RESUMO
OBJECTIVE: To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG). DESIGN: Retrospective comparative cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25). INTERVENTION: The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest"). MAIN OUTCOMES MEASURES: Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs. RESULTS: Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated $5336 for a unilateral ABG and $7265 for a bilateral ABG compared to "Open Harvest." CONCLUSIONS: The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.
Assuntos
Enxerto de Osso Alveolar , Analgésicos , Transplante Ósseo , Criança , Estudos de Coortes , Custos de Cuidados de Saúde , Humanos , Ílio , Tempo de Internação , Dor Pós-Operatória , Estudos RetrospectivosRESUMO
INTRODUCTION: Peripheral nerve damage is associated with high long-term morbidity. Because of beneficial secretome, immunomodulatory effects, and ease of clinical translation, transplantation with adipose-derived stem cells (ASC) represents a promising therapeutic modality. METHODS: Effect of ASC delivery in poloxamer hydrogel was assessed in a rat sciatic nerve model of critical-sized (1.5 cm) peripheral nerve injury. Nerve/muscle unit regeneration was assessed via immunostaining explanted nerve, quantitative polymerase chain reaction (qPCR), and histological analysis of reinnervating gastrocnemius muscle. RESULTS: On the basis of viability data, 10% poloxamer hydrogel was selected for in vivo study. Six weeks after transection and repair, the group treated with poloxamer delivered ASCs demonstrated longest axonal regrowth. The qPCR results indicated that the inclusion of ASCs appeared to result in expression of factors that aid in reinnervating muscle tissue. DISCUSSION: Delivery of ASCs in poloxamer addresses multiple facets of the complexity of nerve/muscle unit regeneration, representing a promising avenue for further study. Muscle Nerve 58: 251-260, 2018.
Assuntos
Adipócitos/transplante , Hidrogéis , Regeneração Nervosa/fisiologia , Nervos Periféricos/crescimento & desenvolvimento , Poloxâmero , Transplante de Células-Tronco/métodos , Adulto , Animais , Axônios/ultraestrutura , Feminino , Humanos , Imuno-Histoquímica , Neurônios Motores , Fibras Musculares Esqueléticas , Músculo Esquelético/crescimento & desenvolvimento , Músculo Esquelético/inervação , Ratos , Nervo Isquiático/lesões , Neuropatia Ciática/terapiaRESUMO
Repair of scalp defects with exposed calvaria remains a difficult clinical problem. Herein, we present a simple alternative method of scalp reconstruction. Coverage of bare skull with GammaGraft (Promethean LifeSciences, Inc, Pittsburgh, PA) promotes the evolution of granulation tissue and permits subsequent skin grafting without need for burring, drilling, or other manipulation of the outer table of the calvaria. A retrospective review of patients undergoing scalp reconstruction utilizing GammaGraft and subsequent skin grafting was performed at our institution. From our cohort, 5 patients treated with GammaGraft and subsequent skin grafting had both immediate and long-term follow-up available. Indications for scalp reconstruction included erosions of prior skin grafts and direct excision of full-thickness scalp and pericranium. Average time to definitive skin grafting was 3 weeks; repeat application of GammaGraft was required in some patients with reapplication to subsequent smaller wounds as healing occurred. Complications were minor and consisted of ongoing wound drainage. Alternative flap reconstruction was not required in any patient due to treatment failures. No major complications, wound infections, or early reoperations occurred in any of the patients; 1 patient to date has required repeat reconstruction due to recurrent disease. Coverage of bare skull with GammaGraft and subsequent skin grafting provides a simple and elegant solution to an often too difficult clinical problem. Confirmed by results in out limited series, the utilization of GammaGraft in calvarial reconstruction represents an alternative method in surgical care of complex scalp defects with exposed bone.
