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Carsten W Schlickewei, Sinef Yarar, Johannes M Rueger Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Abstract: Despite continuous advances in surgical procedures and antibiotic therapies, osteomyelitis still remains one of the most devastating complications in trauma and orthopedic surgery. Treatment of osteomyelitis represents a severe and challenging problem, even if the treatment of acute cases with systemic antibiotics has good success rates. Chronic cases need a consequent resection of dead or infected bone in addition to an improved systemic and local antibiotic therapy. The gold standard therapy is the implantation of polymethylmethacrylate as spacer and local antibiotic carrier. Besides other drawbacks, nonbiodegradable polymethylmethacrylate implants need to be removed. This led to an ongoing search for a biodegradable antibiotic bone graft substitute for the treatment of osteomyelitis to avoid secondary removal. The number of clinically available products grows, but still, the available number of peer-reviewed clinical trials to prove their efficiency is limited. This review gives an overview of the current available literature. Keywords: osteomyelitis, bone infection, eluting antibiotics, bone graft substitutes, antibiotic bone graft

Aim: In the present study, we demonstrated that total cardiac 201Tl uptake changes associated with histological findings in DOX-induced early myocardial injury. Method: Early DOX cardiotoxicity was induced in normal rats by giving 15 mg/kg DOX intraperitoneally. Cardiac uptake studies and the blood sampling for creatine kinase (CK) and lactate dehydrogenase (LDH) assay has been performed on the 3rd (acute phase) and 16th days (subacute phase) after the treatment, respectively. Rats were killed by heart puncture and the hearts removed by dissection at 60 min after the injection of 7.4 MBq 201Tl. The ratio of total cardiac uptake to the injected dose (%ID/g x BW, where ID is injected dose and BW is body weight) was calculated. Result: DOX led to a significant decrease in myocardial uptake of 201Tl in both treatment groups (p< 0.05). There was no significant difference in the %ID/g x BW between acute and subacute phases (p>0.05). DOX induced a significant increase in the levels of CK and LDH in serum, indicating its early cardiotoxicity (p=0.01). DOX treatment produced disorganization of myocardial fibers, vacuolation of the cardiac myocytes and myocardial necrosis (p=0.01). These cardiomyocyte injuries were accompanied by increased numbers of mononuclear cells (p< 0.05). LDH, CK, cardiyomyopathy and mononuclear cell infiltration scores were not found significantly different between acute and subacute phases (p>0.05). Conclusion: The DOX-induced cardiac injury at early stage can be evaluated by 201Tl and the findings may be associated with the myocardial inflammation. Due to the complicated mechanism of DOX injury, we believe that the development process of cardiac injury and the pathological findings should be taken into consideration in interpreting the radiopharmasotic studies to be conducted for the evaluation of the early and late stage cardiac injuries. [ABSTRACT FROM AUTHOR]

Nerve conduits could be used to provide a bridge between both nerve endings. In this study, the tuba uterina of female rats were prepared in a vascularized pedicled flap model and it used as a nerve conduit. The aim was to investigate the effectiveness of a vascularized pedicle nerve conduit and its ciliated epithelium in a sciatic nerve defect. The study was conducted between May and August 2018, and used a total of 60, 14-16-week-old female Wistar albino rats. Six groups were created; Cut and Unrepaired Group, Nerve Graft Group, Flap-Forward Group (Tuba uterina tubular flap, forward direction), Flap-Reversed Group (Tuba uterina tubular flap, reverse direction), Graft-Forward Group (Tuba uterina tubular graft, forward direction) and Graft-Reverse Group (Tuba uterina tubuler graft, reverse direction). Nerve regeneration was evaluated 3 months (90 days) after the surgery by the following methods: (1 ) Sciatic Functional Index (SFI) measurement, (2) Electromyographic (EMG) assessment, (3) Microscopic assessment with the light microscope and (4) Microscopic assessment with the electron microscope. According to the SFI, EMG and microscopic assessments with the light and electron microscope, it was observed that the transfer of tuba uterina tubular conduit as a graft was statistically better in its effect on nerve regeneration than flap transfer, but also indicated that the direction of the ciliated structures had no significant effect. We believe that as this model is improved with future studies, it will shed light on new models, ideas and innovations about nerve conduits.

