Clinical experience and indications of the free serratus fascia flap: a report of 21 cases

The free "serratus fascia" flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor-site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three-dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences.     

Moxonidine inhibits Na+/H+ exchange in proximal tubule cells and cortical collecting duct

The lateral arm free flap can be harvested as a fascial flap or fasciocutaneous flap. In this report we describe the use of the lateral arm fascial flap for degloving injuries of the fingers and for skin loss on the dorsum of the hand with exposure of tendons and bones. Concomitant reconstruction of a missing phalanx with a portion of the distal humerus is also described. The use of the fascial flap allows a large area of tissue to be harvested, and still, the donor site can be closed primarily. The fascia is thin and pliable and so conforms well to the contour of the fingers. Its bulk does not interfere with finger motion, and its undersurface creates a gliding surface for tendons. Complications in the reported cases were negligible.     

A historical review of mental health services in Hong Kong (1841 to 1995)

OBJECTIVE: To review the experience of 1 microvascular surgeon during an 11-year period in performing 210 vascularized bone-containing free flaps for oromandibular reconstruction. DESIGN: Retrospective medical records review of patients who underwent primary and secondary oromandibular reconstruction with the use of vascularized bone free flaps. SETTING: Academic medical center. PATIENTS: A total of 201 patients underwent 210 composite free-flap reconstructions of the mandible for various disorders and with a range of bony and soft tissue defects. INTERVENTION: All patients underwent the microvascular transfer of vascularized bone flaps from the ilium, fibula, or scapula. In selected cases, 2 simultaneous free flaps were transferred to achieve an optimal bone and soft tissue reconstruction. Endosteal dental implants were used in 81 patients, with a total of 360 fixtures placed during these 11 years. MAIN OUTCOME MEASURES: The success of microvascular free tissue transfer, dental implant extrusion, and short- and long-term complications at the recipient and donor sites. RESULTS: Of the 210 mandibular reconstructions that were performed, 202 were successful in reestablishing mandibular continuity. Reexploration for vascular-related complications was done in 16 patients, 8 of whom were successfully treated, yielding an overall success rate of 96%. The overall success rate for endosteal dental implants was 92%. The implant success rate was 86% when the bone in which the fixtures were placed was irradiated postoperatively. The success rate was 64% in the 14 fixtures that were placed into previously irradiated bone. CONCLUSIONS: The success of the use of vascularized bone free flaps in restoring continuity to the mandible is clearly demonstrated in this series. There was an acceptable incidence of donor- and recipient-site complications that resulted in minimal long-term morbidity. The careful selection of a donor site(s) for oromandibular reconstruction allows for an optimal restoration of bony and soft tissue defects. Dental implants can be safely used in oromandibular reconstruction with a high level of success. Placing these implants during the initial surgery shortens the duration for achieving dental rehabilitation and enhances the success of the implants when postoperative radiotherapy is administered.     

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.     

Chondrocyte-seeded collagen matrices implanted in a chondral defect in a canine model

