Multimodal Conservative Treatment of Complicated Open Wound After Total Knee Replacement Arthroplasty in Patients With Comorbidities.

Total knee replacement arthroplasty is a common procedure and postoperative wound complications are sometimes inevitable. Although invasive reconstructive surgery may be an option for nonhealed wounds, such procedures can limit early rehabilitation, adversely affecting the range of joint motion. Patients can achieve a wider range of motion if they undergo early rehabilitation with a conservative approach. From 2015 to 2017, 5 patients with comorbidities who underwent total knee replacement arthroplasty were referred to the reconstructive surgery department for nonhealed open wounds. Depending on their comorbidities and conditions, the patients underwent negative-pressure wound therapy based on multimodal conservative treatment. During the treatment, the patients continued rehabilitation. In the 5 patients, the mean duration of complete wound healing was 65.2 days (range = 57-81), during which all open wounds were well healed. For final wound closure, the patients underwent skin grafting, dermatotraction, or collagen dressing. Four patients achieved ranges of joint motion over 100 degrees after treatment. We believe that early coverage is important for open wounds. For complicated open wounds after total knee replacement arthroplasty in patients with comorbidities, less invasive multimodal treatment along with early rehabilitation may be more effective to achieve adequate final range of joint motion.

Thinning of Calvarial Bone by Skull Growth in a Pediatric Patient After Skull Grinding Injury.

ABSTRACT: Several treatment options have been suggested for the treatment of scalp defects that occur following head trauma. Growth changes should be considered, especially for children. The authors report a case of delayed cranial bone absorption after successful free latissimus dorsi flap coverage following skull grinding injury in a pediatric patient.A 3-year-old patient was referred to the reconstructive surgery department because of a 7 × 8 cm-sized scalp defect in the temporoparietal area due to dragging and grinding injury. Debridement and free latissimus dorsi musculocutaneous flap coverage with split-thickness skin graft were performed. The operation was successful and antibiotics were administered for 4 weeks to prevent the occurrence of osteomyelitis (OM). The patient was discharged after confirming the absence of OM via magnetic resonance imaging.Thinning of cranial bone was observed in the skull series taken one year postoperatively. The size gradually increased, but no significant changes in size occurred after 5 years of patient's age. Magnetic resonance imaging was performed used to confirm the occurrence of OM and no specific findings were observed. It is well-known fact that the cranium grows to 90% of its adult capacity by the age of 5. In this regard, we believe that the current case and the demonstrated cranial thinning is due to bone absorption associated with the growth.In the pediatric population, injuries involving the cranial vault should be considered in the context of bone resorption due to skull growth, which may lead to cranial bone thinning. Reconstructive surgeons should closely observe the presence or absence of skull defects through long-term follow-ups.

Minimally Invasive Method for Correcting Reducible Cryptotia.

Various surgical methods have been used to treat cryptotia; however, there is a drawback of these methods in that they leave a permanent scar. The authors describe a 7-year-old child who missed the optimal corrective time for cryptotia. Minimally invasive surgery was planned as a 3rd alternative to external splinting or invasive surgery by taking advantage of 2 methods. Silly putty was prefabricated as an auricular sulcus retainer, and fixation sutures between the deep dermis and temporal fascia were placed through small incisions along the future auricular sulcus. Then the prefabricated auricular sulcus retainer was maintained for 2 months. After 6 months, the corrected ear shape remained stable with the inconspicuous scar. With minimally invasive correction, a successful treatment effect can be expected while minimizing scarring in patients who are not expected to have a therapeutic effect with a simple reduction.

Surgical Site Infection Caused by Mycobacterium Septicum Following Blepharoplasty.