Assuntos
Tecido de Granulação/patologia , Procedimentos de Cirurgia Plástica/métodos , Couro Cabeludo/cirurgia , Transplante de Pele/métodos , Crânio/cirurgia , Retalhos Cirúrgicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias Cutâneas/cirurgia , Adulto JovemRESUMO
Vascularized composite allotransplantation represents a potential shift in approaches to reconstruction of complex defects resulting from congenital differences as well as trauma and other acquired pathology. Given the highly specialized function of the eye and its unique anatomical components, vascularized composite allotransplantation of the eye is an appealing method for restoration, replacement, and reconstruction of the nonfunctioning eye. Herein, we describe conventional treatments for eye restoration and their shortcomings as well as recent research and events that have brought eye transplantation closer to a potential clinical reality. In this article, we outline some potential considerations in patient selection, donor facial tissue procurement, eye tissue implantation, surgical procedure, and potential for functional outcomes.
Assuntos
Cegueira/cirurgia , Olho/transplante , Alotransplante de Tecidos Compostos Vascularizados/métodos , Animais , Humanos , Seleção de Pacientes , Cuidados Pós-Operatórios/métodos , Ratos , Coleta de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/métodosRESUMO
Whole eye transplantation (WET) remains experimental. Long presumed impossible, recent scientific advances regarding WET suggest that it may become a clinical reality. However, the ethical implications of WET as an experimental therapeutic strategy remain largely unexplored. This article evaluates the ethical considerations surrounding WET as an emerging experimental treatment for vision loss. A thorough review of published literature pertaining to WET was performed; ethical issues were identified during review of the articles.
Assuntos
Cegueira/cirurgia , Olho/transplante , Transplante de Órgãos/ética , Fatores Etários , Beneficência , Cegueira/etiologia , Transplante de Face/ética , Humanos , Terapia de Imunossupressão/efeitos adversos , Transtornos Linfoproliferativos/etiologia , Neoplasias/etiologia , Regeneração Nervosa , Transplante de Órgãos/efeitos adversos , Justiça SocialRESUMO
Chondroitin sulfate proteoglycans (CSPGs) are potent inhibitors of neural regeneration in the peripheral nervous system. Following nerve injury, inhibitory CSPGs accumulate within the endoneurium and Schwann cell basal lamina of the distal nerve stump. The utilization of chondroitinase ABC (chABC) has led to a marked increase in the ability of injured axons to regenerate across gaps through the CSPG-laden extracellular matrix. Experimental models have repeatedly shown chABC to be capable of degrading the CSPGs that hinder neurite outgrowth. In this article, the characterization of CSPGs, their upregulation following peripheral nerve injury, and potential mechanisms behind their growth and inhibition are described. To date, the literature supports that the adjunct use of chABC may be beneficial to peripheral nerve repair in digesting inhibitory CSPGs. chABC has also shown some indication of synergism with other therapies, such as stem cell transplantation. Evidence supporting the use of chondroitinase as a treatment modality in nerve repair, either alone or in combination with other agents, is reviewed within. Finally, several shortcomings of chABC are addressed, notably its thermal stability and physiologic longevity - both hindering its widespread clinical adoption. Future studies are warranted in order to optimize the therapeutic benefits of the chondroitinase enzyme.
Assuntos
Adjuvantes Imunológicos/farmacologia , Condroitina ABC Liase/farmacologia , Regeneração Nervosa/efeitos dos fármacos , Traumatismos dos Nervos Periféricos/terapia , Animais , Proteoglicanas de Sulfatos de Condroitina/metabolismo , Humanos , Imunomodulação , Traumatismos dos Nervos Periféricos/fisiopatologiaRESUMO
BACKGROUND: Basal joint arthritis is a common form of osteoarthritis. There is no consensus procedure for maintenance of trapezial height following trapeziectomy. Suture-only suspension arthroplasty (SSA) is a simple method for stabilizing the thumb metacarpal following trapeziectomy. METHODS: This single-institution, prospective, cohort study compares trapeziectomy followed by either ligament reconstruction with tendon interposition (LRTI) or SSA for the treatment of basal joint arthritis. Patients underwent LRTI or SSA from May of 2018 to December of 2019. Visual analogue scale pain scores; Disabilities of the Arm, Shoulder and Hand questionnaire functional scores; clinical thumb range of motion, pinch, and grip strength data; and patient-reported outcomes were recorded and analyzed preoperatively and at 6 weeks and 6 months postoperatively. RESULTS: Total number of study participants was 45 (LRTI, n = 26; SSA, n = 19). Mean ± SE age was 62.4 ± 1.5 years; 71% were female patients; and 51% underwent surgery on the dominant side. Visual analogue scale scores improved for LRTI and SSA ( P < 0.0001) over 6 months, with no differences between groups at any time point ( P > 0.3). Disabilities of the Arm, Shoulder and Hand questionnaire scores improved for LRTI and SSA over 6 months ( P < 0.0001), with no differences between groups at any time point ( P > 0.3). Following SSA, opposition improved ( P = 0.02), but not as well for LRTI ( P = 0.16). Grip and pinch strength decreased following LRTI and SSA at 6 weeks but recovered similarly for both groups over 6 months. Patient-reported outcomes were generally no different between groups at all time points. CONCLUSION: LRTI and SSA are similar procedures following trapeziectomy relative to pain, function, and strength recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