The objective of our study was to evaluate reparative tissues formed in chondral defects in an adult canine model implanted with cultured autologous articular chondrocytes seeded in type I and II collagen GAG matrices. Two defects were produced in the trochlea grooves of the knees of 21 dogs, with cartilage removed down to the tidemark. This study includes the evaluation of 36 defects distributed among five treatment groups: Group A, type II collagen matrix seeded with autologous chondrocytes under a sutured type II collagen flap; Group B, type I collagen matrices seeded with chondrocytes under a sutured fascia flap; Group C, unseeded type I collagen matrix implanted under a sutured fascia flap; Group D, fascia lata flap alone; and Group E, untreated defects. All animals were killed 15 weeks after implantation. Six other defects were created at the time of death and evaluated immediately after production as 'acute defect controls'. In three additional defects, unseeded matrices were sutured to the defect and the knee closed and reopened after 30 min to determine if early displacement of the graft was occurring; these defects served as 'acute implant controls'. The areal percentages of four tissue types in the chondral zone of the original defect were determined histomorphometrically: fibrous tissue (FT); hyaline cartilage (HC); transitional tissue (TT, including fibrocartilage); and articular cartilage (AC). New tissue formed in the remodeling subchondral bone underlying certain defects was also assessed. Bonding of the repair tissue to the subchondral plate and adjacent cartilage, and degradation of the adjacent tissues were evaluated. There were no significant differences in the tissues filling the original defect area of the sites treated with chondrocyte-seeded type I and type II matrices. Most of the tissue in the area of the original defect in all of the groups was FT and TT. The areal percentage of HC plus AC was highest in group E, with little such tissue in the cell-seeded groups, and none in groups C and D. The greatest total amount of reparative tissue, however, was found in the cell-seeded type II matrix group. Moreover, examination of the reparative tissue formed in the subchondral region of defects treated with the chondrocyte-seeded collagen matrices (Groups A and B) demonstrated that the majority of the tissue was positive for type II collagen and stained with safranin O. These results indicate an influence of the exogenous chondrocytes on the process of chondrogenesis in this site. In all groups with implants (A-D), 30(50% of the FT and TT was bonded to the adjacent cartilage. Little of this tissue (6-22%) was attached to the subchondral plate, which was only about 50% intact. Remarkable suture damage was found in sections from each group in which sutures were used. Harvest sites showed no regeneration of normal articular cartilage, 18 weeks after the biopsy procedure. Future studies need to investigate other matrix characteristics, and the effects of cell density and incubation of the seeded sponges prior to implantation on the regenerative response.     

The use of autogenous fat, fascia, and nonvascularized muscle grafts in the head and neck

We have reviewed the transplantation of autogenous fat, fascia, and nonvascularized muscle. Although none of these tissues satisfies all of the requirements for an ideal transplantation material, understanding the indications and each material's limitations will broaden the surgeon's armamentarium when soft-tissue grafting is desired. Although the use of autogenous fat grafts in head and neck surgery has been associated with some unpredictability, fat remains an excellent choice for obliteration of frontal sinuses, for myringoplasty, and for limited soft-tissue augmentation. In most applications, significant resorption of the transplanted fat can be expected, and it should be compensated for accordingly by initial overcorrection. Future research endeavors, including development of preadipocyte transplants and hormonal manipulation of fat grafts, will perhaps improve results of transplantation. The grafting of fascia has been shown to be a very reliable technique, especially when tensile strength is required of the transplant material. In grafts, fascia is much more predictable than fat, in that the majority of the fascia survives as living tissue that retains its original characteristics. A relative lack of three-dimensional bulk, however, limits the use of fascia in soft-tissue augmentation. The transplantation of nonvascularized muscle, because of its enormous metabolic requirements, almost always results in death of the muscle cells and subsequent partial replacement by fibrous tissue. Free muscle grafts therefore have very limited application, except in circumstances in which fibrous tissue obliteration of small defects (such as the nasofrontal duct or eustachian tube) is the desired result. In clinical situations in which maintenance of the substance or bulk of the transplanted material is of paramount importance, consideration should be given instead to the transfer of vascularized tissue. For this purpose, numerous simple and composite flaps of fascia, fat, muscle, and other tissues are now available. Vascularized tissue transfers are certainly not the solution to every reconstructive problem, however. When properly selected and applied, the transplantation of fat, fascia, and occasionally muscle remains an important option for soft-tissue replacement in head and neck surgery.     

Injury of the popliteal artery & the popliteal branches: analysis of 31 consecutive cases

In complex traumas of lower limbs it is fundamental the reducing of the time of ischemia to reduce the number of failures in repairing surgery and the percentage of the demolishing of necessity surgery. The experience of the authors is based on 31 complex traumas of lower limbs with distal vascular injuries to Hunter's canal, which were associated to bone, nervous and muscular lesions. In total we are treated 37 vascular injuries by interposition of venous autografts in 37 cases, lateral pacth in one case ant suture T-T in two cases. The protection of the reconstructed vases, in case of a concomitant loss of substance, was entrused to microvascular flaps for 7 times latissimus dorsi, iliac crest and fascio-cutaneous for 5 times posterior reversed with distal baset and for three times antero-lateral, which in three cases of them needed successively a dermoepidermic grafts. The bone injuries, which were treated by external fixation, intramedullary nailing, plate and screws, just in two cases became worse in pseudoarthroses and just in one in osteomyelitis. The reparation of nervous injuries had bad results just in two cases. The percentage of saving of the limb it was about 83.9%.     