BACKGROUND: M fortuitum and M chelonae are commonly reported in surgical site infections caused by nontuberculous mycobacterium, but M septicum is rarely known. Herein, the authors report the first case of surgical site infection caused by M septicum in an immunocompetent patient after blepharoplasty. METHODS: A 37-year-old woman had persisting bilateral masses on the upper eyelids at 3 months after a blepharoplasty. The excision and revision were performed in a local clinic with the administration of the empirical antibiotic (clarithromycin) for 2 months, but the masses recurred. The patient was referred to the authors' hospital after the steroid was injected. As the right eyelid skin was very thin with the pus pocket, curettage was performed, while the mass on the left eyelid was completely excised. A bacterial, Acid Fast Bacilli culture with antibiotic susceptibility testing, and a DNA-polymerase chain reaction test were performed. RESULTS: The polymerase chain reaction test identified M septicum. The antibiotic treatment was delayed to identify the susceptibility to antibiotics, but the Acid Fast Bacilli culture result showed no growth. In the meantime, the mass on the right eyelid recurred. Levofloxacin and clarithromycin were administered for 6 months in consultation with the Division of Infectious Diseases. Then the mass was excised. There was no recurrence after 1 year of follow-up. CONCLUSION: There are a few reports of M septicum catheter-related infection and pulmonary disease, but surgical site infection has not been reported. When a localized mass on a surgical site is found, surgeons should consider M septicum infection and find out the pathogen with its antibiotics susceptibility.

Identifying Preoperative Factors Associated with the Volume Discrepancy in Patients Undergoing Breast Reconstruction with the Extended Latissimus Dorsi Musculocutaneous Flap Coverage.

BACKGROUND: The latissimus dorsi (LD) flap is a versatile option for breast reconstruction. However, the indications are limited because of volume discrepancy between the breast and the flap. We conducted this study to identify preoperative factors associated with the volume discrepancy in patients undergoing breast reconstruction with the extended LD flap. METHODS: A retrospective study was performed in 69 patients (69 breasts) who underwent breast reconstruction with the extended LD flap between March 2015 and March 2018. We evaluated age, body weight, height, preoperative body mass index (BMI), postoperative BMI, breast skin defect size, breast volume, flap volume, and volume discrepancy [breast volume - flap volume]. RESULTS: Mean age, height, body weight, preoperative BMI, postoperative BMI, skin defect size, breast volume, flap volume, and volume discrepancy were 45.6 ± 7.1, 157.8 ± 0.1, 59 ± 8.1, 23.7 ± 3.2, 23.5 ± 3.3, 16.5 ± 9.3, 252.2 ± 107.1, 229.4 ± 95.6, and 32.6 ± 31.4, respectively. Spearman's rank correlation coefficients indicated significant positive linear correlations between volume discrepancy and preoperative BMI (correlation coefficient = 0.267, P = 0.027), volume discrepancy and breast volume (correlation coefficient = 0.472, P < 0.001), and between volume discrepancy and skin defect size (correlation coefficient = 0.609, P < 0.001). Stepwise multiple regression analysis yielded the following formula: predicted log volume discrepancy (ml) = 1.2891 + 0.0639 × skin defect size + 0.0025 × breast volume (R2 = 0.421). CONCLUSION: Skin defect size and breast volume were preoperative factors associated with volume discrepancy in patients who have undergone breast reconstruction with the extended LD flap. Considering these factors, we can predict the lack of volume and plan any necessary secondary procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Novel effect of biphasic electric current on in vitro osteogenesis and cytokine production in human mesenchymal stromal cells.

Electrical stimulation (ES) can activate diverse biostimulatory responses in a range of tissues. Of various forms of ES, the application of biphasic electric current (BEC) is a new approach to bone formation. This study is to investigate the effects and mechanism of action of BEC in osteoblast differentiation and cytokine production in human mesenchymal stromal cells (hMSCs). Using an in vitro culture system with a modified version of the BEC stimulator chip used in our previous study, we exposed hMSCs to a 100 Hz ES with a magnitude of 1.5/15 muA/cm(2) for 250/25 mus. hMSCs showed increased proliferation during static BEC stimulation for 5 days. However, alkaline phosphatase activity and calcium deposition were enhanced in hMSCs 7 days after the stimulation, rather than during the period of ES. BEC induced vascular endothelial growth factor (VEGF) and BMP-2 production; the former can enhance the proliferation of human umbilical vein endothelial cells in culture using conditioned media from BEC cultures. Treatment with selective inhibitors of p38 MAPK (SB203580) or Erk (PD98059), as well as calcium channel blockers (verapamil and nifedipine), reduced the BEC-mediated increase of VEGF expression and cell proliferation. These findings reveal that BEC is involved in the osteoblast differentiation of hMSCs through enhancement of cell proliferation and modulation of the local endocrine environment through VEGF and BMP-2 induction through the activation of MAPK (Erk and p38) and the calcium channel. Thus, local stimulation using BEC might be most beneficial in promoting osteogenic differentiation of hMSCs, resulting in enhanced bone formation for bone tissue engineering.