Assuntos
Articulações Carpometacarpais , Osteoartrite , Trapézio , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Prospectivos , Estudos de Coortes , Artroplastia/métodos , Osteoartrite/cirurgia , Ligamentos/cirurgia , Tendões/cirurgia , Polegar/cirurgia , Trapézio/cirurgia , Suturas , Articulações Carpometacarpais/cirurgia , Amplitude de Movimento ArticularRESUMO
Restoration with sufficient functional recovery after long-gap peripheral nerve damage remains a clinical challenge. Silk has shown clinical promise for numerous tissue engineering applications due to its biocompatibility, impressive mechanical properties, and Food and Drug Administration approval. The aim of this study was to evaluate the efficacy of silk fibroin--based nerve guides containing glial cell line-derived neurotrophic factor (GDNF) in a long-gap sized (15 mm) rat sciatic nerve defect model. Four groups of nerve conduits were prepared: (1) silk conduits with empty silk microspheres, (2) silk conduits with GDNF-loaded silk microspheres uniformly distributed in the conduit wall, (3) silk conduits with GDNF-loaded silk microspheres in a controlled manner with the highest GDNF concentration at the distal end, and (4) isograft. After 6 weeks, the nerve grafts were explanted, harvested, and fixed for histologic analysis. Nerve tissue stained with the S-100, and neuroendocrine marker PGP 9.5 antibodies demonstrated a significantly increased density of nerve tissue in the GDNF-treated groups compared with the empty microsphere (control) group (P < 0.05). GDNF-treated animals with a higher concentration of GDNF in the distal portion possessed a significantly higher density of PGP 9.5 protein middle conduit part than comparison to GDNF uniform-treated animals (P < 0.05). Silk-based nerve conduits possess optimal mechanical and degradative properties, rendering them potentially useful in peripheral nerve repair. This study demonstrates that novel, porous silk fibroin--based nerve conduits, infused with GDNF in a controlled manner, represent a potentially viable conduit for Schwann cell migration and proliferation in the regeneration of peripheral nerves.
Assuntos
Fibroínas , Fator Neurotrófico Derivado de Linhagem de Célula Glial/administração & dosagem , Regeneração Tecidual Guiada/métodos , Regeneração Nervosa , Nervo Isquiático/cirurgia , Alicerces Teciduais , Animais , Fibroínas/química , Microesferas , Músculo Esquelético/inervação , Distribuição Aleatória , Ratos , Células de Schwann/fisiologia , Nervo Isquiático/lesões , Nervo Isquiático/fisiologiaRESUMO
PURPOSE: Prophylactic antibiotics have been shown to prevent surgical site infection (SSI) after some gastrointestinal, orthopedic, and plastic surgical procedures, but their efficacy in clean, elective hand surgery is unclear. Our aims were to assess the efficacy of preoperative antibiotics in preventing SSI after clean, elective hand surgery, and to identify potential risk factors for SSI. METHODS: We queried the database from an outpatient surgical center by Current Procedural Terminology code to identify patients who underwent elective hand surgery. For each medical record, we collected patient demographics and characteristics along with preoperative, intraoperative, and postoperative management details. The primary outcome of this study was SSI, and secondary outcomes were wound dehiscence and suture granuloma. RESULTS: From October 2000 through October 2008, 8,850 patient records met our inclusion criteria. The overall SSI rate was 0.35%, with an average patient follow-up duration of 79 days. The SSI rates did not significantly differ between patients receiving antibiotics (0.54%; 2,755 patients) and those who did not (0.26%; 6,095 patients). Surgical site infection was associated with smoking status, diabetes mellitus, and longer procedure length irrespective of antibiotic use. Subgroup analysis revealed that prophylactic antibiotics did not prevent SSI in male patients, smokers, or diabetics, or for procedure length less than 30 minutes, 30 to 60 minutes, and greater than 60 minutes. CONCLUSIONS: Prophylactic antibiotic administration does not reduce the incidence of SSI after clean, elective hand surgery in an outpatient population. Moreover, subgroup analysis revealed that prophylactic antibiotics did not reduce the frequency of SSI among patients who were found to be at higher risk in this study. We identified 3 factors associated with the development of SSI in our study: diabetes mellitus status, procedure length, and smoking status. Given the potential harmful complications associated with antibiotic use and the lack of evidence that prophylactic antibiotics prevent SSIs, we conclude that antibiotics should not be routinely administered to patients who undergo clean, elective hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.