Traumatic myositis ossificans. Posttraumatic non-neoplastic heterotopic ossification

Myositis ossificans traumatica (MOT) is a nonneoplastic, heterotopic ossification of soft tissues i.e. skeletal muscle, tendons, aponeuroses and fascia. It is often encountered in young male athletes participating in contact sports as a result of a single or repeated contusion. MOT tends to be solitary, localized and well circumscribed with a self-limited growth potential that may culminate in regression. The pathogenesis of MOT is still enigmatic. Recent animal experiments have led to a theory that mesenchymal connective tissue cells, undergo metaplasia induced by trauma and probably osteogenic proteins, to fibroblasts and osteoblasts. These cells deposit and structure osteoid centripetally in the lesion. As the lesion matures, cancellous bone develops into mature, lamellar bone in the periphery of the lesion. In its earlier stages MOT is easily cytologically and radiologically confused with osteogenic sarcoma. The management of MOT is largely conservative and the principles are of considerable value to physicians and physiotherapists engaged in the treatment of sports injuries. This article reviews the various forms of myositis ossificans as well as the pathology, diagnosis and treatment options.     

Expression of c-met proto-oncogene product (c-MET) in benign and malignant bone tumors

The expression of c-met proto-oncogene product (c-MET) has been reported to be related to invasive growth or tumor stage in some tumors, but little is known concerning the significance of c-MET expression in bone tumors. With use of formalin-fixed, paraffin-embedded tissue specimens and polyclonal antibody for c-MET, we studied the expression of c-MET in 122 cases of malignant bone tumors (43 osteosarcomas, 24 chondrosarcomas, 21 malignant fibrous histiocytomas of bone, 16 Ewing's sarcoma versus primitive neuroectodermal tumors, 18 chordomas), 65 cases of benign tumors and tumor-like lesions (including 8 giant cell tumors of bone, 8 chondroblastomas, 12 enchondromas, 7 osteochondromas, 10 fibrous dysplasias), 7 cases of articular cartilaginous tissue, and 10 cases of fetal vertebral tissue consisting of foci of enchondral ossification and notochordal tissue. In malignant tumors, c-MET expression was most frequently detected in chordoma (94.4%), followed by chondrosarcoma (54.2%) and osteosarcoma (23.3%). Among the osteosarcoma specimens, c-MET expression was frequently detected in the chondroblastic subtype (66.7%), but the incidence was low in the cases with other subtypes of osteosarcoma. We found no significant correlation between the c-MET expression and the histologic grade of malignancy in either osteosarcoma or chondrosarcoma. c-MET expression was either rarely observed or completely negative in malignant fibrous histiocytomas of bone (4.8%) and primitive neuroectodermal tumors (0%). In benign tumors and tumor-like lesions, c-MET expression was frequently detected in cartilaginous tumors, such as chondroblastoma (62.5%), enchondroma (66.7%), and osteochondroma (71.4%), but no expression was observed in giant cell tumors of bone or any other benign tumors or tumor-like lesions. In normal tissue, c-MET expression was frequently detected in the articular cartilage (100%) and notochord (70.0%) specimens examined. We conclude that c-MET expression as frequent as that observed in the notochordal tissue, chordomas, articular cartilage, and cartilaginous tumors is related to the development of both normal tissue and chondroid tumors.     