Activity-dependent neuronal cell migration induced by electrical stimulation.

Recently, we found that electrical stimulation can induce neuronal migration in neural networks cultured for more than 3 weeks on microelectrode arrays. Immunocytochemistry data showed that the aggregation of neurons was related to the emergence of astrocytes in culture. In this study, when neurons were cocultured with astrocytes, electrical stimulation could induce the migration of neuronal cell bodies after only 1 week in culture, while the same stimulation paradigm caused neural necrosis in neuron-only cultures. In addition, the stimulation-induced migration was inhibited by blocking action potentials in neural networks using the voltage-gated sodium channel blocker, tetrodotoxin. Immunocytochemistry was performed to monitor precisely the neuronal migration and count the number of neurons. These results indicate that neuronal migration of cell bodies is dependent on neuronal activity evoked by electrical stimulation and can be enhanced by coculturing with astrocytes. We believe this method can be employed as a means for modifying neural networks and improving the interface between electrodes and neurons.

Electrical stimulation-induced cell clustering in cultured neural networks.

Planar microelectrode arrays (MEAs) are widely used to record electrical activity from neural networks. However, only a small number of functional recording sites frequently show electrical activity. One contributing factor may be that neurons in vitro receive insufficient synaptic input to develop into fully functional networks. In this study, electrical stimulation was applied to neurons mimicking synaptic input. Various stimulation paradigms were examined. Stimulation amplitude and frequency were tailored to prevent cell death. Two effects of stimulation were observed when 3-week-old cultures were stimulated: (1) clusters of neural cells were observed adjacent to stimulating electrodes and (2) an increase in spontaneous neuronal activity was recorded at stimulating electrodes. Immunocytochemical analysis indicates that stimulation may cause both new neuron process growth as well as astrocyte activation. These data indicate that electrical stimulation can be used as a tool to modify neural networks at specific electrode sites and promote electrical activity.

Biphasic electric current stimulates proliferation and induces VEGF production in osteoblasts.

This study investigated biphasic electric current (BEC) functions as a new type of electrical stimulation to induce rat calvarial osteoblasts to proliferate, differentiate and synthesize cytokines. The culture system was designed so that biphasic current flowed between upper and lower gold plates. BEC helps to minimize the net charge accumulation during cell exposure to the electrical stimulation. Osteoblasts were exposed to electrical stimulation of 1.5 microA/cm2 at 3000 Hz, and the effect of BEC was assessed in the interrupted mode (6 h daily) and in the continuous mode (24 h daily), depending on the interval of stimulation. Whereas proliferation increased by 31% after stimulation in the continuous mode for 2 days, it was unaffected in the interrupted mode. The transcriptional expression of osteogenesis-related genes such as alkaline phosphatase (ALP), osteopontin, and type I collagen was unchanged 4 days after stimulation in both modes, while cbfa1 was decreased under the same conditions. There was no detectable change in mRNA expression of growth factors (BMP-2, -4, IGF-2 and TGF-beta1) that promote osteoblast differentiation. However, real-time RT-PCR and ELISA demonstrated that vascular endothelial growth factor (VEGF) was markedly up-regulated by BEC. Induction of VEGF by BEC was not hypoxia driven. In conclusion, the present in vitro study demonstrates that BEC increases cell proliferation and induces the production of VEGF. The BEC was more effective with continuous stimulation than with interrupted stimulation. To confirm whether BEC can enhance osteogenesis, further in vivo studies are needed.

A high-yield fabrication process for silicon neural probes.

There is a great need for silicon microelectrodes that can simultaneously monitor the activity of many neurons in the brain. However, one of the existing processes for fabricating silicon microelectrodes-reactive-ion etching in combination with anisotropic KOH etching-breaks down at the wet-etching step for device release. Here we describe a modified wet-etching sidewall-protection technique for the high-yield fabrication of well-defined silicon probe structures, using a Teflon shield and low-pressure chemical vapor deposition (LPCVD) silicon nitride. In the proposed method, a micro-tab holds each individual probe to the central scaffold, allowing uniform anisotropic KOH etching. Using this approach, we obtained a well-defined probe structure without device loss during the wet-etching process. This simple method yielded more accurate fabrication and an improved mechanical profile.