Assuntos
Antibioticoprofilaxia , Procedimentos Cirúrgicos Eletivos/métodos , Mãos/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Distribuição por Idade , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/métodos , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Pacientes Ambulatoriais/estatística & dados numéricos , Procedimentos de Cirurgia Plástica/efeitos adversos , Valores de Referência , Estudos Retrospectivos , Distribuição por Sexo , Resultado do TratamentoRESUMO
Wrist pain is a common patient complaint with a myriad of clinical conditions that can explain the underlying cause. Short of wrist arthroscopy, no technique other than formal wrist arthrotomy exists for direct examination of the hyaline cartilage coating the articular surfaces of the carpal bones. Magnetic resonance imaging (MRI) has been proven accurate in evaluating joint surfaces of large joints such as the shoulder, hip, and knee with articular cartilage surface thickness is in excess of 1 mm. However, in the carpus the thickness of the cartilage and the contours present have precluded accurate imaging. Advances in MRI technology over the last several decades are now making imaging of small joint surfaces, such as the carpus, an area worth revisiting. Herein we provide a review of these efforts with a specific focus on the evaluation of the wrist.
Assuntos
Cartilagem Articular/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Articulação do Punho/diagnóstico por imagem , Articulações do Carpo/diagnóstico por imagem , Articulações Carpometacarpais/diagnóstico por imagem , Humanos , Fibrocartilagem Triangular/diagnóstico por imagemRESUMO
Biomaterials derived from human adipose extracellular matrix have shown promise in vitro and in animal studies as an off-the-shelf adipogenic matrix for sustained volume replacement. Herein, we report the results of a randomized prospective study conducted with allograft adipose matrix (AAM) grafted into the pannus of presurgical abdominoplasty patients 3 or 6 months before scheduled surgery. This is the first report of a longitudinal histologic analysis of AAM in clinical use. METHODS: Ten healthy patients undergoing elective abdominoplasty were recruited to receive AAM before surgery. Enrolled subjects were randomized into either a 3-month follow-up cohort or a 6-month follow-up cohort. Subjects were monitored for adverse events associated with AAM grafting in addition to undergoing serial biopsy. Following surgical excision of the pannus, representative samples from the AAM surgical sites were stained and evaluated with hematoxylin and eosin for tissue morphology, Masson's trichrome for collagen, and perilipin for adipocytes. RESULTS: All subjects tolerated AAM with no severe adverse events reported. At 3 months following implantation, AAM remained visible within the confines of the subjects' native surrounding adipose tissue with sparse adipocytes apparent within the matrix. By 6 months, AAM had remodeled and was primarily composed of perilipin-positive adipocytes. Histologic analysis confirmed tissue remodeling (hematoxylin and eosin), adipogenesis (perilipin), and angiogenesis (Masson's trichrome) occurred with the presence of AAM. CONCLUSIONS: AAM is a safe, allogeneic, off-the-shelf regenerative matrix that is adipogenic and noninflammatory and promotes angiogenesis.