Zonal expression of angiotensin II-AT1-receptor genes in rat kidneys

The trapezius osseomyocutaneous flap is the only pedicled flap that is able to transfer vascularized bone for mandibular reconstruction as well as skin for intra-extra oral reconstruction. The trapezius muscle also helps to fill the defect created by the neck dissection and covers the vessels of the neck. This flap has been used in our maxillofacial surgery service during the past 14 years. In spite of having incorporated microvascular flaps in our reconstructive techniques it continues to be one of the flaps we use in selected patients for bone and soft tissue compound defects of the oral cavity. We describe in this article our experience using this flap with dental implants in order to achieve a functional reconstruction. We also discuss when we use this flap for mandibular reconstruction and when a free vascularized flap is used.     

"Window" laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery

Endoscopic laser resection of early laryngeal carcinoma is an increasingly used treatment modality; however, the limited exposure achieved and the alteration of vocal function are still major problems. A new surgical procedure, "window" laryngoplasty, has been devised and tested in an in vivo study in 6 canines with 50 days' survival. The right vocal cord was incised endoscopically with the carbon dioxide laser, and the en bloc specimen with adjacent thyroid cartilage was removed through a window approach made in the thyroid cartilage. A sternohyoid muscle flap based superiorly was inserted into the cartilaginous window to reconstruct a pseudocord with coverage of either mucosa or fascia. A diode laser soldering technique was used to secure the mucosal graft in place. Epithelial transplantation can be accomplished externally with precise endoscopic guidance for reliable placement of the pseudocord. The results show that the new technique, a combination of endoscopic and open approaches, may be a better treatment choice than standard vertical partial laryngectomy in selected patients. Advantages of this technique include adequate en bloc resection, including adjacent cartilage for pathologic evaluation, preservation of the integrity of most of the laryngeal framework, avoidance of tracheotomy, and better functional results.     

Low CD83, but normal MHC class II and costimulatory molecule expression, on spleen dendritic cells from HIV+ patients

Iliac and sacral articular cartilage of 25 human sacroiliac joints (1-93 years) are examined by light microscopy and immunohistochemistry in order to gain further insight into the nature and progress of degenerative changes appearing during aging. These changes can already be seen in younger adults as compared to cartilage degeneration known in other diarthrodial joints. Structural differences between sacral and iliac cartilage can already be observed in the infant: the sacral auricular facet is covered with a hyaline articular cartilage, reaching 4 mm in thickness in the adult and staining intensely blue with alcian blue at pH1. Iliac cartilage of the newborn is composed of a dense fibrillar network of thick collagen bundles, crossing each other at approximately right angles. A faint staining with alcian blue suggests a low content of acidic glycosaminoglycans. In the adult, iliac cartilage becomes hyaline and its maximal thickness reaches 1-2 mm. Both articular facets exhibit morphological changes during aging that are more pronounced in the iliac cartilage and resemble osteoarthritic degeneration; the staining pattern of the extracellular matrix becomes inhomogenous, chondrocytes are arranged in clusters and the articular surface develops superficial irregularities and fissures. Sometimes fibrous tissue fills up these defects. Nevertheless, large areas of iliac cartilage remain hyaline in nature. Sacral articular cartilage often remains largely unaltered until old age. The sacral subchondral bone plate is usually thin and shows spongiosa trabeculae inserted at right angles, suggesting a perpendicular load on the articular facet. Iliac subchondral spongiosa shows no definite alignment and joins the thickened subchondral bone plate in an oblique direction. The iliac cartilage therefore seems to be stressed predominantly by shearing forces, arising from the changing monopodal support of the pelvis during locomotion. The subchondral bone plate on both the iliac and sacral auricular facet is penetrated by blood vessels that come into close contact with the overlying articular cartilage. These vessels may contribute to the high incidence of rheumatoid and inflammatory diseases in the human sacroiliac joint. Immunolabelling with an antibody against type II collagen reveals a diminished immunoreactivity in the upper half of adult sacral cartilage and only a faint and irregular labelling in the iliac cartilage. Type I collagen can be detected in a superficial layer on the sacral articular surface and around chondrocyte clusters in iliac cartilage, as in dedifferentiating chondrocytes during the development of osteoarthritis.     