Background: The objective of this study was to investigate the effects that the application of mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) following tendon repair have on the strength and healing of the tendon and also to examine the possible mechanisms of action that take place., Methods: The Achilles tendons of 80 rats were repaired and divided into eight groups. Following the repairs, MSCs obtained from humans were injected into the rat tendons in groups 1 and 2, a combination of MSCs from humans and PRP from rats was injected into the tendons in groups 3 and 4, and PRP from rats was injected into the tendons in groups 5 and 6. These procedures all took place simultaneously. Groups 7 and 8 did not receive any injections following the repairs. The rats were sacrificed at the end of the first and second months following the procedures, and biomechanical and histopathological analyses were performed., Results: Inflammatory cell density increased most significantly in the combined group when compared to the first and second months. T he fibroblast density on the tendon repair region was significantly lower in the second-months groups of each intervention compared to their first-month groups (p = 0.001). For the analysis of the maximum tensile breaking force, the behaviors of the groups over time were significant when compared to the control groups (p = 0.0015). Also, the mean maximum breaking force in the combined group was statistically significantly higher at the end of the second month than at the end of the first month (p = 0.0008).

Primary intraosseous vascular malformations (PIVMs) are rare intraosseous lesions, accounting for approximately 0.5-1% of all intraosseous tumours. In this case report, we aimed to present a rare case of intraosseous vascular malformation causing a large lytic area in the parietal bone. A 25-year-old male patient was admitted to the clinic with a mass on the parietal bone. On physical examination, it was observed that the hair density on the mass was decreased, the mass had a soft consistency, and there was no pain on palpation. The patient was operated under local anaesthesia with a provisional diagnosis of a trichilemmal cyst. However, intraoperative diagnosis was a vascular malformation. There was a 3-cm full-thickness defect on the parietal bone caused by the lesion. The mass was excised completely while preserving the integrity of the dura. The resulting defect was reconstructed with bilateral rotation advancement flaps. The calvarial defect was not reconstructed due to equipment inadequacy. No complications were encountered in the postoperative period. Ninety-three PIVM cases have been reported in the skull since 1845. In very few of these cases, the mass is located in the parietal bone. The pathogenesis of PIVMs is not completely understood. The definitive diagnosis is made by histopathological examination. The therapeutic gold standard is surgery. Surgeons should keep in mind that radiological examination before the operation could prevent undesirable complications., Competing Interests: The manuscript was not sponsored by an outside organization. We (all of the authors) have agreed to allow full access to the primary data and to allow the journal to review the data if requested. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. The authors declare that there is no conflict of interest., (Copyright © 2021 by S. Karger AG, Basel.)

Background: In general, capsular contracture is the underlying cause of complications such as pain, stiffening, breast asymmetry, and animation deformity that are seen in the late postoperative period due to the use of silicone breast prostheses. Considering the positive effects of HBO therapy on wound healing, the objective of this study was to investigate the effect of HBO therapy on capsule reaction occurring due to silicone implants., Material and Methods: Rats were divided into four groups. 1 cm × 1 cm silicone implants with rough surface were inserted in subcutaneous plane on the m spinotrapezius muscle fascia at just right of the dorsal region midline in rats in Group 1, while implants with same properties were inserted beneath m spinotrapezius muscle in rats in Group 2.Implants with the same properties were inserted in the subcutaneous area on the m spinotrapezius muscle in rats in Group 3 and into the area under the muscle in rats in Group 4. Beginning from the first postoperative day, rats in Groups 3 and 4 received HBO therapy for 90 min under 2.5 ATM pressure as one session a day over 15 days., Results: The mean capsule thickness was statistically significantly lower in the groups treated with HBO compared to the control groups. Fibroblast, neutrophil and macrophage counts were statistically significantly lower in the groups treated with HBO compared to the control groups., Conclusion: We believe that HBO therapy can be used as an adjuvant treatment options to decrease capsule contraction occurring after silicone implant application.

