differentiation.

Faster Detection of Ischemia in Free Muscle Transfer When Using Microdialysis.

BACKGROUND: Microdialysis is a clinical method used to detect ischemia after microvascular surgery. Microdialysis is easy to use and reliable, but its value in most clinical settings is hampered by a 1- to 2-h delay in the delivery of patient data. This study evaluated the effectiveness of an increase in the microdialysis perfusion rate from 0.3 to 1.0 µL/min on the diagnostic delay in the detection of ischemia. METHODS: In eight pigs, two symmetric pure muscle transfers were dissected based on one vascular pedicle each. In each muscle, two microdialysis catheters were placed. The two microdialysis catheters were randomized to a perfusion rate of 0.3 or 1.0 µL/min, and the two muscle transfers were randomized to arterial or venous ischemia, respectively. After baseline monitoring, arterial and venous ischemia was introduced by the application of vessel clamps. Microdialysis sampling was performed throughout the experiment. The ischemic cutoff values were based on clinical experience set as follows: CGlucose < 0.2 mmol/L, CLactate > 7 mmol/L, and the lactate/pyruvate ratio > 50. RESULTS: The delay for the detection of 50% of arterial ischemia was reduced from 60 to 25 minutes, and for the detection of all cases of arterial ischemia, the delay was reduced from 75 to 40 minutes when the perfusion rate was increased from 0.3 to 1.0 µL/min. After the same increase in perfusion, the detection of 50% of venous ischemia was reduced from 75 to 40 minutes, and for all cases of venous ischemia, a reduction from 135 to 95 minutes was found. CONCLUSION: When using microdialysis for the detection of ischemia in pure muscle transfers, an increase in the perfusion rate from 0.3 to 1.0 µL/min can reduce the detection delay of ischemia.

Different Materials for Plugging a Dehiscent Superior Semicircular Canal: A Comparative Histologic Study Using a Gerbil Model.

HYPOTHESIS: The choice of the material for plugging a dehiscence of the superior semicircular canal is based on the ease of use and the success of the procedure to permanently relieve symptoms without adverse side effects. BACKGROUND: Dehiscence of the superior semicircular canal can lead to autophony, conductive hearing loss, and vertigo. Surgical treatment by plugging the canal is a highly effective treatment of the symptoms in many patients, although, the procedure can be associated with some degree of hearing loss in more than or equal to 25% of the patients. The available data indicate that adverse effects may be more frequently observed with bone wax as compared with other materials. METHODS: In the present study we compare the tissue reactions induced by plugging the superior semicircular canal with autologous bone pate/bone chips, muscle, fat, artificial bone wax, and teflon in the gerbil model in an attempt to identify the material leading to successful plugging with the least adverse tissue reactions. RESULTS: Our data show that successful plugging was achieved in 100% of the ears by bone pate/bone chips, teflon, and bone wax while the success rate was significantly lower (<50%) following muscle and fat. The proportion of adverse tissue reactions was significantly more pronounced using bone wax as compared with teflon and bone pate/bone chips. CONCLUSION: The use of teflon or autologous bone as a material for plugging a dehiscent superior semicircular canal should be favored over bone wax, muscle, and fat.

Repair of Cerebrospinal Fluid Leak in Cochlear Implantation.