RESUMO
Severe injuries to peripheral nerves are challenging to repair. Standard-of-care treatment for nerve gaps >2 to 3 centimeters is autografting; however, autografting can result in neuroma formation, loss of sensory function at the donor site, and increased operative time. To address the need for a synthetic nerve conduit to treat large nerve gaps, we investigated a biodegradable poly(caprolactone) (PCL) conduit with embedded double-walled polymeric microspheres encapsulating glial cell line-derived neurotrophic factor (GDNF) capable of providing a sustained release of GDNF for >50 days in a 5-centimeter nerve defect in a rhesus macaque model. The GDNF-eluting conduit (PCL/GDNF) was compared to a median nerve autograft and a PCL conduit containing empty microspheres (PCL/Empty). Functional testing demonstrated similar functional recovery between the PCL/GDNF-treated group (75.64 ± 10.28%) and the autograft-treated group (77.49 ± 19.28%); both groups were statistically improved compared to PCL/Empty-treated group (44.95 ± 26.94%). Nerve conduction velocity 1 year after surgery was increased in the PCL/GDNF-treated macaques (31.41 ± 15.34 meters/second) compared to autograft (25.45 ± 3.96 meters/second) and PCL/Empty (12.60 ± 3.89 meters/second) treatment. Histological analyses included assessment of Schwann cell presence, myelination of axons, nerve fiber density, and g-ratio. PCL/GDNF group exhibited a statistically greater average area occupied by individual Schwann cells at the distal nerve (11.60 ± 33.01 µm2) compared to autograft (4.62 ± 3.99 µm2) and PCL/Empty (4.52 ± 5.16 µm2) treatment groups. This study demonstrates the efficacious bridging of a long peripheral nerve gap in a nonhuman primate model using an acellular, biodegradable nerve conduit.
Assuntos
Fator Neurotrófico Derivado de Linhagem de Célula Glial/administração & dosagem , Fator Neurotrófico Derivado de Linhagem de Célula Glial/química , Regeneração Nervosa/fisiologia , Animais , Axônios/efeitos dos fármacos , Axônios/metabolismo , Preparações de Ação Retardada , Fator Neurotrófico Derivado de Linhagem de Célula Glial/farmacologia , Macaca , Regeneração Nervosa/efeitos dos fármacos , Células de Schwann/efeitos dos fármacos , Células de Schwann/metabolismoRESUMO
The purpose of the present study was to develop a biodegradable and biocompatible polyurethane drug delivery system based on lysine diisocyanate (LDI) and glycerol for the controlled release of 7-tert-butyldimethylsilyl-10-hydroxy-camptothecin (DB-67). DB-67 has yet to be implemented in any clinical therapies due to the inability to delivered it in sufficient quantities to impact tumor growth and disease progression. To remedy this, DB-67 was covalently incorporated into our delivery system by way of an organometallic urethane catalyst and was found to be dispersed evenly throughout the LDI-glycerol polyurethane discs. Scanning electron micrographs indicate that the LDI-glycerol discs are uniform and possess a pore distribution typical of the non-solvent casting technique used to prepare them. The release rates of DB-67 from the LDI-glycerol discs were found to vary with both time and temperature and were shown capable of delivering therapeutic concentrations of DB-67 in vitro. Cellular proliferation assays demonstrate that empty LDI-glycerol discs alone do not significantly alter the growth of malignant human glioma cell lines (U87, T98G, LN229 and SG388). DB-67-loaded LDI-glycerol polyurethane discs were found to inhibit cellular proliferation by 50% on average in all the malignant glioma cell lines tested. These results clearly demonstrate the long-term, slow release of DB-67 from LDI-glycerol polyurethane discs and their potential for postoperative intracranial chemotherapy of cancers.