Background: Fournier's gangrene (FG) is a rarely encountered necrotizing fasciitis principally affecting skin and subcutaneous tissues of the genital region, perineum, and abdominal wall. The overall incidence of FG is 1.6 cases per 100 000 per year; the incidence in males is higher. Management techniques described in the literature have both advantages and disadvantages, and there is no gold standard treatment technique., Objective: This study evaluated whether the Limberg flap can be used reliably in scrotal defects with fewer complications than are seen with traditional techniques. The results of unilateral or bilateral Limberg flaps for scrotal reconstruction after FG were assessed., Materials and Methods: This retrospective, single-center study analyzed records from 29 male patients with scrotal defects after multiple debridements who were treated from January 2013 to January 2018. Twenty-one patients (72.4%) with hemiscrotal defects and 8 patients (27.6%) with defects involving greater than 50% of the scrotal surface were included in this study. Demographic data that were analyzed included smoking history, comorbid conditions, time of surgery, and time of follow-up. Flap dimensions were measured. Patients were evaluated in terms of flap viability and postoperative complications., Results: Mean age was 64 years (range, 47-80 years). The mean follow-up period was 16 months (range, 12-26 months). Dehiscence with seroma were detected in 4 patients (13.7%) on postoperative days 4 and 5. The average size of the flaps was 11 cm × 15 cm. Seroma and dehiscence were encountered in 4 patients (13.7%) during postoperative follow-ups. No postoperative infection was observed in any patient, and no partial or total flap loss was reported., Conclusions: These results suggest that use of the Limberg flap technique for scrotal reconstruction following FG has the important benefits of being easily harvested while providing tension-free repair and acceptable cosmetic results.

Competing Interests: None declared.

Introduction The aim of this study was to determine usability of the reverse dorsal terminal vein flap (hat flap) in the reconstruction of Tamai zone 1 defects. Materials and Methods A total of 31 patients with fingertip amputation in Tamai zone 1 defect in the finger operated upon between 2014 and 2016 were included in this study. Flaps were designed from the proximal end of the nail bed to the middle phalanx according to the defect size. After passing through the skin, the proximal parts of the dorsal vein and branches were knotted. The flap was harvested by preserving the paratenon and dorsal digital terminal vein. Then, the flap was rotated and the defect was closed. Results A total of 32 patients were included in this study. The average size of the defects was 2 × 2.2 cm. Loss of epidermis in five patients and partial flap loss in two patients were observed (7/32, 21.8%), but total flap loss was not observed in any patient. Conclusion The reverse flow terminal dorsal vein-based pedicle flaps can be used as a viable surgical technique in the reconstruction of Tamai zone 1 amputations. Level of Evidence This is a Level IV study., Competing Interests: Conflict of Interest None declared., (© Thieme Medical Publishers.)

Background: Saddle nose deformity (SND) is a collapse of the cartilage and bone structures forming the dorsal projection of the nose. After the use of autologous cartilage in the treatment of SND, resorption and warping continue to be a problem., Methods: This study presents results from 11 patients with SND types III and IV from 2005 to 2017 treated with autologous cartilage fixed with microplates and microscrews. The patients were monitored for at least 1 year. Resorption and warping were measured using postoperative photographs of the patients in the 3rd and 12th months after treatment., Results: No signs of resorption or warping were noted in the patients., Conclusions: Our findings indicate autologous cartilage use with microplates and microscrews is a viable, long-term treatment option for patients with SND types III and IV.

Background: Ultrasound-assisted liposuction (UAL) has been previously used for postoperative flap thinning. Although it had been reported that UAL causes less damage to the vessels, the simultaneous use of UAL with free flap reconstruction has not been reported. The aim of this report was to determine the results and the complication rates of simultaneous use of UAL with free flap reconstruction., Patients and Methods: Twelve patients who underwent simultaneous flap thinning with UAL during free anterolateral thigh flap surgery between 2014 and 2016 were included in this prospective study. The mean age of the patients was 46.7 (ranging 10-76) years. The mean body mass index of the patients was 26.81 (ranging 25.2-29.8). Flaps were thinned with UAL before harvesting. The mean flap thicknesses were measured using a metal ruler before and after the UAL procedure. Biopsies were performed lateral to the center of the flaps, after completion of the UAL procedure. Vascular and collagen structures were histopathologically examined. The Likert scale, which evaluates the general appearance, shape, color, and texture, was used to assess the aesthetic results of the UAL procedure., Results: The average flap size was 13 × 9 cm. The mean pedicle length was 8.3 (ranging 7-10) cm. The mean flap thickness was 23 (ranging 19-27) mm and decreased to a mean of 8.1 (ranging 5-11) mm. Wound dehiscence and partial skin necrosis was observed in 2 patients (2/12, 16.66%). None of the patients had total flap necrosis. Vascular and collagen structures of the biopsied samples were normal. Patients were followed for an average of 13 months post UAL. The mean Likert score was 17.1 (ranging 15-19)., Conclusions: Flap thinning with UAL can be safely performed during the initial free flap reconstruction operation., (© 2018 Wiley Periodicals, Inc.)