OBJECTIVE: The aim of this study is to evaluate the treatment of cerebrospinal fluid (CSF) leaks from cochleostomy after cochlear implantation intraoperatively and postoperatively. METHODS: Three hundred seven patients (age ranges 13 months to 18 years) were undergone cochlear implantation and 14 (4.56%) of them had CSF leakage intraoperatively (2 normal, 12 anomalous cochlea). Complete packing of the around electrode in cochleostomy with muscle had performed to control CSF leak intraoperatively for primary surgery in 10 patients. Cerebrospinal fluid leakage was observed in 3 patients after cochlear implantation postoperatively. Revision surgeries for CSF leakage with fat tissue sealing were performed for them also. Fat tissue packing was performed for the last 4 patients in primary surgery. Outcomes of management methods for sealing were evaluated. RESULTS: Sealing the cochleostomy with muscle was performed for 10 patients. Fibrin glue applications were used for excessive leakage for 5 patients with cochlear anomalies and 3 of these patients had CSF leak from cochleostomy postoperatively (Patients I, II, III). Secondary surgeries with fat tissue sealing were performed. But CSF leakage also was occurred in Patient III. Subtotal petrosectomy and obliteration of cavity with fat tissue had been performed for Patient III. Cerebrospinal fluid leakage has not been seen in primary surgeries with fat tissue packing in other 5 patients. CONCLUSION: Cerebrospinal fluid leakage may occur in cochlear implantation patients with inner ear anomalies postoperatively. Sealing of the cochleostomy with fat tissue is more useful than muscle intraoperatively.

Joint-preserving treatment options for irreparable rotator cuff tears.

An irreparable cuff tear is defined as the inability to achieve direct repair of native tendon to the great tuberosity despite intra- and extra-articular release of the remaining tissue. Three distinct anatomic patterns are identified: posterosuperior cuff tears which involve the supraspinatus, infraspinatus and teres minor; anterosuperior tears which involve the supraspinatus and subscapularis; and global tears which comprise both. Subacromial debridement and tenotomy or tenodesis of the long head of the biceps are proposed for older patients with a functional but very painful shoulder. Partial repair-particularly the infraspinatus and the subscapularis-is indicated for young patients if the muscle is still trophic with a fatty infiltration less than 3. It can be combined with a tendon transfer. In irreparable posterosuperior tears, latissimus dorsi or lower trapezius transfer has been reported to improve active elevation and external rotation. In anterosuperior cuff tears, pectoralis major or latissimus transfer has been used. If the lack of external rotation is isolated with good active forward elevation, the L'Episcopo procedure is the procedure of choice. New techniques with a short follow-up have been proposed recently: implantation of a balloon-shaped, biodegradable spacer in the subacromial space to maintain the position of the humeral head and to facilitate deltoid action; capsular superior reconstruction with a fascia lata or an artificial graft implanted between the superior glenoid rim and the great tuberosity to reproduce the natural capsule of the supra- and infraspinatus and to stabilize the humeral head.

Free-flap salvage: muscle only versus skin paddle - an Australian experience.

BACKGROUND: Free-tissue transfer flaps are an effective reconstructive option for complex wounds; however, flap failure is a dreaded complication requiring timely re-exploration and salvage. The aim of this study was to determine whether salvage rates were higher in skin flaps, as opposed to muscle flaps, due to the durability of the overlying skin paddle allowing for better visual post-operative monitoring and more timely recognition of the threatened flap. METHODS: We conducted a retrospective analysis of all patients who underwent a free flap at an Australian tertiary centre between 2004 and 2014. Data were collected on patient demographics, indication, flap type, time of recognition of the threatened flap and re-exploration outcome. Data were analysed using Stata version 13 (StataCorp, College Station, TX, USA). Student's t-test, analysis of variance and Pearson's chi-squared test were used to compare groups. RESULTS: There were 560 patients who underwent 573 free flaps. The most common indication was trauma. There were 58 re-explorations with a successful salvage rate of 79.3% (46/58). Overall complete flap loss rate was 2.1% (12/573). In flaps requiring re-exploration, there was a higher complete flap loss rate for muscle only flaps versus those with a skin paddle (P-value = 0.041). CONCLUSION: While timely recognition and re-exploration of the compromised free flap in the early postoperative setting is important in determining the flap salvage success, it is demonstrated that salvage rates are poorer for muscle only flaps compared with flaps with a skin paddle.

Disinfection of human musculoskeletal allografts in tissue banking: a systematic review.