Assuntos
Camptotecina/análogos & derivados , Glioma/patologia , Glicerol/metabolismo , Isocianatos/metabolismo , Lisina/análogos & derivados , Compostos de Organossilício/farmacologia , Poliuretanos/metabolismo , Próteses e Implantes , Camptotecina/química , Camptotecina/farmacologia , Morte Celular/efeitos dos fármacos , Linhagem Celular Tumoral , Preparações de Ação Retardada , Ensaios de Seleção de Medicamentos Antitumorais , Glicerol/química , Humanos , Isocianatos/química , Lisina/química , Lisina/metabolismo , Microscopia Eletrônica de Varredura , Compostos de Organossilício/química , Soluções , Espectrometria de Fluorescência , Espectroscopia de Infravermelho com Transformada de Fourier , ComprimidosRESUMO
The purpose of the present study was to develop biodegradable and biocompatible polyurethane foams based on lysine diisocyanate (LDI) and glycerol to be used as drug-delivery systems for the controlled release of 7-tert-butyldimethylsilyl-10-hydroxy-camptothecin (DB-67). The impact of urethane catalysts on cellular proliferation was assessed in an attempt to enhance the biocompatibility of our polyurethane materials. DB-67, a potent camptothecin analog, was then incorporated into LDI-glycerol polyurethane foams with two different amine urethane catalysts: 1,4-diazobicyclo[2.2.2]-octane (DABCO) and 4,4'-(oxydi-2,1-ethane-diyl)bismorpholine (DMDEE). The material morphologies of the polyurethane foams were analyzed via scanning electron microscopy, and DB-67 distribution was assessed by way of fluorescence microscopy. Both foam morphology and drug distribution were found to correlate to the amine catalyst used. Hydrolytic release rates of DB-67 from the polyurethane foams were catalyst dependent and also demonstrated greater drug loads being released at higher temperatures. The foams were capable of delivering therapeutic concentrations of DB-67 in vitro over an 11week test period. Cellular proliferation assays demonstrate that empty LDI-glycerol foams did not significantly alter the growth of malignant human glioma cell lines (P<0.05). DB-67 loaded LDI-glycerol polyurethane foams were found to inhibit cellular proliferation by at least 75% in all the malignant glioma cell lines tested (P<1.0x10(-8)). These results clearly demonstrate the long-term, catalyst-dependent release of DB-67 from LDI-glycerol polyurethane foams, indicating their potential for use in implantable drug-delivery devices.
Assuntos
Antineoplásicos/química , Camptotecina/química , Preparações de Ação Retardada/química , Composição de Medicamentos/métodos , Isocianatos/química , Lisina/análogos & derivados , Poliuretanos/química , Antineoplásicos/administração & dosagem , Camptotecina/administração & dosagem , Catálise , Preparações de Ação Retardada/administração & dosagem , Difusão , Gases/química , Lisina/química , Teste de MateriaisRESUMO
BACKGROUND: Pediatric plastic surgeons perform reconstructive surgeries for various congenital, oncologic, and traumatic injuries. METHODS: Our Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center (UPMC) Plastic Surgery team was tasked to care for a young man who suffered a proximal humeral amputation of his dominant upper extremity. RESULTS: A multidisciplinary team collaborated throughout his entire acute care and postoperative course, guiding treatment and care in effort to maximize function of his replanted extremity. CONCLUSIONS: This case report details the patient's unique journey and highlights his determination and courage to return back to a normal life.
RESUMO
Nerve conduits are a proven strategy for guiding axon regrowth following injury. This study compares degradable silk-trehalose films containing chondroitinase ABC (ChABC) and/or glial cell line-derived neurotrophic factor (GDNF) loaded within a silk fibroin-based nerve conduit in a rat sciatic nerve defect model. Four groups of silk conduits were prepared, with the following silk-trehalose films inserted into the conduit: (a) empty; (b) 1 µg GDNF; (3) 2 U ChABC; and (4) 1 µg GDNF/2 U ChABC. Drug release studies demonstrated 20% recovery of GDNF and ChABC at 6 weeks and 24 h, respectively. Six conduits of each type were implanted into 15 mm sciatic nerve defects in Lewis rats; conduits were explanted for histological analysis at 6 weeks. Tissues stained with Schwann cell S-100 antibody demonstrated an increased density of cells in both GDNF- and ChABC-treated groups compared to empty control conduits (p < 0.05). Conduits loaded with GDNF and ChABC also demonstrated higher levels of neuron-specific PGP 9.5 protein when compared to controls (p < 0.05). In this study we demonstrated a method to enhance Schwann cell migration and proliferation and also foster axonal regeneration when repairing peripheral nerve gap defects. Silk fibroin-based nerve conduits possess favourable mechanical and degradative properties and are further enhanced when loaded with ChABC and GDNF. Copyright © 2014 John Wiley & Sons, Ltd.