Background/aim: The aim of this study was to determine the specific component of Rosmarinus officinalis (RO) responsible for increased flap survival and how RO displays its efficacy. Materials and methods: Rectangular random-pattern flaps were elevated from the back of each rat. Group I was the control group. In group II 0.1 mL of cineole, in group III 0.1 mL of alpha-pinene, in group IV 0.1 mL of camphor, in group V 0.1 mL each of alpha-pinene and cineole, in group VI 0.1 mL each of alpha-pinene and camphor, in group VII 0.1 mL each of cineole and camphor, and in group VIII, 0.1 mL each of alpha-pinene, cineole, and camphor was orally administered once a day before surgery. The luminal area of the largest blood vessel in the proximal flap was measured. Interleukin-1, tumor necrosis factor alpha, thiobarbituric acid reactive substances, and vascular endothelial growth factor values were measured. Results: The mean percentage of the viable surface area was significantly greater in groups VIII, III, and V. The mean percentage of vessel diameter was significantly greater in groups V, VIII, and VII. Conclusion: We suggest that alpha-pinene and cineole were the components of RO that were responsible for increased flap survival. The most effective of feature of RO was the antiinflammatory effects.

Background: Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for young Hurler patients. Despite halting of neurocognitive decline and improvement of life expectancy, the beneficial effect on the skeletal system is limited. As orthopedic complications are one of the most disabling factors following HSCT, this points to the need for new treatment strategies. The study summarizes musculoskeletal manifestations in 19 transplanted Hurler patients., Methods: Data were obtained retrospectively. Patients' charts for physical examinations of the joint range of motion (JROM) of shoulders, elbows, hips and knees were reviewed. Radiographic evaluations of thorax, spine, pelvis and hands were performed. MRI scans of the craniocervical junction were analyzed to determine odontoid hypoplasia and the prevalence of craniocervical stenosis., Results: Nineteen Hurler patients (10 females, 9 males) with an average age of 8.1 years (range 2.5-23.8) at the latest follow-up, who underwent allogenic HSCT between 1991 and 2012, were assessed after an average follow-up period of 6.4 years (range 0.7-22.5). Seventeen patients achieved long-term engraftment, two developed graft failures. The majority of patients showed a steady state or improvements in the mobility of knees (31 %/63 %), hips (47 %/40 %) and elbows (56 %/38 %). However, shoulder abduction was impaired in ¾ of patients and showed the highest rate of progression (31 %). In patients with graft failure, progressive restrictions in JROM were noted. Assessments of the craniocervical junction by MRI showed stable or improved diameters in 67 % of patients. Correction or stabilization of odontoid hypoplasia was found in 64 %. However thoracolumbar kyphosis, scoliosis, hip dysplasia and genua valga were progressive despite HSCT. At the last follow up, 47 % of patients were partially wheelchair dependent, 10 % wheelchair bound and 25 % regularly experienced pain in the spine, hips and lower extremities due to orthopedic problems., Conclusion: Joint mobility, odontoid hypoplasia and craniocervical stenosis might stabilize or even improve in Hurler patients following HSCT. However, despite the beneficial effects on some musculoskeletal manifestations, skeletal complications are frequently observed and the overall burden of orthopedic disease is significant. Frequent multi-disciplinary follow-up in a specialized center are essential. Novel therapeutic approaches (e.g. anti-inflammatory drugs) are needed to improve musculoskeletal outcomes.