Musculoskeletal allografts are typically disinfected using antibiotics, irradiation or chemical methods but protocols vary significantly between tissue banks. It is likely that different disinfection protocols will not have the same level of microorganism kill; they may also have varying effects on the structural integrity of the tissue, which could lead to significant differences in terms of clinical outcome in recipients. Ideally, a disinfection protocol should achieve the greatest bioburden reduction with the lowest possible impact on tissue integrity. A systematic review of three databases found 68 laboratory and clinical studies that analyzed the microbial bioburden or contamination rates of musculoskeletal allografts. The use of peracetic acid-ethanol or ionizing radiation was found to be most effective for disinfection of tissues. The use of irradiation is the most frequently published method for the terminal sterilization of musculoskeletal allografts; it is widely used and its efficacy is well documented in the literature. However, effective disinfection results were still observed using the BioCleanse™ Tissue Sterilization process, pulsatile lavage with antibiotics, ethylene oxide, and chlorhexidine. The variety of effective methods to reduce contamination rate or bioburden, in conjunction with limited high quality evidence provides little support for the recommendation of a single bioburden reduction method.

Estrategias de reanimación facial: resultados preliminares de un estudio de cohorte / Results of a face reanimation protocol in patients with facial paralysis

Objetivo: El objetivo de este trabajo es presentar el protocolo de reanimación facial y determinar los resultados del tratamiento quirúrgico de la parálisis facial. Materiales y métodos: Se realizó un estudio de cohorte prospectiva con todos los pacientes que ingresaron en el Hospital Clínico de la Universidad de Chile (HCUCH) y se sometieron al protocolo de reanimación facial, desde el año 2008 al 2014. Los resultados quirúrgicos se evaluaron según el protocolo de medición directa publicado por Mantkelow. Se utilizó estadística descriptiva para caracterizar la muestra y analítica para determinar el cambio en la excursión de la comisura labial como indicador de movilidad facial. Resultados: Desde el año 2008 hasta la fecha se han intervenido 21 pacientes, de los cuales 6 han completado su protocolo de tratamiento y período de seguimiento. La edad promedio fue de 35 años, el seguimiento promedio alcanzó los 22 meses. La excursión de la comisura labial postoperatoria promedio alcanzó los 12,8 mm, lo que significa una mejoría significativa, con un promedio de 7 mm respecto al preoperatorio. La excursión postoperatoria promedio del labio superior fue de 5,9 mm, lo que también constituye una mejoría significativa respecto al preoperatorio. Conclusiones: Existe una mejoría significativa en la movilidad facial en los pacientes sometidos al protocolo de reanimación facial. Si bien estos cambios pueden parecer pequeños en magnitud, implican un cambio profundo en la calidad de vida. Con el fin de optimizar resultados resulta esencial una terapia de rehabilitación especializada, con terapias individualizadas.

Background: The deformity caused by facial paralysis has important functional and psychological consequences. Aim:To report a face reanimation protocol and the results of surgical treatment of facial paralysis.Materials and methods: Prospective intervention of 25 patients aged 8 to 79 years (13 males) with facial paralysis, between 2008 and 2014. Surgical results were evaluated using measurements according to Mantkelow protocol. Results: Patients were followed for 22 months. Postoperative excursion of the labial commissure reached 12.8 mm, which was 7 mm better than before surgery. The postoperative excursion of the upper lip was 5.9 cm, which also represented an improvement. Conclusions: There is a significant improvement in facial movements in these patients subjected to the face reanimation protocol. Although changes are of low magnitude, they have an impact in their quality.