Repair of large full-thickness articular cartilage defects with allograft articular chondrocytes embedded in a collagen gel

Full-thickness articular cartilage defects are a major clinical problem; however, presently there is no treatment available to regeneratively repair these lesions. The current therapeutic approach is to drill the base of the defect to expose the subchondral bone with its cells and growth factors. This usually results in a repair tissue of fibrocartilage that functions poorly in the loaded joint environment. The use of phenotypically appropriate chondrocytes embedded in a collagen gel delivery vehicle may provide a method that could be used to repair full-thickness articular cartilage defects with functionally satisfactory hyaline cartilage. Allograft articular chondrocytes embedded in a type I collagen gel were transplanted into large (6 x 3 x 3 mm), full-thickness articular cartilage defects in condylar and patellar weight-bearing surfaces to develop clinically applicable methods to repair articular cartilage defects. Chondrocytes were isolated from the articular cartilage of 4-week-old New Zealand rabbits and embedded in type I collagen gels. This composite was transplanted into a full-thickness defect on the medial femoral condyle and patellar groove of adolescent host rabbits. The repair cartilage was assessed histologically by a semiquantitative scoring system and biomechanically with a microindentation technique of specimens 4-48 weeks after chondrocyte transplantation. Defects in both locations were repaired with histologically apparent hyaline cartilage observed from as early as 4 weeks until 48 weeks after transplantation. The repair cartilage in the medial femoral condyle was more irregular than in the patellar groove, but in all other respects was similar. The grafted tissue did not remodel and differentiate into the morphological zones seen in normal articular cartilage. No tidemark or subchondral bony plate formed even 48 weeks after transplantation. Biomechanically, the repaired cartilage demonstrated indentation values similar to normal articular cartilage 12 weeks after transplantation and remained the same 48 weeks after transplantation. By contrast, the control (i.e., empty) defects healed with tissue that exhibited very poor metachromatic staining and exhibited very high indentation values. Incomplete bonding of the repair tissue to the normal cartilage was seen, and the surface was significantly irregular with major discontinuities. These observations provide the basis for considering the use of allograft articular chondrocytes to repair articular cartilage defects in the weight-bearing regions of the knee.     

Efficacy of perichondrium and a trabecular demineralized bone matrix for generating cartilage

A pedicled auricular perichondrial flap wrapped around trabecular demineralized bovine bone matrix can generate an autologous cartilage graft. In earlier experimental studies, it was demonstrated that this graft could be used for nasal and cricoid reconstruction. It was assumed that the vascularization of the perichondrial flap was obligatory, but it was never proven that the flap should be pedicled. Moreover, for clinical use, the dimensions of the auricle would set restrictions to the size of the graft generated. Therefore, the possibility to generate cartilage with a composite graft of a free perichondrial flap wrapped around demineralized bovine bone matrix, by using young New Zealand White rabbits, was studied. This composite graft was implanted at poorly (subcutaneously in the abdominal wall; n = 12), fairly (subcutaneously in the pinna; n = 12), and well-vascularized sites (quadriceps muscle; n = 12). As a control, trabecular demineralized bovine bone matrix was implanted without perichondrial cover. Half of these grafts (n = 6) were harvested after 3 weeks, and the remaining grafts (n = 6) after 6 weeks of implantation. In histologic sections of these grafts, the incidence of cartilage formation was scored. Furthermore, the amount of newly formed cartilage was calculated by computerized histomorphometry. Trabecular demineralized bovine bone matrix without perichondrial cover demonstrated early resorption; no cartilage or bone was formed. In demineralized bovine bone matrix wrapped in perichondrium, early cartilage formed after 3 weeks at well- and fairly vascularized sites. No cartilage could be detected in grafts placed at a poorly vascularized site after 3 weeks; minimal cartilage formed after 6 weeks. In summary, the highest incidence of cartilage formed when trabecular demineralized bovine bone matrix was wrapped either in a pedicled auricular perichondrial flap or in a free perichondrial flap, which was placed at a well-vascularized site. Second, a significantly higher percentage of the total area of the graft was cartilaginized at well-vascularized sites after 3 weeks. The newly generated cartilage contained collagen type II and proteoglycans with hyaluronic acid binding regions, whereas collagen type I was absent, indicating the presence of hyaline cartilage. This study demonstrates that new cartilage suitable for a graft can be generated by free perichondrial flaps, provided that the site of implantation is well vascularized. Consequently, the size of such a graft is no longer limited to the dimensions of the auricle.     