Purpose: Various reconstruction options are available for the soft-tissue coverage of meningomyelocele defects. For small defects, primary closure or local single flaps may be sufficient, while large defects require more complex reconstructive techniques. This study suggests an easy way for surgeons to close large meningomyelocele defects using triple rhomboid flaps., Methods: The hexagonal structure of a honeycomb was considered when planning for the coverage of large meningomyelocele defects. The intact skin around the defect was imagined as multiple hexagons, which allowed us to plan triple rhomboid flaps correctly and more easily. This technique was used in seven patients with defects ranging from 7 × 5 to 12 × 8 cm in size., Results: No major postoperative complications were seen. Minimal dehiscence was observed in two patients and healed secondarily., Conclusions: The honeycomb modification for planning triple rhomboid flaps is an easy, practical, and memorable approach for surgeons reconstructing large meningomyelocele defects.

The construction of an L-lysine biosensor on ammonium-selective poly(vinylchloride) (PVC) membrane electrode is described in this study. The construction procedure occurs in two stages: (I) the preparation of ammonium-selective poly(vinylchloride) (PVC) membrane electrode and (II) the chemical immobilization of lysine oxidase on this ammonium-selective electrode by using glutaraldehyde. The ammonium ions produced after enzymatic reaction were determined potentiometrically. The sensitivity of the lysine biosensor against ammonium ions and lysine were studied. The response time, linear working range, reproducibility and life time of the biosensor were also determined. The interfering effect of other amino acids on the biosensor performance was also studied and potentiometric selectivity coefficients were calculated. Although the biosensor responded mainly against tyrosine, a lot of amino acids and ascorbic acid that can be present in some real samples did not show any important interference. Additionally, lysine assay in commercial pharmaceutical lysine tablets and capsules was also successfully carried out. The results were in good agreement with previously reported values.

Objective: The aim of this study was to compare the Winograd and knot techniques based on efficiency, complication rate, surgery time, and amount of local anesthetic required. This study also aimed to determine the etiology of ingrown nails, whether due to involvement of the nail or soft tissue., Methods: Seventy-five patients with a total of 90 ingrown nails (stages 2 and 3) who presented at our clinic between 2012-2014 were included in this study. Patients were divided into 2 groups: those treated with the knot technique and those treated with the Winograd technique. Patients in both groups were evaluated for the amount of local anesthetic required, intraoperative pain, effectiveness of preventing/stopping hemorrhage, surgery time, complications, postoperative nail size, recurrence, nail deformities, and secondary surgery rates., Results: The mean surgical time, relapse rate, number of additional surgeries required, and amount of local anesthetic were significantly greater in the Winograd group than in the knot group. The mean nail diameter was significantly decreased, with a mean of 3 mm in the Winograd group. No statistically significant differences were found between the groups in the incidence of infection, intraoperative pain, hematoma, or nail deformity., Conclusion: This study demonstrated that the knot technique, consisting of wedge excision of soft tissue without affecting the nail itself, is a simple technique to treat ingrown nails with a lower complication rate and shorter surgical time. We believe that successful treatment of ingrown nails depends only on excision of soft tissue, with no need to operate on the nail bed.

Background: Human amniotic fluid (HAF), including hyaluronic acid (HA) and several growth factors, has been used experimentally in tendon, nerve, and cartilage regeneration and in bone defects because of its positive stimulating effects on regeneration potential. This study was performed to investigate whether HAF was effective on fracture healing., Materials and Methods: We created 36 tibial fractures in 20-week-old Wistar rats that were divided into three groups. In group 1, fracture lines were instilled with HAF collected at 18th week of the gestation and, in group 2, fracture lines were instilled with HAF obtained at the end of the gestation. HAF which was collected from different period of gestation was used, because the concentration of HA and growth factors in HAF varies considerably during gestation. Group 3 was used as an operative control group., Results: Fracture-healing score was highest in group 1 radiologically at the 3rd and 5th week (P = 0.037, P = 0.018, respectively). In the scintigraphic evaluation, metabolic activity at the fracture site was observed in group 1 more than the others at the 3rd week (P = 0.010). Histologically, the highest scores were obtained from group 1 as compared to other groups at the 3rd and 5th week. In the 5th week, predominant cartilage with some woven bone was observed in group 3, while predominantly woven bone with some cartilage was observed in group 1 (P = 0.036)., Conclusions: Our data suggest that HAF had a positive effect on fracture healing in rat tibia, and also this positive effect was observed more in group 1.