Evaluation of elbow flexion following free muscle transfer from the medial gastrocnemius or transfer from the latissimus dorsi, in cases of traumatic injury of the brachial plexus / Avaliação da flexão do cotovelo após transferência muscular livre do gastrocnêmio medial ou transferência do latíssimo do dorso na lesão traumática do plexo braquial

To compare the gain in elbow flexion in patients with traumatic injury of the brachial plexus following muscle transfer from latissimus dorsi with the gain following free muscle transfer from the medial belly of the gastrocnemius. METHODS: This was a retrospective study in which the medical files of a convenience sample of 13 patients operated between 2000 and 2010 were reviewed. Group 1 comprised seven patients who underwent transfers from the gastrocnemius and group 2 (controls) comprised six patients who underwent transfers from the latissimus dorsi. The following functions were evaluated: (1) range of motion (ROM) of elbow flexion, in degrees, using manual goniometry and (2) grade of elbow flexion strength, using a muscle strength scale. Satisfactory results were defined as: (1) elbow flexion ROM ≥ 80° and (2) elbow flexion strength ≥ M3. The Fisher exact and Kruskal-Wallis tests were used (p < 0.05). RESULTS: The patients' mean age was 32 years (range: 17-56) and 72% had been involved in motorcycle accidents. Elbow flexion strength ≥ M3 was observed in seven patients (100%) in group 1 and in five patients (83.3%) in group 2 (p = 0.462). None of the patients presented M5, and one patient (16.7%) in group 2 had a poor result (M2). Elbow flexion ROM with a gain ≥ 80° (daily functions) was found in six patients (86%) in group 1 and in three patients (50%) in group 2 ( p = 0.1). CONCLUSION: The patients in group 1 had greater gains in strength and ROM than did those in group 2, but without statistical significance. Thus, transfers from the gastrocnemius become a new surgical option, if other techniques cannot be used.

Comparar o ganho de flexão do cotovelo em pacientes com lesão traumática do plexo braquial após transferência muscular do latíssimo dorsal (TMLD) com a transferência muscular livre do ventre medial do gastrocnêmio (TMLGM). METÓDOS: Estudo retrospectivo, revisão de prontuários, amostra de conveniência, com 13 pacientes operados, entre 2000 e 2010. Grupo 1 (TMLGM) com sete pacientes e grupo 2 ou controle (TMLD) com seis. Função avaliada: 1) amplitude de movimento (ADM) em graus da flexão do cotovelo, goniometria manual; 2) grau de força de flexão do cotovelo, por escala de força muscular. Satisfatórios: 1) ADM: flexão do cotovelo ≥ 80°; 2) Força: flexão do cotovelo ≥ M3. Testes exato de Fisher e Kruskal-Wallis (p < 0,05). RESULTADOS: Média de idade foi de 32 anos (17 a 56). Acidente de moto em 72%. Força de flexão do cotovelo ≥ M3 no grupo 1 em sete pacientes (100%) e o grupo 2 em cinco (83,3%) (p = 0,462). Não tivemos M5 e o grupo 2 apresentou um paciente (16,7%) com resultado ruim M2. ADM na flexão do cotovelo com ganho ≥ 80° (funções diárias) foram encontrados no grupo 1 em seis pacientes (86%) e no grupo 2 em três (50%) (p = 0,1). CONCLUSÃO: Pacientes do grupo 1 tiveram um ganho maior de força e ADM, quando comparados com os do grupo 2, sem significado estatístico. Assim, TMLGM se torna uma nova opção cirúrgica, caso não possam ser aplicadas outras técnicas.

Insertion site and sealing technique affect residual hearing and tissue formation after cochlear implantation.

Tissue formation around the electrode array of a cochlear implant has been suggested to influence preservation of residual hearing as well as electrical hearing performance of implanted subjects. Further, inhomogeneity in the electrical properties of the scala tympani shape the electrical field and affect current spread. Intracochlear trauma due to electrode insertion and the insertion site itself are commonly seen as triggers for the tissue formation. The present study investigates whether the insertion site, round window membrane (RWM) vs. cochleostomy (CS), or the sealing material, no seal vs. muscle graft vs. carboxylate cement, have an influence on the amount of fibrous tissue and/or new bone formation after CI implantation in the guinea pig. Hearing thresholds were determined by auditory brainstem response (ABR) measurements prior to implantation and after 28 days. The amount of tissue formation was quantified by evaluation of microscopic images obtained by a grinding/polishing procedure to keep the CI in place during histological processing. An insertion via the round window membrane resulted after 28 days in less tissue formation in the no seal and muscle seal condition compared to the cochleostomy approach. Between these two sealing techniques there was no difference. Sealing the cochlea with carboxylate cement resulted always in a strong new bone formation and almost total loss of residual hearing. The amount of tissue formation and the hearing loss correlated at 1-8 kHz. Consequently, the use of carboxylate cement as a sealing material in cochlear implantation should be avoided even in animal studies, whereas sealing the insertion site with a muscle graft did not induce an additional tissue growth compared to omitting a seal. For hearing preservation the round window approach should be used.