Toxic effects of quinolone antibacterial agents on the musculoskeletal system in juvenile rats

Quinolone antibacterial agents have adverse effects on the musculoskeletal system in humans, consisting mainly of myalgia and arthralgia, and additionally of tendon disorders and rhabdomyolysis. The present study was conducted to examine the toxic effects of quinolones on the musculoskeletal system in juvenile rats using light microscopy, 5-bromo-2'-deoxyuridine (BrdU) immunohistochemistry and electron microscopy. Single oral administration of 900 mg/kg pefloxacin (PFLX) or levofloxacin (LVFX) was found to induce lesions in the muscle + fascia, tendon + sheath, and synovial membrane, in addition to articular cartilage in the fore- and hindlimbs. Articular cartilage lesions were not necessarily associated with changes in the muscle, tendon, and synovial membrane, or the reverse. Among all lesions, the ankle and elbow showed the highest incidence and severity. Changes were more severe in the PFLX than in the LVFX group. Lesions in the muscle + fascia, tendon + sheath, and synovial membrane were similar and characterized by edema and increased number of mononuclear cells, many of which were positively stained with BrdU, as well as vascular endothelial cells in the Achilles tendon sheath and synovial membrane in the ankle. Electron microscopic examination revealed an increased number of fibroblasts and macrophages and collagen deposition in the matrix of the synovial membrane and tendon sheath. Capillary endothelial cells were hypertrophied, increased in number, and stratified. These results suggest that quinolones have toxic potentials in the muscle, tendon, and synovial membrane in addition to articular cartilage, and that local vascular hyperpermeability may contribute to the development of these lesions.     

Vascularized bone grafts for congenital pseudarthrosis of the tibia

Eight vascularized fibula grafts and two vascularized rib grafts were used for the treatment of 10 Boyd's Type II congenital pseudarthrosis of the tibia. All but one vascularized fibula graft united within 4 months. The two vascularized rib grafts did not unite until receiving a conventional bone graft. Nine spontaneous fractures were seen in four patients; all were subsequently treated successfully with cast or conventional bone graft. Corrective osteotomies were done in two patients. Follow-up averaged 8 years and 5 months (range, 5 years and 1 month to 14 years and 4 months). Average age at end of follow-up was 13 years and 6 months (range, 7 years and 10 months to 20 years and 4 months). After bony union was achieved, shortening of the affected leg averaged 3.8 centimeters, flexion deformity averaged 20 degrees, and valgus deformity averaged 24 degrees. In three patients, whose leg discrepancy averaged 4.9 centimeters, the leg was lengthened at an average patient age of 13 years and 9 months (age range, 11 years and 7 months to 15 years and 2 months). The resulting limb length discrepancy averaged 2.2 centimeters. Vascularized bone grafting is a reliable technique for achieving bony union in congenital pseudarthrosis of the tibia. Residual shortening may be corrected later by limb lengthening.     