Assuntos
Condroitina ABC Liase/farmacologia , Fibroínas/química , Fator Neurotrófico Derivado de Linhagem de Célula Glial/farmacologia , Regeneração Nervosa/efeitos dos fármacos , Nervos Periféricos/fisiologia , Animais , Liberação Controlada de Fármacos , Imuno-Histoquímica , Músculos/efeitos dos fármacos , Tamanho do Órgão/efeitos dos fármacos , Nervos Periféricos/efeitos dos fármacos , Ratos Endogâmicos LewRESUMO
Decellularized scaffold materials are capable of regenerating missing tissues when utilized under appropriate conditions. Fat grafting also has reported advantages in revitalizing damaged tissue beds. This report details a case of traumatic fingertip amputation treated with a combination of decellularized materials in conjunction with fat grafting, resulting in a supple and functional reconstruction of the affected digit. After traumatic fingertip amputation, a patient was initially treated with decellularized porcine urinary bladder matrix powder. As a second stage, the healed tip scar tissue was reexcised, and a second application of powder was applied. As a third stage, the tip scar tissue was reexcised and a decellularized bilayer was sewn into the soft tissues of the debrided tip, resulting in an improved soft tissue envelope. As a final stage, the restored fingertip soft tissue envelope was fat grafted for additional bulk. Patient underwent treatment every other day with decellularized porcine urinary bladder matrix (powder and bilayer) and was able to reasonably regenerate the traumatic fingertip soft tissue envelope. This resulted in an envelope that was further enhanced with fat grafting. The resulting digit was sensate with maintained length, and possessed a more normal appearance than would be achieved by healing by secondary intention, or local flap or graft coverage. Decellularized materials can be utilized in conjunction with fat grafting to treat traumatic fingertip amputations in select patients. This combination approach is able to achieve a sensate fingertip and regain length lost in the affected digit. Additionally, we describe a novel technique that can be employed to maximize the amount of soft tissue regenerated by the decellularized products.
RESUMO
Ulnar neuropathy is caused by compression of the ulnar nerve in the upper extremity, frequently occurring at the level of the elbow or wrist. Rarely, ulnar nerve entrapment may be seen proximal to the elbow. This report details a case of ulnar neuropathy diagnosed and localized to the arcade of Struthers with electromyography (EMG) and ultrasound (US) imaging and confirmed at time of operative release. US imaging and EMG findings were used to preoperatively localize the level of compression in a patient presenting with left ulnar neuropathy. In this case, ulnar entrapment 8 cm proximal to the medial epicondyle was diagnosed. Surgical release was performed and verified the level of entrapment at the arcade of Struthers in the upper arm. Alleviation of symptoms was noted at 8-week follow-up; no complications occurred. US imaging can be used in complement with EMG studies to properly diagnose and localize the level of ulnar nerve entrapment. This facilitates full release of the nerve and may prevent the need for revision surgery.
RESUMO
BACKGROUND: The goal of this study was to assess the long-term arterial patency of repaired arteries in the upper extremity and any morbidity resulting from the subsequent occlusion of these vessels. Concurrently, a new questionnaire, the modified Cold Intolerance Symptom Severity (mod CISS) questionnaire, was developed to allow for better assessment of cold intolerance. METHODS: Thirteen patients who had undergone repair of the radial (4 patients), ulnar (6 patients), brachial (1 patient), digital (1), and an undefined lower arm artery (1) were examined using questionnaires, physical examination, and high-resolution ultrasound. RESULTS: Outcome measures that were statistically significantly worse in the group of patients who presented with nerve injuries included cold intolerance symptoms, Disabilities of the Arm, Shoulder, and Hand score, Michigan Hand Questionnaire, and grip strength (middle setting on dynamometer). The results from the mod CISS correlated with high statistical significance with the results of the CISS score for the injured hand. Of note, wrist extension was significantly better with patent arteries. CONCLUSIONS: Sixty-seven percent of arterial repairs remained patent at 6 years (mean) follow-up. The presence of nerve injury has a higher impact on the outcome metrics assessed in this study than arterial patency. Our modification of the CISS score enhances its utility as a survey of cold intolerance.