Immature muscular tissue differentiation into bone-like tissue by bone morphogenetic proteins in vitro, with ossification potential in vivo.

The objective of this study was to induce bone formation from immature muscular tissue (IMT) in vitro, using bone morphogenetic proteins (BMPs) as a cytokine source and an expanded polytetrafluoroethylene (ePTFE) scaffold. In addition, cultured IMTs were implanted subcutaneously into Sprague-Dawley (SD) rats to determine their in vivo ossification potential. BMPs, extracted from bovine cortical bones, were applied to embryonic SD rat IMT cultures, before 2 weeks culture on ePTFE scaffolds. Osteoblast-like cells and osteoid tissues were partially identified by hematoxylin-eosin staining 2 weeks after culture. Collagen type I (Col-I), osteopontin (OP), and osteocalcin (OC) were detected in the osteoid tissues by immunohistochemical staining. OC gene expression remained low, but OP and Col-I were upregulated during the culture period. In vivo implanted IMTs showed slight radiopacity 1 week after implantation and strong radiopacity 2 and 3 weeks after implantation. One week after implantation, migration of numerous capillaries was observed and ossification was detected after 2 weeks by histological observation. These results suggest that IMTs are able to differentiate into bone-like tissue in vitro, with an ossification potential after implantation in vivo.

Simple technique for augmentation of the facial soft tissue.

Due to the request of numerous patients to improve the aspect of the perioral area in combination with other types of cosmetic and reconstructive surgery, we started to use autologous fillers. In fact, there are numerous potential fillers that can be utilized during various operations executed in many bodily areas, such as the breast, abdomen, and face. The muscular fascia as well as the dense connective tissue which the surgeon encounters in various bodily areas during some stages of the operation, in fact, can be removed and replaced both by themselves or superimposed in order to increase their thickness. The insertion of the grafts is carried out by using a needle, but other methods can also be used with the same success. The consistency of the area treated, after a few days of edema, is very similar to the host area, and the volume obtained remains uniform in time (our followup is after 24 months). The time utilized for the removal and the insertion in the chosen area was only a few minutes. The result was extremely satisfactory in all the 30 patients treated, and there was no complication or side effects.

Artificial muscle: facts and fiction.

Mechanical devices are sought to support insufficient or paralysed striated muscles including the failing heart. Nickel-titanium alloys (nitinol) present the following two properties: (i) super-elasticity, and (ii) the potential to assume different crystal structures depending on temperature and/or stress. Starting from the martensite state nitinol is able to resume the austenite form (state of low potential energy and high entropy) even against an external resistance. This one-way shape change is deployed in self-expanding vascular stents. Heating induces the force generating transformation from martensite to the austenite state while cooling induces relaxation back to the martensite state. This two-way shape change oscillating between the two states may be used in cyclically contracting support devices of silicon-coated nitinol wires. Such a contractile device sutured to the right atrium has been tested in vitro in a bench model and in vivo in sheep. The contraction properties of natural muscles, specifically of the myocardium, and the tight correlation with ATP production by oxidative phosphorylation in the mitochondria is briefly outlined. Force development by the nitinol device cannot be smoothly regulated as in natural muscle. Its mechanical impact is forced onto the natural muscle regardless of the actual condition with regard to metabolism and Ca2+-homeostasis. The development of artificial muscle on the basis of nitinol wires is still in its infancy. The nitinol artificial muscle will have to prove its viability in the various clinical settings.