A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects

PURPOSE: This study compared vascularized and nonvascularized bone grafts for the reconstruction of segmental defects of the mandible. PATIENTS AND METHODS: The results in 39 patients having vascularized bone grafts (38 fibulas and one iliac crest) and 29 patients having nonvascularized bone grafts (26 iliac crest [22 corticocancellous block grafts, four cancellous bone grafts in a tray] and three rib grafts) for segmental mandibular reconstruction were evaluated in terms of overall success rate, total number of surgeries performed, total blood loss, total number of hospital days, and total number of hours in the operating room. RESULTS: Of 39 vascularized bone grafts, two failed (95% success rate), whereas of 29 nonvascularized bone grafts, seven failed (76% success rate). Failure for the nonvascularized bone grafts was closely correlated to the length of the defect. Nonvascularized bone graft patients underwent an average of one more surgical procedure for total reconstruction than vascularized bone graft patients, including osseointegrated implants. However, vascularized bone graft patients spent a mean of over 14 additional days in the hospital for all of their reconstructive procedures and an additional 3 hours in the operating room as compared with nonvascularized bone graft patients. Blood loss was similar in both groups (1,100 mL). Only 20% to 24% of patients in each treatment group have completed reconstruction to include osseointegrated implants. CONCLUSIONS: The success rate for vascularized bone grafting is high and is the treatment of choice when primary reconstruction is required, when the patient has been previously irradiated, or when simultaneous replacement of soft tissue is required. Vascularized bone grafts are also the treatment of choice for mandibular replacements over 9 cm in length. Nonvascularized bone grafts create a better contour and bone volume for facial esthetics and subsequent implant insertion, and may be the treatment of choice for secondary reconstruction of defects less than 9 cm in length.     

Interferon or corticosteroid: treatment of patients with chronic hepatitis C positive for serum markers of autoimmune diseases

From 1979 to 1994, reparative and reconstructive surgery were used to repair the war injuries of skins, bones, blood vessels and nerves of the limbs in 800 cases. A systematic clinical study was carried out. Many new operative methods were used and the results of treatment were good. Innovations and modifications were made in technique. In 120 cases of war injuries having soft tissues defects including skin and muscles, various tissue transplantations were used with the hope to accomplish one-staged repair of the defect and reconstruction of motor function of muscle. To those infections of bone and joint in war injuries, following early eradication of infected focus, transplantation of musculo-cutaneous flap or omental graft was immediately carried out with the aim to obtain primary healing of the wound. In the treatment of bone defects from war wounds with loss of skin and muscles, the vascularized skeleto-cutaneous graft was used. In the treatment of 150 cases of injury of peripheral nerve from forearms, the result of good to fair rated 68.8 percent for upper extremity and that for lower extremity, it was 62.2 percent. Following the early repair of 500 cases of injury of peripheral blood vessels, the patency rate of the blood vessel was 90 percent. The result following by pass vascular graft in the treatment of forearms injury of blood vessels even with very poor local condition was still very successful.     

Cranioplasty with neovascularized autogenous calvarial bone

We have presented two cases of cranioplasty with neovascularized autogenous calvarial bone. A surgical procedure applying the principle of flap prefabrication has been applied to the preservation of autogenous calvarial bone obtained during external cranial decompression. The rectus abdominis muscle flap was elevated. A subcutaneous pocket was prepared for preservation of calvarial bone integrated with the rectus abdominis muscle. The outer cortex of calvarial bone was removed partially by bone chiseling. The muscle flap was attached to the bone graft by means of two holes on the bone by suture. The calvarial bone, grafted onto the rectus abdominis muscle flap, was inserted into the subcutaneous pocket. Several weeks later, the neovascularized calvarial bone flap was dissected along with inferior epigastric pedicle. Cranioplasty was performed using the bone element of the flap. Revascularization was achieved by anastomosing the inferior epigastric vessels to the temporal vessels. The postoperative films demonstrated marked radiolucency at the borders of the flap, although bone scan documented that the flap was vascularized. We speculate that the transferred bony segment was not completely vascularized.     

Nomenclature of dyspepsia, dyspepsia subgroups and functional dyspepsia: clarifying the concepts

Aging implies changes in joint components over a continuum of time that contribute later in life to an increasing frequency of clinical complaints and impairments in function and mobility. This article considers how aging appears to modify the articular cartilage, subchondral bone, muscle, the soft tissues, synovial membrane, and synovial fluid. Whether the changes in aging inevitably progress through an intermediary phase of "degenerated cartilage" to the fibrillated state of osteoarthritis is not clear.