[Clinical application of abductor digiti minimi muscle flap].

OBJECTIVE: To discuss the surgery procedure and the clinical effectiveness of repairing skin and soft tissue defects in the lateral foot and the heel with the abductor digiti minimi muscle flap. METHODS: Between July 2002 and October 2010, 8 patients with skin and soft tissue defects in the lateral foot and the heel were treated. There were 6 males and 2 females with an average age of 42 years (range, 28-65 years). The locations were the left foot in 5 cases and the right foot in 3 cases. Defects were caused by ulcer of the heel in 2 cases, by poor healing of incision after calcaneus fracture surgery in 1 case, and by crushing in 5 cases. The defect size ranged from 1.5 cmx 1.0 cm x 8.0 cm x 2.6 cm. The disease duration was 30 minutes to 26 months. The result of bacterial culture was positive in 2 cases. After 9 to 15 days of debridement and dressing change, defects were repaired with the abductor digiti minimi muscle flap of 5.6 cm x 1.5 cm to 7.6 cm x 1.8 cm at size. The donor site were sutured directly. RESULTS: Partial necrosis of muscle flap occurred in 1 case at 4 days after operation, which was cured by symptomatic treatment, and the other muscle flaps survived. All incisions of the donor sites healed by first intention. The muscle flaps survived and the granulation grew well at 9-21 days after operation, and the muscle flap wounds were repaired by free leg edge thickness skin grafting. Wounds were repaired by one-stage free skin grafting in 1 case and by two-stage free skin grafting in 7 cases; all skin flaps survived and wounds healed by first intention. Seven patients were followed up 9-18 months (mean, 11 months). The appearance, texture, and sensation were satisfactory. The two-point discrimination was 16-23 mm (mean, 19.5 mm). Epidermal abrasion occurred in 1 case of heel ulcer after weigt-bearing walking. Hallux valgus and muscle weakness occurred in 1 case of necrosis of the peroneus length tendons; and the satisfactory results were achieved in the other patients. CONCLUSION: It has satisfactory effectiveness to use the abductor digiti minimi muscle flap for repairing skin and soft tissue defects in the lateral foot and the heel, which has the advantages of easy-to-operate, safe, less injury at donor site, good appearance and texture, and good recovery of sensation.

Parathyroid hormone 1 (1-34) acts on the scales and involves calcium metabolism in goldfish.

The effect of fugu parathyroid hormone 1 (fugu PTH1) on osteoblasts and osteoclasts in teleosts was examined with an assay system using teleost scale and the following markers: alkaline phosphatase (ALP) for osteoblasts and tartrate-resistant acid phosphatase (TRAP) for osteoclasts. Synthetic fugu PTH1 (1-34) (100pg/ml-10ng/ml) significantly increased ALP activity at 6h of incubation. High-dose (10ng/ml) fugu PTH1 significantly increased ALP activity even after 18h of incubation. In the case of TRAP activity, fugu PTH1 did not change at 6h of incubation, but fugu PTH1 (100pg/ml-10ng/ml) significantly increased TRAP activity at 18h. Similar results were obtained for human PTH (1-34), but there was an even greater response with fugu PTH1 than with human PTH. In vitro, we demonstrated that both the receptor activator of the NF-κB ligand in osteoblasts and the receptor activator NF-κB mRNA expression in osteoclasts increased significantly by fugu PTH1 treatment. In an in vivo experiment, fugu PTH1 induced hypercalcemia resulted from the increase of both osteoblastic and osteoclastic activities in the scale as well as the decrease of scale calcium contents after fugu PTH1 injection. In addition, an in vitro experiment with intramuscular autotransplanted scale indicated that the ratio of multinucleated osteoclasts/mononucleated osteoclasts in PTH-treated scales was significantly higher than that in the control scales. Thus, we concluded that PTH acts on osteoblasts and osteoclasts in the scales and regulates calcium metabolism in goldfish.